Acne scars are permanent textural changes and indentations that occur on the skin as a result of severe acne.
In severe acne, large pus-filled spaces known as acne cysts are formed. These cysts destroy skin tissue which is not replaced during the healing process. When the cyst eventually empties and the area heals, it usually leaves behind an indentation (or scar) on the face. On the chest and back the scarring can be lumpy (known as “hypertrophic” or “keloid” scarring).
Acne scarring on the face appears as damage to the skin texture with depressed (or indented) areas of various sizes. On the back and chest, scars tend be raised and lumpy. Scars are usually a normal skin colour. Some keloid scars can remain red for many years.
The following are the main types of acne scars.
- Box car acne scars
Box car scars are depressed scars which are shallow to medium in depth with well-defined edges, most commonly located on the cheeks and temples. Due to the relatively shallow depth, this type of scarring responds well to numerous treatments including full resurfacing, fractional lasers, dermal fillers and radiofrequency treatments.
- Ice pick acne scars
Ice pick scars are deep and narrow scars that extend into the lower layer of the skin. Due to the depth of ice pick scars, procedures such as fractional treatments are not as effective as TCA CROSS (trichloroacetic acid chemical reconstruction of skin scars). The foundation of ice pick scar treatment is either to raise the depth of scarring or excise (remove surgically) the pick itself. Procedures such as punch excision or TCA CROSS can improve deep ice pick scars. Once scars are raised up to a shallower level, laser resurfacing provides the finishing touches.
- Rolling, atrophic and depressed acne scars
Rolling acne scars appear as undulations and depressions on the skin. Some scar areas may be anchored to deeper structures. A number of methods can be used to treat rolling scars and tethered scars including subscision, fractional laser resurfacing, radiofrequency and dermal fillers. The basis behind scar revision is to free up bound scars and fill up depressions with collagen. This form of acne scarring will usually require several treatments for the best possible outcome.
- Mixed acne scars
This is the most common form of acne scarring. Most people will have a mixture of acne scars, including tethered or anchored scars, ice pick scars, box car scars and rolling scars. Different types of acne scars will require different treatments and a tailored approach to scar revision therefore provides the best outcome.
- Red acne scars – macular scars
Macular acne scars are commonly seen on the cheeks and forehead areas and present as red areas. They occur as a result of early acne scarring. This type of scarring can fade over 6 to 12 months without treatment however vascular laser treatment can sometimes hasten the resolution of scars. Several treatments are required for best results.
- Lumpy hypertrophic and keloid scars
This type of acne scarring results in lumpy red scars, most commonly seen around the jawline, neck, chest and back areas. Lumpy scars are best treated with a series of corticosteroid injections. Most people will require 2 to 4 injections spaced 6 weeks apart. Redness in scars can be treated with vascular lasers however 3 to 4 treatments may be needed for best results.
How is acne scarring treated?
There are many treatments available for acne scars which can improve and soften the appearance of the scarring. A combination of treatments may be required. It is unrealistic to expect the return to completely normal skin following treatment.
The following information describes the various methods of treating acne scarring.
- Laser treatments
There are two main types of laser treatments – ablative and non-ablative. Ablative (or wounding) lasers remove thin layers of skin. Non-ablative (non-wounding) lasers stimulate collagen growth and tighten underlying skin. Although non-ablative laser resurfacing is less invasive and requires less recovery time, it is less effective than ablative laser resurfacing for deeper scars.
- Fractional non-ablative (non-wounding) lasers
Variable wavelengths of fractional laser devices have been shown to improve acne scarring. They are best used for atrophic and rolling scars.
These lasers can cause some temporary redness but do not actually break the skin surface.
The advantages of non-ablative fractional lasers are rapid recovery times, the ability to treat darker skin types and higher safety profile.
Recovery time following fractional laser treatment ranges between 3 to 8 days. Most people will benefit from a series of fractional laser treatments (2 to 5).
- Ablative (wounding) lasers
Ablative lasers are the “gold standard” for the treatment of box car scars. There are two types of ablative lasers, fractional ablative and fully resurfacing.
The downside of ablative lasers is the longer recovery times which can be up to 2 weeks. Redness following ablative lasers is a common side effect.
- Radiofrequency (RF)
Radiofrequency is a non-invasive method of scar remodelling.
This treatment is best employed in early acne scars, atrophic scarring, rolling scars and in darker skin types.
New forms of RF incorporate skin needling which delivers higher energy deeper into the dermis (skin).
- TCA CROSS (Chemical reconstruction of skin scars)
This method uses high strength TCA (50-100%).
This form of scar revision is ideal for ice pick scars and can be safely used for all skin types. At higher concentrations this TCA acid is very strong, and high concentration treatments are only performed personally by Dr McCann.
2 to 3 treatments are ideal for best results.
This method uses a needle or cannula (which is a long slightly blunted needle), to break up scar tissue under the skin. This form of scar revision is ideal for tethered scars, rolling scars and areas of uneven texture that may be more noticeable with talking or smiling. This treatment requires considerable experience and skill, and is only performed personally by Dr McCann who has more than 9 years experience in cannula use with dermal fillers and 3 experience with cannula use in non surgical thread use, and has attended advanced facial anatomy training in order to safely perform this procedure. 2-3 treatments may often be required.
The ultimate goal for treating acne scars is improvement rather than complete disappearance or “cure”. The degree of improvement is dependent on the scar type and the skin colour of the individual.
Each person’s acne scars present as a unique challenge for the specialist. Treatments are tailored to each individual’s goals, tolerances, acne scar type and skin type along with the specialist’s preferences, equipment and expectations.
At Whitsunday Cosmedics Skin Clinic, we recommend all patients, other than those with very mild scars, book a consultation with Dr McCann to discuss treatment options. The safest and most effective treatment outcomes are achieved when a full examination of your skin is performed by an experienced doctor, and the type of scarring, your skin type, any tendency to Post Inflammatory Hyper pigmentation, ongoing active acne etc can all be assessed and the optimal treatment recommended.