Acne Scars

About Acne Scars

Acne scarring is an unfortunate result of many acne outbreaks.  Although it frequently appears as unattractive divots or dark pockets in the skin, acne scars may actually appear in several forms:  hypertrophic and “keloid” scars, ice pick scars, rolling scars, and boxcar scars.

Named for the various shapes that these scars take, each scar type has a different appearance and requires a different treatment approach.

• Hypertrophic and Keloid Scars
  Both hypertrophic scars and keloid scars are raised scars, extending above the surface of the skin.  While hypertrophic scars remain with the boundary of the original wound, keloid scars are overgrowths of tissue that extend beyond those boundaries.  You can usually identify a keloid scar by its rubbery, firm texture.
• Ice pick Scars
  Likely the most common type of acne scar, ice pick scars are deep and narrow, forming a pit in the skin where the original wound or blemish occurred.
• Rolling Scars
  Rolling scars are wide, shallow scars with a rounded bottom.  They create a wave-like appearance on the epidermis where they occur.
• Boxcar Scars
  Boxcar scars take after chickenpox scars, exhibiting a rectangular, hard-edged shape on the skin’s surface.  These scars occur most commonly on the temples and cheeks.

Unlike the majority of scars, which affect the epidermis (the surface of the skin), acne scars occur deeper down—in the dermis.  As a result, acne scars are bound down or depressed, like tiny dents in the skin’s surface.

Acne Scar Causes

Acne scars are caused and preceded by acne.

Acne itself is the result of blocked or clogged hair follicles.  When natural oils in the skin are metabolized by acne-causing bacteria, that metabolized oil irritates the skin and blocks those follicles, or“pores.” Once this blockage occurs, debris begins to collect below the skin’s surface and acne appears on the skin.

Acne scarring occurs because of our bodies’ natural immune response to blocked-pore debris.  As with any infection, our body produces white blood cells and attacks the site of the plugged hair follicle.  While this effort serves to eradicate the infection, it also causes a small wound below the surface of the skin where the debris lies.  Scarring occurs as the wound heals, leaving the skin pitted and marred.

Treatment

Treatment for acne scarring takes several forms, with the most common and effective option being laser treatment.

Laser Treatment

Laser treatment for acne began with the use of Carbon Dioxide (CO2) Lasers.  CO2 lasers treated scars by destroying the surface of the skin, with healing taking up to ten days. This often produced very dramatic results, however the greater rewards of CO2 laser resurfacing also involved much higher risks. These included the risk of scarring or hypopigmentation (loss of color), and difficult wound care. As a result CO2 resurfacing is now used in very specific cases[1].

Laser treatment then graduated from CO2 laser resurfacing to non-ablative lasers, a family of non-destructive lasers that leave the surface of the skin intact.  Pulse-dye lasers have been proven especially effective in treating acne scarring, as they also treat the redness that often characterizes most acne scarring.  Non-ablative laser treatments are generally administered at one-month intervals, with scarring improving throughout the month following each treatment. These are a good option, especially in cases where any downtime is not possible[2][3][4][5].

Fractional laser treatment has recently come into favor as the treatment of choice for many physicians for their patients with acne scars[6][7]. Developed by Drs. Deiter Manstein and Rox Anderson at Wellman, the fractional laser works by creating a series of tiny, vertical wounds in the skin.  These wounds, which alternate with spaces of untreated, healthy skin, are subsequently replaced by new, healthy, and scar-free tissue.  This process is referred to “fractional resurfacing.” My patients with acne scars have been really pleased with their results and I often recommend it as an option for scarring.

Laser treatment involves a minimum of discomfort for most patients and is usually well handled.

Microdermabrasion

Microdermabrasion is an umbrella term encompassing several methods of superficial skin treatment that employ abrasive particulate or non-particulate scrubs to remove dead skin cells.  Because microdermabrasion techniques only remove the layer of protective, dead skin cells at the surface of the skin, it is not usually highly effective for acne scarring, but can aide in introducing topical products into the skin more effectively[8].

Chemical Peels

Chemical peels, like microdermabrasion techniques, focus on removing the surface layer of the skin in order to promote new cell growth.  Instead of using an abrasive scrub, chemical peels involve the application of a chemical solution to the surface of the skin.  Left on for a period of time, the solution dissolves tissue cells, which are later replaced by new and healthy cells. For my patients I usually use chemical peels such as glycolic or alpha-hydroxy acid peels, which are great for active acne as they help open up closed pores[9][10][11].

Punch Techniques

Punch techniques are divided into three main techniques: punch excision, punch excision with skin grafting, and punch elevation.

Punch excision and punch excision with skin grafting both involve the surgical removal of scar tissue from the site of a scar.  After administering a local anesthetic, the doctor excises or cuts out the scar tissue and sutures the wound closed.  In the case of a punch excision with skin graft, sutures and stitches are omitted and the wound is fitted with a graft of the patient’s own skin.

While punch excision is predominantly associated with the treatment of ice pick scars, punch elevation is a surgical solution for deep boxcar scars.  As with the excision, the scar tissue is surgically removed from the site, but instead of grafting or suturing the wound, it is instead closed by reattaching the removed tissue at the surface of the skin.  This prevents discoloration from further scarring and creates a level surface in place of the boxcar divot.

Dermal Fillers

Dermal fillers are exactly what they sound like—injections that fill the pocks and indentations created by acne scars.  Dermal fillers raise the surface of the skin via the injection of hyaluronic acid, collagen, or even fat tissue.  However, injections are a temporary solution in nearly all cases, requiring repeated visits as dermal fillers break down and scars return to their recessed states[12].

Subcision

Subcision surgically separates the dermis from the subcutaneous layerof skin beneath it, freeing up the bound-down tissue of the acne scar.  A topical anesthetic accompanies the procedure, and healing may involve some bruising around the treatment site for about a week afterward[13].

Topical Treatments and Medications

Certain topical medications, such as those that stimulate collagen formation, may contribute to the treatment of acne scarring. Retin-A and alpha hydroxy acid (AHA) can assist in the exfoliation and improvement of skin that has suffered from acne scarring, but these topical treatments are not usually a solution in and of themselves[14][15].

Preventing acne scarring

The best way to prevent acne scarring is to prevent acne itself.

The first step in preventing acne is seeing a professional dermatologist.  A qualified dermatologist can help you determine how to best treat your existing acne, whether with oral prescription drugs or medicated topical treatments, or combination therapies.  While some over-the-counter medications are also effective, a dermatologist has the experience and education to determine what will work for you in the long run.

All individuals in the process of treating their acne should also be vigilant about wearing sunscreen.  Alpha hydroxy acid, salicylic acid, keratolytics, and other over-the-counter acne treatments make your skin especially sensitive to sun damage, and wearing a high-SPF block can protect your skin while it heals.