Scarring can result from severe acne, whether or not it is picked or squeezed. Less severe untreated and persistent acne can also lead to scars.
The best form of management of acne scarring is prevention and early treatment by qualified dermatologists.
Scarring refers to a permanent textural change to the skin. Acne scarring often appears with areas of depression in the skin leading to inconsistencies and irregularities of the skin surface. Certain lighting conditions, such as being under elevator lights, can make acne scars appear more pronounced. Patients with acne scarring often feel they appear more aged, angrier and can affect self-esteem and lead to depression. Considering how common acne and acne-scarring is, however, some patients choose not to address there acne scarring as it does not pose a significant problem to their appearance or their lives. If your acne scarring is causing you distress of any nature, please contact your GP or seek assistance from counsellors.
Acne scarring is classified by a dermatologist based primarily on their depth and shape. Four main types of acne-scarring exist which includes rolling and atrophic scars, boxcar scars, ice pick scars and keloidal scars.
Patients with acne may also be concerned about persistent red or dark marks on the skin once acne lesions heal. Whilst this is not technically scarring, such changes can often persist for years and also warrant treatment if bothersome to patients.
Rolling and Atrophic Scars
Rolling and atrophic scars are seen as broad valleys caused by tethering of superficial structures of the skin to deeper components. The terms rolling and atrophic scar are often used to describe the same type of scar occurring in different parts of the body. When these types of scars appear on the face, they are termed rolling scars. When they occur on other areas of the body such as the back or chest, they are referred to as atrophic scars.
Rolling and atrophic scars can be tricky to treat and requires experience. Such scars can be improved with subcision, Radio frequency Micro-needling, dermal filler injections and ablative CO2 laser resurfacing .
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Boxcar scars have well defined edges with a flat and broad base. Such scars can appear dark as the surrounding skin casts a shadow in the valley of the scar. Boxcar scars do not disappear when the skin is stretched out.
Boxcar scars can be improved by a form of chemical peel applied to the scar called TCA CROSS. Radiofrequency micro needling, dermal filler injections, punch excision/elevation and ablative laser resurfacing are also used to treat boxcar scars.
Ice-pick scars are deep, narrow and sharp scars with angled edges. Ice-pick scars do not improve when the skin is stretched and can also appear dark in the centre due to the shadow cast by the surrounding skin. Ice pick scars can be confused with prominent pores which some patients with severe acne suffer from.
Ice-pick scars treated with lasers and needling alone will not improve. The main methods used to treat ice-pick scars include TCA CROSS and punch excision or elevation. Radiofrequency micro needling and ablative laser resurfacing can bleed scars in with surrounding skin.
Scars that thicken up and becoming bumpy are referred to as keloid scars. Keloidal scars due to acne occur mostly on the chest and back. Such scars are often itchy and can appear discoloured, either darker or more red than surrounding skin.
Keloidal acne scars often require injections with cortisone or similar solutions. Thin keloidal scars can also be improved with cortisone creams and silicone gel sheets and silicone based creams. Surgical intervention is sometimes required however the risk of repeated keloid scars after surgery is high if preventative measures are not taken.
Persistent redness (post-inflammatory erythema)
In most cases, once an acne lesion clears, it leaves behind a red mark. This mark is referred to as post-inflammatory erythema and can take anywhere between weeks to years to fade. In some cases, red marks associated with other forms of acne scarring can persist for life unless treated.
Sun-protection is essential to avoid worsening and aid in the healing of post-inflammatory erythema due to acne. Vascular laser treatments such as the Excel V Laser Genesis and KTP532 [link] help reduce this redness.
Persistent darkness (post-inflammatory hyperpigmentation)
In darker skin individuals, once an acne lesion clears, it can leave behind a darker brown mark. This is referred to as post-inflammatory hyperpigmentation (PIH) and can take months to years to fade. When associated with other forms of acne scarring, PIH can persist indefinitely unless the acne scar is treated.
Sun-protection is essential to prevent and avoid worsening of PIH. Treating acne early and reducing inflammation is paramount in darker skin individuals. Various topical (cream) treatments are available to reduce PIH. Whilst some of these treatments can be utilised while treating active acne, others are used when the active acne has been successfully treated. Laser Genesis may aid in reducing pigmentation and even out discolouration.
Treatments: The journey of acne scar treatments.
Acne scars can be improved significantly by a number of treatments using different methods and techniques. It is important to realise that in many cases, acne scar treatments regimens can take months to years to complete with repeated treatments required. In some instances, acne scars will never completely disappear.
Marketing strategies by some franchise laser, skin and cosmetic clinics which use terms such as ‘scar removal’ should be a warning sign to patients. If you are concerned, seek the opinion of a dermatologist before proceeding with any acne-scarring treatments. It is important that the right treatment is selected for the specific type of acne scarring seen. Other factors also need to be taken into account including patient characteristics such as age, skin type and social circumstances. Microdermabrasion is often offered as a treatment for acne scarring. However, microdermabrasion does not offer any improvements in acne scarring as the treatment is too superficial. Dermabrasion (not microdermabrasion) is now superseded by fractional laser treatments.