How to treat acne scars - An overview of treatment options

AUTHOR - DR. DAVID JACK

Acne is often more than just a passing phase in our teenage years. For many, it leaves behind reminders in the form of scars, indentations, and hyperpigmentation. If you are affected by acne scarring, understanding your options for treatment can be the first step towards reclaiming confidence in your skin.

In this article, I will discuss the causes of acne scarring, explain how you can manage with skincare for acne scars, discuss home treatments for acne scarring and explore advanced treatments for acne scars.

Why does Acne Scarring Occur?

Acne scarring is a complex condition resulting from the interplay of inflammation, tissue damage, and disrupted repair mechanisms in the skin. At the heart of this process is the inflammatory response triggered by the proliferation of Propionibacterium acnes (P. acnes) within the hair follicles of the skin, known as ‘pilosebaceous units’. When these bacteria multiply in blocked hair follicles, they lead to the formation of comedones (whiteheads and blackheads). These can further progress into inflammatory lesions, such as papules, pustules, nodules, and cysts.

As the body tries to fight the bacterial infection, it releases inflammatory molecules, including cytokines and enzymes. While these mediators target the bacteria, they also cause collateral damage to the surrounding tissue, breaking down collagen and elastin fibres. The body then attempts to repair this tissue damage. If the repair process is optimal, the skin can heal without scars. However, if there's excessive collagen production, raised scars (hypertrophic or keloids) can develop. Conversely, if there's insufficient collagen as the skin heals, it leads to depressions or atrophic scars, such as ice pick, boxcar, or rolling scars. Factors like genetics, the severity and duration of acne inflammation, delayed treatment, and physical manipulation of lesions (like popping pimples) can influence the likelihood and severity of scar formation.

What are the different types of Acne Scars?

Acne scars can manifest in a variety of ways, and their appearance often dictates their classification. There are two main categories of acne scars: atrophic (depressed) scars and hypertrophic (raised) scars.

There are three subtypes of atrophic acne scars:

1. Ice pick scars, which are narrow, deep, and pitted
2. Boxcar scars, which are round or oval depressions with defined vertical edges
3. Rolling scars, which are wider, shallow dents in the skin that give it a wavy texture

Hypertrophic scars, on the other hand, are raised scars that stand above the surface of the skin, typically confined to the boundary of the original acne lesion, while keloids (a more extreme form) grow beyond the initial acne lesion's boundaries.

To standardise the assessment of acne scars, several grading systems have been developed. The Goodman and Baron is one such widely referenced system, grading scars on a scale from Grade 1 (macular) to Grade 4 (severe atrophic or hypertrophic/keloid scarring). Each grade represents a range of scar severity, allowing doctors to tailor treatments and track progress over time.

What about hyperpigmentation following acne?

Treatment Options

Effective acne scar treatment is often characterised by a process of trial and error, reflecting the intricate and individual nature of acne scarring itself. Each scar, unique in its depth, type, and location, demands a tailored approach, underscoring the essential need for exploring a range of treatments with an experienced practitioner to identify what works optimally for you as an individual. The multi-faceted aspect of acne scarring often necessitates a combination of treatments to achieve the most compelling results. The layering of different therapies gradually over time can address various aspects of scarring, from discoloration to texture irregularities, working synergistically to restore the skin's appearance more effectively. Visit one of our advanced practitioners to help create a plan for you. In our clinic, we offer a number of treatments for acne scarring including:

