Acne scars can affect anyone—here’s what you should know
A dermatologist lays out the treatment methods that pave the way to smoother skin.
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Plain and simple: Part of having skin is experiencing breakouts, at least for most people. When a blemish pops up on your face, you can effectively treat it with pimple patches, salicylic acid, or other exfoliating products. And some of the time, that’s the end of the story. But when a bump remains long past healing, or a wave-like texture develops where there once was acne, you have a longer-term issue on your hands (er, face) in the form of scarring. As it turns out, diminishing acne scars requires a different treatment plan than getting rid of acne.
To learn how you can identify the type of acne scarring you have and then how to handle it, we consulted Dr. Farah Moustafa, a Boston-based dermatologist with Tufts Medical Center.
What are acne scars?
There are two main types of acne scarring: atrophic and hypertrophic. Atrophic, the more common of the two, refers to scars that are depressed into the skin. These occur from a loss of collagen (a protein that gives skin its structure) as a result of the inflammation from an acne lesion, Moustafa says. Atrophic scars fall into three categories defined by their shape: boxcar (a shallow, broad depression), rolling (a wave-like texture to the skin), and icepick (very small but deep focal depressions). It’s common to experience a mixture of the three types if you develop atrophic scars.
Hypertrophic scars are raised above the skin’s surface rather than sunken below it. These can also become keloids, a form of three-dimensional scarring, if the scar tissue mounds up above where the original wound was. These types of scars are an overproduction of collagen following a breakout. Moustafa explains: “Your body tries to overcompensate [for the injury to the skin] and create more collagen and then you end up with thickened, irregular collagen and that’s when you see hypertrophic or keloidal.”
No one is more or less susceptible to acne scarring in general—if you experience breakouts, there’s a chance of scarring (especially if you pick your skin—more on that coming). The type of scar you see may depend on your ethnicity, however. People with darker complexions are about 15% more likely to develop hypertrophic scars than those with lighter skin tones.
Is hyperpigmentation acne scarring?
What’s not considered an acne scar, though is often associated with them, is hyperpigmentation. Scars indicate an alteration in the collagen in the dermis (the layer below the epidermis), which causes a change in texture. Post-inflammatory hyperpigmentation (PIH) is the result of pigment changes, not textural changes. So while you might refer to discoloration as “scars,” dermatologists classify it differently, and there are different treatments for hyperpigmentation.
PIH can look pink, red, purple, or brown, depending on your skin tone, and occurs right at the site of the blemishes. If the color is pink, red, or purple, this type of hyperpigmentation is more specifically referred to as post-inflammatory erythema (PIE). The cause is the same: an alteration of pigment due to inflammation in the skin caused by acne. If you run your fingers over the hyperpigmented areas, you’ll likely notice that the skin is flat, despite it potentially looking textured—the eye can play tricks and make discoloration look like a textural change. A red dot may look like a bump when it’s actually a healed wound. That said, you can experience hyperpigmentation and acne scarring, in which case there would be both a color and texture change.
Can you prevent acne scars?
There’s no way to know if you’ll experience scarring following a breakout or a flare-up of acne, but you can prevent or minimize the development of scarring. “The best way to prevent acne scarring is to be vigilant about acne treatment,” Moustafa says. “[Stop] the inciting factor that’s causing the scar, [i.e.,] the acne.” If you’re experiencing recurring breakouts that you can’t get under control with the usual OTC acne methods, consult a dermatologist about topical or oral prescriptions. If you’ve already noticed scarring with your acne, you most likely need an oral treatment, such as Isotretinoin (a.k.a. Accutane), Moustafa says, to stop the breakout cycle before more damage is done.
Another way to minimize scarring? Resist picking your skin. “Manipulation of the lesions is probably one of the biggest reasons why we have [acne scarring],” Moustafa says. Scratching, scraping, or squeezing pimples heightens the risk of scarring because it introduces more inflammation and trauma to an already-injured wound. Plus, any bacteria under your fingernails can further irritate the wound or even lead to a secondary infection.
How can you treat acne scars at home?
The good news: There are effective ways to treat both atrophic and hypertrophic acne scars and achieve a smoother skin surface. The so-so news: The most effective methods require professional, costly treatments. But there’s a huge benefit to not delaying a trip to the doctor. “If you start to see acne scarring, the sooner and earlier you treat it, the better your outcomes will be,” Moustafa says.
Atrophic scars are the only ones that make a good candidate for at-home treatment, though Moustafa only recommends using a topical retinoid called Tretinoin, which is only available via prescription. Like other retinoids, Tretinoin exfoliates the skin and studies show that it can stimulate collagen production, which will then plump up the divots and ridges left by atrophic scars. You can also opt for an over-the-counter retinoid (referred to as retinol in the nonprescription strength), such as Adapalene 0.1%, but by definition, OTC options are weaker and may not produce the same results within the same time frame. One huge benefit from using any retinol-containing product: It’s very effective at tempering breakouts, if you’re experiencing new acne while wanting to treat scars.
Whether you choose a prescription or OTC retinoid, you want to be patient, temper your expectations, and consider also receiving an in-office procedure. “The results are conservative at best for using a topical once you have a visible loss of collagen, so I don’t think you can rely on that alone,” Moustafa says. “With any of these medications, you give it a few months to work and the longer you use it, the better it works.”
