The fact that acne plagues us in the present should be enough, but zits have a tendency to leave their mark in the months — and even years — that follow. From post-inflammatory hyperpigmentation (PIH) that frustratingly lingers far beyond its welcome to deep scars that permanently disrupt our skin’s texture and integrity, acne is an unkind and unforgiving beast.
“All types of acne scars are caused by a significant inflammatory process in the dermal layer of your skin,” explains Dr. Rosalyn George, a board-certified dermatologist based in Wilmington, North Carolina. “This causes tissue damage and subsequent scarring. I have found that even mild acne can leave significant scarring, which can have long term impacts.”
She stresses the importance of seeking the assistance of a dermatologist early in your acne “journey.” Not only can a medical professional help you determine the cause of your acne and get on a treatment plan — saving you years of emotional turmoil and expenses — but doing so can also curb scarring.
If you’re beyond the treatment stage and are left with residual acne scars, you and your skin are not forever doomed. The good news is that we live in an era when treatments for acne-related scarring are accessible and continue to improve in efficacy. Below, we’ve broken down the three types of acne scars — atrophic, hypertrophic, and post-inflammatory — and outlined the best treatment options for each.
Atrophic / Depressed Acne Scarring: Ice Pick, Boxcar, and Rolling Scars
Atrophic acne scars look like indentations or depressions in the skin and are the result of inflammation that has damaged collagen production. There are a handful of marks that fall into this category, including ice pick, boxcar, and rolling scars.
“Ice pick acne scars appear as small, deep, vertical punctures in the skin and can be some of the most difficult to treat,” says Dr. George. “My first line therapy for these types of scars are using what is called the TCA (trichloroacetic acid) cross method, where a higher concentration of the acid is placed with a toothpick-type applicator.” This causes an inflammatory response in the area, which in turn promotes collagen production, reducing the depth and appearance of the scar.
However, some ice pick scars are so deep that they require a more intensive treatment approach. In such cases, they’re treated with what’s called a “punch excision.” The scar is actually removed with a cookie-cutter type device and then the area is sutured. Basically, your dermatologist is replacing the existing, deep scar with a more shallow, superficial scar. They then monitor and treat the wound to ensure it heals correctly — without the depth of the previous scar.
“In some cases, we use a punch elevation, where no tissue is removed,” explains Dr. George. For this treatment, the same punch tool is used to elevate the skin (without excising it!). It is secured with a stitch or tape, and then allowed to heal. “This helps even out deep scars, the doctor adds.”
Rolling atrophic scars aren’t as deep as ice pick scars — they resemble the texture of an orange peel — and therefore are much easier to treat. Boxcar scars are similar in depth, too, only they take a larger, oval shape (similar to a chicken pox scar). The treatment approach for both is similar. Dr. George says that she usually uses a combination of treatments for these marks, depending on the patient’s age, skin response, and severity of the scarring. As a rule, though, the goal is to cause small skin injuries to stimulate collagen production and remodeling.
“I look to chemical peels for the more superficial scars,” notes Dr. George. “You can do multiple lighter peels with products like salicylic acid, glycolic acid, or Jessner's solution [a proprietary blend of lactic and salicylic acids and resorcinol].” She adds that laser treatments can also be effective. “They can either be ablative — which removes damaged tissue and helps remodel collagen — or non-ablative lasers, which don't remove tissue but help remodel collagen.” The most common types of ablative laser are CO2 and Erbium:Yag lasers and the most common non-ablative laser is Fraxel®. To learn more about laser treatments, go here.
Dr. Gerald Imber, a board-certified plastic surgeon in New York City, notes that laser resurfacing is one of his preferred methods for treating minor atrophic acne scarring. He says, “The theory behind this is to smooth down the edges of the scars, which encourages collagen growth in the depression. The overall effect is a smoother, more even skin surface.”
Microneedling is yet another treatment option for shallow atrophic scars. Dr. George says that the ones intended for at-home use (and in non-medical spas) are very superficial and probably not deep enough to truly affect these deeper types of scars. However, the microneedling tools used by medical professionals can be adjusted to go further into the skin to help smooth those deeper scars.
“There are also microneedling devices with radiofrequency that combine the benefits of microneedling with the benefits of deeper collagen remodeling with the heat from radiofrequency,” she says. “The icing on the cake in my practice is the addition of PRP (platelet rich plasma), which seems to enhance the healing and overall results from either laser, microneedling, or microneedling with radiofrequency.”
Hypertrophic Acne Scarring: Raised Scars and Keloids
Sometimes the skin’s response to acne-related inflammation and infection isn’t to atrophy. Rather, it does the opposite. Dr. Imber says, “This acne scarring is the result of collagen overgrowth, and results in hypertrophic, or raised scars [sometimes called keloids].”
In addition to being raised, they also tend to be pinker in color compared to surrounding skin. Keloid acne scars rarely occur on the face. Instead, they’re more likely to develop on other parts of the body with little underlying fatty tissue, including the back and chest. They’re the rarest form of acne-related scarring, but Dr. Imber and Dr. George both agree keloids are the most difficult to treat.
As a result, it’s also likely that keloid scars will require the most rounds of treatment. In her practice, Dr. George typically starts by injecting the area with a steroid to help soften the tissue, then using a pulsed dye laser like the VBeam Perfecta® to help reduce redness and remodel collagen. “This process can be very slow and will require multiple treatments — sometimes up to 12 — to get noticeable results,” she says.
If you can’t get into a doctor’s office just yet, Dr. George adds that at-home massage and topical scar creams can also help improve the appearance of keloid scars. In particular, she recommends SkinMedica® Scar Recovery Gel ($44) and Stratamed® Scar Gel ($35).
The third form of acne-related scarring is post-inflammatory hyperpigmentation (PIH), which is also referred to as post-inflammatory erythema (PIE). Medically speaking, this residual inflammation isn’t considered a true scar since it may eventually heal on its own over time. That said, there are a handful of ways you can expedite the healing process.
These darker spots are best improved with topical brightening treatments. “Four percent hydroquinone is often used,” notes Dr. George, “but other products containing tranexamic acid, kojic acid, niacinamide, and botanicals like arbutin and licorice have been shown to lighten the skin.” We’re particularly fond of Paula’s Choice RESIST® Pure Radiance Skin Brightening Treatment ($36), which contains both niacinamide and licorice to help reduce the dark color of some PIH.
[Editor’s note: Talk to your doctor to see if and what topical treatment may be right for you.]
If your marks tend to be red rather than a dark color, pulsed dye laser can help improve their appearance by targeting the redness with light. Whatever you choose, note that extended or unprotected exposure to the sun can exacerbate PIH, which makes sunscreen application doubly important. We recommend selecting a product that’s specifically intended for acne-prone or sensitive skin, like Shiseido® Ultimate Sun ProtectionTM; Lotion Broad Spectrum SPF 50+ WetForce® for Sensitive Skin & Children ($42)
Ultimately, though, it’s essential to recognize that every person — and their skin — differs, and so will treatment. That all depends on your type of scar, its intensity, your skin’s type, and how responsive it is to different procedures. It’s essential that you visit a dermatologist so he or she can thoroughly assess your skin and work on a personalized treatment approach.
Dr. Rosalyn George is a paid Allergan® consultant.
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