A detailed and comprehensive discussion of acne scars starts with causes of scarring, prevention of scarring, types of scars, and treatments for scars.
Before talking about scars, a word about spots that may look like scars but are not scars in the sense that a permanent change has occurred: Even though they are not true scars and disappear in time, they are visible and can cause embarrassment. Macules or “pseudo-scars” are flat, red or reddish spots that are the final stage of most inflamed acne lesions. After an inflamed acne lesion flattens, a macule may remain to “mark the spot” for up to 6 months. When the macule eventually disappears, no trace of it will remain — unlike a true scar.
Post-inflammatory pigmentation is discoloration of the skin at the site of a healed (or healing) inflamed acne lesion. It occurs more frequently in darker-skinned people, but occasionally is seen in people with white skin. Early treatment by a dermatologist may minimize the development of post-inflammatory pigmentation. Some post-inflammatory pigmentation may persist for up to 18 months, especially with excessive sun exposure. Chemical peeling may hasten the disappearance of post-inflammatory pigmentation.
Causes of Acne Scars
In the simplest terms, scars form at the site of an injury to tissue. They are the visible reminders of injury and tissue repair. In the case of acne, the injury is caused by the body’s inflammatory response to sebum, bacteria, and dead cells in the plugged sebaceous follicle. Two types of true scars from acne exist (which we’ll discuss further momentarily): depressed areas such as ice-pick scars, and raised thickened tissue such as keloids.
When tissue suffers an injury, the body rushes its repair kit to the injury site. Among the elements of the repair kit are white blood cells and an array of inflammatory molecules that have the task of repairing tissue and fighting infection. However, when their job is done they may leave a somewhat messy repair site in the form of fibrous scar tissue or eroded tissue.
White blood cells and inflammatory molecules may remain at the site of an active acne lesion for days or even weeks. In people who are susceptible to scarring, the result may be an acne scar. The occurrence and incidence of scarring is still not well understood, however. There is considerable variation in scarring between one person and another, indicating that some people are more prone to scarring than others. Scarring frequently results from severe inflammatory nodulocystic acne that occurs deep in the skin. But scarring also may arise from more superficial inflamed lesions. Still, nodulocystic acne is the most likely to result in scars.
The life history of scars is also not well understood. Some people bear their acne scars for a lifetime with little change in the scars, but in other people the skin undergoes some degree of remodeling and acne scars diminish in size with time.
People also have differing feelings about acne scars. Scars of more or less the same size that may be psychologically distressing to one person may be accepted by another person as “not too bad.” The person who is distressed by scars is more likely to seek treatment to moderate or remove the scars.
Preventing Acne Scars
The occurrence of scarring is different in different people. It is difficult to predict who will scar, how extensive or deep scars will be, and how long scars will persist. It is also difficult to predict how successfully scars can be prevented by effective acne treatment.
Nevertheless, the only sure method of preventing or limiting the extent of scars is to treat acne early in its course, and keep treating it for as long as necessary. The more that inflammation can be prevented or moderated, the more likely it is that scars can be prevented. Any person with acne who has a known tendency to scar should be under the care of a dermatologist or cosmetic specialist.
Types of Acne Scars
There are two general types of acne scars, defined by tissue response to inflammation: scars caused by increased tissue formation (which are usually raised), and scars caused by loss of tissue, which appear as indentations.
Scars caused by increased tissue formation are called keloids or hypertrophic scars. The word hypertrophy means “enlargement” or “overgrowth.” Both hypertrophic and keloid scars are associated with excessive amounts of the cell substance collagen. Overproduction of collagen is a response of skin cells to injury. The excess collagen becomes piled up in fibrous masses, resulting in a characteristic firm, smooth, usually irregularly-shaped scar. The photo shows a typical severe acne keloid:
(Photo used with permission of the American Academy of Dermatology National Library of Dermatologic Teaching Slides)
The typical keloid or hypertrophic scar is 1 to 2 millimeters in diameter, but some may be 1 centimeter or larger. Keloid scars tend to “run in families” — that is, abnormal growth of scar tissue is more likely to occur in susceptible people, who often are people with relatives who have similar types of scars. Hypertrophic and keloid scars persist for years, but may diminish in size over time.
