Acne Scars and Acne Scarring
Acne
is a common condition that affects most people at some
point in their lives. For reasons that are not understood
some people develop severe acne that leads to permanent
and sometimes disfiguring scarring. The term "scarring"
refers to a process where collagen within the skin is
damaged from inflammation, leading to permanent texture
changes in the skin. However, many patients refer to
scarring when they see color changes that remain for
months after an acne lesion has healed. Scarring, color
changes, and treatment options will be discussed below.
Types of Acne Scarring
There are different
kinds of acne scarring: ice pick scarring,
atrophic scarring, and hypertrophic
scarring. Ice pick scars are deep pitted scars
with steep edges. Atrophic scars are pitted but have
smooth borders and are not as deep. Hypertrophic scar,
more common on the back and chest, are thick lumpy scars
that sit above the surface of the skin.
Color changes in acne in more common than scarring and
can resolve but may take years to completely disappear.
Color changes come in three basic flavors: post inflammatory
erythema (pink and purple patches at the site of acne
lesions), post inflammatory hyperpigmentation (brown/black
discoloration at the site of the acne lesion), and post
inflammatory hypopigmentation (white marks at the site
of a healed acne lesion). Post inflammatory hyperpigmentation
is very common in those with darker skin tones or in
those who tan easily and can significantly worsen the
appearance of acne.
Ethnic Skin and Acne Scars
Acne is one of the
most common skin conditions in patients with darker
skin. African American patients usually have post inflammatory
hyperpigmentation and are at higher risk of scarring.
Hispanics and those of Middle Eastern descent also commonly
have post inflammatory hyperpigmentation. Asians have
a lower risk of hyperpigmentation than African Americans,
but higher risk than Caucasian patients. The risk of
hypertrophic and keloidal scars is 5-15 times higher
in African American patients and 3-5 times higher in
patients of Asian descent. Thus, treating acne early,
before scar formation and discoloration is recommended.
Treatment of Acne Scars
Acne scarring is permanent but can be treated.
No treatment is 100% effective and the best result is
improvement, not perfection. Treatment of scarring may
require many different kinds of treatments, depending
on the kind of scarring present. Treatment of acne scarring
can be expensive and may not be covered by insurance.
It is important that all the acne is clear before treating
scarring. Otherwise, new scars form and the procedures
are wasted. The most effective treatments are surgical
and there are many types.
• 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 destroy 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 then sewn together with a suture.
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.
Treatment of Discoloration From Acne
Discoloration from acne (red, purple, brown, black,
and white) is less permanent and easier to treat than
acne scarring. However, it is also much more common.
Both topical medications and surgical methods are employed.
• Topical Medications
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.
• Chemical Peels
Chemical peels are described above
(and see section on Chemical
Peels). In general, chemical peels 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.
- » Find an Acne Scars Treatment Specialist
All photos courtesy of S. Zimmet, MD and P. Bitter Jr., MD
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