Acne scars are one of the more difficult skin issues to overcome. They do not go away over time and corrective measures are often a lengthy and painful process.
For some, genetics play a greater role than others, making them more susceptible to acne and scarring in general. Everyone is, however, vulnerable to scarring as a result of trauma to the skin. Furthermore, it is not always the result of severe acne lesions; mild acne can lead to scarring if it is picked and poked.
The best way to treat acne scars is to do everything possible to break the acne cycle and prevent scarring from occurring in the first place. Starting early is key. Because of hormonal factors, the lesions of the early teenage years tend to be the most severe and result in the worst type of scarring. For that reason, it is highly recommended to start a preventive program as early as twelve years old.
A consistent skin care routine that includes regular exfoliation, along with anti-inflammatory, antibacterial, and antioxidant products, is critical to skin health. It is also important to stick to a nutrient-rich diet, limit ultraviolet exposure, reduce stress, and maintain sufficient rest and hydration.
Once acne scarring has already occurred, the focus switches to corrective procedures. Unfortunately, scars cannot simply be erased, but there is much that can be done to minimize their appearance and greatly enhance the surface texture of the skin to achieve a smoother appearance.
First, it is important to understand exactly what constitutes an acne scar. Dark marks left behind after a pimple disappears are not acne scars. These are the marks of post-inflammatory hyperpigmentation (PIH), the body’s melanin response to inflammation and irritation. Post-inflammatory hyperpigmentation marks linger, but are typically not permanent. They can be addressed through a combination of exfoliation and topical brighteners. Vitamin A propionate, kojic acid, mandelic acid, lactic acid, hydroquinone, and niacinamide are among the top ingredients for fading dark marks caused by PIH. Ultraviolet radiation can worsen PIH, so it is imperative to limit exposure and use sunscreen.
True acne scars are not just surface. They are alterations to tissue resulting from of the body’s attempts to heal from damage. They appear as depressions, sometimes quite deep and wide – box car or rolling scars – or small, shallow pockets like those known as ice pick scars. Acne scars can also appear as raised hypertrophic tissue, or in the most severe cases, as dense keloid scars formed by excess tissue in the healing process.
True acne scars require more intensive treatment than the dark marks of PIH.
Before beginning any major corrective treatment for acne scarring, the first consideration is to prevent further damage by bringing acne under control with a targeted treatment program. Once acne is under control and a maintenance regimen is in place, attention may be turned to reducing the scars.
An effective acne management system should include a vitamin A corrective serum to accelerate cell renewal and clear impactions, as well as a vitamin C and E serum to strengthen cell function and help with collagen synthesis.
HOW TO TREAT ACNE SCARS
This method can be used both for scar prevention and diminishing the appearance of existing scars. A shot administered at the site of a pimple in the very early stages of eruption can immediately reduce inflammation to reduce the severity of the pimple and prevent scarring. When performed on existing hypertrophic or keloid scars, the steroid injection can have the effect of flattening the scar. This effect, however, is only a temporary fix and only affects the specific area, so the overall texture of the skin is not improved.
A peel improves skin texture and tone by removing the top layers of skin, including cellular buildup and impactions. Over time, it will also reduce scar tissue. It takes several chemical peels to equal the depth achieved with one dermabrasion, so the tradeoff is a less-immediate result for a less-invasive procedure.
Liquid collagen injection is a popular technique for filling in sunken acne scarring. The material is injected under a depression where the collagen forms a lattice-like network of fibers. The action stimulates the patient’s tissue to grow in and raise the depression.
As skin ages and loses collagen, acne scars can become more pronounced. For this reason, dermal fillers are often a good option for treating scars in aging skin. Dermal fillers can also be a great option for younger patients with deeper scars. The filler will add volume to the skin, which can enhance the effects of a laser treatment.
While collagen is derived from natural sources, it can still be interpreted by the human body as a foreign substance and cause allergic reactions. Fillers require several injections to improve a scar and results are temporary, meaning the treatment remains ongoing.
Not all scars respond well to fillers. Some will appear worse after injections. A rigid scar that is bound down into the tissue may become more pronounced. If professionals pinch up the area around a scar between their fingers to elevate it and the scar disappears, then it is not bound down to the underlying tissue and an injection may improve it. However, if the professional feels a rigid mass between their fingers, as if the scar is more pronounced when pinched, it is not a good candidate for injection. Each scar should be individually addressed when considering dermal fillers.
Also known as collagen induction therapy (CIT), microneedling works by introducing micro-injury to the skin to induce a reaction. The injury prompts the body to send collagen to the epidermis to repair the skin. While there are home kits for microneedling, those use shorter needles that do not provide enough stimulation to affect acne scars. Longer needles used at the dermatologist’s or aesthetician’s office are required for this process. As a relatively new treatment, this procedure has shown good results in reducing moderate scarring.
