What is acne scarring?

Acne scarring is a reaction to the inflammation in the skin caused by acne. During the inflammatory process, tissue is destroyed and in an attempt to heal the skin, a reaction called fibrosis occurs. Fibrosis leads to changes in the texture of the skin that can be thinner (called atrophic) or thicker (called hypertrophic) than normal skin. Scarring is permanent.

Why aren’t the dark spots that form around my acne lesions called scars?

Scarring is defined as fibrosis of the collagen in the dermis (the deep layer of the skin). The color changes seen with acne are usually more superficial and gradually fade with time.

What causes the dark spots around my acne lesions?

Inflammation caused by acne leads to redness of the skin. Redness usually starts when the acne lesion is active. Even after the acne lesion has improved, however, inflammation may continue deep in the skin, causing persistent redness of the skin. Inflammation also stimulates the production of the pigment molecule called melanin, leading to brown or black discoloration. Thus, in those who tan easily or with darker skin tones, melanin production is stimulated by the inflammation leading to brown discoloration around the acne lesion. Although the discoloration lasts longer than the acne lesion itself, the discoloration will fade with time- sometimes several months.

What acne treatment options are available for acne scars?

Treatment for acne scarring is difficult. Thus, the best treatment is prevention. For many, however, it is too late for prevention and the following treatments are available.

• Dermabrasion

Mechanical resurfacing of the skin (see section on Dermabrasion) involves the use of abrasive tools to remove the outer layers of the skin to produce an improved appearance. Dermabrasion is primarily used for the treatment of acne scarring. Superficial and deep techniques are available. There are two layers of the skin; the outer layer is called the epidermis and the inner layer, the dermis. Superficial dermabrasion removes portions of the epidermis and deep dermabrasion removes all of the epidermis and portions of the dermis. Deep methods are the preferred method for treatment of scarring. Deep methods are effective but generally require weeks of healing time and carry a higher risk of complications. Improvements continue for months after the procedure as collagen remodels underneath the skin. It is important that the physician performing dermabrasion is experienced in the procedure. Dermabrasion has been proven to improve the cosmetic appearance of the skin, especially in the treatment of acne scarring. However, deep ice pick scars typically do not improve significantly with dermabrasion.

-Motorized dermabrasion is a medium-deep or deep procedure and employs the use of a motorized brush or diamond cylinder. These tools are used to remove the outer layers of the skin in a controlled setting. Local anesthesia is used for pain control during the procedure.

-In manual dermasanding the physician abrades the skin with silicone carbide sandpaper. This method is usually considered to be a medium depth procedure and is sometimes used in combination with other methods, such as chemical peels, carbon dioxide lasers, and motorized dermabrasion.

-Not everyone is a good candidate for dermabrasion. Those with active acne, infections, and other scarring skin conditions may need treatment before undergoing dermabrasion. Complications are rare but include infection, prolonged healing, hyperpigmentation, and scarring. Dermabrasion may not be recommended for those with darker skin types because of the risk of hyperpigmentation or darkening of the skin. You and your physician need to decide if dermabrasion is the right procedure for you.

• Laser Resurfacing

Laser resurfacing (see section on Laser Resurfacing) has been used for the treatment of acne scarring. All lasers use a high-energy beam of light that targets specific structures in the skin. The CO2 and Erb:Yag lasers used for laser resurfacing are less specific and target the epidermis and superficial dermis. Like dermabrasion, laser resurfacing is ablative meaning that it destroys the outer layers of the skin. Ablative techniques are more effective but less popular because they require recovery time. Side effects are similar to dermabrasion and need to be discussed in detail with your doctor.

• Subcision

Subcision is used for atrophic scarring. Local anesthesia is used and a needle is then inserted under the scar and gently moved underneath the skin to release the scar tissue. This method has been tested in recent studies and shown to be effective.

• Punch excision and grafting

For deep ice pick scars, the only effective treatment is complete removal of the scar. A small round cookie cutter like device (called a punch) is used to cut out the scar and the edges of the wound are sewn together with a stitch. In this case, a deep, large scar is traded for a tiny line scar that can later be treated to further blend into the rest of the skin. Larger scars can be removed and then filled with a skin graft, taken from skin (usually behind the ear). Grafts are later contoured with dermabrasion to blend them into the rest of the skin.

• Fillers

Substances that add volume to the skin (see section on Fillers) can be used alone or in combination with the above procedures. Fillers can improve the appearance of acne scars by flattening the scar but their effect is temporary. To maintain the result, the lesions must be re-injected at regular intervals.

• Chemical Peels

Chemical peels, also known as chemical resurfacing (see section on chemical peels), are chemical treatments to produce an improved appearance of the face, including acne scars. Chemical peels produce controlled injury to the skin that promotes the growth of new skin with an improved appearance. Many different chemicals are used including glycolic acid, trichloroacetic acid (TCA), salicylic acid, “Jessners” solution, and phenol. The different chemical solutions produce different degrees of injury to the skin. Medium depth and deep peels produce injury within the dermis and can improve the appearance of atrophic acne scars. The deeper peels are more effective but carry more risks such as infection, scarring, and discoloration, especially for patients with dark skin. However, more studies are being performed in patients with dark skin and certain peels are proving to be beneficial. For example, in one study of Asian patients, glycolic acid peels (which are superficial) improved acne scarring and pore size. Further studies are in progress.

Treatment of Hypertrophic Acne Scars

Although less common, hypertrophic (and keloid) scars can be more disfiguring and harder to treat than other kinds of acne scarring. This type of scarring is more common on the chest and back. For reasons that are not understood, hypertrophic scars tend to recur after removal. Treatment usually involves topical steroids, injected steroids, silicone dressings, and/or cryosurgery. Recently, pulse dye lasers have been employed with some success. More work is needed in this area.

What treatment options are available for acne discoloration?

• Creams (topical therapies)

Over-the-counter bleaching creams may improve hyperpigmentation from acne. Over-the-counter creams contain 2 percent hydroquinone, a bleaching agent. Prescription creams may use single agents, such as Retin-A (tretinoin) or combinations of medications such as hydroquinone with tretinoin plus a cortisone cream. These treatments can be quite effective when used properly. You need to discuss the risks of each medication with your doctor.

• What are the risks?

In general topical treatments have fewer side effects. In general, the most common side effect is irritation and redness. However, another less common side effect is discoloration. You and your physician will decide on the right treatment for you.

What new treatments are available for the treatment of discoloration from acne?

• Chemical Peels

Chemical peels are described above (and see section on Chemical Peels). In general, chemical are effective for improving discoloration from acne. More superficial peels have proven effective which is beneficial because there is less risk and less recovery time. However, several peels may be needed to obtain the desired effect.

• Microdermabrasion

Often referred to as a "lunch time" procedure (see section on Microdermabrasion), microdermabrasion is a popular procedure which is classified as light, or very superficial dermabrasion. This method employs aluminum oxide crystals that are propelled at the skin and immediately sucked up. Although not scientifically proven to improve the appearance of skin, many patients report that their skin feels smoother. It is used to treat acne, and the hyperpigmentation caused by acne. It is also popular because it is painless and there is no recovery time after the procedure. However, to effectively treat acne discoloration, up to 15 treatments may be necessary which can be very expensive. Newer devices now are crystal-less.

Are any pills effective for acne scarring and skin discoloration?

No, there are no systemic medications for acne scarring or discoloration. A good diet with lots of fruits and vegetables can help maintain healthy skin.

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