Acne scars are a problem a huge number of people face, affecting around 90% of people in the 11-30 year age group. Around 45% of people with acne develop scars. While the majority of people that scar have severe cases of acne, about 70% of individuals with acne scars come from mild or moderate acne conditions. Permanent scars can have devastating psychosocial impacts, particularly on the young age group that is most commonly affected. Understanding acne scar risk factors, prevention, and treatments are essential if you want to minimize your chances of developing acne scars on your face and other body areas.
Who Is Most Likely To Develop Acne Scars?
Risk factors for developing acne scarring are:
- more severe cases of acne
- delaying treatment
- acne that recurs after seeming to resolve
- picking and popping acne
- male gender
Areas of the body that are prone to acne scars include the face, chest, upper back, and shoulders.
People With Acne Scars Face Unique Challenges:
Individuals with acne scars face multiple challenges. The cosmetic issues posed by permanent scarring of the face and/or other body areas lead not only to cosmetic and aesthetic challenges but potentially severe psychosocial impacts. Studies on the psychosocial impact of acne have documented that people with acne scars develop issues with appearance, embarrassment, self-consciousness, and lack of self-confidence. Anxiety, depression, anger, and decreased self-esteem overall are all common.
Causes Of Acne Scars:
Acne is caused by the complex interaction of factors including increased sebum (oil) production, hormonal influences, and increased bacterial presence in the oil glands of the skin. A bacteria known as Propionibacterium acnes has been specifically implicated in acne. All of these factors lead to inflammation within the hair/oil gland units of the skin. Inflammation ultimately damages the local area and stimulates the body’s wound healing process. The end-point of this damage to the skin is the unfortunate consequence of permanent scarring.
Types Of Acne Scars:
Atrophic Scars
An atrophic acne scar is one in which the damage from acne heals with a net loss of collagen, creating a depressed, indented type of acne scar. About 85% of all scars are atrophic. The atrophic scar presents itself in three main forms: ice pick scars, rolling scars, and boxcar scars. In many cases, a person’s scars from acne will consist of a mix of these three types of scars.
Ice Pick Scars:
Ice pick scars are the most common type of atrophic acne scar. These are narrow, deeply indented scars resembling enlarged pores.
Rolling Scars:
Rolling scars from acne are wider and shallower than icepick scars, with a generally rounded edges.
Boxcar Scars:
Boxcars scars from acne are also wider and shallower than icepick scars, but unlike rolling scars, boxcar scars have edges that are quite vertical (rather than rounded).
The three variations of atrophic scars are illustrated below:
Hypertrophic Acne Scars:
Hypertrophic scars are less common than atrophic scars. These scars result when a net gain of collagen occurs at the site. Unlike the indented, depressed character of atrophic scars, the hypertrophic scar is a raised, thickened, and often pigmented mound of scar tissue. Keloid scars are a particularly severe form of this type of acne scar. With keloids, extreme amounts of collagen are produced that seem to grow far outside of the area of the acne pimple that caused the scar in the first place. Risk factors for keloid scars from acne include dark skin tone, a family history of keloid scars, and they are more commonly found among chest and back acne scars.
Hypertrophic Acne Scars Keloid Acne Scars
Hyperpigmentation (Acne Marks):
Hyperpigmentation refers to dark blemishes on the skin at sights where acne exists or used to be. These dark acne marks are not scars but represent localized areas of increased blood flow and melanin pigment. Acne pigmentation is more common in individuals with darker skin tones such as African-Americans, Latinos, Pacific Islanders, and Asians. Acne blemishes and hyperpigmentation are most commonly caused by more severe cases of acne in which inflammation is significant. It is important to distinguish hyperpigmentation blemishes from true scars because the treatment for the two problems is different. Prevent hyperpigmentation by avoiding heavy inflammation of your acne. This means seeking treatment early on and avoiding picking and popping. It’s critical that you use a high-quality sunscreen to avoid any significant sun exposure, which is a major contributor to post-inflammatory hyperpigmentation.
