Scars from Acne
Causes of scarring, prevention, types and treatments for scars caused by acne.
Occasionally we see spots that may look like scars but are not true scars and no permanent change has formed in the skin affected. Despite these being not true scars and usually fade away over time, they are visible and can cause concern.
Definitions:
Macules or "pseudo-scars" are flat, red or reddish spots that are the ultimate result of most inflammatory acne lesions. When such an inflamed acne lesion flattens, a macule can remain to "mark the spot" for 6 months or sometimes longer. After the macule eventually disappears, there is usually no trace left which is unlike a scar.
Post-inflammatory hyper-pigmentation is discoloration of the skin, usually dark areas, at the site of a healed or healing inflammatory acne lesion. This occurs more frequently in darker-skinned individuals, but can be seen occasionally in persons with lighter skin color. Early treatment may minimize the development of post-inflammatory hyper-pigmentation. Some post-inflammatory hyper-pigmentation may last for up to 18 months, especially with excessive sun exposure. Certain chemical peel such as TCA may help reduce post-inflammatory hyper-pigmentation.
Acne Scar Causes:
Simply, scars form at the site of tissue or skin injury. They are the healed areas of injury after tissue repair. For acne, the injury is caused by the body’s inflammatory response to bacterial growth from sebum and dead cells in the plugged sebaceous follicle. Two types of true scars can form: (1) depressed areas such as ice-pick scars, and (2) raised thickened skin such as hypertrophic scars or keloids.
When an injury occurs, the body’s response is to send its “repair team” injury area. Included in the team members of this repair force are white blood cells and a host of inflammatory mediator molecules that have the ability of repairing injured tissue and fighting infection. However, when their job is done they may leave a somewhat messy repair site in the form of fibrous scar tissue. It is akin to a fire fighting team leaving the yard a mess after the house fire is put out.
White blood cells and inflammatory mediators may remain at the site of an active acne lesion for a long time. The result may be formation of an acne scar. Why scarring happens often in some people and not others is still not well understood. Some people are more prone to scarring than others. Scarring frequently results from severe inflammatory nodulocystic acne that occurs deep in the skin. But, scarring also may arise from more superficial inflamed lesions.
The progression of the history of scars is not well understood. Some people may have acne scars for a lifetime with little change in the scars, but in others the skin can undergo a degree of remodeling and acne scars diminish in appearance.
Individuals may have different emotions about their acne scars. Scars of more or less the same size that may be psychologically disturbing to one person and may be accepted by another person as "not too bad." Those who are distressed by scars are more likely to seek treatment to modify the scars.
Acne Scar Prevention:
As acne scar occurrence varies from person to person, it is difficult to predict who will scar, how extensive or deep scars will be, and how long scars will persist. It is also difficult to predict how successfully scars can be prevented by effective acne treatment.
Regardless, the only logical method of preventing or reducing the extent of scars is to treat acne early in its course, and for as long as needed. If inflammation can be prevented or moderated, the more likely it is that scars can be prevented.
Types of Acne Scars.
There are two general types of acne scars, defined by the tissue response to inflammation: (1) scars caused by increased tissue formation or hypertrophic, and (2) scars caused by loss of tissue or depressed.
Hypertrophic Scars:
The scars caused by increased tissue formation are called hypertrophic scars. Some times these are confused with keloids which are hypertrophic scars that have a different anatomy and course, and are less common. The word hypertrophy means "enlargement" or "overgrowth." Both hypertrophic and keloid scars are associated with excessive amounts of the cell collagen. The collagen is produced as a response of skin cells to the injury. The excess collagen becomes heaped up in fibrous piles, resulting in a characteristic firm, smooth, usually irregularly-shaped scar.
The typical hypertrophic scar from acne is 1-2 millimeters in width, but some may be much larger. Keloid scars tend to "run in families"—that is with similar scars froming in people with relatives who have these types of scars.
Hypertrophic scars may persist for years, but may diminish in size over time. Keloid scars usually do not diminish over the years.
Depressed Scars:
Acne scars associated with loss of tissue—similar to scars that result from chicken pox—are more common than keloids and hypertrophic scars. Such scars are:
Depressed fibrotic scars are usually quite large, with sharp edges and steep sides. The base of these scars is firm.
Soft scars, superficial or deep have a soft feel. They have gently sloping rolled edges that merge with normal skin. They are usually small, and can be either circular or linear in shape.
