Acne scarring: exploring common myths and misconceptions

Posted by Cedars Dermatology Clinic, 21st October 2015

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Acne can be annoying enough, but scars that result from it can be very upsetting and can persist a lot longer than the original acne.  It’s thought that facial scarring occurs to some extent in up to 95% of cases.  A delay of up to 3 years between acne onset and adequate treatment is related to the ultimate degree of scarring. However there are many potential ways of dealing with scars.

What is a scar?

Before talking about treatment it’s important to understand what people mean when talking about scarring. A scar is an area of fibrous tissue that replaces normal skin after injury. In acne this injury results from intense inflammation and cyst formation.

A scar consists of the same protein (collagen) that forms part of normal skin but the collagen is aligned differently resulting in inferior function and appearance compared with normal skin. Scars can be indented (atrophic) or they can be raised above the surrounding skin (hypertrophic or keloid when extending beyond the boundaries of the original injury). The key difference between a scar and normal skin is the textural change.

Scars can be discoloured but a colour change without textural change does not constitute a scar. Patients, the media and the health professionals don’t highlight this distinction often enough. The difference is important because colour change without scarring may improve more quickly and even without treatment whereas a true scar will take longer and is unlikely to improve much without treatment if it is significant.

Scar prevention

Very subtle scarring may not need any treatment if it is barely noticeable and may improve in appearance over time. However more significant scars usually need some form of treatment. So actually the best way of dealing with them is to prevent their formation by getting early treatment for active acne – this is covered in our earlier blogs Acne: tips from the experts and Acne: more tips from the experts.

Sun protection can help prevent a scar from becoming discoloured. Also avoid picking at an acne spot as this can worsen inflammation which contributes to acne scarring.

Scar treatments

– Creams and ointments

Some topical treatments like self-drying silicone can help with scar prevention and treatment. Studies have shown they can improve texture and colour of raised scars by over 80%. In clinical practice we have rarely found it to be this effective either because patients do not use these treatments in real life as they might in the study or other flaws within the study methodology. Nevertheless they are safe and can be useful for both acne scars and surgical scars

Vitamin E is often cited as a useful treatment for scars but actually its benefits are controversial. A study by the University of Miami showed that it actually made either no difference or made things worse in 90% of cases and that a third of patients developed a contact dermatitis so it isn’t something we routinely recommend.

Retinoids such as tretinoin can help induce collagen formation and so can help with subtle atrophic scars if used for a period of months or years but many people can’t tolerate them because they cause too much dryness and redness

 – Interventional treatments

Indented scars

There are a range of interventions that can be used for acne scarring with often very good success.  The type of treatment depends on the type of scarring you have.  There are various ways of classifying acne scars.  Most commonly indented scars are classified as boxcar that have a flat often u-shaped base; icepick scars which have pitted pinpoint depressions; and rolling scars which have a gentle undulating base.

The purpose of scar classification is determine which would be the best treatment.  From this point of view I think it’s more meaningful and simpler to think of scars as distensible or non-distensible.  In other words does the scar become less noticeable if you stretch the skin around it.  If the answer is yes then a procedure which will plump up the skin from underneath such as filler or collagen induction treatments (such as subcision) are usually most effective.  If the scar is non-distensible then a resurfacing treatment such as dermbrasion or ablative laser is better.  Often a combined approach is best because many scars will be partly distensible.

  • Resurfacing

There are many ways to resurface a scar.  This can be done with lasers such as carbon dioxide, erbium chemical peels or mechanical dermabrasion.  The choice will depend on the skin type, the degree of scarring, cost and acceptable recovery time

  • Fillers

There are a number of different fillers for acne scarring the most common being hyaluronic acid.  They can give an immediate improvement but the effect is often only temporary.  Collagen stimulators like poly-l-lactic acid can give a longer result for more generalised distensible scarring

  • Subcision

This is a cheap effective and often underused technique for distensible scarring.  It involves introducing a needle underneath the skin to break up the scar and also trigger bleeding which will stimulate collagen.  The results can take some months to appear but the results can be very good.

  • Excision

Some scars particularly icepick scars are best treated with excision.  The line scars are often less noticeable than the pinpoint depressions.

Raised scars

These can be treated with cortisone injections, ablative laser, excision or pulsed dye laser or a combination of the above.

Discolouration in scars

This can often improve without treatment but if it persists then lasers such as pulsed dye laser for red scars and Q-switched Nd:YAG for brown scars) are usually the best option.

In summary there are many options for treating acne scars.  The key to successful treatment is understanding the nature of the scar, the patient and their skin type and picking the right modality or combination of modalities.

Dr Nisith Sheth is a Consultant in the Dermatology Surgery and Laser Unit of St John’s Institute of Dermatology. He trained in the UK, Canada and the USA. He sees and treats all skin conditions.

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