Botox and Acne Scars: Why Botox isn't the Best Treatment
As a beauty lover and aesthetic nurse practitioner, I've been seeing a lot of information circulating and individuals questioning if Botox is a good treatment option for acne scarring.
In order to best answer this question, it's important to understand what botox is and its mechanism of action and understand why the body forms scars.
Let's start with what Botox is. Botox, short for botulinum toxin, is a neurotoxic protein produced by the bacterium Clostridium botulinum. Clostridium botulinum bacteria are commonly found in soil, dust, and untreated water. They can also be present in improperly processed or preserved foods, particularly those with low acidity and low oxygen levels, such as canned goods or vacuum-sealed foods. Of course, the way we manufacture and obtain botulinum toxin is a little more eloquent than that. There are many companies that manufacture botulinum toxin. The most commonly known companies are Allergan (now part of AbbVie and known for Botox (Botox is a brand name), Merz Pharmaceuticals (produces Xeomin), Ipsen Pharmaceuticals (produces Dysport).
When most people think of Botox treatments they think of cosmetic procedures, but botulinum toxin is used medically to treat various conditions, including muscle spasms, excessive sweating (hyperhidrosis), migraines, TMJ pain, and certain bladder and bowel disorders. In cosmetic procedures, it's injected into the facial muscles to temporarily improve the appearance of facial wrinkles.
So what exactly is the mechanism of botulinum toxin and how does it work?
At a high level, botulinum toxin works by blocking the release of a neurotransmitter in a neuron synaptic gap. Our body has neurons (nerve cells) all over. There are small spaces (junctions) between neurons or neuron-to-muscle cells. The neurotransmitter that is blocked from binding in a synaptic gap is acetylcholine. Acetylcholine is involved in transmitting signals across these synapses, enabling communication between neurons and between neurons and muscle cells. By preventing this release, Botox inhibits muscle activity, leading to temporary paralysis of the targeted muscles. Botox does not migrate great distances, thus, the muscle that is affected is close to the injection site and dependent on the needle depth. This effect helps reduce wrinkles in cosmetic applications or alleviate muscle spasms in medical treatments.
After botox injections, the effects are temporary, typically lasting for several months. During this time, the synaptic gaps are not permanently altered. The body gradually metabolizes the botulinum toxin, allowing nerve signals to resume transmission across the synaptic gaps, restoring normal muscle function. The body doesn't necessarily make new synapses; rather, it re-established communication between existing ones once the effects of botox wear off.
Okay, I know that was a lot of information but it's important to understand the mechanism to be able to completely understand if botox can aid in acne scarring.
How is a scar formed?
Scars form as a natural part of the body's healing process in response to an injury or damage to the skin. This may be a simplified overview of how scars are formed, but let us get into it. When the skin is injured, whether through a cut, burn, or other trauma, the body responds by initiating the healing process. Enter into the room- the inflammatory phase. Immediately after the injury, blood vessels in the area constrict to reduce bleeding. Then, blood vessels dilate to increase blood flow, bringing in all the good stuff and our helpers. Immune cells arrive at the site to clean up debris and take care of business. The immune cells defend against infection as well. This process results in swelling, redness (erythema), and an increase in temperature. We then enter into the proliferative phase. During this phase, which typically lasts several days to weeks, new tissue forms to repair the wound. Fibroblasts, specialized cells in the skin, produce collagen, a protein that helps rebuild the damaged tissue. The wound contracts as collagen fibers align and connect, reducing its size. This is probably a fan-fav stage lol.
Lastly, our body begins the remodeling phase. In the final phase of wound healing, the scar undergoes remodeling. Excess collagen is broken down and rearranged to strengthen the scar tissue. However, the new tissue is often different than the original tissue, leading to the formation of a scar.
Okay, are you still with me?? Hang tight, there's a reason I'm going through this!
I feel like Mrs. Frizzle navigating the magic school bus through the body's healing process lol. (Ugh oh, I'm revealing my age!)
Are all scars the same?
The formation of acne scars is dependent on the individual- skin type, skin tone, and (if caused by acne) types of acne. There are many types of scars, including ice pick scars, boxcar scars, rolling scars, hypertrophic scars, and keloid scars. Acne scars can leave an individual with any of the aforementioned scars.
Ice pick scars are deep, narrow scars that extend into the skin resembling holes or pits (think as an "ice pick poked you"). These scars are challenging to treat.
Boxcar scars are a type of acne scar characterized by sharp, well-defined edges and a flat, box-like appearance. This scar is typically a result of inflammatory acne, where the skin tissue is destroyed- leading to a depressed acne scar or craters in the skin. These scars are a bit wider than ice-pick scars.
Rolling scars are broad depressions with sloping edges that give the skin a wavy appearance. These scars are a result of the tethering of the deeper tissue and are usually a result of deep, inflammatory acne.
Hypertrophic scars are a result of too much collagen production during the wound-healing process. These scars are raised and may appear red or purple in color. Hypertrophic scars remain within the boundaries of the wound and do not extend past that. Usually, these scars begin to flatten out over time (which can take years) and do not require as much treatment as keloid scarring does.
Keloid scars are raised, firm scars that extend beyond the boundaries of the original wound. Unlike hypertrophic scars, keloid scars may not improve over time (often do not) and can last a lifetime- usually requiring intervention.
Okay, so you may be thinking, "Why the heck does it matter if I understand the mechanism of Botox, how our body heals, and types of scars?" In order to best understand why botox (botulinum toxin) is not the best treatment for acne scarring.
