Scars are a response after it has been damaged by a wound or injury as part of the skin’s healing process. The skin tries to repair itself by forming new collagen fibers that usually don’t end up as smooth and flawless as the original skin. As the wound heals, the body can sometimes produce too much collagen, creating a mass of raised tissue on the skin's surface (such as keloids).
Acne scars on the face are usually caused by inflamed and enlarged pores that leave a break in the follicle wall. If there is a deep break in the wall of the pore, the infected substance can spill out into surrounding tissue, causing deeper injury to the skin. When you have an inflammatory breakout, such as red, inflamed, irritated papules and pustules, collagen is destroyed and skin tissue is lost. Without much support of the skin’s building-block, the skin over this area then collapses, turning into atrophic or depressed scars.
Types of Acne Scarring
Ice Pick Scars
As the name suggests, ice pick scars look like the skin has been pierced with an ice pick or sharp instrument. These narrow and pitted scars often caused by cystic infection of inflamed blemish, are deep, extending into the dermis or lower layer of the skin. As a result, skin tissue is destroyed, leaving a long, column-like scar.
Box scars have round or oval depression with steep vertical sides, but they appear broader and boxier than ice picks. These broad depressions are shallow with well-defined edges, unlike the rounder, softer edges of rolling scars. Commonly found on areas like the cheeks and temples, boxcar scars range from superficial to severe, depending on the amount of tissue lost.
Unlike box scars, rolling scars though depressed, have smoother edges with wave-like depressions across the skin, resembling tiny hills and valleys, leaving skin with an uneven and wavy texture. Rolling scars are often a result of long-term inflammatory acne that hasn’t been treated, causing fibrous bands of tissue to develop between the skin and the subcutaneous tissue below. It is these bands that are pulling the epidermis from within that creates the rolling appearance of the skin.
Hypertrophic or Keloid Scars
Common after a minor injury (even from just a pimple), deep invasive wound or trauma, hypertrophic scars develop, appearing as raised, firm scars growing above the skin’s surface. These type of acne scars are often found around the jawline, neck, chest and torso.
Keloids on the other hand, are a more severe form of raised scar. They differ from hypertrophic scars as keloids grow larger than the original wound. What’s worse is that they not only expand much farther than the wound itself, they can continue to grow long after the original wound has healed.
Unlike ice pick and boxcar scars, hypertrophic scars are not caused by a loss of tissue, but they develop due to an overproduction of collagen and granulation tissue. In the case of keloids, it's like the skin doesn't know that the wound has healed, and continues to produce collagen.
Unfortunately, certain ethnicities such as Asian and African descent are more prone to developing keloids.
Some acne scars are not true scars but rather a temporary discoloration of the skin after a pimple or underlying skin disease (trauma, skin infection, eczema or a drug reaction) has healed. These are known as post-inflammatory hyperpigmentation (PIH) which develop as the skin heals, over producing melanin, and leaving a dark mark on the area.
Dos and Don’ts
Don't squeeze, pop, or pick at pimples
Doing so can force debris deeper into the dermis, spreading an infection to other tissue and worsening inflammation. Know that popping pimples can also extend the healing time and increase the chance of a permanent scar.
Do treat your acne ASAP!
Begin treating acne early, as soon as it comes up, and seek professional help immediately if your acne isn't getting any better with over-the-counter treatments. Quick treatment helps to keep breakouts to a minimum and prevent it from worsening.
Your objective is to calm inflammation and avoid doing anything that will further irritate the skin. Avoid harsh products like scrubs and skincare products with strong ingredients. Look for a simple but effective at-home routine that takes care of excess oil, get rid of acne-causing bacteria and prevent blemishes and acne spots from worsening.
Avoid picking at your scabs
Do not pick your scab even if it looks dry and “ripe” for picking. A scab is like the skin's natural "bandage" that protects the wound as it heals. Picking a scab off a wound before it is ready prolongs the healing process and increases chances of scarring.
