Acne scars are a painful reminder of bad skin, whether its from our puberty or from recent acne outbreaks. Whenever the acne occurs, it's very common to be left with scarring from excess collagen when those pimples heal. Acne scarring tends to occur more commonly in the more severe forms of acne with large nodules and inflammation, such as nodulocystic acne. If treated, the overall prognosis for persons with acne is good, however in some cases it can lead to long-lasting psychosocial impairment and physical scarring.
How are acne scars formed?
To understand how acne scars are formed it’s important to first understand the how acne forms (pathogenesis). Acne develops as a result of plugged follicles. Hyperkeratinization and formation of a plug of keratin and sebum (a microcomedo) is the earliest change. Enlargement of the sebaceous glands and an increase in sebum production (oil) occur with increased androgen production during puberty.
The microcomedo can enlarge to form an open comedone (blackhead) or closed comedone (whitehead). In these conditions the naturally occurring bacteria called Propionibacterium acnes can cause inflammation, leading to inflammatory lesions (papules, infected pustules, or nodules) in the dermis. This inflammatory reaction in the dermis results in redness and may eventually cause permanent scarring or hyperpigmentation.
Treatment & Prevention
First, preventing scar formation in the first place is obviously ideal, and this can be done by routine acne treatments, avoiding picking, daily sunscreen use and using lotions with alpha-hydroxy acids. Alpha hydroxy acids may help remodel the skin. The key before pursuing any acne scar treatment is to get a handle on all active acne breakouts first.
Once the scars have formed, however, there are now several methods that can be used for improving the look and feel of acne scars. There have been a number of exciting advances in laser medicine which have resulted in vast improvements in our ability to treat acne scars. There is now a whole range of lasers that can be used to achieve satisfactory results. In the early days of laser medicine they used a Carbon Dioxide laser, which destroys the top layers of the skin, which in turn allows the body to grow a new scar-free surface. There’s a prolonged healing period, about a week to ten days, during which the skin is essentially an open wound. Additionally there’s a reasonable risk of side-effects with CO2 laser, such as permanent whitening of the skin and other types of scarring.
We now use non-ablative lasers, which, unlike CO2 lasers, do not remove the top layers of the skin and are non-destructive. These lasers have a lot less risk and are more effective at treating acne scarring than the ablatives. My treatment of choice for acne scarring is a pulsed-dye laser. One of the benefits of the pulsed-dye laser is that it can take the redness out of the acne scars. Since often acne scars are red, this can very quickly, within a month, improve the appearance of acne scars tremendously.
Another type of laser that's been used to treat acne scars recently is the fractionated laser, such as Fraxel® or Affirm®. Fractionated laser treatments have been reported to produce remodeling in acne scars without the downtime of ablative resurfacing.
A week after the initial non-ablative treatment, you'll begin seeing collagen remodeling which continues for about three months. I typically administer four treatments at monthly intervals.
Choosing the right treatment for your particular scarring depends on the types of scars present. Typical scars tend to fit into the following categories:
- Icepick Scars: Icepick scars are the most common type of mark left behind by acne. Icepick scars are deep, narrow scars characterized by the pits they form in your skin. These facial blemishes are often the result of persistent acne.
- Boxcar Scars: Similar to chickenpox scars, boxcar scars have angular, well-defined edges and can usually be found on your temples or cheeks.
- Rolling Scars: Indicated by their wave-like appearance on your skin’s surface, rolling scars are wide and shallow indentations left behind by pimples. Rolling scars are caused by bands of tissue developing between the epidermis and the skin tissue below, pulling your skin down in a scar that leaves rolls on your face.
- Hypertrophic / Keloid Scars: Unlike other acne scars, hypertrophic scars are raised above the surface of your skin and remain within the boundary of the original blemish. The good news about these types of scars is that they can reduce in size as time goes on. However, Keloid scars can expand beyond the original pimple site as well, and can feel rubbery and firm and can even itch.
In addition to laser treatment, a number of other treatment options have long been available to those looking to remove their acne scars. Although laser treatment has largely eclipsed these as a front-line therapy, in some cases these treatments may be preferable to laser. These may include:
This treatment is performed by a physician who surgically frees up the deeper, dermis layer of the skin in the area where scarring is most prevalent. It involves the use of a needle or surgical scissors to physically separate the dermis and subcutaneously layers of tissue. Topical anesthetic is applied to the treatment area prior to treatment. The skin may experience some bruising in and around the treatment around afterwards. This typically clears within a week or so.
Punch techniques are typically used for deep acne scarring like “ice pick” scars. The procedure involves the physical removal of the tissue containing the scar and either the suture or replacement of the remaining tissue. There are three main punch techniques used. These are:
- Punch Excision
A punch excision utilizes a punch biopsy tool which may vary in width depending on the size of the treatment area, generally between 1.5 mm and 3.5 mm. Local anesthesia is applied to the area and the tool is used to remove the scar and its surrounding edges. The scar now removed, the skin is sutured together and heals. The scar produced from treatment typically fades after treatment.
- Punch Excision with Skin Grafting
Punch excision may also be performed with the inclusion of a skin graft in the place of a suture. The scar will be removed with a punch biopsy tool and rather than suture the wound, the physician will fill it with a skin graft of the patient’s own skin.
- Punch Elevation
Punch elevation is used mainly on deeper boxcar scars. The concept is to remove the scar using the same excision technique where a biopsy tool removes the scar, but rather than suture or graft the wound, the scar tissue is then elevated and reattached. This diminishes the depth of the scar and minimizes the likelihood of discoloration from different skin being grafted in its place.
Misconceptions & Myths
There are a number of myths and misperceptions about both acne and its associated scarring. I hear these a lot in my office. I’ll bullet these out for quick reference:
- It's OK to Pop: No it's not! This can add more injury and bacteria. A no-no.
- A scar is a scar: Also not true. There are various types of scars and treatments should be matched to your particular case.
- Sun helps improve acne/scarring: Not true! Sun protection (eg hats or sunscreen) is ALWAYS a must to protect your skin. 365, rain or shine.
- There's 'nothing to treat acne scars': As I've said above, we now have a number of treatments available to improve acne scarring.
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