The treatment and prevention of acne scars.

Acne is one of the few dermatological conditions that cause scarring and long lasting marks. As it is most likely to affect the face, it can leave a highly visible reminder of past acne. The good news is that not everybody with acne will develop scars and marks, and using the correct treatments as soon as acne appears will help prevent them.

Acne scars and marks can occur in any place affected by spots, including the back, chest and shoulders. Treating scars and marks in these parts of the body presents huge challenges. To make things worse, some scarring seems to get progressively more visible as the body ages because the skin’s natural elasticity decreases and collagen is lost. Once past the age of 40, we can lose up to 1% of our collagen each year, making our skin more prone to sagginess.

It is possible to avoid scarring and marking by following the advice in this article. Minimising the effects of existing scars and marks can also be achieved by ever-widening choice of acne treatment options. Treating scars and marks, just like treating acne, will often demand patience and may not give 100% improvement, so try to keep your expectations realistic.

Preventing scars

Avoiding scars is a challenge, especially if the acne is severe or you develop deeper cysts. Common-sense steps to avoid or minimise the risks of scarring are:

• Avoid picking or squeezing spots. 
• Only touch those spots that are ready to be squeezed, and never use force to burst the contents. Pushing, squeezing or pinching the skin hard can cause it to become damaged and inflamed, which may increase the chances of getting a scar.
• Always use treatments as prescribed.
• Slapping on creams or doubling up tablets will not make the spots disappear more quickly; nor, more importantly, will it stop new spots forming.
• Use the right type of treatment for the right type of spots.
• Treat acne as soon as you get it – waiting too long will increase the chances of getting scars. You don’t need to wait before you take action – choose from a range of medication skincare products available in pharmacies or supermarkets and keep using them.
• Don’t wait – if you are worried that your skin is starting to scar, ask your doctor for help.

If you do decide to squeeze a spot, then follow the traffic light guide listed below:

Article on traffic light guide to squeezing acne spots

While some people end up with scarring, others may find their skin doesn’t scar or mark at all. Whatever type of skin you have, it is important to take early action against spots. Stick to your treatments and, at the first sign of scarring, ask for a referral to a dermatologist.

Why do some people scar and not others?

It might be thought that scarring is a sign of failure to treat acne effectively. However, this may be an unreasonable assumption as there are many other factors to take into consideration.

These can include:

• Being predisposed to developing scars.This can run in families, and some people who developed acne scarring have inherited their parents’ skin types.
• How severe the acne was, not necessarily how long the acne lasted.
• Whether the skin was excessively picked or squeezed (not following the traffic light guide to squeezing discussed in this article).

Different types of acne scars and marks

A scar is the result of damage to the skin. Each scar will appear different, even on the same person. There are various types of scar, although it is possible to be predisposed to more one type than another, and scars may be more severe in some areas than others. Scarring can either be seen as:

• A change in pigment (although strictly speaking this is a mark, not a scar)
• Raised above the normal level of the surface (hypertrophic)
• Pitted or dipped below the surface (atrophic)
• Rolling scars (wave-like in appearance)

Skin types

Understanding what type of skin you have can help to ensure that you keep your skin well protected from sun exposure, as well as helping you to choose the types of skin camouflage you might need.

The Fitzpatrick scale of skin types

• Type I always burns, never tans; sensitive to exposure; redheaded, freckles.
• Type 2 burns easily, tans minimally; fair skinned, blue, green or grey eyes
• Type3 burns moderately, tans gradually to light brown.
• Type 4 burns minimally, always tans well to moderately brown; olive skin.
• Type 5 rarely burns, tans profusely to dark; Brown skin.
• Type 6 rarely burns, least sensitive; deeply pigmented skin.

Pigmented changes

These marks are where the skin either loses the colour-giving cells known as melanocytes due to deep tissue damage from the spot or cyst, or produces more melanocytes. This is more commonly seen on the back. In the case of hypo-pigmentation (hypo meaning ‘less’), the skin appearing lighter, having little or no natural pigment. For others, especially in darker and Asian skin types, the damage left by a spot leaves a mark known as hyper-pigmentation (hyper meaning more). In either case the skin is likely to recover over time but may not always return to the original colour. Although they may be very distressing, these flat marks can be quite easy to disguise using camouflage or concealers.

