One of the biggest causes of heartache for acne sufferers is the aftermath. Even if you work hard to treat acne and clear it up, it can still leave behind hyperpigmentation and acne scars. These can persist even after acne is long gone and usually do not completely go away by themselves. In this blog post, we examine the different types of acne scars and review the broad array of acne scarring treatments treatments for them.
How Acne Scars Form
Acne scarring is the result of the body’s inflammatory response to acne lesions and the wound healing response this triggers. Acne forms when excess dead skin cells and sebum block a skin pore. This creates a breeding ground for P.acnes bacteria and sets of an inflammatory response. The result of this is formation of lesions such as pustules, papules and in severe cases nodules.
Severe acne can damage the skin by breaking down collagen, which gives the skin its elasticity and structure. The body, in an attempt to repair this damage, produces collagen. If too little is produced, depressions on the skin’s surface form atrophic scars like ice pick, boxcar, or rolling scars. On the other hand, if there is overproduction this results in raised hypertrophic scars or keloids. Inflammation can also cause skin discolouration or post-inflammatory hyperpigmentation which is often associated with acne scars especially in skin of colour. Scarring is more common with severe or persistent acne. It can also be caused by genetics, or through trauma like when you pick or squeeze pimples.
Types of Acne Scars
There are four main types of acne scars and the difference between them matters because it dictates the best acne scars treatment. As with any scar treatment, it is essential to consult a dermatologist or other experienced doctor to determine the best treatment approach for your specific acne scars.
Ice Pick Scars
These are deep, narrow scars that extend into the dermis (the second layer of the skin). Ice pick scars are get their name from their narrow, deep and pitted appearance.They are typically the result of severe acne, such as nodules or cysts. As such they occur when there is extensive damage to the skin and its underlying tissues.
These scars can be challenging to treat due to their depth and steep sides. The most effective ice pick acne scar treatments are ones that can help promote skin regeneration. These include punch excision (which physically removes the scar), deeper chemical peels like TCA (trichloroacetic acid) peels, dermabrasion, laser resurfacing and microneedling.
This type of acne scar is wide and rectangular with steep, defined edges. They look much like the shape of a boxcar on a train, which is where they get their name. Boxcar scars are often found on the temples and cheeks and can vary in depth and size. They result from the loss of collagen, which leaves a depression or pit in the skin, much like ice pick scars, but they are larger, shallower and more geometrically shaped. Boxcar scars are generally caused by inflammatory acne, such as nodules or cysts, which destroy collagen in the skin. This leads to a loss of support in the affected area and, once the acne resolves, the overlying skin is left unsupported. This creates a depression.
The best acne scar treatments for boxcar scar depends on the size and depth of the scar. Effective treatments include punch excision or elevation, laser resurfacing, microneedling, and dermal fillers. These stimulate collagen production and level out the skin.
Rolling scars are a type of atrophic acne scar that give the skin a wavy, undulating appearance. These scars occur when fibrous bands of tissue develop between the skin and the subcutaneous tissue underneath. These bands pull the epidermis, the skin’s top layer, down to deeper structures. This leads to a rolling or “hill and valley” appearance on the skin’s surface. Unlike boxcar or ice pick scars, rolling scars are not sharply defined. Instead, they have sloping edges that merge with the normal skin. They tend to be wide and shallow. Rolling scars are typically caused by long-term inflammatory acne. Over time, repeated episodes of inflammation within the same area of skin causes it to break down and result in a rolling scar.
Treating rolling scars often requires breaking up the fibrous bands beneath the skin that cause the rolling appearance. Effective treatments include subcision, a minor surgical procedure that involves inserting a needle under the skin to break up the fibrous bands, laser, and microneedling.
Hypertrophic or Keloid Scars
Unlike the other types of atrophic scars mentioned, hypertrophic and keloid scars are raised. They form above the skin’s surface. They occur when the skin produces too much collagen as the acne wounds heal. Hypertrophic scars are thick, raised scars that stay within the boundary of the original acne wound. Keloid scars, on the other hand, are larger and more raised than hypertrophic scars. They can grow beyond the boundary of the initial wound, forming a large, irregularly-shaped scar that can continue to grow over time.
There are a variety of methods that can treat hypertrophic and keloid scars. These include steroid creams or injections to help reduce inflammation, silicone sheets to flatten the scar, laser therapy to resurface the skin and reduce redness, cryotherapy to freeze the scar tissue, or surgical removal in more severe cases. The choice of treatment will depend on the size and location of the scar, and a dermatologist or skin care professional can advise the best course of action.
Acne Scarring Treatments
Whilst acne scars are hard to treat, it’s not impossible. There are a number of different acne scars treatments available ranging from skincare to minor surgery and everything in between. The best way to treat acne scars very much depends on the type of acne scars you have and their severity. Below is some of the most effective acne scarring treatments for atrophic acne scars.