You can use the module below to take a short test that will help you understand your own risk for acne scarring and hyperpigmentation:
Acne Scar Treatment
Prevention Is The Best Approach:
Preventing severe acne and its resulting inflammation is the primary method to avoid permanent scarring. Seeking formal treatment by a dermatologist, and avoiding picking and popping acne is key to reducing inflammation in the skin and the formation of scars ultimately caused by the inflammatory process. Once established, acne scar treatment depends mostly on the type of acne scar (atrophic or hypertrophic ).
Acne Scar Home Remedies
Many acne scar home remedies and treatments can be found on the market. Always keep in mind that for more severe cases, it has been established that the time between onset and effective control and treatment is critical to minimize or prevent scars. If you’re acne and acne scarring is more than very mild or is not responding to acne home remedies, make sure to see a dermatologist as soon as possible. Doing so will definitely help you avoid more severe permanent acne scarring.
For milder situations, acne home remedies are generally topical ointments, gels, or washes that contain products such as salicylic acid, retinoids (vitamin A), lactic acid, or alpha hydroxy acids. These products are essentially exfoliants that lift the upper layers of skin, promote cell regeneration, and can also help lighten pigmented scars and blemishes.
Acne scar home remedies for hypertrophic scars (raised and thick) include medical-grade silicone gel and silicone strip products. Medical grade silicone has been found in many studies to be effective to both prevent and treat these types of scars. At-home treatments for raised scars must be used consistently for 3 to 6 months to be effective.
Treatments Provided By Dermatologists
Atrophic Scars:
| Method | How It Works | Comments |
| chemical peels | uses a mild acid to induce peeling of the upper skin layers | best for boxcar atrophic scars, but also used for icepick and rolling scars |
| dermabrasion | uses a spinning “sanding” tool to lift upper layers of skin promoting collagen formation and skin regeneration | boxcar and rolling scars |
| laser | some lasers (CO2, Yag:Erbium) remove the upper layers of skin and tighten the deeper skin layers, others (Nd:Yag) only tighten deeper layers | best for boxcar scars but also for other atrophic scars |
| fractional resurfacing | similar to laser with lesser risk of hyperpigmentation (dark discoloration) and scarring side effects due to more precise and pinpoint control compared with laser systems | can work well for all types of atrophic scars (icepick, boxcar, rolling) |
| microneedling/dermarolling | uses a roller with many tiny needles to cause controlled skin puncturing, stimulating collagen formation | best for wider atrophic scars; generally needs 3 treatments spaced 4-6 weeks apart |
| fillers | use of synthetic materials or fat to “fill-in” and flatten the depressed areas | rolling and boxcar, not effective for ice-pick scars; often temporary effect needing repeat treatments |
| subcision | surgical technique in which a needle is used to release deep attachments of atrophic scars and also stimulates new collagen formation to replace missing collagen of atrophic scars | |
| punch grafting | removes the upper layers of skin from atrophic acne scars with replacement using “normal” skin from another other body area or synthetic dermal materials | |
| surgery | surgically excises the atrophic scar with normal skin edges stitched side-to-side |
Here’s a video showing dermatologist, Dr. Jason Emer, using a Fraxel fractionated laser to treat atrophic acne scarring.
Hypertrophic Scars:
| Method | How It Works | Comments |
| cortisone injections | reduce collagen production and decrease inflammation | can be used to prevent and treat hypertrophic and keloid acne scars |
| 5-FU, verapamil, and bleomycin injections | all have been shown to help improve thick scarring | less commonly used than cortisone injections |
| radiation | powerful modality, usually used after surgery | can have sever side effects so generally only used in extreme cases |
| surgery | generally consists of excision of the scar with stitching to flatten and narrow heavier scars | raised thick scars; recurrence of similar type scars is a major challenge |
Conclusions:
Acne is a problem that a majority of people experience to some extent or another. Factors such as delaying treatment and greater acne severity predispose to permanent scars. People with acne scars face a host of aesthetic and psychosocial challenges. Acne scars can be atrophic (depressed) or hypertrophic (raised), with the former being more common. Prevention is the best approach because the complete removal of scars from acne is usually not possible. Understanding the type of scars you have, or are at risk to develop, is essential to choosing home remedies and dermatologist-provided acne scar treatments that will work best for you.