Acne leaves scars in 95% of patients, especially if the acne is inflammatory or treatment is delayed.1 Various treatments are available, such as laser therapy, light treatment, subcision, chemical peeling, dermal fillers, platelet-rich plasma, debulking procedures, and microneedling.2
Acne-induced papular scarring of the nose and chin is an under-recognized variant that was first described in 1990.3-4 Several treatment options have been proposed, but none seems to be successful.
We herein report a series of patients with papular scars of the nose and chin treated with ablative carbon dioxide laser therapy with a considerably high success rate.
Five patients with papular scars of the nose and chin due to acne were treated at an outpatient dermatology clinic. All had type V skin according to the Fitzpatrick skin classification. Ablative carbon dioxide laser therapy (10,600 nm, continuous mode, energy of 15 W) was performed under topical anesthesia. Infiltration of a local anesthetic agent (1% lidocaine without adrenaline) was used to achieve anesthesia. Topical emollients and sunscreen were applied until the lesions healed. The patients were re-examined at 2- to 3-week intervals, and laser treatment was repeated as needed. The progress of the lesions was monitored by digital photography.
The five patients (three women, two men) ranged in age from 22 to 36 years. One patient was treated for papular scars of the chin, and all others were treated for papular scars of the nose (Fig. 1A, C, and E). The change in the size of the popular scars was measured to assess the results of the laser therapy. Digital photographs were used to take measurements. Table 1 summarizes these results. At the end of the first treatment, the patients showed about 50% improvement in the scars (Fig. 1B). However, two patients who underwent four treatment sessions showed 80% improvement (Fig. 1D and 1F).
Table 1 -
Treatment effects of ablative carbon dioxide laser
for papular scars of nose and chin due to acne.
||Site of the scar
||Number of treatment sessions
||Final improvement (%)
None of the patients developed post-laser hyperpigmentation, hypopigmentation, or infection. However, disadvantages of the treatment were mild to moderate pain during the procedure and the need for post-treatment skin care. All lesions were re-epithelialized by about 14 days after the procedure. During follow-up, no patients developed relapse of the condition or adverse events. All of the patients provided written informed consent.
Papular scars of the nose and chin are the most difficult acne scars to treat because of the destruction of collagen and elastic tissues around the hair follicle. The lesions comprise multiple non-scaling, skin-colored, soft fibrous papules that are typically distributed over the nose and chin. They have a cobblestone appearance and become flatter during facial expressions such as smiling, differentiating them from hypertrophic scars.5
Of the five patients in this study, four had lesions over the nose and one had lesions over the chin. After a single treatment, three patients showed about 50% improvement in their scars. Two patients showed about 80% improvement after four treatment sessions. The lesions were ablated until they completely disappeared. After laser treatment, the lesions healed with buildup of some scar tissue, but not to the original severity. This might have been prevented if the ablation had been performed below the skin surface.
Injection of local anesthetic agents to the site also partly obscured the lesions. Before the ablations, the lesions were marked with a skin marker to prevent this complication. However, tissue swelling likely obscured the true size of the lesion.
Accurate objective assessment of the lesions was difficult because they were tiny and not on a uniform surface. Even in a photograph, the curvatures of the nose and chin change the true appearance of the scars, and this is a limitation of the present study. Importantly, the patients’ satisfaction was high and no adverse events were noted.
Papular scarring of the nose and chin is under-reported, probably not because of its rarity but instead because of inadequate attention paid by clinicians. A study in the United Kingdom showed that 4% of 149 patients attending a tertiary dermatology clinic had papular scars over the chin and nose. The study also showed male predominance and an association with other types of acne scaring.4 Histological examination of the lesions showed fibrous scarring with a few ectatic blood vessels and mild chronic inflammation.4
Two studies have been performed to evaluate the treatment options for these difficult-to-treat scars. One report described a technique in which radiofrequency energy was delivered directly to the lesions through a hypodermic needle, and good results were attained. The authors claimed that this technique minimizes the post-inflammatory hyperpigmentation/hypopigmentation and scarring associated with superficial ablation.6
Another study showed successful treatment of papular scars using an erbium:yttrium-aluminum-garnet laser by the pinhole method, which involves the creation of multiple tiny holes that penetrate from the epidermis into the deeper dermis. Two patients were treated with good aesthetic results.7 This method is likely to be effective because 2940-nm erbium:yttrium-aluminum-garnet lasers target water-containing tissues more than other types of lasers.
Because of the profound psychological impact of acne and acne scars, it is very important to treat the scars effectively.8 The currently available evidence to guide treatment is in the preliminary stage, necessitating the performance of well-designed studies and exploration of newer techniques to treat this challenging condition.
. Layton AM, Henderson CA, Cunliffe WJ. A clinical evaluation of acne scarring and its incidence. Clin Exp Dermatol 1994;19 (4):303–308. doi:10.1111/j.1365-2230.1994.tb01200.x.
. Kravvas G, Al-Niaimi F. A systematic review of treatments for acne scarring. Part 1: Non-energy-based techniques. Scars Burn Heal 2017;30 (3):2059513117695312. doi:10.1177/2059513117695312.
. Wilson BB, Dent CH, Cooper PH. Papular acne scars. A common cutaneous finding. Arch Dermatol 1990;126 (6):797–800. doi:10.1001/archderm.1990.01670300097016.
. Ali FR, Kirk M, Madan V. Papular acne scars of the nose and chin: an under-recognised variant of acne scarring. J Cutan Aesthet Surg 2016;9 (4):241–243. doi:10.4103/0974-2077.197075.
. Gan SD, Graber EM. Papular scars: an addition to the acne scar classification scheme. J Clin Aesthet Dermatol 2015;8 (1):19–20.
. Patra S, Kaur M, Gupta S. Intralesional radiofrequency with a thin hypodermic needle in the management of papular acne scars. J Am Acad Dermatol 2021;84 (6):e259–e260. doi:10.1016/j.jaad.2019.12.004.
. Lee SJ, Kim JM, Kim YK, et al. The pinhole method using an erbium: YAG laser for the treatment of papular acne scars. Dermatol Ther 2017;30 (5):1–3. doi:10.1111/dth.12512.
. Chuah SY, Goh CL. The Impact of Post-Acne Scars on the Quality of Life Among Young Adults in Singapore. J Cutan Aesthet Surg 2015;8 (3):153–158. doi:10.4103/0974-2077.167272.