Acne Scars and Treatment
People who squeeze, pinch, or pick their blemishes risk developing scars. Acne lesions can form in areas where pressure is frequently applied to the skin. Frequent rubbing and touching of skin lesions should be avoided.
Types of Scars. Acne scars generally fall into two categories: 1) increased tissue formation during healing and 2) scars due to loss of viable tissue.
Scars that result in an increased tissue formation are sometimes known as keloids (hypertrophic scars). In response to skin cell injury, collagen is produced during the healing process. Over production of collagen results in the characteristic mass of fibrous tissue scars. Acne keloids are usually firm, smooth and irregularly shaped.
Scars associated with loss of tissue:
- Ice-pick Scars. Small, jagged edged scars usually on the cheek. These scars can often be very deep. The hard variety cannot be stretched out to improve appearance while the soft variety can.
- Depressed Fibrotic Scars. These scars are thought to be ice-pick scars that have evolved to a large area over time. The edges are usually sharp, firm and deep.
- Soft Scars. As the name implies, these scars are soft, non-jagged and fades in with normal skin. Soft scars are usually small and superficial (although deep cases are not considered rare).
- Atrophic Macules. These scars can vary in size and appear soft and wrinkled. Generally, atrophic macules appear white.
- Perifollicular Elastolysis. Sometimes referred to as follicular macular atrophy or maculofollicular atrophy. These lesions are small, soft and white in appearance. They are less likely to be present on the face and scalp (look for them on the body, especially the chest).
Treatment of Scars. There are many options here but care must be taken to decide whether treatment is even necessary. Surgical treatments are often expensive and unnecessary. Since most acne scars are not life threatening, the motivation for undergoing surgery should be firmly established. If you are trying to get rid of scars that are barely noticeable to anyone, your physician may suggest alternative options. If your scars are noticeable and it affects your quality of life and mood, surgery may be a fine treatment. Some scars may not be reparable and total restoration is often not possible. However, the general appearance can be vastly improved. An open and honest discussion with your physician is recommended.
Current treatments include:
Collagen injections (Zyderm). Collagen is a normal substance of the body that is injected through a needle directly under the skin to stretch and fill out certain types of superficial and deep soft scars. This evens out the skin underneath the scar and gives the skin a smoother appearance. Unfortunately, collagen injections do not work as well for ice-pick scars and keloids. Collagen derived from cows or other non-human sources cannot be used in people with autoimmune diseases. In such cases, human collagen or fascia is helpful for those allergic to cattle collagen (symptom include swelling, redness and itching). The cosmetic benefits from collagen injections usually last 3 to 6 months. Repeated collagen injections to maintain the cosmetic benefit are done.
Fat transfer. Fat is taken from another place on your own body and injected beneath the surface of the skin to elevate depressed scars. This method of autologous fat transfer is usually used for deep contour defects caused by scarring from severe acne (nodules and cysts). Since the injected fat is reabsorbed into the skin over a period of 6 months to 2 years, the procedure usually must be repeated to maintain cosmetic benefit.
Chemabrasion. Also known as chemical or acid peels. Acids such as glycolic, salicylic, lactic or trichloroacetic acid are applied to the skin to induce peeling of the surface layer. Superficial peels are usually painless and require no anesthesia. Several rounds of the procedure may be necessary to attain cosmetic benefit. Deep scars may not be completely treated. The time period between peels are often when the skin appears swollen or red during the healing process.
Dermabrasion . Widely thought to be the most effective treatment for acne scars. Under local anesthesia (and sometimes other sedatives), a high-speed wire brush is used to remove the outermost layer of skin and alter the scar contours. Superficial scars may be removed altogether, and deeper scars may be reduced in depth. Dermabrasion does not work for all kinds of scars (ice-pick scars actually become more noticeable). In some people, dermabrasion may cause skin discolorization that require additional treatment. Cold compresses are recommended during the healing process.
Microdermabrasion. A surface form of dermabrasion, microdermabrasion uses aluminum oxide crystals passing through a vacuum tube to remove surface dead skin. This procedure stimulates new cell growth. Since only the very surface cells of the skin are removed, patients show minimal redness and swelling after the procedure. No anesthesia is required and very few side effects have been documented. Multiple procedures are often required and scars may not be significantly improved. Microdermabrasion works best for very mild cases of acne.
Laser Resurfacing. Currently, this is the most popular treatment. Lasers of various wavelengths and intensities are used to peel the surface layer of the skin in a controlled burn to recontour the scarred area. This stimulates new skin and collagen growth at the site of treatment. The type of laser used varies with intended use to be determined on an individual basis. In some cases, skin tissue may be removed with more powerful lasers such as the carbon dioxide laser and the YAG laser. Often times, a single treatment is all that will be necessary to achieve permanent results. Because the skin absorbs powerful bursts of energy from the laser, there may be post-treatment redness and tenderness for several weeks to several months. There is also a small risk of skin discoloration due to sun exposure post treatment.
Punch Excision. This is a form of skin surgery useful in some cases of ice-pick scars. Using a punch tool, individual ice-pick scars may be removed by excising the scar down to the layer of subcutaneous fat. The resulting hole in the skin is repaired with sutures or with a small skin graft. Subcision is a surgical technique in which a probe is used to lift the scar tissue away from unscarred deeper tissue. Blood pools underneath the scar and promotes new connective tissue formation. The scar that once was depressed has now been surgical elevated.