Acne Scarring

Acne scars are common and their impact can be as distressing or of even greater concern than ongoing acne. Scarring is common and can be particularly marked in those who have experienced severe acne (with tender cysts and nodules) and also in those with persistent and ongoing acne breakouts.

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If acne scars have a negative impact on self-esteem and confidence the good news is there is a growing range of effective treatments spanning skin care through to lasers, energy-based devices and injectables.

  • Treating acne early and effectively helps prevent scars
  • DON’T pick or squeeze pimples as this also contributes to and worsens scarring

Are my acne scars severe?

If acne scarring is having a negative impact on how you feel about yourself or reduces your confidence, you should explore safe and effective treatment options.
The clinical severity of acne scars (scored by your health professional) is not accurate at assessing the distress caused by acne scars. When assessing acne scar severity, you will also be asked to tell us and quantify and share the impact your acne scars are having on you and your life.

What are Acne Scars and why has my skin scared so badly due to acne?

The inflammation that occurs in acne can be particularly damaging and destructive to many of the skin’s normal components and can lead to an abnormal healing response. The inflammation (the blood’s white cells along with cytokines that regulate the body’s immune response) in acne is not confined to the hair follicle where acne lesions start. As the walls of the hair follicles become blocked and distended, this inflammation leaks into the surrounding skin, collagen, and even subcutaneous fat layers. When hair follicles rupture and discharge their contents which includes shed skin cells, irritating oils, and microbes the inflammation that results can be particularly severe and damaging.

This inflammation can lead to damage and loss of normal tissue producing skin depressions (known as atrophic scars) and loss of pigment (hypopigmented scars).

Healing of skin injured by acne inflammation can also be abnormal leading to too much tissue (e.g. hypertrophic or raised itchy, painful and tender keloid scars) along with fibrosis (where the scars are tethered or pulled in by abnormal thick short bands of collagen) to cause depressed sunken skin areas.

Acne scars are permanent, discoloured, and textural changes on the skin that occur because of inflammatory acne lesions. To assist in the targeted treatment of acne scars, acne scars are classified into several different types.

Types of Acne Scars:

  1. PIE & Persistent Red Marks: Some redness (Post-Inflammatory Erythema) after an acne lesion flattens is normal (fading over weeks) but this can also be persistent and prolonged and associated with ongoing skin damage (loss of collagen).
  2. Atrophic Scars: These scars appear as depressions or pits on the skin’s surface and are further classified into three subtypes:
    1. Icepick Scars: Deep, narrow scars that resemble small puncture marks.
    2. Boxcar Scars: Broad depressions with defined edges, similar to chickenpox scars.
    3. Rolling Scars: Wavy or rolling texture caused by loss of collagen and subcutaneous fat plus bands of fibrous tissue that pull the scared skin inwards forming deeper depressions.
  3. Hypertrophic and Keloid Scars: These scars result from excess collagen production during the healing process, causing raised, thickened areas on the skin. Hypertrophic scars remain within the boundaries of the original acne lesion, while keloid scars extend beyond them.
  4. Post-Inflammatory Hyperpigmentation (PIH): PIH refers to darkened patches or spots that develop after acne lesions have healed. While not true scars, they can persist for months or even years.

Acne Scar Treatment Options:

  • There is a growing range of safe and effective acne scar treatment options.
  • Like the many types of scars caused by acne there are many different treatments and treatment approaches
  • Best results often require both a combined treatment approach (e.g. acne scar surgery, targeted chemical peeling of scars, subcision, combinations of lasers +/- dermal filler including biostimulatory fillers) and multiple treatment sessions
  • Different options may be suggested based on both acne scar type, their severity plus your skin type (skin colour and risk of PIH).

Your acne scar treatment plan can be tailored depending on your available downtime and consideration of treatment risks. For effective severe acne scarring management, optimal treatment does best involve downtime for healing and recovery. Stronger scar treatments in people with darker skin types can be associated with the occurrence of transient post inflammatory hyperpigmentation amongst other risks.

Topical (cream and serum) Treatments

Over-the-counter or prescription creams, gels, or serums containing ingredients like retinoids, alpha hydroxy acids (AHAs), or vitamin C can help improve mild acne scars and PIH. These products work by promoting cell turnover, reducing discoloration, and stimulating collagen production. Effective acne control also helps prevent new scars from forming.

Chemical Peels (including TCA CROSS)

Chemical peels involve the application of a chemical solution to the skin, which exfoliates the outer layers and encourages new skin cell growth. They can be effective in treating superficial acne scars and PIH.

A strong peeling agent (Trichloracetic Acid TCA) can also be used at high concentration painted carefully to the sides or ‘shoulder’ of punched out acne scars (ice pick and small box car scars). This really targets the scars (CROSS Chemical Reconstruction of Skin Scars). A series of 3-6 treatments is often involved.

Microneedling and Radiofrequency (RF) Microneedling

This procedure uses a device with tiny needles to create controlled micro-injuries in the skin, stimulating collagen production and remodelling. Microneedling can help improve the appearance of atrophic scars and enhance overall skin texture.

Radiofrequency (RF) Microneedling involves both needling but also the delivery of electrical energy at predetermined skin depths to address acne scar changes. This leads to collagen or scar contraction along with a ‘normalising’ skin healing process which sees the production of new collagen and elastin.

