Scarring as a result of acne is a common condition, which can have a significant impact on an individual’s self confidence. It occurs in approximately 30% of individuals with moderate to severe acne vulgaris, and is particularly common in certain subtypes. It can be very disheartening to finally ‘get on top of’ one’s acne, which often involves long courses of treatment with significant side effects, only to find that there is a permanent reminder of the spots that once were there.
It is important to remember that the best treatment for acne scarring is prevention. Once acne begins to show signs that it is causing scarring, it is vital that appropriate treatment is prescribed to prevent further scars occurring. Acne at this stage is best managed by a dermatologist, whose expertise is vital in determining the best and most appropriate treatment for an individual patient.
Patterns of scarring
There are a number of typical patterns of acne scarring seen. Identification of which type is present is important, as it will guide the most appropriate treatment(s) in an individual case.
Discoloration of the skin may persist months to years after a spot heals. The colour depends on the skin type in which it occurs, and can range from pink/ red to dark brown. Being vigilant about sun protection is vital to prevent this problem occurring. It is important to choose a non-comedogenic formulation, in order to avoid causing more spots. While the pigmentation should improve with time, this process may be hastened by the use of bleaching creams (such as hydroquinone) or azeleic acid, which reduced pigmentation as well as treating mild to moderate acne.
Also known as pitted scars, these appear as small, deep ‘holes’ in the skin. Some patients compare their appearance to that of a large open pore. These scars are relatively deep, and there is no cream or ointment that is effective in improving their appearance.
Punch excision: This involves cutting out the scar with a small “cookie cutter” type instrument, and stitching the area closed in a straight line. It is effective in reducing the visual impact of these scars. Because the deep part is removed, the dark shadow is significantly lessened, and the scar appears less noticeable.
Subcision: A specially-designed needle is used to break the band of scar tissue tethering the surface of the scar to deeper tissues. Releasing this band will reduce the depth of the scar, making it less prominent.
Laser: Resurfacing techniques such as ActiveFX, performed after any surgical procedures for the scarring are completed can further improve the end result.
It is always worth remembering that no treatment will completely get rid of the scarring. Generally speaking, patients are pleased with the results they achieve – but almost always wish that they could have achieved an even better result.
Atrophic/ cobblestone scars
These are sunken scars, which are often a little paler than the surrounding skin. They are obvious because of the ‘step’ at the edges which casts a shadow – for this reason they cannot be concealed completely with make-up.
Surgical techniques such as excision (cutting out the scar and stitching the resultant wound) and subcision (as above) are sometimes useful. In older patients where there is some general laxity of the skin, a facelift procedure can be quite useful in reducing the appearance of these scars.
Dermal fillers are also useful on occasion.
Laser resurfacing (such as ActiveFX) is another option, and should be performed after any surgical procedure.
Hypertrophic and keloid scars
The treatment of these scars in the context of acne is very similar to that of hypertrophic and keloid scars occurring as a result of other causes.
Lasers may be used to reduce the bulk of the scar or redness
Injection therapies are very useful in reducing both bulk and redness. Steroid, with or without 5-fluorouracil (a drug that reduces cell turn-over) is injected into the scar. Three to six treatments are typically necessary.