Microneedling has some advantages over more invasive resurfacing. It does not cause epidermal injury that can lead to PIH, skin heals quickly, and the treatment costs far less. The treatment is usually performed at four- to eight-week intervals.
Lasers use rapid pulses of light to vaporize the top layers of skin and spur cell renewal and collagen production. The damaged scar tissue is removed in the process and replaced by new, smoother skin. There are varying levels of intensity ranging from non-ablative (non-vaporizing) treatment – best for superficial scarring – to the high-intensity fractional treatment that is used for scarring caused by severe cystic acne. This latter approach is trained on the effected sections of the skin while leaving the surrounding skin intact.
Four to six laser treatments, over a period of two months, can significantly improve skin texture. In addition to diminishing the appearance of scars, skin appears rejuvenated after a course of treatment. The relative ease of mastering the technique has made it very popular among skin care professionals, but it does have some limitations. The results can be inconsistent because of the way the spectral distribution and the nature of the light pulses interact with the geography of the skin.
Furthermore, the process is painful and healing is extended. Skin can be raw and red for several days following the procedure. The intense heat can trigger PIH, especially in darker skin tones. Hypopigmentation can also occur over time from repeated insult to the cells.
Dermabrasion, essentially planing the skin down to a level below the scar tissue and allowing the skin to grow back anew, has been around since the early 1950s. The process has evolved a great deal since the earliest days when surgeons used sandpaper. Surgeons eventually moved on to a rotating wire brush and a fraise, a rotating disc of diamond particles. Dr. James Fulton further advanced the method in 1976 when he designed enhanced surgical instruments driven by compressed nitrogen gas. His improvements took the speed of the disc rotation from an average 48,000 rotations per minute to 80,000 rotations per minute. The faster speed reduced tissue drag and allowed the operator greater control and the ability to go deeper for greater scar elimination.
Dermabrasion works best on shallow ice pick scars. Deeper depressions are less likely to be improved by dermabrasion alone, though the procedure may de-emphasize those scars by leveling out harsh edges, which create shadows. Patients will get the best results in the center of the cheek where the skin is thicker and allows for a deeper plane.
In general, dermabrasion brings consistent, lasting results. However, dermabrasion is not the best procedure for everyone. Some acne scars that are larger underneath and show less on the surface could actually look worse after attempting to plane down through them. It all depends on the type of scar, the patient’s skin type, and how the skin heals. This procedure also requires a very skilled technician to avoid complications.
The recovery time for dermabrasion is about two weeks and, during that time, care must be taken to avoid infection. When dermabrasion is done more than once, the improvement is most dramatic with the first procedure and diminishes with subsequent dermabrasions. Follow-up procedures are best for addressing problem areas and fine-tuning the ultimate results.
As with lasers, pigmentation changes can occur due to PIH, especially in darker skin tones. Sometimes the disturbance to pores can trigger an acne flare-up. This flare-up can be controlled by decreasing the use of greasy healing ointments and switching to a mild acne-control program. The herpes simplex virus can be activated by the healing process following dermabrasion. Patients are given antiviral therapy for a week or so after procedure.
For severe cases, laser and dermabrasion may be combined. Laser abrasion may be used first and followed with dermabrasion for the deeper acne scars. The laser tightens the skin and the diamond disc planes out the scars. These two methods together yield better results than just one of the procedures alone.
Subcision with Dermabrasion
Fulton often used a technique in conjunction with dermabrasion, which involved punching out the scar tissue and stitching the wound. After four days, the stitches would be removed, leaving no signs of the scar.
Fillers can also be used following dermabrasion to fill in any remaining signs of deeper scars. However, unless using silicone, the filler will not yield a permanent result and another injection will be required in about a year.
In the case of the more invasive treatments, the skin of the face has some advantages that promote faster healing. Oil glands temporarily take over the function of producing new skin cells to quickly renew the surface. Additionally, the plentiful blood supply in the face provides nutrients for rapid new cell growth.
The type of treatment will ultimately depend on the skin type, the severity of the scarring, and the patient’s personal feelings. Thoroughly discuss all the options with clients, including pain scale, healing time, and any possible drawbacks or complications associated with each treatment option.
For many, the emotional scars can be as damaging as those visible on the skin. While discussing the options, take time to listen to the client and be sensitive to the surrounding emotional issues. The skin care professional’s job is to improve the skin, but by listening to the client’s concerns at every level and offering support, they can reduce anxiety surrounding the procedures and relieve stress associated with the appearance of the skin, a vital component in the success of the treatment.
Please note that any procedure that penetrates beyond the outer layers of the skin to the deeper layers of the dermis must be performed by a physician, registered nurse, or physician assistant under supervision.
Sara Fulton is the co-founder and president of Vivant Skin Care. She has more than 40 years of research, formulating, manufacturing, and clinical experience with skin care.