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Case Note

Case Note: Acne scarring on the face

History

16-year-old healthy male, with a past medical history of nodulocystic acne with scarring presents for management of acne scarring

Initial evaluation

  • Healthy-appearing male
  • Firm, raised, indurated papules and linear plaques noted across the jawline and chest
  • Image 1
    Image 1

Enter your diagnosis

Diagnosis

  • A diagnosis of keloids (secondary acne) is rendered

Initial Treatment

  • Recommendations:
    • Intralesional triamcinolone (20 mg/cc) injections
  • Follow-up in 4 weeks

Follow-up evaluation strategy

4-week follow-up evaluation:

  • Improved (lesions much smaller in size, flatter, softer)
  • No adverse effects noted (atrophy, telangiectasia)

Further recommendations:

  • Repeat injections to several persistently thickened lesions
  • Several lesions require intralesional triamcinolone (40 mg/cc)
  • Follow-up in 4-week intervals (requires a total of four additional visits to improve the majority of lesions)

General discussion

Scarring is a common complication of wound healing. Keloids are defined as scars that grow beyond the boundaries of the original wound site and are often marked by significant, persistent thickening and are pruritic or painful. They may occur between 3 and 12 months following the inciting skin trauma and clinically, are firm and raised and can be hyperpigmented or marked with telangiectasia. Common sites for keloid formation include the ears, upper back, chest, and upper arms. Keloids are more common in certain populations, including those with a family history of keloid scars and individuals of Asian, African and Hispanic descent.

Fibroblast dysfunction, including increased production of type I procollagen, cytokines, and connexins, may underlie the development of keloids, and thickened collagen bundles are the histologic hallmark on biopsy. Keloids can be symptomatic, marked by pruritus, tenderness, or extreme hyperesthesia.

Intralesional corticosteroids remain the first-line therapy of choice and have good safety profiles, although cryosurgery is also considered safe and effective and may be used in conjunction. Corticosteroids may be effective in 50-100% of cases but often require multiple injections with on-going monitoring for atrophy, telangiectasia and hypopigmentation. Start with triamcinolone acetonide (20 mg/cc) injection with a ½ inch, 30-gauge Luer lock needle and tuberculin syringe at several adjacent sites at 0.5-1.0 cm apart. Repeat this at monthly intervals until the degree of involution and/or symptomatic relief is achieved and if no change occurs, increase the dose to 40 mg/cc. After this, consider surgical excision.

In addition, isotretinoin can be considered for treatment in patients with persistent acne and in patients with keloids to prevent further formations.

Surgical excision may be effective if keloids remain unresponsive, although consider concomitant injection with triamcinolone acetonide (20 mg/cc at 2-week intervals over 3-4 months) at multiple loci along the excision site to avoid recurrences.

Following excision, alternative steps include silicone sheeting, imiquimod 5%* (used for 8 weeks), laser ablation and radiotherapy, although there is limited evidence to support their use. In addition, intralesional 5-fluorouracil* or bleomycin* and topical mitomycin C* can be used, but are associated with adverse effects.

Management of side effects may be achieved with pulse dye laser (for minimizing erythema or telangiectasia) and some anecdotal evidence suggests that scar massage may help to relieve postsurgical scarring.

A common pitfall is the recurrence of keloids after excision. Recurrences can be more disfiguring than the original lesions, particularly if an ablative method, such as electrosurgery, was employed. Elective surgery should be avoided in patients with a history of keloid formation, especially at sites where keloids are likely to occur.

 

*Off-label use

Further reading

Chike-Obi CJ, et al. Keloids: pathogenesis, clinical features, and management. Semin Plast Surg 2009;23:178-184.

Shin TM, Bordeaux JS. The role of massage in scar management: a literature review. Derm Surgery 2012;38:414-423.

Tziotzios C, et al. Cutaneous scarring: pathophysiology, molecular mechanisms, and scar reduction therapeutics, Part II. J Amer Acad Dermatol 2012;66:13-24.

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