Chickenpox scars result when the wound healing process produces insufficient collagen and skin connective tissues to compensate for the tissue loss from the inflammatory process. Most often than not, the end result is a an atrophic scar of the boxcar variety, whereby the flat-bottom depression is sharply demarcated from the surrounding skin by vertical edges. This scar can be shallow or deep, and variable in size (usually 1.5 - 4mm).
Generally, I would categorize the many treatments available according to the aims of the treatment:
- Resurfacing: the difference in depth between atrophic scars and the surrounding normal skin is improved with various techniques, such as, lasers, chemical peels, microneedling, dermabrasion, subcision. The end result is a less distinct demarcation between the depressed scar and the surrounding skin. However, with deeper scars, some of these techniques may not be able reach the entire depth of the scar to produce enough new collagen to fill up the depression.
- Lifting / volumization: this is to replace lost volume in the depressed scars with filling agents e.g. hyaluronic acid, poly-L-lactic acid (Sculptra), autologous fat.
- Surgical removal: techniques e.g. punch excision, punch elevation, punch grafting, may be useful for scars <4mm - deep boxcars, large ice-pick scars.
Looking at your pictures, you mainly have boxcars of variable sizes, and the depths of which need to be examined in person during consultation with a doctor.
I would suggest a combination of:
- Subcision: although subcision is known to have better results for rolling scars, it can be tried for some boxcars which are assessed to be tethered.
- Fractional treatments e.g. fractional ablative lasers (CO2 or Er:YAG), or fractional micro-needling radiofrequency (INFINI).
- TCA CROSS (Chemical Reconstruction Of Skin Scars): this treatment can be considered for the deep and small scars.
- Volumization: filling of the larger depressed scars. Personally I would prefer hyaluronic acid (HA). Using longer-lasting fillers can be considered, but with caution.
- Rejuran S: this is a relatively new treatment involving the injection of salmon-derived polynucleotide into the scar areas. The rationale is to provide the building blocks needed for the repair of the damaged skin cells. A series of 3-4 treatments can potentially improve the appearance of scars. Rejuran S is a formulation specifically indicated for scars, in contrast with the usual Rejuran for rejuvenation of the skin in general.
- Surgical removal: these treatments modify the existing deep scars into more level scars by excision, grafting or elevation. Other treatments may be needed thereafter to reduce the appearance of the surgical scars.
I believe the key to an optimized result is a combination of techniques individualized to each particular scar. As such, factors such as the type of the scar, the depth and the size of the scars need to be considered.
Scar management is a treatment process that requires repeated combination treatments over a period of time. Be persistent, and I wish you the best of luck in this journey.
