Acne Scarring—What You Need to Know

Jun 29

Acne scarring is one of the most distressing consequences of acne. Unlike the typical residual redness or dark spots that are left once acne resolves, scarring is permanent and difficult to treat. Scarring results from either inflammatory acne lesions or from any type of acne that has been manipulated (squeezing, popping, picking).

Learn more about the types of scarring that may occur following acne resolution—either spontaneous or after treatment—as well as different treatment options for each type.

Acne Scar Treatment Considerations

It isn’t known why some people are more susceptible to acne scarring, but older individuals tend to be at higher risk. Moreover, untreated scars tend to get worse with age, as our collagen and elastin repair systems become less efficient.
Acne scar treatments involve multiple sessions and generally aren’t covered by insurance, which can be costly.
Treatments have a variety of risks associated with them—find more details below.
Scars can never be completely removed—the best result is 40-80% improvement.
The location of acne scars determines the response to treatment. Scars on the chest, shoulders, and back are the most resistant and have the highest risk of complications from therapy.

Four types of scarring may occur. They all include textural change, which, in contrast to temporary post-inflammatory changes, is always present and is a defining characteristic of scarring. Scars can be either indented or bumpy. Treatments target each type of scar differently and are associated with different risks or complications.

Most patients have a combination of two or three types of scars and require two to three types of treatments. Some treatments need to be repeated monthly over a course of four to six months.

Ice Pick Scars

As the name suggests, these are very small but very deep scars that may appear after cystic acne resolution. They are generally spontaneous scars and not a result of picking. However, attempting to squeeze a deep cyst may cause a deeper scar than would have otherwise formed spontaneously. The depth makes them very challenging to treat. Most treatments do not penetrate the skin to the depth needed to treat ice pick scars.

The most effective treatment found in clinical trials to improve ice pick scars is TCA CROSS (which stands for Trichloroacetic Acid Chemical Reconstruction of Skin Scars) technique. It involves placing a very strong chemical peel (70%-100% TCA) directly into the scar. Great care must be taken in applying the chemical directly on the scar, as it is extremely caustic and may cause ulcerations and new scars.

When performed by a trained physician, it can be very effective at clearing the majority of small ice pick scars and reducing the appearance of larger ones. The procedure has a high patient satisfaction rate due to low downtime, low cost, and great effectiveness. However, it does require four to six treatment sessions.

Box Scars

These scars are also indented but are shallower than ice pick scars and have sharp geometric margins. They may form from cystic or nodular acne and, in some susceptible individuals, from more superficial inflammatory acne.

TCA CROSS can be beneficial in treating smaller box scars, but it’s not as effective for larger ones. Resurfacing procedures, such as ablative lasers and skin needling techniques, are more effective in treating box scars. In addition, deeper scars can be treated with excision and a technique called “punch elevation,” where a small incision is made around the depressed portion of the scar, then elevated to match the surrounding skin, and secured in place with a suture or steri strip.

There are varying risks and downtimes involved with each procedure and the cost range is large, with ablative resurfacing lasers carrying the highest risks and cost.

Rolling Scars

As the name suggests, these scars are also depressions in the skin, but without the sharp edges of box scars. These scars create an undulating surface in the skin, reminiscent of rolling hills (where the hills are actually normal skin and the valleys are the scars). Rolling scars can vary in their depth and are often a result of deep cystic or nodular acne or picking at inflammatory acne lesions.

Large rolling scars have a firm deep tethering underneath, which makes them resistant to most resurfacing procedures, chemical peels, or TCA CROSS. They must be treated with excision or subcision (using a sharp instrument to go under the scar to break up the deep tethering). Subscisions are most effective when used together with filler injections to further help elevate the scar tissue.

Shallow or small rolling scars may be treated with medium-depth chemical peels, non-ablative or ablative fractional resurfacing lasers, and skin needling.

Hypertrophic Scars and Keloids

These are the only elevated scars of the four types. Hypertrophic scars are bumps within the borders of the scar. Keloids are bumps that can grow quite large—way beyond the original scar or acne lesion. They form more commonly on the chest, shoulders and back. Keloids from acne seem to appear most in people who are prone to keloid formation from other forms of injury (such as ear piercings and tattoos).

Hypertrophic scars and keloids are treated with a series of steroid injections to flatten the scars, lasers to reduce the redness of the scars, and silicone sheets to help further flatten and reduce discoloration.

Prevention Is the Best Treatment

The best way to maintain smooth skin is to prevent scarring in the first place. Prevention is achieved by early initiation of appropriate acne therapy, as well as avoiding picking at active acne lesions.

If you have a type of acne that leaves scars, we recommend seeking help from a board-certified dermatologist to clear your acne as soon as possible and then, if needed, come up with a plan to treat residual acne scars.

Remember, the best treatment for acne scars is prevention!

Any questions? Consult one of our board-certified dermatologists. Please contact SSDP to schedule an appointment with any of our physicians.

Christine Urman, MD