Hypertrophic (raised) scars

The scars rise above the surface of the skin but not beyond the area of the original spot. Many hypertrophic scars will settle eventually, leaving little or no scarring. However, if the scar grows beyond this area, it is known as a keloid scar. Both of these types can be treated in the same way, although it keloids tend to spread and to be harder to control because they often return.

Keloid scars

A common type of hypertrophic scar is called a ‘keloid’ scar. This scar is more likely than normal hypertrophic scars to spread beyond the original area of injury. They occur when the skin lays down extra layers as a response to injury. These may look like little more than bumps, while some experience the skin bubbling and growing around the area to huge proportions. Keloids happen because someone is predisposed to getting them. They can result from any injury, not just acne – sometimes something as small as a scratch or bite (there have been cases where the original injury to the skin cannot be identified at all). Keloid scars are formed of collagen, a natural fibre that maintains the skins shape and texture. This overgrowth may appear shiny and be rubbery touch but can also be quite painful or itchy. The scars seem to be more common in African and Asian skin types (skin type 6 on the Fitzpatrick scale).

Atrophic (dipped) scars

This scarring is quite common in people who have acne and may appear in a few different varieties. The scars occur when the skin has lost collagen beneath the surface, like a soufflé that has collapsed, leaving a mini crater similar to a saucer shape. Atrophic scars can be successfully treated for many people using a variety of techniques that aim to re-plump the skin and push the scar back to the same level as the surrounding skin tissue.

Ice-pick scars

These dipped scars are the classic acne scars. Usually quite fine, they make the skin appear as if it has been punctured with an ice pick, hence the name. Because of the depth, it may be difficult to get good results from some types of laser or dermabrasion treatments, but some other options still remain.

Box-car scarring

This type of dipped scarring is angular and most commonly found on the temples and cheeks. It is similar to chickenpox scarring. The scars may look like they’ve been pressed into the skin, similar to the impression that might be left after using a punch excision (when a tiny patch of skin is removed to be investigated). Where they differ from ice-pick scars is that their edges are not sloped but vertical.

Rolling scars

These look wave-like as the name suggests. They happen because tissue beneath the top level of skin has become connected in fibrous bands, causing the skin to contract in places. This might be compared to rucks in a carpet when thread has been pulled underneath, leaving small ripples. In order to help these types of scar, they need to be released from underneath rather than from the top, similar to releasing the threads from beneath the snagging in the carpet.

Acne scar and mark treatments

Before you consider any treatment options, it might be helpful to think about your expectations. Each scar or mark will be different from the next. Sometimes one person may have every type of scar or mark described in this section; some of these may be deeper, older, newer, softer or harder than the ones next to it. No one particular treatment for scarring or marking will give a guaranteed improvement, despite some claims to the contrary. Scar tissue is a sign of (and a reaction to) damage to the skin, and treating that damage will usually require the skin to undergo more trauma, either by using creams that dissolve the top layers, or by a variety of other means. Skin that is delicate scars easily and may not respond so well to scar treatments. 

Things to consider

A few key points to think about before considering any treatments for scars might be:

• How do I feel about my scars? If you feel depressed about them, consider seeking advice about how you feel before undergoing invasive surgery. The treatments may not end up making you feel any better at all.
• How old is my scar? Give your skin plenty of time to settle down after acne has been treated. A recent scar is often only scar a sign of the skin healing.
• How much do I have to spend, or am I prepared to spend? Some scar treatments can be very expensive. The decision about how much you are willing to spend should depend upon what you need and what type of results you expect to achieve. Some companies offer credit and repayment options.
• What if I’m promised only a 30 to 50% improvement? Will that be enough?

It may be helpful to consider these questions carefully before proceeding with scarring treatment options, especially those that carry more risk. There is the possibility that some might not work at all or leave the skin looking worse than before. Luckily this is rare, but make sure that you get professional advice from someone you feel you can trust.

How old are the scars or marks?

Young scarring may heal naturally after a year, so try to leave the new scars alone for as long as possible to give them a chance to improve on their own. Healing spots are also known as macules, and the red marks associated with them will usually fade away altogether. Try covering these with camouflage creams or use a cosmetic concealer stick.

Where are the scars?

