Acne is no fun and the scars it leaves behind can go a lot deeper than just on our skin. Acne and scarring can be a real blow to your confidence and self-esteem.
Well, there is some good news. You do not have to ‘live with’ acne scars. Getting rid of them entirely can be tricky. But you can significantly fade them, flatten them and improve their appearance.
Let’s dive in and level up your acne scar knowledge, I warn you though once you have this knowledge you will be analysing the skin of everyone you know.
Why Acne Scars Form
Scarring is a complication that some people get from having acne. Not everyone who has acne will get scarring and some people will scar badly and some not at all.
Why some people get acne scars and others don’t is not clear, the severity of your acne doesn’t mean you will end up with scars.
Research does show that the earlier you can intervene with inflammation and cystic acne the more post-acne scarring you can prevent.
What science also tells us is that acne scars can form as a severe inflammatory response to Propionibacterium acnes – the bacteria that causes inflamed acne. Acne scars are also more likely if you pick or squeeze acne as it inflames the surrounding skin.
Acne Scar Types:
Acne scars fall into two camps. They are either atrophic scars or hypertrophic scars. So, what’s the difference?
Atrophic Scars – These are by far the most common type of acne scars. They form below the surface of your skin and cause a depression or ‘pit’ in the skin This is why this type of acne is also called pitted acne.
Atrophic or pitted acne scars are further broken down into 3 subtypes;
Icepick scars – These make up 60 to 70 percent of atrophic scars. These are narrow V-shaped scar that have a sharp edge. Because of how they extend into the skin that are the hardest type of scar to treat.
Boxcar scars -Boxcar scars comprise 20 to 30 percent of atrophic scars. These scars are wider, 1.5-to 4.0mm, round-to-oval depressions with sharply demarcated vertical edges. Shallow boxcar scars (0.1–0.5mm) respond very well to resurfacing treatments, whereas deep boxcar scars (≥0.5mm) are harder to improve.
Rolling scars -Rolling scars comprise 15 to 25 per cent of atrophic scars. These scars are the widest and can get up to 5mm in diameter. They form anchors from the dermis into the fatty layer under your skin, which gives the skin an undulating appearance (like rolling hills – hence the name).
Rolling scars need to be treated on the surface of your skin and also in the deeper layers as well.
Hypertrophic and Keloid Scars
Much more uncommon are hypertrophic or keloid scars. Hypertrophic scars are raised above the surface of the skin, and you can feel them when you run your fingers across them.
They form because to much collagen was made by your skin when acne was healing. What triggers the skin to make excessive amounts of collagen is unknown.
What is the differences between hypertrophic and keloid scars?
Hypertrophic acne scars the same size as the acne that caused them. Keloid scars can grow much larger than the original acne.
Keloid scars form when the collagen used to heal the wound is overproduced. They are more common on the jawline, chest, back and shoulders. People with darker toned skin are also at a higher risk of developing keloid scarring. Hypertrophic scars on your face respond to treatment better than scars on your chest or shoulders.
If you get acne scars you will probably have more than one type of scarring so you may need a few different types of treatment to improve it.
While not strictly a scar – The dark patches and spots also known as hyperpigmentation and post-inflammatory hyperpigmentation (PIH) are nearly always associated with acne scars.
Post Inflammatory hyperpigmentation.
This is the dark spots that remain on your skin once acne has healed. PIH is caused by an overproduction of melanin when your acne was healing. These annoying dark spots can go away with treatment and vigorous sun protection.
The treatment of scarring is more difficult but the good news is that it is possible to reduce the appearance of most types of scaring.
Atrophic scars like boxcar, icepick and rolling scars are treated in two stages. The first stage is going to require a visit to your dermatologist as you will need to have one or more of the following treatments.
Treating Acne Scars
In medical terms, the treatment of acne scars is called scar remodelling. This term is used because scars will never vanish completely but they can be ‘remodeled’ to significantly improve their appearance.
Unfortunately, you can not ‘remove’ acne scars at home. There are certain things you can do that will fade PIH and treat active acne but scars are going to require a visit to a registered dermatologist.
How Do Dermatologists Treat Scars?
Not every dermatologist is an acne scar specialist. So if you can, find one that has experience with treating acne scars.
Brisbane based dermatologist Dr Davin Lim is an acne scar specialist and has lots of information on his fabulous youtube channel about acne scars and their treatment. More from Dr Lim in a moment.
