What are acne scars?
Acne scars are permanent textural changes and indentations that occur on the skin as a result of severe acne. They can present clinically as shallow depressions, ice-pick scars or box-cart scars.
It does not refer to the colour changes from the acne condition(eg. redness or darkening of the skin after inflammation).
What are postinflammatory colour changes?
These colour changes occur after the inflamed bumps from the acne subside.
1. Post-inflammatory erythema – pink or purple flat patches
2. Postinflammatory pigmentation – brown marks (pigmentation), seen in people who can tan easily
3. Postinflammatory hypopigmentation – white marks
Postinflammatory colour changes improve with time, but it can take many months for them to completely resolve.
What causes acne scarring?
They are caused by moderate to severe inflammation in the deeper layers of the skin. Examples are nodulocystic acne or infected acne from trauma or manipulation.
Hence, it is important that we treat acne in order to prevent scarring from acne. Scarring from acne is permanent, although there are laser treatments that can partially improve the scars.
What does acne scarring look like?
They can present clinically as:
Truncal acne can lead to keloid formation, where the scars enlarge over time and present as redness and itchiness over time. This is treated with regular corticosteroids injections for an indefinite period of time.
Box-cart acne scars
Box car scars are depressed scars which are shallow to medium in depth with well-defined edges, most commonly located on the cheeks and temples. Due to the relatively shallow depth, this type of scarring responds well to numerous treatments including full resurfacing, fractional lasers, dermal fillers and radiofrequency treatments.
Ice pick scars are deep and narrow scars that extend into the lower layer of the skin. Due to the depth of ice pick scars, procedures such as fractional treatments are not as effective as TCA CROSS (trichloroacetic acid chemical reconstruction of skin scars). The foundation of ice pick scar treatment is either to raise the depth of scarring or excise (remove surgically) the pick itself. Procedures such as punch excision or TCA CROSS can improve deep ice pick scars. Once scars are raised up to a shallower level, laser resurfacing provides the finishing touches.
Rolling, atrophic and depressed acne scars
Rolling acne scars appear as undulations and depressions on the skin. Some scar areas may be anchored to deeper structures. A number of methods can be used to treat rolling scars and tethered scars including subcision, fractional laser resurfacing, radiofrequency and dermal fillers. The basis behind scar revision is to free up bound scars and fill up depressions with collagen. This form of acne scarring will usually require several treatments for the best possible outcome.
Mixed acne scars
This is the most common form of acne scarring. Most people will have a mixture of acne scars, including tethered or anchored scars, ice pick scars, box car scars and rolling scars. Different types of acne scars will require different treatments and a tailored approach to scar revision therefore provides the best outcome.
Red acne scars – macular scars
Macular acne scars are commonly seen on the cheeks and forehead areas and present as red areas. They occur as a result of early acne scarring. This type of scarring can fade over 6 to 12 months without treatment however vascular laser treatment can sometimes hasten the resolution of scars. Several treatments are required for best results.
Hypertrophic and keloid scars
This type of acne scarring results in lumpy red scars, most commonly seen around the jawline, neck, chest and back areas. Lumpy scars are best treated with a series of corticosteroid injections. Most people will require 2 to 4 injections spaced 6 weeks apart. Redness in scars can be treated with vascular lasers however 3 to 4 treatments may be needed for best results.
How is acne scarring treated?
There are many treatments available for acne scars which can improve and soften the appearance of the scarring. A combination of treatments may be required. It is unrealistic to expect the return to completely normal skin following treatment.
The ideal treatment will depend on four main factors:
Acne treatments available:
Hyaluronic filler injections are best used for atrophic scars and rolling scars. They have the advantage of immediate improvement and minimal downtime. The treatment is initially repeated at 6 monthly intervals but eventually the frequency may be reduced to twice yearly.
Intralesional corticosteroid injections are best used for bumpy acne scars.
Several injection treatments may be needed. The main side effects of these injections are the thinning of the skin and the fat around the area. This treatment can also be combined with a vascular laser.
A combination of ablative or nonablative lasers can be used to stimulate collagen remodelling of the skin, causing tightening and smoothing of the scars. At IDS clinic we can use a combination of the fractional Erb;YAG laser, fractional Erbium Glass (Mosaic laser) and the Pico-laser in the fractionated mode to treat the scars. Again, a series of monthly sessions are required. Patients can expect a 1 week downtime after each session.
There are two main types of laser treatments – ablative and non-ablative. Ablative (or wounding) lasers remove thin layers of skin. Non-ablative (non-wounding) lasers stimulate collagen growth and tighten underlying skin. Although non-ablative laser resurfacing is less invasive and requires less recovery time, it is less effective than ablative laser resurfacing for deeper scars.
Fractional non-ablative (non-wounding) lasers
Variable wavelengths of fractional laser devices have been shown to improve acne scarring. They are best used for atrophic and rolling scars.
These lasers can cause some temporary redness but do not actually break the skin surface.
The advantages of non-ablative fractional lasers are rapid recovery times, the ability to treat darker skin types and higher safety profile.
Recovery time following fractional laser treatment ranges between 3 to 8 days.
Most people will benefit from a series of fractional laser treatments (2 to 5). Darker skin types will usually require more treatments compared with lighter skin types.
Ablative lasers are the “gold standard” for the treatment of box-cart scars.
At IDS we use the erbium YAG laser to remove the superficial layers of the skin, followed by treatment of the dermis of the skin to break down the scar tissue at this level, using the fractional mode.
The downside of ablative lasers is the longer recovery times(up to 2 weeks). Redness following ablative lasers is a common side effect.
Radiofrequency is a non-invasive method of scar remodelling. Heat generated from the movement of electrons in the skin creates deep heating of the skin, leading to remodelling of the skin.
This treatment is best employed in early acne scars, atrophic scarring, rolling scars and in darker skin types.
At IDS clinic, we use the Thermage technology to treat the scar non-invasively.
New forms of radiofrequency incorporate skin needling which delivers higher energy deeper into the dermis (skin).
TCA CROSS (Chemical reconstruction of skin scars)
This method uses high strength TCA (50-100%).
This form of scar revision is ideal for ice pick scars and can be safely used for all skin types.
2 to 3 treatments are ideal for best results.
Surgical methods of scar removal
Procedures such as punch excision, punch elevation and subcision still remain a useful method for treating deep ice pick scars as well as anchored or tethered scars.
In most cases, surgery is followed by laser resurfacing several months later.
Skin needling can be effective in the treatment of acne scars. Pen held devices have largely replaced skin needling rollers.
Skin needling, as the name suggests, delivers needles of varying depths (0.5 to 3 mm) into the dermal layers of the skin.
Needling breaks down scar tissue and stimulates the formation of new collagen.
This treatment is ideal for darker skin types however it is not as effective as fractional laser treatments. Lasers deliver controlled heating of the dermal layers, resulting in greater stimulation of collagen and more effective scar revision.
What is the likely outcome of acne scarring?
The final outcome is a partial improvement in the texture of the acne scars. It is therefore important that patients’ expectations are managed. This can be visible to patients and many will describe that makeup sits longer and spreads easier over the treated skin.
Make-up can help cover up scars and can be particularly useful for facial scars
Camouflage make-up specially designed to cover up scars is available over the counter at pharmacies and department stores.