Acne is most likely to be seen on the face but it can also affect the neck, back, chest or shoulders. Having spots in these areas may also lead to scarring, especially as spots may be easily disturbed by clothing and body movement. This can, in turn, lead to the spot failing to heal properly, which can give an increased chance of scarring. This is why it’s important to use treatments that help acne in these areas of the body and not just the face. There are also many challenges with scar treatment options on wider areas of the body:

1. Treating scars usually requires a ‘grading in’ system that graduates the edges to help blend in the break between the treated area and surrounding normal skin. This may be difficult if the skin has widespread scars over a large area. The surgeon may be unwilling or unhappy to treat such scars because of the risk of infection following the procedure or because of the challenges of treating scars on a larger body area. Patients may have difficulty with after-care on areas such as the back because they are difficult to reach.

2. Scarring on the body, especially the back, may be difficult to reach difficult to reach to apply camouflage or other non-surgical procedures described later in this article.

3. The larger the body area to treat, the more expensive the treatments will be.

Sun exposure

If you have had any type of a ablative laser surgery or dermabrasion your skin will be more vulnerable to ultraviolet (UV) light as the skin will be more damaged and may lose its natural pigment. It is vital to protect your skin from ultraviolet rays. You will need to wear a sun cream with a high protection factor throughout the year. If you are fair skinned, this change in skin colouring may not be too obvious, but the dark your skin tone, the more likely it is to be noticeable. If you are not willing to do this, then you may wish to think carefully before undergoing some of the more invasive options listed.

Skin type

It is unfortunate that the skin type that is most likely to scar may also be the skin type that is least likely to recover well from invasive procedures. If you are prone to getting raised scarring such as keloid scars then the procedures designed to help the scars may also bring on a keloid scar. When considering your skin type, this includes the colouring of the skin. Many of the options described in this article are invasive, meaning that they dig below the surface of the skin, exposing skin that doesn’t have the natural melanin which defines our colouring. If the melanin is removed, the overall effect is to lighten the skin. If your skin type is three or higher on the Fitzpatrick scale (see earlier in article above), then the removal of skin pigment will be very obvious.

It needn’t feel like all doom and gloom. There are still options for most people, including those with different skin colours and types as well as with deep or shallow scarring. New scarring will usually respond better to treatments than older scars, so once the acne has been successfully controlled, a sensible time to discuss treatments would be around 6 to 12 months from the last acne flare-up.

If you have been treated with isotretinoin (Roaccutane), you should leave any scar treatments for at least 1 to 2 months after treatment has stopped – you should consult your dermatologist or doctor. This is because the skin may be very delicate and requires time to recover after a course of treatment with isotretinoin.

Treating pigmentation marks

A small selection of off-the-shelf skin care products, such as oils and scar creams, claim to help reduce skin pigment changes that are commonly seen in pigmentation marks. Try them for at least two months to see results before giving up. If they work, they will usually need to be used continuously to maintain improvement. Small trials of some of these products have claimed to show good results.

Some prescription creams that may help include: azelaic acid, hydroquinone and topical retinoids. All these can reduce pigment changes but need to be used regularly for an on-going period. They may have a bleaching effect on other areas of surrounding skin, so ask a pharmacist how to use them correctly before getting started. Any of these creams may leave the skin vulnerable to sun exposure, so it is advisable to use an acne friendly sun cream at the same time. Ask your doctor or nurse about the benefits and risks of trying these treatments.

While treating pigmented marks, consider trying a concealer (equally suitable for men) or getting expert advice on skin makes skin camouflage, both of which can be used at the same time.

Treating keloid and hypertrophic scarring

There are several choices for treating these types of scars, but none can provide give a 100% guarantee of working. Unfortunately, some treatments designed to remove keloids may actually encourage more growth in the same area, especially if they have been surgically removed. However, many treatments can help.

The options include one or more of the following:

Steroid injections

These injections are made directly into the tissue of keloid scars and are considered to be the most effective treatment. Their success is not always certain and they can be very painful, although local anaesthetic creams may be used. These injections will need to be given by a dermatologist. It might be difficult to find someone experienced in using this technique, so ask around before you commit to a course of treatment. To help speed the healing a special steroid-impregnated tape (Haelen tape) can be applied.

Surgery

Surgical options may be available depending on the severity of the keloid, but there are still risks that the keloid may return. You will need a referral to a dermatologist or surgeon for further advice.

Cryosurgery

This involves freezing scars but will also remove skin pigment so may not be suitable for those with Fitzpatrick skin types 3-6. This technique might be useful in conjunction with a course of steroid injections.