• Chemical Peels for acne scars
  Chemical peels for acne scars use various exfoliating agents like glycolic acid, salicylic acid, or trichloroacetic acid (TCA) that are applied to the skin, creating a controlled damage to the skin's surface layers. This process helps in shedding the old, scarred skin and stimulates the growth of a refreshed, smoother layer - stimulating production of new collagen and elastin. For those specifically targeting acne scars and hyperpigmentation, certain peels such as the Perfect Peel can significantly enhance skin texture and tone. Depending on the severity of the acne scarring, there are different peel intensities available — ranging from superficial (light) chemical peels, which offer gentle exfoliation with minimal downtime, to deep peels that can reduce pronounced scars but come with extended recovery periods.
• Microneedling for acne scars
  Also known as collagen induction therapy, microneedling uses fine needles to create hundreds of tiny, invisible puncture wounds in the top layer of the skin. This action triggers the body's natural wound healing process, stimulating new collagen and elastin production. This in turn can result in improved texture and contours of the skin, making stubborn acne scars less visible. Microneedling is a minimally invasive procedure that can significantly reduce the appearance of acne scarring by promoting skin regeneration and enhancing the absorption of topical products, enhancing their efficacy. Alongside microneedling, other treatments can further enhance the collagen stimulation process, such as Exosomes and platelet-rich plasma (PRP).
• Laser Resurfacing and Fractional Radiofrequency for acne scars
  Laser Resurfacing operates by targeting the outermost layers of skin, promoting regeneration by removing damaged skin cells and encouraging the growth of new, healthy ones. Techniques such as fraxel laser (CO2 laser) and erbium YAG are examples of laser resurfacing treatments. This technique uses energy to create tiny injuries on the surface of the skin, stimulating a healing response, similar to that of microneedling.
  
  
  
  

  Fractional Radiofrequency for acne scarring (e.g. Morpheus8 resurfacing) goes a step deeper. By delivering controlled RF energy into the skin via tiny microneedles, it stimulates the production of collagen and elastin in the dermis of the skin, naturally healing and reducing the visibility of acne scars from within. With any energy-based resurfacing treatment, there will be a short period of downtime (usually about a week or so), where the face can be slightly red and irritated. Certain new treatments, such as exosomes - which can reduce inflammation - can be used in combination with resurfacing techniques to minimise downtime and optimise the results.

• Subcision and Dermal Fillers for acne scars
  Subcision for acne scars is a unique procedure where a needle is inserted into an area of acne scarring and used to break fibrous bands beneath the skin, lifting and smoothing out deep, tethered scars (e.g. icepick scars). This method specifically targets and releases the underlying structures causing the indentation, allowing the skin to elevate to a more even level. The elevated tissue can be more permanently lifted by injecting small quantities of Dermal Fillers to provide a longer-lasting lift to atrophic scars. These can also stimulate collagen production, further enhancing skin's natural healing. Subcision and dermal fillers for acne scars is an expert technique offered by all of the practitioners at the Dr. David Jack clinics.
  
  
• Steroid Injections for acne scars
  Hypertrophic acne scars and keloids, characterised by an overproduction of collagen leading to raised skin tissue, can be particularly challenging to address. Steroid injections are an option for these types of scars by reducing the size, flattening and improving the texture of these elevated scars. By injecting corticosteroids such as Kenalog or dexamethasone directly into the scar tissue, the inflammation is reduced, collagen production is slowed, and the scar begins to flatten over time.
  
  This method often offers a fairly rapid response, with many patients finding notable improvements after just one session. A series of treatments (usually about 6-8 weeks’ apart) is often needed for near-complete resolution. For those plagued by persistent, raised acne scars, steroid injections provide a clinically-backed approach.
  
  Following steroid injections, skin resurfacing to improve skin texture can then be used.
  

Prevention and Maintenance

While treatments can be significantly effective, prevention remains paramount:

• Avoid picking at pimples or acne wounds, regular facials with controlled extractions of open and closed comedones can help.
• Protect your skin from the sun, as UV rays can darken scars. Select an effective, broad-spectrum SPF moisturiser.
• Use non-comedogenic skincare products including a retinoid.
• Consult a dermatologist at the onset of severe acne.

Final Thoughts

Acne scarring, with its various manifestations and deeply personal impact, requires a nuanced, individualised approach to treatment. From the outset, it's vital to understand that no singular treatment offers a universal solution. Instead, the journey often involves experimenting with a range of therapies, sometimes in tandem, to discover the most effective strategy for your unique scarring profile. The essence of trial and error in this process, though sometimes challenging, ensures that each individual finds the best-suited treatment or combination of treatments.

Book in now for a consultation with one of our expert doctors to start your acne scar treatment journey now!

Useful Resources

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onlinelibrary.wiley.com