Topical Acne Scarring Treatments
Skincare is typically the initial step in combatting acne scars and can be very effective if started early and used consistently. The most effective topical treatment for acne scars are retinoids. In particular prescription retinoids like Tretinoin which increases cell turnover and promotes skin regeneration. Tretinoin exfoliates the surface of the skin and stimulates collagen as well as elastin production. This smoothes the skin and also treats any ongoing acne as well as hyperpigmentation. Tretinoin is also often combined with hydroquinone which helps fade the appearance of acne scars quicker.
Vitamin C and exfoliating acids like glycolic acid can also help smooth the appearance of acne scars and promote skin cell renewal. In general topical treatments are best suited for early-stage, superficial scars and post-acne hyperpigmentation. They can also help improve more severe scarring which can increase the effectiveness of more invasive skin treatments.
Isotretinoin, often known by its brand names Accutane or Roaccutane, is a powerful medication typically used to treat severe cases of acne that haven’t responded to other treatments. It reduces the size of the skin’s oil glands by 35-58% and significantly reduces the amount of oil these glands produce. Isotretinoin also stimulates new skin cell production and accelerate the skin’s natural turnover process. By reducing the oil production, it prevents the skin’s pores from becoming clogged, thus reducing the formation of new acne.
Whilst isotretinoin is primarily used to treat acne, it can also have an impact on acne scars, albeit indirectly. The primary way isotretinoin helps with acne scars is by preventing the formation of new acne, which in turn, prevents new scars from forming. However, isotretinoin itself doesn’t directly improve existing acne scars. It is a powerful medication with potential serious side effects. As such it is not usually the primary method for treating deep, well-established acne scars.
Dermabrasion and Microdermabrasion
Dermabrasion involves using a rapidly rotating device to remove the skin’s top layer. This smoothes the skin and minimises the appearance of deeper scars. Its less invasive sibling, microdermabrasion, gently exfoliates the surface layer of dead skin cells. This encourage new skin to grow. These treatments can improve the appearance of shallow boxcar or rolling scars. However, they offer less dramatic results for deeper or larger scars. They may also not be suitable for skin of colour as they can trigger post-inflammatory hyperpigmentation in darker skin tones.
Laser resurfacing uses concentrated beams of light to the skin’s outer layer. It also stimulates collagen production within the underlying skin layers. This treatment is suitable for most types of acne scars, including ice pick, boxcar, and rolling scars. However it can trigger post-inflammatory hyperpigmentation in more pigmented skin tones. Additionally, recovery time can stretch up to two weeks, and the procedure may lead to temporary pigmentation changes in the skin. You will need a course of treatments for noticeable results.
Similar to laser therapy, chemical peels remove the outer layers of the skin. This promotes skin regeneration and improves overall skin texture. Whilst they can help minimise the appearance of mild to moderate boxcar and rolling scars, chemical peels may not significantly affect deep scars like ice pick scars. They can also lead to pigmentation changes in darker skin tones. Again, you will need a course of treatments to get noticeable results.
Microneedling & RF Microneedling
Traditional microneedling, also known as Collagen Induction Therapy, is a minimally invasive skin treatment that uses a device with tiny, fine needles to create micro-punctures in the skin. These tiny wounds trigger your body’s wound healing process which stimulates collagen and elastin production. This process helps to fill in acne scars and reduces their appearance over time. Microneedling is particularly effective for rolling scars and boxcar scars. It can also help treat smaller ice pick scars.
RF (Radiofrequency) Microneedling adds radiofrequency energy to the traditional microneedling procedure. In addition to the benefits seen with the micro-injury provided by the traditional microneedling, RF microneedling also delivers RF energy deep into the dermis further enhancing skin tightening and acne scar reduction.
Both procedures, when performed by a qualified professional, can significantly improve the texture of your skin and reduce the visibility of acne scars. You will need to have multiple sessions and the number of which will depend on the severity of your scars.
Hyaluronic acid dermal fillers are can be highly effective for indirectly treating certain types of acne scars. They work by adding volume to the skin, thereby lifting and smoothing out the depressed areas. Dermal fillers are especially beneficial for rolling scars and boxcar scars.
Dermal fillers provide immediate results, and the procedure is relatively quick. However, as the body naturally breaks down the filler over time, you’ll need to repeat the procedure every few months to maintain the results. As such they do not provide a permanent solution like the above treatments. However, they can be helpful in isolated scars that have not responded to anything else.
Acne scars are challenging to treat. Thankfully there are numerous acne scarring treatments that can substantially improve their appearance or even eliminate them. Patience is key here, as most treatments need time and consistency to deliver satisfactory results. You might even need a combination of treatments if you have particularly severe or different types of acne scars. As always, you should seek a qualified and experienced doctor who can advise you on the best acne scarring treatment for you.
Our doctor-led prescription skincare service provides personalised treatments for acne, acne scars and hyperpigmentation. Please schedule a virtual consultation with us today and let our doctors create a bespoke treatment plan for your specific to your needs and skin goals. The journey towards better skin starts here.