The burning question: Can the use of botox (botulinum toxin injections) reduce acne scarring?
So think about the mechanism of botox and what we reviewed above. In simple terms, botox prevents muscle contraction. There are very few circumstances in which Botox will aid in reducing the appearance of the scars. The only circumstance that I can think of, that would accomplish this, is if you have a scar (usually caused by another mechanism and more linear in appearance), that falls within the normal skin folds. This can help soften the appearance, but not rid it. Botox can help minimize the amount of oil produced and in turn, may aid in reducing acne breakouts, but it does not address the primary concern- riding the skin of acne scars. There are also better treatments for oily skin IMO. Acne scars are often primarily seen on the cheeks... botox is not typically injected on the cheeks, as this can result in a dropped smile and poor control of your muscles that aid in speech.
Can we talk about the cost of Botox for a moment?! Depending on the brand (Botox, Xoemin, Dysport) and the med spa, botulinum toxin can range between $9-15 per unit. How many units are required to treat an area?? Well, that's a very good question and can range. Let me insert a picture of what is recommended by most companies that manufacture botulin toxin. This is per muscle group:
Image obtained from: https://www.weilerplasticsurgery.com/blog/how-many-units-of-botox-do-i-need/
I do not own rights to the image.
Of course, this can be dependent on the person and how strong the muscles are, but it's not uncommon to see people paying upwards of $1000 per treatment (and Botox wears off in about 3 months). I mean, this is a luxury treatment, bestie! Don't get me wrong, I am a ride-or-die for Botox and there is no better way to rid fine lines (in my humble opinion).
I don't want you to feel discouraged... there are a lot of really great treatments that are geared toward acne scarring that will give you better results and better skin texture! I just don't suggest you spend your hard-earned dollars on a treatment that will minimally help, at best!
My recommendations for acne scar treatment:
It all boils down to the severity of the scars and the type of scarring.
Topical treatments: Prescription creams or gels containing ingredients like retinoids (help with cell turnover), hydroquinone (in simple terms, skin bleaching), or azelaic acid can help improve the appearance of mild acne scars by promoting cell turnover and fading pigmentation. This is all prescribed by medical professionals or board-certified dermatologists.
Chemical peels: Chemical peels use acids to remove the outer layer of skin, promoting new skin growth and reducing the appearance of shallow acne scars. Different types of peels, such as glycolic acid, salicylic acid, or trichloroacetic acid (TCA), may be used depending on the depth of the scars. These can range anywhere from $100-500 per treatment and usually, multiple treatments are needed.
Microdermabrasion: okay, I'm going to include it, but would not recommend it for scar treatment. Let's just leave it at that. It has it's place, but in my opinion it is not an effective treatment for acne scarring. I would put your money elsewhere.
Laser therapy: Now we're getting into the fun stuff! Various types of laser treatments, such as fractional laser resurfacing, pulsed dye laser therapy, or ablative laser therapy, can target different types of acne scars by stimulating collagen production, promoting skin remodeling, and reducing redness or pigmentation. Although, not everyone is a good candidate for laser treatments, this would further be explored by your aesthetic practitioner. There can be a bit of downtime for these procedures, especially ablative lasers. I am most familiar with the CO2 laser and have seen wonderful results with it. It can be rather expensive, around $3000-$6500; however, usually only one treatment is needed. This is not medical advice, talk to your med spa!
Microneedling: Also known as collagen induction therapy, microneedling involves using a device with fine needles to create tiny punctures in the skin, stimulating collagen production and promoting skin regeneration. Microneedling can improve the appearance of acne scars, including boxcar scars and rolling scars. Some spas will even couple this with platelet-rich plasma (PRP). PRP is obtained when your blood is drawn and spun down. This separates the components of the blood. Red blood cells are heavier and sink to the bottom, while the plasma floats to the top. These layers are separated by a "buffy coat layer", filled with growth factors, platelets, and white blood cells. The buffy coat and the plasma is separated and drawn up with a needle and reapplied to your skin while microneedling. Sounds wild, huh?! The best way I can describe this procedure is like aerating your lawn and applying fertilizer lol. This can be done every 6-8 weeks and usually, multiple treatments are required. Treatments range from $300-650.
Dermal fillers: If you have a few scars and just want those taken care of, dermal fillers are a great option! Dermal fillers have a greater role than just providing augmented lips. Just as the name sounds, they add volume or fill an area. People often think Botox and dermal fillers are interchangeable- they are not. There are many types of filler, and it just depends on the type of filler you need to accomplish your goals. Your injector will review this with you and make recommendations. You can utilize a filler that's high in G prime and gives you good support under the scar, then refine and perfect the scar with a more pliable filler like Belotero. I tend to like Belotero for a lot of reasons, but it's kinda equivalent to a magic erase marker. I could chase fine lines and acne scarring all day with it. Dermal fillers are a wonderful option if you do not want to undergo a ton of downtime and don't want to spend a fortune on treatments. I would budget for about $2000 if you choose this route. Dermal fillers can last anywhere from 6 months to 2 years (or more).
Surgical procedures: In some cases, surgical techniques like punch excision, subcision, or punch grafting may be used to physically remove or revise more severe acne scars.
It's essential to consult with a dermatologist or skincare specialist to determine the most appropriate treatment plan based on your individual needs and the type of scars you have. Combination treatments may be needed for optimal results.
Remember, your physical shell is only a piece of you. It does not define you. Beauty comes from your soul. I understand wanting to enhance your appearance, but you are beautiful- even with the scars. Have a good week, bestie!