Acne scars associated with loss of tissue — similar to scars that result from chicken pox — are more common than keloids and hypertrophic scars. Scars associated with loss of tissue include “ice-pick” scars, which usually occur on the cheek. They are usually small, with a somewhat jagged edge and steep sides — like tiny versions of wounds from an ice pick. Ice-pick scars may be shallow or deep, and may be hard or soft to the touch. Soft scars can be improved by stretching the skin, but hard ice-pick scars cannot be stretched out. Depressed fibrotic scars are usually quite large, with sharp edges and steep sides. The base of these scars is firm to the touch. Ice-pick scars may evolve into depressed fibrotic scars over time. Soft scars, whether superficial or deep, are soft to the touch. They have gently sloping rolled edges that merge with normal skin. They are usually small, and either circular or linear in shape.
Atrophic macules are usually fairly small when they occur on the face, but may be a centimeter or larger on the body. They are soft, often with a slightly wrinkled base, and may be bluish in appearance due to blood vessels lying just under the scar. Over time, these scars change from bluish to ivory white in color in light-skinned people, and become much less obvious.
Follicular macular atrophy is more likely to occur on the chest or back of a person with acne. These are small, white, soft lesions, often barely raised above the surface of the skin — somewhat like whiteheads that didn’t fully develop. This condition is sometimes also called “perifollicular elastolysis.” The lesions may persist for months to years.
Treatments for Acne Scars
A number of treatments are available for acne scars through dermatologic surgery. The type of treatment selected should be the one that is best for you in terms of your type of skin, the cost, what you want the treatment to accomplish, and the possibility that some types of treatment may result in more scarring if you are very susceptible to scar formation.
A decision to seek dermatologic surgical treatment for acne scars depends not just on the severity of your scars, but the way you feel about scars. Do your acne scars psychologically or emotionally affect your life? Are you willing to “live with your scars” and wait for them to fade over time? These are personal decisions only you can make.
Scar treatments that are currently available include:
Dermal filler injection. Hyaluronic acid, a normal substance of the body, is injected under the skin to “stretch” and “fill out” certain types of superficial and deep soft scars. Dermal fillers usually do not work as well for ice-pick scars and keloids. Benefits from this injection usually last up to 6 months, but then they must be repeated to maintain the appearance.
Autologous fat transfer. Fat is taken from another site on your own body and prepared for injection into your skin. The fat is injected beneath the surface of the skin to elevate depressed scars. This method of autologous (meaning from your own body) fat transfer is usually used to correct deep contour defects caused by scarring from nodulocystic acne. Because the fat is reabsorbed into the skin over a period of 6 to 18 months, the procedure usually must be repeated. Longer-lasting results may be achieved with multiple fat-transfer procedures.
Dermabrasion. Under local anesthetic, a high-speed brush or fraise used to remove surface skin and alter the contour of scars. Superficial scars may be removed altogether, and deeper scars may be reduced in depth. Dermabrasion does not work for all kinds of scars; for example, it may make ice-pick scars more noticeable if the scars are wider under the skin than at the surface. In darker-skinned people, dermabrasion may cause changes in pigmentation that require additional treatment.
Microdermabrasion. This new technique is a surface form of dermabrasion. Rather than a high-speed brush, microdermabrasion uses aluminum oxide crystals passing through a vacuum tube to remove surface skin. Only the very surface cells of the skin are removed, so no additional wound is created. Multiple procedures are often required but scars may not be significantly improved.
Laser Treatment. Lasers of various wavelength and intensity may be used to recontour scar tissue and reduce the redness of skin around healed acne lesions. The type of laser used is determined by the results that the laser treatment aims to accomplish. Tissue may actually be removed with more powerful instruments such as the carbon dioxide laser. In some cases, a single treatment is all that will be necessary to achieve permanent results.
Skin Surgery. Some ice-pick scars may be removed by “punch” excision of each individual scar. In this procedure each scar is excised down to the layer of subcutaneous fat; the resulting hole in the skin may be repaired with sutures or with a small skin graft. Subcision is a technique in which a surgical probe is used to lift the scar tissue away from unscarred skin, thus elevating a depressed scar.
At Rejuvé, we recommend that you meet with Dr. Tang to determine whether you might benefit from the available treatments and to determine which treatment modality is best suited for you. To schedule an appointment, call us today at 408-740-5320.
14410 Big Basin Way, Ste B, Saratoga, CA 95070 | (408) 740-5320
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