Years after outgrowing acne, the aftermath of acne scars persists. Advances in acne therapy and dermatologic surgery have made it unnecessary for acne patients, both current and past to endure acne scarring.
An Ounce of Prevention
Prevention may sound like a glib answer to how to handle acne scars. But since an estimated 10 million Americans become scarred to some extent by acne each year, intervention is by far the best solution.
Who will develop acne scars and how severe will scarring be? Short of a crystal ball, much of that is left to chance. What we do know is that genetics play a definite role in the likelihood of acne severity and consequent scar formation. Also, the severity of preteen acne lesions is linked to a more severe form of scarring later in adolescence or adulthood.
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Because 95 percent of acne patients will develop scarring to some degree, the earlier the treatment appropriate for the severity of the outbreak is initiated, the better the odds are that scar formation will be mild. Delaying acne therapy by three or more years is likely to increase one's risk of more significant acne scarring.
For the lucky majority, acne scarring is a minor annoyance, obvious to the one affected yet difficult for others to see. For some, however, acne scarring can cause devastating long-term emotional suffering. Teens may deal with depression, become withdrawn and lose self-confidence. (In fact, acne scarring has been cited as a risk factor for male suicide.)
Newer acne therapies make it needless for anyone to suffer from severe acne or develop scarring. Early medical intervention is key to preventing unnecessary disfigurement. While this doesn't mean that everyone suffering a solitary blemish or minor premenstrual flare-up should rush to schedule an appointment with a dermatologist, I can't stress enough that acne unresponsive to over-the-counter therapies should be evaluated by a specialist.
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PIH: The Great Fake Out
I lost count long ago of the number of acne patients returning for their initial 6 to 8 week follow-up concerned about their new acne scars, when, in actuality, there wasn't a scar in site. What they were really noticing was color change. This post-inflammatory hyperpigmentation (PIH) is not an acne scar. It is the normal remnant of the skin's inflammatory process.
For those with pale skin tones, this aftermath color change is usually pink, red or purple in color. Patients with darker skin tones may notice brown or black spots where their acne once was.
PIH can fade unassisted, usually within six to 12 months. Unfortunately, the darker the PIH, the longer it may take to resolve. It may also require some intervention in order to hasten the process. While PIH is not a true scar, when it lasts past a year, it certainly may feel "permanent.”
For areas that are brown in nature, the use of a skin bleaching agent can be very helpful in speeding up the clearing process. Both prescription and over-the-counter options can be effective.
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Sun avoidance is crucial as ultraviolet light will darken the skin, preferentially darkening areas of abnormal discoloration. Sun protection prevents this process, allowing bleaching treatments to work without interruption.
Cause and Effect
As an acne cyst forms, the neck of the sebaceous gland expands, filling with bacteria, cells and sebum that are unable to pass through to the skin's surface. Eventually the cyst ruptures this "foreign matter" deep within the dermis, quickly attacked by white blood cells responsible for fighting infection.
Topical vitamin A creams and gels can both prevent and clear blemishes before they lead to scar formation, making them an important tool in acne therapy. Many excellent prescription options are available. While not recognized by the FDA for acne therapy, over-the-counter retinol in the 0.4-1.0 percent range can have a beneficial effect by helping to clean out debris from clogged pores.
All acne scars are not alike. A forceful inflammatory response can have two results. The most common outcome is loss of tissue as collagen is destroyed. Skin overlying the collapse of the area is provided no support and a soft saucer-shaped depression (aka pock mark) or jagged ice pick scar is formed. This is more typical on the face and is seen in both men and women.
Less frequently, excessive scar tissue (keloid) is formed as fibroblasts (the dermal cells which produce collagen) are triggered. This is more commonly seen on the male torso.
Patients are often surprised to discover that another skin change is in fact a form of acne scarring. Tiny firm white bumps surrounding hair follicles on the upper arms or upper torso are known as follicular macular atrophy. These scars can last indefinitely.
