Dear Paula,

I am so confused and could sure use your help! For the last few years, I've had many consultations with dermatologists regarding acne scar treatments. Every doctor recommended something different. I couldn't tell whether they were being honest or just trying to sell me on the latest and/or most expensive treatment. They told me my scars are not deep, which I already knew. I replied that I am only after better tone and texture, not complete scar elimination. I've been told to have treatments such as Thermage, Fraxel, Pixel, V-Beam, etc. and am frustrated with all the choices. You mentioned you did Intense Pulsed Light and Botox; how did you know these treatments were the right ones for you? How do I go about finding honest answers to my quest for smoother skin? Your help would be greatly appreciated. Keep up all the good work that you do. I use your products and have had better skin and more control of my acne than I've had in years —my only regret is that I didn't know about them sooner!

Audrey, via email

Dear Audrey,

I’m sorry your quest for smoother skin has become so frustrating. Generally speaking, I’m incredibly disappointed that so many dermatologists have become salespeople seemingly making recommendations to cover the costs of the machines they’ve purchased rather then disseminating objective information. What all of these doctors should have said is that there are many options for improving acne scars, each with different benefits, and all with limitations you should have been told about.

I think it’s great that you were smart enough to seek the opinion of more than one dermatologist, but because the doctors you saw presented one-sided information that ended up making matters more confusing than they need to be.

Separate from the current dermatology practice lending itself more to a spa then medical impartiality, even with the most objective dermatologist, there are lots of choices to treat superficial or even deep skin damage from acne, sun damage, or conditions such as rosacea. In short, there isn’t an agreed-upon “best” option for each situation. For example, treating sun damage with in-office cosmetic corrective procedures could mean a series of glycolic acid peels coupled with tretinoin (Retin-A) therapy or could be as extensive as CO2 (ablative) laser resurfacing. Then there are the wide selection of non-ablative lasers, intense pulse light (IPL), radio frequency (Thermage), and a new version of a CO2 laser called Fraxel (though there are other versions). Within these options there are dozens of machines that even the best dermatologist has no chance of keeping track of or being able to afford every time a new option or improved version comes to market.

Any treatment you choose and its outcome always depends on the amount of damage, your expectations vs. what’s actually possible, budget, and time (some of these procedures have considerable recovery time, while others can be done on your lunch hour but require multiple treatments year after year) and the expertise of the dermatologist.

Beware of any dermatologist that promises instant gratification and impressive results or downplays the side effects (every cosmetic corrective procedure has side effects that must be considered before you make the decision to have something done). A good dermatologist will explain the pros and cons and detail what you can realistically expect after one and, in most cases, several treatments.

As for how I decided to have IPL and Botox, I did my homework by looking over the published research about these procedures. I was also willing to experiment to see which ones produced the best results. I knew that each of these treatments needs to be done repeatedly over time so experimenting seemed natural to the process. Just be sure you never make a decision based on a newspaper article, single study, what’s popular with celebrities, or what a friend of a friend did.

As it turned out, I’ve been happy with my choices (though Thermage was not my favorite) and I have always kept my expectations realistic (for example, my acne scarring improved, but it did not go away).  I was also adamant about using my own skin-care routine designed to work with, rather than against, the benefits these procedures have. A lot of the products dermatologists sell are not the best or comprehensive enough to work as well as you might think.

Regarding your acne scars, you mentioned they weren’t deep, so I am assuming you’re dealing with slightly pitted scars, not the discolored areas (referred to as post-inflammatory hyperpigmentation) that are left after a blemish has healed. These marks, which technically aren’t scars, will fade on their own in time and with diligent sun protection. Procedures such as IPL and at-home use of a well-formulated AHA or BHA exfoliant can hasten the fading. The type of acne scarring you’re dealing with may respond well to a variety of treatments, including those you mentioned in your email. The latest research indicates that a combination of treatments, such as Fraxel and IPL (which I’ve done), produces better results than either procedure on its own.

The best advice I can give you is to weigh the pros and cons of each treatment suggested with your expectations (which seem to be quite realistic) and your budget. The number of options at your disposal may seem overwhelming, but with guidance from a dermatologist plus factoring in your needs (including how much you can comfortably spend; remember, in most cases a series of treatments are required for best results) I am confident you’ll make an intelligent decision.

Sources for the information above: Photodermatology, Photoimmunology, and Photomedicine, June 2009, pages 138-142; Dermatologic Surgery, April 2009, Epublication; Aesthetic Surgery Journal, November-December 2008, pages 675-680; Dermatologic Surgery, October 2008, pages 1,327-1,332; and Journal of the European Academy of Dermatology and Venereology, August 2007, pages 877-890).