Marks, scars, and tattoos: Evolving treatment options

Long regarded as difficult or impossible to remove, scars, pigmented lesions, and tattoos can now be treated more effectively thanks to advances in dermatology. New techniques have expanded therapeutic options, helping reduce their visibility and improve skin appearance. Outcomes, however, vary from one patient to another and depend notably on the skin tone and the extent of the lesion.

“Scars are no longer inevitable,” says Associate Professor Boutros Soutou, Head of the Dermatology Department at Hôtel-Dieu de France Hospital and Université Saint-Joseph.

But before a scar can be improved, it is essential to understand its characteristics and determine what caused it. If the underlying condition remains active, it must be treated first.

Scars can take several forms. These include post-surgical scars, which “may heal poorly when they are located in certain areas of the body, such as behind the ear, on the upper back or over the sternum.”

Some develop into hypertrophic scars, “meaning that the healing process continues longer than normal after the wound has closed.” In more advanced cases, keloid scars may form. These occur when fibroblasts – the cells responsible for producing connective tissue that helps wounds heal – become overactive, leading to excess scar tissue beyond the original wound. There are also pigmented scars, characterized by persistent redness or discoloration.

Choosing the right treatment

Depending on the scar type, treatment may range from topical medications to intralesional injections and laser therapy. “What is important is to establish a proper dermatological diagnosis and to weigh the benefits and drawbacks of each treatment,” Soutou stresses, noting that a combination of approaches is often recommended.

For atrophic scars, a topical silicone-based treatment may be prescribed “to optimize wound healing,” along with retinoids to accelerate cell turnover. Depigmenting agents are used for pigmented scars, while erythematous scars are treated with anti-inflammatory medication. Hypertrophic scars and keloids are managed with intralesional corticosteroid injections. Intralesional injections of enzymes or collagen fragments may be performed.

Laser therapy can also be used, with parameters tailored to the scar type and skin tone. Q-switched lasers deliver very short, high-energy pulses that break down pigment particles and are used for pigmented lesions. Vascular lasers reduce redness by targeting small blood vessels, while fractional lasers create microscopic zones of controlled skin injury to stimulate collagen production and improve skin texture in atrophic scars.

In patients with darker skin tones, “dermatologists use lasers that do not stimulate melanocytes in the epidermis, to prevent post-inflammatory hyperpigmentation. One option is the Nd:YAG laser.”

Finally, atrophic or “depressed” scars, which create visible indentations, often require combined treatments such as hyaluronic acid injections, microneedling, radiofrequency or chemical peels. Fractional lasers – which create controlled microscopic injuries to stimulate collagen production – are also used and are often considered effective for deeper scars.

Benefits and limitations 

Often described as the treatment of choice for scars, laser therapy nevertheless has limitations. “The advantage of this therapeutic approach is that it is non-invasive, safe, and causes tolerable discomfort,” Soutou stresses.

He sounds a note of caution, however, regarding pregnancy-related melasma. “Laser treatment should be considered only as a last resort. In such cases, Q-switched lasers may be used, but only after testing a small area and assessing the skin’s response following sun exposure. Melasma should not be treated lightly with lasers.”

More broadly, laser therapy is not without risks, although side effects are generally limited. Patients can be burned if the device is used by someone without proper training, which may worsen the scar or lead to infection. This is why it is important to seek qualified dermatologists.

Laser treatments also have limits: “Several sessions are often required to achieve visible results,” Soutou notes. Most people will notice an improvement, but patients may still be dissatisfied because they expect the scar to disappear completely. In many cases, that goal can be achieved, but not always.”

Tattoo removal

As for tattoos, “they are no longer as fashionable as they once were.” “Tattoo removal has gained popularity, particularly in Europe,” Soutou points out. “Laser treatment remains the preferred approach, especially Q-switched lasers, which penetrate deep into the skin and break down pigment into tiny particles cleared by macrophages. A month is typically required between sessions.”

Several factors influence success. The first is pigment density, which is generally higher in professional tattoos than in amateur ones. The depth and composition of the pigment also matter. “In professional tattoos, the pigment is deposited at a relatively uniform depth, unlike amateur tattoos. In addition, organic or mineral pigments used professionally are often more difficult to remove than carbon or graphite-based pigments commonly found in amateur or ethnic tattoos.”

Particle size is another factor. Larger ones tend to be easier to break down, while tattoo color also affects treatment. Lighter shades are easier to target, whereas darker pigments often require a greater number of sessions.

Traumatic tattoos, caused when particles such as shrapnel residue or asphalt become embedded in the skin, present additional challenges. Because these particles are often lodged deep within the skin – beyond the reach of lasers, which typically penetrate no deeper than the mid-dermis removal is more difficult. A CO₂ laser may first be used to vaporize the upper layers of the skin before tattoo-removal laser treatment is performed.

In the end, whatever the approach, the right diagnosis remains the starting point.