RF Microneedling (Secret and Candela Matrix) is a good option for atrophic acne scars (depressed ‘soft’ scars) but also reduces ice pick scars and improves box car scarring (combined treatments lead to greater benefits). Ablative Fractional Radiofrequency treatments can also be helpful but these do not go as deeply in the skin as the RF microneedling and on their own are not as effective for deeper acne scars.

Laser and Light Therapies

The laser or combination of lasers chosen depends on your scar type, their severity and downtime available.

For red scars and minor textural skin scarring the combination of Pulsed Dye Laser (Candela V Beam Prima 595nm) and Intense Pulsed Light (IPL Candela Nordlys) is considered.

Non-Ablative Fractional Laser (NAFL Frax style laser including Frax Pro 1550nm by Candela or ALMA Hybrid 1570nm) is helpful for less severe forms of acne scarring. The fractionated nature helps normalise skin changes (colour, texture and collagen loss) with the infrared wavelength leading to collagen contraction and new collagen and elastin formation. We often combine Vascular Laser / IPL with NAFL treatments.

Ablative Lasers (CO2 laser is our gold standard treatment in severe scaring).

CO2 lasers (CO2RE, Fraxis Duo and ALMA Hybrid) are our go to treatment in those with more severe scarring. This can be used to ablate and vaporise (surgically remove) deep ice pick scars or fully resurface and contract and help fill box scar scars. The fractional mode is good for rolling scars where collagen is contracted and healing leads to more normal collagen production. Fractionated treatments can also assist with scars that have lost pigment (hypopigmented or white acne scars).

Often the Hybrid Laser (ALMA) is a good option which combines both CO2 laser and NAFL in the same treatment allowing a greater amount of the skin to be treated without the same downtime as pure CO2 laser ablation and by firing through the same ‘hole’ can allow deeper scars to be treated more effectively.

Pico and Q-switched laser

Where pigmentation (PIH post inflammatory hyperpigmentation) is an issue Candela Nordlys IPL is an option or Q switched and PicoLaser. In darker skin types with less severe acne scarring the PicoLaser (fractionated with pulse stacking) can be used to target problem skin areas with less risk of transient pigment disturbance or downtime (PicoWay Resolve).

Dermal Fillers

Injectable dermal fillers containing substances like hyaluronic acid can temporarily raise depressed acne scars, making them less noticeable. This approach provides immediate results, but the effects are temporary and require repeated treatments.

Biostimulatory fillers are also useful for treating acne scarring. These provide a scaffold plus stimulus for new collagen and elastin production with the aim of longer lasting skin changes or scar revision.

Surgical Interventions

For larger deep scars (>3mm in diameter) surgery may be recommended before laser treatment. This involves small circular punch removal or excision of the scars. Laser can then be utilized to blend in the treated areas (doing a NAFL before surgical interventions has also has been shown to minimise any new scarring due to surgery).
Acne scars if not treated see accelerated photoaging as people get older with increasingly lax skin. For older patients with severe scarring a face lift can be beneficial (Plastic Surgery).

Subcision Acne Scar Revision

This is utilized for rolling (depressed) and tethered (pulled in by fibrous bands) acne scars. This can be performed in combination with other treatments including laser and dermal filler injections.

Techniques for subcision have evolved and this is now performed in multiple layers to address the different skin layers acne scars can affect. The cannula method is our current preference as this can reduce your recovery time and carries reduced risks including bruising or haematoma formation (collection of blood).

During this procedure local anaesthetic (‘tumescent’) is utilized

New promising treatments

Laser Assisted ‘Drug’ and Cosmeceutical Delivery

Every time we use a fractionated laser or energy device to treat acne scars we also take advantage of the increased delivery of actives to deeper layers of the skin to both speed healing and shorten recovery times plus to improve collagen response and reduce risk of transient uneven pigmentation due to laser. Poly-L-lactic acid (PLLA) and even insulin are used to increase collagen production after laser, Vitamin C and E also speed healing and reduce risk of pigment disturbance, other agents are utilized to encourage pigment cells (melanocytes) to help repair scars with reduced or disturbed pigment cell function.

HiFU or Microfocused Ultrasound (Ultraformer MPT)

If significant skin laxity has occurred in association with ‘atrophic’ acne scars microfocused ultrasound can be considered. With new more effective and better tolerated devices that combine ultrasound enhanced skin delivery of actives this may become a treatment option as part of a combination treatment approach.

Skin of Colour

With darker skin types where post inflammatory hyperpigmentation risks after scar treatments are elevated this needs to be factored into treatment plans. Radiofrequency needling has a much lower risk of pigmentation disturbance as does PicoWay laser. These could be good options for appropriate scar types and scar severity. If a stronger laser treatment is required, post inflammatory hyperpigmentation should be expected including the need to treat or address this as part of your acne scar treatment.

Get in touch with our medical team to help determine a tailored and suitable approach and plan for your acne scar treatment program. Consultation with a dermatologist is essential to help you choose the most suitable tailored approach. Our team of dermatology nurses however work closely with our dermatologists and can be consulted for initial scar assessment and management advice.

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