Acne scarring in general practice: control inflammation early, retinoids including trifarotene, and the procedural toolbox

Speaker

Unnamed dermatologist. The speaker describes themself as a dermatologist who prescribes retinoids "every day" and presents three patients from their own clinic. No name or affiliation is given in the transcript.

Session context

Otter title Acne Scarring Treatment Seminar · id OggZ0sgRE8wX-bPiaie_IfeDI2k · ~23 min. One speaker throughout. The recording starts mid-sentence, so the opening slide title and any sponsor statement were not captured.

Key messages for GPs

• Acne scarring is very common (scars of some degree in up to about 95% of people with acne, as spoken) and is mostly atrophic (loss of collagen, the "dents").
• Do not ignore it. Scarring is linked with anxiety, depression, low self-esteem and suicide risk, and even a small improvement makes patients feel much better.
• Early, effective treatment of inflammatory acne is the most important step. It prevents new scars and on its own improves many existing ones. "Jump in" before acne becomes deep and inflamed.
• No single treatment wins. There is no real consensus guideline, and combined approaches work better than any one modality.
• Trifarotene is a fourth-generation topical retinoid targeting the retinoic acid receptor gamma. The START randomised trial showed fewer atrophic scars and fewer acne lesions than vehicle over 24 weeks.
• Counsel on how to use it: one pump for the whole face, bland moisturiser straight on top, start once or twice a week and build slowly. Most people never need it every night.
• Tell patients to hang in there. Six weeks is too early to judge; improvement continues to 24 weeks.
• The speaker prefers lower-dose isotretinoin for longer over the old weight-based cumulative regimens.

Why acne scarring matters

Acne is extremely common, affecting up to about 85% of young people (the age range was garbled in the transcript, likely 12 to 25), and some degree of scarring occurs in up to 95% of those with acne. Scars can be:

• Atrophic: a loss of collagen, giving indented scars. This is the majority of acne scars.
• Hypertrophic: a gain of collagen, giving raised scars (and keloids at the extreme).

Anxiety, depression and lowered self-esteem track with scarring severity, and acne scarring itself is linked to depression and suicide risk. In quality-of-life studies, patients report feeling much better with even small improvements in their scars.

How scars form: inflammation is the driver

The speaker described a direct link between inflammation and scarring. Acne starts with a precursor lesion that "doesn't look like much", an open or closed comedone. In acne-prone people this can quickly progress to a papule or pustule, then a nodule or cyst, leaving redness and then a scar. Scarred skin shows more helper T cells. Upregulation of toll-like receptor 2 drives matrix metalloproteinases (MMPs), which regulate cytokines; when the balance is upset, collagen is either lost (atrophic) or overproduced (hypertrophic).

Scar types and the treatment toolbox

With no single proven best treatment, dermatologists combine tools on the same patient, matched to the scar type. The speaker listed:

Retinoids: four generations

The speaker's favourite tool: "I love retinoids, use retinoids every day." Acne has several drivers at once (bacteria, extra oil, inflammation and hyperkeratinisation), and retinoids reduce all of them through effects on inflammatory and immune pathways, acting mainly through nuclear retinoic acid receptors (RARs).

Topical retinoids available in Australia that the speaker named: adapalene, adapalene with benzoyl peroxide, tretinoin and trifarotene (Aklief, transcribed "a cleaf"). Topical retinoids have not been well studied for acne scars. The figures quoted (as transcribed, so treat with caution) were: adapalene about 29% improvement in a small study; adapalene with benzoyl peroxide about 15% in a larger study; tretinoin with no percentage reported; and trifarotene 55.3%.

Because trifarotene targets RAR-gamma specifically, the speaker finds it "much more potent and much more effective at low doses" in practice.

Trifarotene and the START trial

The practical lesson: patients often try something for six weeks and decide it "didn't work". Counsel them to persist, because improvement keeps building to 24 weeks.

How to start trifarotene

Because it is more potent, it is used less often. The speaker's routine:

1. One pump for the whole face, applied as a thin layer to all of it (to prevent acne and treat scars), not spot-treated.
2. Apply a bland moisturiser ("the plainer the better") immediately on top.
3. Start once or twice a week.
4. If the skin is not too dry, add one extra night every couple of weeks.
5. Most patients settle at two or three nights a week; only very oily skin tolerates every night.

Isotretinoin: lower dose for longer

The speaker moves away from the old weight-based cumulative-dose regimens of the 1980s and 1990s. Those meant very high doses for a shorter time, with the full burden of side effects, and the speaker said they carry a higher recurrence risk, so some patients needed two or three courses. There is now "a lot of evidence" for lower doses for longer, which almost all patients accept. Doses are escalated while acne is active and reduced as it settles to improve tolerability. For acne-rosacea overlap in an older patient, the speaker uses very low-dose isotretinoin, 10 mg three times a week, often long term.

Three cases from the clinic

Case 1: a 13-year-old with active acne and early scars

A high school student (one age detail was garbled) referred for scarring, but with active cystic and inflammatory acne. She had tried many over-the-counter products (inspired by TikTok) and a topical antibiotic. She was very self-conscious. She was already on the pill for endometriosis, and her father had severe untreated acne with severe scarring.

• Plan: treat acne and scarring together, but get the acne controlled as fast as possible to cut inflammation. Started isotretinoin, later added topical trifarotene, then topical clascoterone (a topical androgen receptor blocker, not drying) for menstrual flares.
• Course: at 8 weeks much of the inflammation had settled and scars were flatter; at 6 months trifarotene was added. By the end of the isotretinoin course there were no active lesions, and many apparently severe scars had disappeared.
• Ongoing: trifarotene once or twice a week, clascoterone twice daily, gentle skincare and sun protection. For her remaining mostly atrophic scars with some redness: ablative CO2 laser, TCA CROSS for indented scars and vascular laser, all possible in one session.

Case 2: a 19-year-old with severe nodulocystic acne

A university student with very severe inflammatory nodulocystic acne, already on isotretinoin 20 mg daily for 8 weeks from another dermatologist, and a strong family history.

• Added erythromycin ethylsuccinate (EES) 500 mg twice daily (8 weeks in total) to settle inflammation; the skin became flatter and less red.
• Still getting large cysts, so isotretinoin was escalated and a tapering course of prednisone added.
• Topical trifarotene was added fairly early for scarring. As she improved, isotretinoin was reduced and then stopped.
• Outcome: almost all the scarring disappeared with medicines alone, and she wanted no procedures. She continues trifarotene once or twice a week.

Case 3: a 50-year-old with old scars, rosacea and ongoing acne

A professional woman who had a high-dose isotretinoin course when young, now with diffuse scarring and textured skin, erythematotelangiectatic rosacea and ongoing occasional cysts. She was perimenopausal or menopausal on HRT, with a strong family history of acne, and was using many heavily marketed products that irritated her skin.

• Low-dose isotretinoin 10 mg three times a week, expected long term, to keep the skin clear.
• Topical ivermectin nightly for inflammatory rosacea (very well tolerated in the speaker's experience).
• Vascular laser for redness, then CO2 laser for texture, and only after that, topical trifarotene.
• Better sun protection and a gentle routine. Result: much smoother skin. For acne- and rosacea-prone patients, consider maintenance vascular or CO2 laser every 6 to 12 months.

Keep skincare simple

"I don't know any dermatologist that has a complex skincare routine." Many patients arrive using ten or more products. The speaker's routine is:

• one gentle cleanser;
• one gentle moisturiser;
• a lip balm if on oral isotretinoin;
• a sunscreen the patient is happy to use through the day.

GP clinic checklist

Transcript caveats

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