A good dermatologist will disscuss your scars with you and explain what types of scars you have and how they can improve or remodel them.
They should show you examples of what to expect from the treatments that they offer and also explain how to look after your skin in between and after their treatments have finished.
There are many options of professional-grade treatments when it comes to scarring and you will save yourself a lot of time, disappointment and making things worse by seeing a qualified dermatologist.
The first thing a dermatologist should recommend is clearing up any active acne and advise you to wear SPF broad-spectrum sunscreen every day for the rest of your life!
They will then talk you through your options based on the type of scars and acne situation that you currently have. Also, keep in mind that scars change as they are being treated.
What types of treatments will a dermatologist recommend for acne scars?
Subcision is a minor surgical procedure used for treating depressed cutaneous scars and wrinkles. It is also called subcutaneous incisional surgery.
Subcision is performed using a special hypodermic needle inserted through a puncture on the skin surface. The sharp edge of the needle is used to break fibrotic strands that are tethering the scar to the underlying tissue.
The release of the fibrotic strands and new collagen deposition caused by wound healing leads to cosmetic improvement of the scar. Subcision can be safely performed in the outpatient setting and is usually well tolerated.
How many treatments are required?
Individuals vary in their ability to form collagen (scar tissue). The number of subcisions required to correct a depression will depend on the type, location, severity of depression, and intensity of treatment.
Three to six visits for the majority of cases of moderate scarring. Intervals of at least one-month in-between treatments are generally recommended.
What are the complications of subcision?
The risks of subcision include:
- Bruising due to bleeding is common
- Pain/tenderness of treated sites
- Infection is very uncommon
- Temporary post-inflammatory hyperpigmentation
The next best treatment for acne scars is TCA.
What is TCA?
TCA is an abbreviation for trichloroacetic acid, which is used in low concentration (20–35%) for a chemical peel and improves the appearance of facial scars.
Microdermabrasion/Dermabrasion: Is one of the oldest resurfacing skin treatments and has been around since the 1950s.
Dermabrasion is where a disc of sterilised sandpaper is rapidly rotated against your skin which sands off the top layer of skin. A numbing cream is applied so that the procedure is comfortable.
It is particularly useful for scars with sharp edges like ice pick scars.
Microdermabrasion has significant disadvantages, however. There is significant downtime of up to one month while the skin heals. There is an increased risk of infection and also of PIH. It has largely been replaced by lasers, which are the gold standard for many forms of scarring.
Laser Resurfacing: Lasers are considered by many dermatologists to be the best way for removing pitted acne scars. They are quick and require very little down time
Microneedling: This has been proven effective at reducing the appearance of atrophic and hypertrophic acne scars. Microneedling breaks down the collagen in the superficial layer of your skin. More collagen is formed under the scar which fills in the indentations, making them flatter and smoother. It works particularly well for box scars and rolling scars, icepick scars don’t respond as well to micro-needling.
You can do micro-needling at home with caution. Watch the youtube video below where Dr Davin Lim explains everything you should know before doing mirco-needling at home.
Micro-needling benefits include breaking down hyperpigmentation and dark spots, smooth fine lines and wrinkles and reduce pore size.
Never use a needling with more than a 0.5mm needle or you risk tearing your skin and creating scarring.
What Dr Davin Lim
Can You Treat Pitted Acne Scars Without Lasers and Surgery?
Cortico steroid (is a prescription-only drug) can help reduce the appearance of ice pick scars. It works by reducing the density of the surrounding skin and reducing the growth of the pimples. The icepick may take some time to heal and steroid have some serious long term side effects.
Retinoids: A derivates of vitamin A and the gold standard of treatment for acne. The potent retinoic acid is prescription only in most countries. Although Differin is available OTC and from Amazon in the USA. You can get retinoic acid to take orally – this is called Accutane. Retinoids also come in a variety of strength and types for topical application.
Antibiotics: Because inflamed acne is caused by bacteria present in the pore, antibiotics can help in tackling hyperpigmentation. It improves the look of a deep scar by improving its texture and reducing the growth of the scar.
Apart from topical retinol – OTC products are going to have very minimal effects on acne scars.
They can help with hyperpigmentation, dark spots and the prevention of acne. If you have acne scars a visit to a dermatologist is probably going to necessary.
Getting on top of acne and breakouts early is the best way to prevent acne scars from happening in the first place.