Before you treat any acne scars, be sure to consult a doctor. The skin expert can help you determine if they are actually scars and not another condition as well as the best method to reduce the appearance of your scars. Patients will find a wide range of treatments available – from over-the-counter serums and creams to in-clinic procedures.
Alpha Hydroxy Acid (AHA) are mild acids that are generally good for removing dead skin cells and preventing clogged pores. But when used on acne scars, they help to exfoliate the outer layer of the skin, which in turn help to remove discoloration and any rough skin. Lactic acid present in any peel or serum is also said to help improve texture, skin pigmentation and lighten acne scars. Another popular one is salicylic acid, which can be found in many skincare products, ranging from spot treatment, lotion to facial wash. Great for treating acne scars, salicylic acid helps to clear pores, reduce swelling and redness, and exfoliate the skin. It may take a few weeks to see a difference and can leave skin feeling dry and irritated.
Retinoids are another acne treatment with scar-smoothing benefits. Over-the-counter retinoid serums and creams are able to help speed up cell regeneration and improve skin’s texture, reducing discoloration and lightening scars in the process.
If OTC treatments don’t seem to be making a difference, consult a medical doctor or dermatologist for further treatments.
The ultimate goal for treating acne scars is improvement rather than complete removal. Do learn to manage your expectations as the choice of treatment and results are dependent on individual goals, tolerance level, acne scar type and skin tone.
Non Light-based Treatments:
Best for scars close to the surface such as shallow boxcar or rolling scars, this is an effective and common treatment that deeply exfoliates the top layer of the skin.
Suitable for treating all types of acne scars, a chemical peel is a strong acid that’s used to remove the top layer of the skin to reduce deeper scars. There are various types of chemical peels but some are mild enough to be used at home, but your medical doctor can provide a stronger solution with more dramatic results.
TCA Cross which means trichloroacetic acid, is typically used in low concentration (20–35%) to treat atrophic acne scars. The aim is to improve the appearance of the scar by causing a localized inflammatory reaction leading to new collagen fibres. This treatment is best combined with other treatments.
For depressed scars that lie more than 1.5mm deep below the skin, microneedling helps. It is a procedure that uses a small, handheld, needle-studded roller containing multiple fine needles to puncture the top layer of your skin. How this works is that it encourages peeling it triggers the production of collagen and elastin as the skin tries to heal, leaving skin with a smoother appearance. Results can be seen within six to 12 weeks after treatment. This is a popular treatment because there’s less risk of side effects, although slight bruising can occur during the process. However, it is not suitable for those currently suffering from an acne breakout, rosacea or eczema.
A few different medications including corticosteroids and chemotherapy drugs fluorouracil (5-FU) and interferons can be effective in treating raised acne scars by softening and flattening them. For best results, the injections are usually performed as a series with one every few weeks.
Acne scars can be filled in with fillers made of collagen. It is often injected under the surface of the skin to help plump up and smooth out depressed scars and even out the skin tone. Most fillers last between 6 to 18 months.
Subcision + Filler
In subcision, a needle is put under your skin and moved in multiple directions to separate the top layer of skin from the scar tissue below. In one session, subcision breaks down old scars and can deliver healing compounds such as PDRN (Rejuran Healer - a filler treatment) to your scar. The resulting healing process causes collagen to form and push the scar up. Essentially, you have scar remodelling (controlled break down) and regeneration (healing) all in one treatment. Results are immediate and long-term acne scar improvements from subcision are as good as lasers.
Light Based Therapies:
Much like a chemical peel and dermabrasion, laser resurfacing helps to lighten acne scars as it smooths away the top layer of the skin. Although it can cause side effects such as redness, swelling, and sensitivity to the sun (post-treatment sunscreen is a must), this treatment typically has a faster healing time and longer lasting results compared to any other resurfacing treatments. However, this treatment is not suitable for those still suffering from breakouts, and it’s not as effective on darker skin tones.
This type of laser works by stimulating the production of new collagen, and has fewer side effects compared to ablative ones. Pico is a type of non-ablative laser that’s often used to treat acne scars. But know that laser treatments can leave your skin more sensitive to the sun.