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Acne scarring is a reaction to the inflammation in the skin caused by acne.
During the inflammatory process, tissue is destroyed and in an attempt to heal the skin,
a reaction called "fibrosis" occurs. Fibrosis causes textural changes to the skin; these
changes can either be thinner (called atrophic) or thicker (called hypertrophic) than normal skin and the scarring is permanent.
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Scarring is defined as fibrosis of the collagen in the dermis (the deep layer of the skin).
The color changes seen with acne are usually more superficial and gradually fade with time.
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Inflammation caused by acne leads to redness of the skin and redness usually starts when the acne lesion is active.
Even after the acne lesion has improved, however, inflammation may continue deep within the skin, causing persistent redness.
Inflammation also stimulates the production of the pigment molecule called melanin, leading to brown or black discoloration.
Thus, in those who tan easily or with darker skin tones, melanin production is stimulated by the inflammation leading to brown
discoloration around the acne lesion. Although the discoloration lasts longer than the acne lesion itself,
the discoloration will fade with time; sometimes several months.
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Treatment for acne scarring is difficult so the best overall treatment is prevention.
For many, however, it is too late for prevention and the following treatments are available.
- Dermabrasion
Mechanical resurfacing of the skin (see section on Dermabrasion) involves the use of abrasive tools to remove the outer
layers of the skin to produce an improved appearance. Dermabrasion is primarily used for the treatment of acne scarring
where superficial and deep techniques are available.
There are two layers of the skin; the outer layer (the epidermis) and the inner layer (the dermis).
Superficial dermabrasion removes portions of the epidermis and deep dermabrasion removes all of the epidermis and portions of the dermis.
Deep methods are the preferred method for treatment of scarring because they are the most effective but generally require
weeks of healing time and carry a higher risk of complications. Improvements continue for months after the procedure as collagen
remodels underneath the skin. Although dermabrasion has been proven to improve the cosmetic appearance of the skin,
especially in the treatment of acne scarring deep ice pick scars typically do not improve significantly with dermabrasion.
Motorized dermabrasion is a medium-deep or deep procedure that employs the use of a motorized brush or diamond cylinder
which removes the outer layers of the skin in a controlled setting.
Local anesthesia is used for pain control during the procedure.
In manual dermasanding the physician grinds down the skin with silicone carbide sandpaper.
This method is usually considered to be a medium depth procedure and is sometimes used in combination with
other methods such as chemical peels, carbon dioxide lasers, and motorized dermabrasion.
Not everyone is a good candidate for dermabrasion and those with active acne, infections, and other scarring skin
conditions may need a previous treatment before undergoing dermabrasion. Complications are rare but include infection, prolonged healing,
hyperpigmentation, and scarring. Dermabrasion may not be recommended for those with darker skin types because of the risk of
hyperpigmentation or darkening of the skin. You and your physician need to decide if dermabrasion is the right procedure for you.
- Laser Resurfacing
Laser resurfacing (see section on Laser Resurfacing) has been used for the treatment of acne scarring.
All lasers use a high-energy beam of light that targets specific structures in the skin. The CO2 and Erb: Yag lasers used for laser
resurfacing are less specific and target the epidermis and superficial dermis. Like dermabrasion, laser resurfacing is ablative meaning that it
destroys the outer layers of the skin. Ablative techniques are more effective but less popular because they require recovery time.
Side effects are similar to dermabrasion and need to be discussed in detail with your doctor.
- Subcision
Subcision is used for atrophic scarring. Local anesthesia is used and a needle is then inserted under the scar and gently moved
underneath the skin to release the scar tissue. This method has been tested in recent studies and is shown to be effective.
- Punch excision and grafting
For deep ice pick scars, the only effective treatment is the complete removal of the scar. A small round cookie cutter-like device
(called a punch) is used to cut out the scar and the edges of the wound are then stitched together. In this case, a deep, large scar
is traded for a tiny line scar that can later be treated to further blend it into the rest of the skin. Larger scars can be removed
and then filled with a skin graft, taken from existing skin (usually behind the ear). Grafts are later contoured with
dermabrasion to blend them into the rest of the skin.
- Fillers
Substances that add volume to the skin (see section on Fillers) can be used alone or in combination with the above procedures.
Fillers can improve the appearance of acne scars by flattening the scar. The effect is temporary and to maintain the result,
the lesions must be re-injected at regular intervals.
- Chemical Peels
Chemical peels, also known as chemical resurfacing (see section on chemical peels), are chemical treatments which produce an
improved appearance of the face, including acne scars. Chemical peels produce a controlled injury to the skin that promotes the growth
of new skin with an improved appearance. Many different chemicals are used including glycolic acid, trichloroacetic acid (TCA), salicylic acid,
"Jessners" solution, and phenol. These different chemical solutions produce different degrees of injury to the skin. Medium depth and deep peels
produce injury within the dermis and can improve the appearance of atrophic acne scars while the deeper peels are more effective but carry more
risks such as infection, scarring, and discoloration, especially for patients with dark skin. More studies are being performed in patients with
dark skin and certain peels are proving to be beneficial. For example, in one study of Asian patients, glycolic acid peels (which are superficial)
improved acne scarring and pore size. Further studies are in progress.
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Although less common, hypertrophic (and keloid) scars can be more disfiguring and harder
to treat than other types of acne scarring. This type of scarring is more common on the
chest and back and for reasons that are not understood, hypertrophic scars tend to recur
after removal. Treatment usually involves topical steroids, injected steroids, silicone
dressings, and/or cryosurgery. Recently, pulse dye lasers have been employed with some
success. More work is needed in this area.
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- Creams (topical therapies)
Over-the-counter bleaching creams may improve hyperpigmentation caused by acne.
Over-the-counter creams contain 2 percent hydroquinone, a bleaching agent.
Prescription creams may use single agents, such as Retin-A (tretinoin) or combinations of
medications such as hydroquinone with tretinoin plus a cortisone cream. These treatments can
be quite effective when used properly but you need to discuss the risks of each medication
with your doctor.
- What are the risks?
In general, topical treatments have fewer side effects with the most common being
irritation and redness with a less common side effect being discoloration. You and your
physician will decide on the right treatment for you.
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- Chemical Peels
Chemical peels are described above (also see section on Chemical Peels) but in general
they are effective for improving discoloration from acne. More superficial peels have proven
effective which is beneficial because there is less risk and require less recovery time,
however, several peels may be needed to obtain the desired effect.
- Microdermabrasion
Often referred to as a "lunch time" procedure (see section on Microdermabrasion),
microdermabrasion is a popular procedure which is classified as a light, or very superficial
dermabrasion. This method employs aluminum oxide crystals that are propelled at the skin and
then immediately sucked up. Although not scientifically proven to improve the skin’s
appearance, many patients report that their skin feels smoother. It is primarily used to
treat acne and the hyperpigmentation caused by acne. It is also a popular procedure
because it is painless and requires no recovery time. Unfortunately, to effectively treat
acne discoloration, up to 15 treatments may be necessary which can be very expensive.
Newer devices now are crystal-less.
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No, there are no systemic medications for acne scarring or discoloration. A good diet with
lots of fruits and vegetables can help maintain healthy skin.
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Cosmetic/Plastic Surgery