Ice-pick scars usually occur on the cheek. These are most often small, with a somewhat jagged edge and steep sides—like wounds from an ice pick. Ice-pick scars may be shallow or deep, and may be hard or soft to the touch. Soft scars can be improved by stretching the skin; hard ice-pick scars cannot be stretched out. These may evolve into Depressed Scars over time.
Follicular macular atrophy is more likely to occur on the chest or back of a person with acne. These are small, white, soft lesions, often barely raised above the surface of the skin—not unlike undeveloped whiteheads. This condition is sometimes also referred to as "perifollicular elastosis." These lesions may last for months to years.
Atrophic macules are usually fairly small when they occur on the face, but may be larger on the body. They are soft, often with a slightly wrinkled base, and may be bluish in appearance due to blood vessels lying just under the scar. Over time, these scars change from bluish to ivory white in color in light skinned people, and become much less obvious.
Acne Scar Treatments:
Various treatments are available for acne scars. Treatments need to be selective based on the type of skin, the cost, what the treatment is trying to accomplish. There is possibility that some types of treatment may result in further scarring if the person is very susceptible to scarring.
A decision to seek treatment for acne scars may depend on a number of factors including:
- Feelings about scars. Are the acne scars psychologically or emotionally affect a person’s life? Is he/she willing to "live with the scars" as they may fade over time?
- The severity of the scars. Is scarring substantially disfiguring, even by objective assessment?
- A physician’s expert opinion as to whether scar treatment is justified in a particular case, and what scar treatment will be most effective.
Before committing to any treatment of acne scars, one should have a detailed discussion with the physician about the treatments and consequences. The physician should conduct a full examination and determine whether treatment can, or should, be undertaken.
The objective of scar treatment is to give the skin a more acceptable physical appearance. Total restoration of the skin, to the way it looked prior to the acne, is usually not possible, but scar treatment may improve the appearance of the skin considerably.
The scar treatments that are currently available include:
Fillers such as Fat, Colagen, Hyaluronic acid and others: Fat is taken from one area of the body and prepared, and injected under the scar to elevate the depressed scar. This method of autologous (from your own body) fat transfer is usually used to correct deep contour defects caused by scarring from nodulocystic acne. Because the fat is reabsorbed into the skin over a period of 6 to 18 months, the procedure usually must be repeated. Longer lasting results may be achieved with multiple procedures or using other longer lasting fillers such as Hyaluronic acid.
Microdermabrasion. Microdermabrasion uses aluminum oxide crystals passing through a vacuum tube to remove surface skin. This is similar sandblasting. Only the very surface cells of the skin are removed, so no additional wound is created. Multiple procedures are often required but scars may not be significantly improved.
Dermabrasion. This can be the most effective treatment for acne scars. Under local anesthetic, a high-speed circular brush is used to remove surface skin and alter the contour of scars. Superficial scars may be completely removed, and deeper scars may be reduced in depth. Dermabrasion does not work for all kinds of scars; for example, it may make ice-pick scars more noticeable if the scars are wider under the skin than at the surface. In darker-skinned people, dermabrasion may cause changes in pigmentation that require additional treatment. This technique if applied by some one not familiar with it may make the scars much worse and cause further scarring.
Laser Treatment. Lasers of various wavelength and intensity may be used to modify scars and reduce the redness of skin around healed acne lesions. The type of laser used is determined by the results that the laser treatment aims to accomplish. Tissue may actually be removed with more powerful lasers such as the carbon dioxide laser. In some cases, a single treatment is all that will be necessary to achieve excellent results. Because the skin absorbs powerful bursts of energy from the laser, there may be post-treatment redness or even hyper-pigmentation for several months.
Skin Surgery. Some ice-pick scars may be removed by "punch" excision of each individual scar. In this procedure each scar is excised down to the layer of subcutaneous fat; the resulting hole in the skin may be repaired with sutures or with a small skin graft. Subcision is a technique in which a surgical probe is used to lift the scar tissue away from unscarred skin, thus elevating a depressed scar.
Skin Grafting. Skin grafting may be necessary under certain conditions—for example, sometimes dermabrasion unroofs massive and extensive tunnels (also called sinus tracts) caused by inflammatory reaction to sebum and bacteria in sebaceous follicles. Skin grafting may be needed to close the defect of the unroofed sinus tracts.
Treatment of keloids. Surgical removal is seldom if ever used to treat keloids. A person whose skin has a tendency to form keloids from acne damage may also form keloids in response to skin surgery. Sometimes keloids are treated by injecting steroid drugs into the skin around the keloid. In some cases the best treatment for keloids in a highly susceptible person is no treatment at all.