Acne Scars

Acne can be a devastating disorder – not only is it frustrating to have active acne in the form of spots, redness and pustules, these lesions can leave their mark in the form of scars and dark spots.

Before we talk about acne scarring, let’s address the difference between scarring and dark spots. When people call our clinic they will ask me about their acne “scarring”, but quite often what they really mean is the dark spots left over from an acne breakout. This is not “scarring”, this is actually called hyperpigmentation – also called post-inflammatory hyperpigmentation. It is often abbreviated to PIH.

When we talk about scarring, we mean marks on the skin where it is pitted or depressed. There are several types of acne scars.

Icepick: Looks like an ice pick has been pressed into the skin. It is generally small in diameter, but can be shallow or deep.
Box: Looks somewhat like a chicken pox scar with more rounded edges. It can be small or large in diameter and is fairly deep, though not usually as deep as icepick scars.
Rolling: Looks like a smooth indentation in the skin. These scars can be deep or shallow, but are generally shallower.
Hypertrophic: Otherwise known as keloids which are the excess growth of scar tissue at the site of a healed skin injury. These types of scars usually take a more aggressive medical modality to see results. The following is a list of those modalities, most of which are performed in a doctor’s office:
Subcision (aka Subcutaneous incision) is a technique in which a depressed acne scar is lifted to the skin surface with a surgical instrument such as a tiny scalpel or needle. The deep portions of the scar are released and the surface elevates with the wound repair process. Several treatments are usually necessary and are performed under local anesthesia to eliminate discomfort. This procedure causes bruising which fades after about 1 week.

TCA CROSS (chemical reconstruction of skin scars) is a method in which trichloracetic acid is used to spot treat each scar. During the treatment, a high concentration of Trichlorocetic acid is introduced just inside the scar. The resurfacing response that occurs inside the depression stimulates collagen production which eventually causes the scar to rise up and close in on itself. Results of this treatment can vary; and we are presently doing clinical trials with this process.

Fillers There are various types of fillers used for acne scars. We will mention a couple of them – Restylane®, a clear, synthetic gel made with hyaluronic acid. Silicone is another filler commonly used on acne scars. Both Restylane® and silicone are injected into acne scars to raise the surface of the skin and give a smoother look. Fillers do not last – they are a temporary solution to acne scar removal.

Scar Excision (aka Punch Excision) is a surgical method of treatment uses a scalpel or punch to remove the scar. Under local anesthesia, the scar is excised and the skin edges are then sutured together. The newly produced scar eventually fades and may not be noticeable. If it is noticeable, it is more amenable now to resurfacing techniques. Excision is typically recommended to patients with deep pitted scars that are not amenable to the TCA CROSS technique.

Punch Elevation is a surgical method of treatment that uses a scalpel or punch to excise the base of the acne scar leaving the walls of the scar intact. The excised base is then elevated to the surface of the skin and attached with sutures, steri-strips, or skin glue. This method lessens the risk of color or texture differences as can be seen with graft replacement, and lessens the risk of producing a visible scar as can be seen when wound edges are sutured.

Laser Skin Resurfacing

Ablative lasers: Using the Erbium:YAG or CO2 laser, the skin is removed layer by layer which eliminates the scar’s surface. Simultaneously, heat produced from the laser tightens the skin, which helps to smooth out the scars. This method has a significant recovery time and is used less frequently since the advent of the Fraxel™ laser.

Nonablative lasers such as fractional laser, Smoothbeam and pulsed dye lasers do not remove layers of skin, but instead penetrate through the skin in an attempt to stimulate collagen growth from underneath the surface of the skin.

Dermabrasion or surgical skin planing, is a surgical procedure in which a surgeon removes or “sands” the skin with a rotary abrasive instrument which improves its contour and gives it a smoother appearance. Recovery from this treatment may take several weeks; but if done by someone skilled in this technique , the results can be very good.