As if acne wasn't distressing enough, acne scarring seems doubly unfair. Acne scars are hard to cover with makeup because the indentations cast a shadow, especially on soft areas like the cheek. (Which isn't much consolation for men!) Facial scars can really damage self-esteem because they are just so visible.
Fortunately, there are lots of acne scar treatments available to help smooth scar tissue.
What is Acne Scarring?
Most scars occur when inflammatory acne (nodules and cysts) burst open and damages collagen in the deeper layers of the skin. The skin tries to heal itself by producing new collagen fibers, but these rarely blend seamlessly into the surrounding skin.
There are three different types of scar formation:
As the skin heals, too much collagen is produced, resulting in a thick, raised, red, keloid scar which is most common on the upper body, jawline and neck.
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As the skin heals, not enough collagen is produced, resulting in indentations. There are three types of atrophic scarring:
Ice pick scars: Small deep holes in the surface of the skin, found mainly on the cheek. These are the most difficult scar to treat.
Rolling scars: Strands of scar tissue develop under the skin and make the surface look uneven. Usually found on the cheek.
Boxcar scars: Round craters in the skin with sharp edges.
These red scars stain the skin for months after acne has cleared up, but can darken in olive and darker skin types.
Treatments To Remove Scar Tissue
Bear in mind that no treatment can eradicate scaring completely. An experienced practitioner will manage your expectations and recommend a layered approach specifically for your skin. For example, surgical revision or ablative laser resurfacing to remove the scar tissue followed by non-surgical treatments and a dermal filler to smooth the skin.
Dermabrasion uses a high-speed brush to remove the top layer of skin in order to reduce the depth of the scar and blur the edges of large scars. However, it's less effective at solving ice pick and deep boxcar scars. (Read Microdermabrasion Vs. Dermaplaning: 5 Ways to Find What Works For You.)
Ablative Laser Resurfacing
Ablative lasers have largely replaced dermabrasion and strong peels because there are fewer complications. Though they can remove a more controlled area of scar tissue than dermabrasion, there's still considerable downtime.
Multiple rolling scars respond well to ablative lasers such as fractional co2 combined with radiofrequency to tighten the skin around the scar.
Rolling scars can be removed surgically using either a needle or microblade to break up the scar tissue, which pushes the scar tissue upwards. Facial subcision can sometimes be done as an outpatient but expect the skin to be inflamed for a couple of hours afterwards.
Large sunken areas on the cheek, however, will require multiple sessions which are often combined with fractional radiofrequency and the dermal filler Sculptra.
There are three types of punch techniques used to treat ice pick and boxcar scars.
Punch Excision: Mild ice pick scars can be surgically removed by punch excision followed by non-surgical treatments to stimulate collagen to plump the skin.
Punch Grafting: Very deep ice pick scars can be surgically removed, then filled with a small skin graft.
Punch Elevation: Boxcar scars can also be surgically removed. The base of the scar is removed, then lifted until it is level with the surrounding skin and reattached to the sides of the scar.
Non-Surgical Options to Smooth the Skin
Non-surgical treatments stimulate collagen production to smooth the skin and help it blend in with the surrounding skin. They are often used once the scar tissue has been removed by surgery or ablative lasers.
Non-ablative lasers are more suited to mild and moderate acne. A different wavelength is used to stimulate new collagen which smooths out the skin without damaging the surface. As the injured scar heals, the new collagen smooths out the scar.
They have become popular because of less skin damage and therefore less downtime, but a course is needed. They're more suited to scars which are only slightly raised or for blending soft indented scars in with surrounding skin and are best combined with cortisone and retinoid creams.
However, raised scars respond better to an ablative laser which is strong enough to vaporize excess tissue.
These reduce blood flow through the scar and are extremely effective in treating large areas of red and inflamed scars. However, multiple treatments are needed and there is a risk of bruising.
Fractional radiofrequency tightens and lifts the skin around sunken and ice pick scars, so they are less noticeable. Radiofrequency has a pixel effect on both the surface and deeper layers of the skin and is often used following ablative laser resurfacing and dermal fillers. It's also safe for darker skins.
Small sunken scars can be filled with hyaluronic acid but larger areas are more suited a longer lasting filler such as Sculptra which stimulates collagen production to fill out scars. Sculptra is often used following subcision and radiofrequency and is also good for darker skins.
Cortisone Cream or Injection
Steroid injections can help flatten thick keloid scars and are commonly used following fractional lasers and radiofrequency. (The laser helps the cortisone cream to penetrate into the scar). Make sure you see an experienced dermatologist to avoid the risk of thread veins.
A course of light peels is popular for reducing red scarring, especially combined with IPL. However they only act on the top layer of skin, so even though small depressed scars may look better afterwards, this is mostly temporary swelling caused by irritation.
Light microdermabrasion has little effect on sunken scars, but deeper microdermabrasion risks bruising and irritation. It's suited for rolling rather than ice pick scars.
Although it's hard to resist, squeezing even a small spot can spread bacteria and lead to a scar. It's so important to seek treatment for acne straight away and prevent scarring in the first place. Scarring is unpredictable because everyone heals differently, but recent scar tissue is so much easier to treat.