If you’re new to using a retinoid, start by using the product once a week and gradually increase usage to multiple times a week, depending on what your dermatologist or the product’s instructions suggest. Ideally, you’d use a small amount of the retinoid every night once your skin builds up a tolerance, Moustafa says. You can apply the retinoid only on the acne scars that have formed or apply it all over the face to help treat and prevent active acne.
What doesn’t work for acne scarring: at-home methods like derma-rolling and jade rolling that claim to stimulate collagen. “They’re fraught with their own issues—they either don't work or they’re not safe to do at home,” Moustafa says. When it comes to poking the skin with tiny needles, as with a derma-roller, the level of sanitation at home is not up to snuff with what you’d find at a professional’s office. Plus, with both of these devices, you may only see temporary effects because the rolling causes swelling in the skin. Once the swelling goes down, the scars will likely look the same.
What medical procedures treat acne scars?
As far as in-office procedures, your dermatologist may recommend any of several options, based on your skin type, skin tone, type of scarring, and ability to have downtime. Most of the procedures can make things appear worse before they get better, with two to five days when the skin may look or feel red, gritty, or flaky. During that time, you must be vigilant with sun protection, as your skin is in a sensitive state and more prone to irritation, and patients tend to prefer staying inside and taking it easy while their skin heals.
And then there’s the cost, which is not insubstantial: Each procedure costs about $1,000 to $1,500 per session, with multiple sessions required for maximum effect. However, these procedures offer a “permanent, incremental improvement” to the acne scars, Moustafa says. (Though you can still get new scars if you continue to experience acne.) Some procedures, from ones that are effective for almost all scars to ones more specialized for particular scars:
Non-ablative fractional laser: This procedure is one of the more common options, as it’s less invasive in terms of side effects than others on this list, like ablative fractional laser. It uses the energy from a laser to create microscopic injuries to the skin that causes cells to “lay down new collagen,” as Moustafa says. The new collagen fills in the scar. For best results, you’ll need four to six sessions, depending on how deep the scarring is and how the scarring improves between sessions. As it takes time for the body to rebuild collagen, you should begin to see texture improve within four to six weeks of each treatment, which is why your sessions will be scheduled that far apart.
Radiofrequency microneedling: This treatment is similar to the non-ablative fractional laser, but it uses radiofrequency instead of laser light as its energy. It involves tiny needles that puncture the skin and create a “controlled injury to the dermis where the scar is and that helps stimulate some remodeling of tissue and new collagen formation,” Moustafa explains. This procedure requires a little less downtime than the laser option, but also requires four to six sessions spaced apart. It’s also safer for skin of color, as laser light can alter the pigmentation of the skin in a way that radiofrequency energy will not.
Ablative fractional laser: Despite sounding similar to the first option, this works differently. Here, a laser "vaporizes" scar tissue in the skin, causing the surrounding, healthy skin to come in and heal over that area with fresh collagen. This procedure is more aggressive than non-ablative fractional laser or radiofrequency microneedling, but Moustafa says it can result in a more dramatic improvement and requires fewer sessions—just two or three, on average. It’s also on the higher end for downtime and patients typically experience skin sloughing that requires soaking it with a wet cloth or applying Vaseline to protect the skin for one to two weeks.
Filler: You may have heard of using filler to plump the lips or smooth fine lines and wrinkles, but it’s a great option for filling in atrophic scars with minimal downtime and for a lower cost per session. This procedure works the same way by injecting the skin with a hyaluronic acid- or polylactic acid-based filler that’ll help plump the skin and camouflage the scar. “You can hide the peaks and valleys of a scar by putting filler in between them [in the valleys] and help smooth the appearance of the skin,” Moustafa explains. Depending on the type of filler and the acne scars, fillers may need to be redone as often as every six months.
TCA Cross: One procedure that works well for icepick scars in particular is chemical peeling, according to Moustafa. TCA Cross is the name for a chemical peel technique that involves injecting tiny amounts of concentrated trichloroacetic acid into the scars, which stimulates collagen production in the injured area. You can expect to need two to three sessions about a month apart from each other and incremental progress from each.
Subcision: For rolling scars that have a wave-like appearance, subcision is an option. The dips into the skin can indicate that fiber strands are pulling the skin down and giving the bumpy texture. To correct this, a dermatologist puts a needle into the dermis where the fibrous tissue is and cuts the fibers loose. This should fix the depressions in the skin and create a more even skin surface. The procedure takes about four to six sessions with four to six weeks in between each.
Steroid injections: Lastly, those raised hypertrophic scars often require a steroid injection to get rid of the excess collagen that’s causing the skin to rise above the surface. Moustafa explains: “It’s usually a series of treatments because you don’t want too much atrophy. You’d see a dermatologist at regular intervals [and] do the injections about four to six weeks apart.” At the end of the sessions, the goal is to have the raised bumps back down to the normal skin surface level.
Should you do anything about acne scars?
With all of this information, you may be wondering if you need to treat your acne scars. First off, no, you don’t need to treat them unless the appearance of them bothers you. You may even see a natural, gradual reduction in acne scarring over time. If you want to treat them, though, improvement is possible. “A scar requires commitment to improve,” Moustafa says. “We can make it look a lot better but we can’t make a scar back-to-normal skin. But you can make it look a lot better and almost normal, so that’s the goal.”
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