Invisible gel sheets

These work on the same basis as pressure garments by applying pressure to the affected area. In effect, they compress the scar and helped to prevent further growth. The sheets can be cut to size to fit around the scar and are transparent so can be used on any skin colouring. They need to be worn for up to 12 hours a day to get the best effect, and ideally applied as soon as the scar starts to appear. They are available from most pharmacists or on prescription. Skin camouflage or daily make-up can be applied on top of gel sheeting.

Treating ice-pick and box-car scars

One way of working out how much improvement you might get from any treatment to an ice pick scar is to gently stretch the skin apart. Whatever improvement you see by doing this is likely to be the degree of improvement that you’ll see after the treatment. As many ice-pick and box-car scars can be quite deep, home remedies or self-help products off-the-shelf may have little noticeable effect.

Other options include the following:

Punch excision

The damaged area is removed using a punch exerciser a bit like an apple corer, taking away a tiny round area that surrounds the damaged skin. This new ‘hole’ created in place of the old damage can then be neatly sewn or sutured back together to make a new scar, which can be less noticeable than before. Steri-strips are used to help keep the skin together after this procedure, and some people advise keeping the steri-strips on for as long as possible to maximise the benefit and allowing the skin to heal properly. Punch excision might be a complete treatment in itself or carried out before a resurfacing procedure.

Sometimes, a piece of skin from behind the ear is removed in the same way, to be used to fill the original hole. This is a type of skin graft. The downside to this is that the skin colouring and texture from the graft may be different from the original skin and therefore look less natural.

Surgical excision

This is where a dermatologist or surgeon cuts out a whole area of skin and sutures together a large section of atrophic scarring with a neat line that is easier to disguise.

Subcision

A fine needle is used to gently ‘poke’ around the area beneath the original scar. The idea behind this is to loosen any tightened collagen fibres, helping to release them and allow the scar to loosen a little. The action of poking around may, itself, help to encourage more collagen regrowth in the area, helping it to re-plump. Like punch excision (see above), this can be done before undergoing other laser or chemical scar treatments.

Injectable dermal fillers

Collagen or synthetic types of collagen are injected directly into the area of the skin to help to plump it out. An anaesthetic cream or gel is applied to help numb the area. Try to find a practitioner who has plenty of experience in carrying out this procedure. This will usually need topping up every few months, although it is reported that over time the frequency of injections needed may reduce.

Punch elevation

Deeper box-car scars can be treated by removing the original scar using the punch excisor (see above) but the removed area is lifted to the top of the skin and stuck in place using a special skin glue and steri-strips. The advantages of this procedure are the ideal match in skin colouring that can be achieved and in the need for only one procedure rather than a graft.

Treating rolling scars

Rolling scars respond best to subcision (see above) as it helps to loosen the tightened fibres at a deeper level in the skin. Other options might include a Dermaroller, chemical peels or laser resurfacing.

Other scar treatments

Dermabrasion

This method of treating scars was used for many years by surgeons. It is now considered quite old-fashioned and has largely been replaced by laser resurfacing. However, if you are offered this type of treatment, it is useful to understand how it works. Dermabrasion is where the top layers of skin are removed by an instrument called a dermabrader. This will be carried out under general anaesthetic and involves literally sanding away the skin, which can be very bloody and messy. Recovery can take several weeks and the skin needs careful post-operative care to reduce the chances of infection.

Micro-dermabrasion

Available from beauty salons, this type of machine operated device can be excellent at rejuvenating the skin and helping improve the appearance of mild scarring. It does not, however, penetrate the lower levels of skin, which is where deeper, longer lasting scars are found. The operator will use a hand-held head attached to a machine. Micro particles such as zinc or crystal are fired under controlled pressure onto the skin, in effect blasting it. This will lift the top layers of dead skin cells and then remove them by sucking them away. Sometimes a diamond tipped head is used instead, which is claimed to deliver better results because of its ability to give a high ‘polish’ to the skin. Micro-dermabrasion is a bit like a super-powered vacuum cleaner that leaves the skin softer and more plump in appearance. The downside is that it will need to be used regularly as the results are never permanent.

There is an increase in the choice and variety of home based micro-dermabrasion kits. These vary in quality and price. Results will probably be noticeable but not long lasting, and they are unlikely to give the same effect as salon based options.

Laser treatments

There are two main types of laser treatment. The first, known as a ablative lasers, will burn away top layers of skin to a precise and carefully measured depth. The other type, non-ablative lasers, will not damage the top layers of skin; instead, it tricks the skin into believing it has been injured, encouraging a self-healing response. If you are thinking about laser resurfacing, those types have their positive and negative sides. Each option needs to be given as a course of treatment and will usually be expensive (costs are rarely covered by the NHS in the UK).