Aging can affect scar visibility. After the age of 40, 1% of the dermal collagen is lost annually. With this additional loss of collagen combined with reduced skin tone, scars can become far more noticeable.
Nobody wants to miss out on the "best" treatment. But when it comes to treating acne scars, there is often no single "best" solution that applies to an individual or to every acne scar. Differences in location, depth, size and number of scars all affect treatment decisions. What is your perception of the scars? Do they cause great anxiety or is this something that you'd simply like to improve if possible? These questions along with cost, your expectations and the amount of effort you plan to devote to the treatment will also be factored into the decision making by the physician.
Luckily, there are a number of new procedures now available that compliment or surpass previous scar-revision techniques. Individually designing a program aimed at the patient's unique situation will help maximize improvement.
There are two major categories of lasers used in acne scar therapy. They are the resurfacing (aka ablative) lasers and the non-ablative lasers.
Ablative lasers literally remove the outer layers of the skin, burning away scar tissue and stimulating the dermal collagen to tighten, reducing the amount of scar visibility. The ultrapulsed carbon dioxide laser and erbium YAG laser are most frequently used in laser resurfacing. The recently introduced Fraxel Dual combines an erbium laser with a more superficial light to simultaneously improve both acne scars and the associated discoloration. Downtime from these types of treatments is approximately one week. Typically, three to five treatment sessions are necessary.
Because the skin is injured and unprotected tissue exposed, great effort must be put into wound care and infection prevention. The skin may remain reddened for several months or a year afterwards.
Non-ablative lasers trigger changes within the dermis without injuring the epidermis. Smoothbeam is an approved laser for this treatment. Smoothbeam targets and heats the sebaceous gland, helping reduce oil production and acne formation. Heating the collagen helps tighten the dermis, resulting in less visible scarring.
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Fillers work best on shallow, saucer-shaped acne scars. The market has seen an increase in the number and ever-improving quality of filler substances used to help "plump up" acne scars. They have immediate results and last anywhere from three to 12 months depending upon the filler used.
Fat transplantation utilizes a patient's own fat removed by a small liposuction cannula, prepared and reinjected into the dermal defect. While none of these methods are permanent, results tend to last between three and six months.
Ice pick acne scars have hard, irregular jagged borders and often the depth is irregular as well. Simple excision of these scars with a sutured closure allows the dermatologist to bring the dermis back together, get rid of the ragged margins, and close the area with a fine, uniform line.
The tiny linear scar may be allowed to fade on its own or the procedure may be performed before a more generalized resurfacing is performed such as dermabrasion, microdermabrasion, chemical peel or laser resurfacing.
In this procedure, the dermatologist undermines the acne scar with a sharp instrument such as a tiny scalpel or needle. Subcision helps break fibrous bands of scar tissue that are creating tension between the epidermis and deeper structures and also helps induce new collagen formation.
In dermabrasion, the skin is anesthetized and frozen and an extremely sharp rapidly rotating blade sheers away damaged tissue. This procedure, the equivalent of deep sanding, has fallen out of favor with the availability of newer, easier techniques.
A chemical peel involves the application of a high-potency acid upon the skin. The more potent the acid, the deeper the penetration into the skin. Personally, I find this more beneficial for post inflammatory skin color changes and the most minor of acne scars.
Topicals for Atrophic Scars
Everyone always wants to know what topicals can help resolve acne scars. Certainly anything that has been shown to help stimulate collagen bundle formation, such as the use of a topical vitamin A creams (which help with exfoliation as well as stimulate collagen) or antioxidant-packed rejuvenating creams (often containing vitamin C), seem like logical choices.
These are certainly options I do encourage those with acne scars to take. I do think that the reality is that a procedure is going to maximize your results, whether done alone or incorporated with a topical agent.
Acne scarring is no longer a problem without a solution. All of the techniques I described have become invaluable treatments for patients seeking to eradicate acne scarring. But never forget, scarring is preventable. Don't put off acne therapy. The earlier it's dealt with, the less likely acne scars will be in your future. Prevention is the best and most effective form of treatment.