Dr Anjali Mahto, Consultant Dermatologist and British Skin Foundation Spokesperson, delves into the topic of acne scarring and some of the most effective treatments for it.
Acne is one of the most common skin conditions that can affect up to 80% of the population at some point. In about 30% of people that have moderate to severe acne, permanent scarring of the skin can result. Unfortunately, scarring can leave behind significant physical and psychological sequelae. Understanding the different types of acne scarring and treatment modalities available can improve the quality of life of those that are suffering.
Why Does Scarring Occur?
Acne scarring typically occurs in association with spots that cause deep inflammation (nodules and cysts). Inflammation and its resolution can result in a number of skin surface abnormalities:
- Deposition of new collagen causing uneven surface elevation of the skin.
- Tethering of the skin surface resulting in small depressions or 'pits'.
- Permanently enlarged or dilated blood vessels as part of the body's natural wound healing response to inflammation resulting in redness.
- Damage to skin cells which cause the release of the pigment melanin causing a brown discolouration.
The altered skin texture and colour contrasts sharply with normal surrounding “unscarred” skin and can attract attention to the eye.
Types of Acne Scar
Scars can either be elevated or depressed from the skin surface.
There are two types of raised scars – hypertrophic and keloid. Both types occur due to overgrowth of dense fibrous tissue after healing of a skin injury. Generally speaking, hypertrophic scars are the same size as the spot that caused them, but keloid scars extend beyond the limits of the injury that created them. Keloid scarring is more common in pigmented skin and typically occurs on the shoulders, angle of the jaw, and chest area. They usually do not resolve by themselves and often require intervention to soften or flatten the areas.
There are three main types of depressed acne scarring.
- Ice pick scars - these are deep, narrow pitted scars that commonly occur following acne to the forehead or mid to upper cheeks.
- Boxcar scars - these are broad depressions with sharply defined edges. The scars can be several millimetres wide and can result in a 'crateriform' appearance of the skin.
- Rolling scars - these are broad depressions with sloping edges., leaving the skin with a rippled or undulating appearance.
Many individuals that have acne scarring are likely to have a combination of the different subtypes.
Who Should You See for Treatment?
An experienced General Medical Council (GMC) registered dermatologist will be able to guide you on the best treatments for your skin. Alternatively a suitable cosmetic dermatologist or dermatological surgeon can be found via the British Cosmetic Dermatology Group website. It is important that any active acne is treated before any scar therapies are commenced and a dermatologist will be able to perform an accurate clinical assessment. Often acne that is leaving scars requires oral medication, some of which can only be prescribed by a specialist.
How Can Scarring Be Treated?
Whilst some acne scarring will improve over time, the skin contour does not usually completely normalize. There are a number of methods that can be used to treat acne scarring if it is causing distress. Sometimes a combination of treatments may be required to get the best result as one person may have several different types of scars.
Steroid injections are often used to flatten raised scars so are ideal for hypertrophic and keloid scars. Small injections, usually with an agent called triamcinolone, are placed directly into the scar. Depending on the size of the scar, several treatment sessions may be required and these are usually done a few weeks apart. This is a safe procedure but should only be carried out by an expert due to potential risks such as skin thinning and pigmentation change.
Surgical treatments such as subcision and punch excision can be a useful method for treating indented or depressed acne scars. Ice-pick and boxcar scars can be removed by punch excision. This method uses a tool known as a punch biopsy to cut out the scarred area under local anaesthetic. The resulting wound is closed by a small suture or stitch. Round, irregular scars can be turned into flat slit-like scars with this technique.
Subcision will treat rolling scars. A needle is inserted into the skin after appropriate numbing and used to break up fibrous bands that are causing tethering of the skin. This causes release of the depressed scar.
Medical microneedling is a clinic-based treatment also sometimes known as collagen induction therapy. The skin is numbed using local anaesthetic cream and a device is used to make multiple small pin-point injuries to the skin. These heal within two days. Micro-injury to the skin is thought to promote new collagen production and may have a role in minor depressed acne scarring. Usually multiple treatments about four to six weeks apart are required.
Tricholoroacetic Acid Chemical Reconstruction of Skin Scars (TCA CROSS)
This is another clinic procedure that can be useful for treating depressed acne scars. Small amounts of trichloroacetic acid (TCA) are deposited directly into the scars in high concentration (70-100%). A local inflammatory reaction is triggered resulting in new collagen production into the scarred area. It can have a useful role in treating icepick, boxcar, and rolling scars. The procedure is usually well tolerated with little complication if performed by an expert. Often multiple sessions may be required.
There are multiple laser therapies available that can improve acne scarring. Depending on your individual skin type and nature and extent of scarring, the correct laser device can be chosen. Commonly used lasers include the Erbium:Yag and carbon dioxide lasers for resurfacing of depressed facial scars. Lasers can use “fractionated” technology. An experienced cosmetic dermatologist will be able to guide you through the best treatment choice for you.
Some Final Thoughts
Acne scarring can have a profound psychological effect on the sufferer long after the acne itself has gone. Misleading information results in much time, money, and effort being wasted on miracle cures without miracle results. There are effective treatments available for managing acne and scarring. If you find your skin concerns are stopping you leading your life the way that you want, it is important to seek medical help.
Ensure your expert is a dermatologist on the GMC specialist register and can talk through the multiple options that are available. It is important to have a discussion about which methods have been chosen and why. And finally, it is vital that the acne process itself is switched off and treated before any scar treatments are started.
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Last revised: 12 September 2016
Next review: 12 September 2019