Ablative lasers:

These will literally remove the outer layers of the skin, burning away scar tissue and causing collagen to change. This results in a tightening effect, which then makes the scar less visible. Examples of ablative lasers include carbon dioxide and erbium: YAG but other types are available. Like dermabrasion (see above), this type of procedure will leave a bloody scar because the skin has been removed (albeit to a very precise, carefully measured level) and the resulting scab will need to be carefully looked after to prevent secondary infection. The layers are removed by using the laser beam to heat the skin, which in turn evaporates water in the skin cells. Initial results of this treatment may seem far better than the final appearance. This is because the skin will swell in response to the laser. Some people are then disappointed when the skin has settled. This type of laser will affect the skin discolouration cells (melanin) so the skin will always need to be protected in the future. The procedure may not be recommended for skin types 3-6.

Non-ablative lasers:

These lasers are more suitable for treating mild scarring and sun damage. They trigger the skin to believe it has been injured, and send out the body’s immune cells to start healing. This healing process can help to re-stimulate collagen. Although this type of laser treatment can be uncomfortable (similar to having an elastic band flicked on the face) it will not require any ‘down time’ – a period of recovery for post-operative wound care, such as after ablative lasers. An anaesthetic gel or cream can be used to help reduce any discomfort. There are a few different varieties of non-ablative lasers available. These include mid-infrared lasers and the two visible light lasers, the pulsed dye laser (PDL).

Chemical peels

These have been used for many years and are available in different strengths according to the depth of the scarring. Milder peeling agents can be used to give a general skin boost but will do little to help scarring. Chemical peels allow the top layers to be removed, revealing fresher skin beneath. Some milder peels include alpha hydroxy acid (AHA), a chemical that occurs naturally in foods such as sugar, and lactic acid, which is found in milk. Stronger peels that penetrate more layers of the skin are usually TCA (trichloroacetic acid) and come in concentrations ranging from 20-50%, depending on how deep it is required to penetrate. TCA peels are more suitable for darker skins up to skin types 6. Usually the skin needs to be prepped using a milder peeling agent such as AHA. This will not give a one-off result and, like many other options, it will be necessary to use it regularly to maintain results. A phenol peel is the strongest that can be safely used. This penetrates the skin to the lower levels, giving a better result. However, the downside is that it may need to be given under a general anaesthetic, which carries its own risks. It will also create a scab on the skin that requires on-going care and maintenance to ensure it doesn’t become infected. This peel leaves the skin requiring future sun protection at all times.

Surgical facelift

This is clearly a drastic option and is not endorsed as a scar treatment in itself. It may help to stretch the skin to reduce the appearance of scars. Only a plastic surgeon will be able to give advice on this option, which will require an expensive operation.

Micro needling

This involves using a gadget, such as a Dermaroller, to stimulate collagen, either in a salon or at home. It looks similar to a cotton reel covered in fine needles approximately 1 mm long, attached to handle to help it to be rolled easily over the skin. Although simple, the design is quite sophisticated and it is usually made of stainless steel. The device is rolled gently over the skin, and although it may tingle, it should not draw blood. The more often it is use the better and longer lasting the result, so it is recommended to be used daily. So it could be used in conjunction with other acne or scar treatments.

Disguising acne scars

While the ultimate aim of treating acne is to reduce the chances of developing scars, this is not always possible. Many scars will fade over time, leaving little or no permanent marks. However, as we have seen, some scars are deep and may require surgery or invasive procedures to help remove the damaged skin. Anybody either waiting for their scars to fade or undergoing treatment can use skin camouflage. This is still a relatively unknown choice, for several possible reasons:

• It is perceived as being make-up and therefore exclude all those who would not normally wear it - men and children.
• It is not usually recommended nor fully understood as an option, by healthcare professionals. This is usually because they don’t know enough about it.
• Access to an expert in skin camouflage is available in many dermatology departments through the British Red Cross, although availability varies around the UK.

Although scarring may be unavoidable to some people, for others it can be prevented by taking swift action to proactively treat acne as soon as it appears. Some might consider scarring to be a result of failed treatment, but despite our best efforts it may simply be impossible not to get some scars. Treatment options are mostly expensive and may be quite invasive, but technology developments may see more choice in the future.