The relief you feel when that angry, red pimple starts to lose its venom is immediately replaced by worry about what kind of mark it will leave on your skin. Acne would be so much more bearable if it would run for just a few painful days and disappear, but for most people, the aftermath is something they have to live with for years to come.
So how do you deal with the scars from your battle with acne?
How Acne Heals
Our skin has the capacity to regenerate after the destruction wrought by acne. A crash course on how this happens is important in understanding how to deal with scars.
The process of healing starts with inflammation, where the body attempts to quell the infection by sending in foot soldiers called neutrophils through a complicated process involving a lot of different cells and chemical messengers.
Once that’s over, it’s time to rebuild the skin. White blood cells called macrophages come to clean up the fallen soldiers and the debris from the fight. They also call in the skin’s repairs department, the fibroblast cells, to secrete the collagen destroyed during the inflammation.
The final step is the secretion of matrix metalloproteinases (MMPs), which are enzymes that will determine the structure of the new skin that rises from the ashes of battle. A good balance of activation and inhibition of these enzymes will result in a smooth texture. But when MMPs do their job a little too well, you get holes and depressions in your skin called atrophic scars. On the other hand, when MMP activities are hampered, you get bumps and protrusions called hypertrophic scars.
The result will differ depending on the kind of pimple your skin recovered from and your skin type. Typically, nodular and cystic acne lesions leave deeper and more lasting marks than pustules or papules. Genetic and environmental factors also influence how quickly and effectively your skin heals.
Scar Grades
A qualitative grading system has been developed to order scars based on their severity and how easy they are to treat.
Macular scars, also known as hyperpigmentation, are at the lowest level. The excessive production of melanin is your skin’s way of protecting itself from further damage, particularly by the sun. Macules are brown, grey or purple spots that lay flat on the surface of the skin and can last for months to years. To move them along faster, you should integrate broad spectrum sunscreen and depigmenting agents such as topical retinoids and chemical exfoliants into your skin care.
The following scar grades involve changes in texture rather than changes in color. When they cause indentations in the skin, they are called atrophic scars. These may be narrow and deep ice pick scars, shallow and gently-sloping rolling scars, or sharply-demarcated and wide box scars. When they protrude from the skin as red- or skin-colored bumps, they are called hypertrophic scars.
- Mild scars are shallow, easily covered by make-up or hair, and are only noticeable at talking range.
- Moderate scars are a little bit deeper and can be seen from a stone’s throw away. But if you stretch your skin out, the scar indentations disappear.
- Severe scarring is deep enough to be noticeable even from a distance, and manually stretching your skin will still not smoothen it out.
We hate to be the bearer of bad news, but the truth is, mild to severe scars do not fade away the way hyperpigmentation does. The added texture is the result of the body’s structural healing process, and once it’s over, that’s it. While it may not be possible to revert back to how smooth your skin was pre-acne, don’t despair! There are many available treatments to make it less noticeable.
Scar treatments
Most skin issues are best addressed with topical agents that work their magic through changing biochemical processes. But since mild to severe scars are physical changes in texture, physical treatments work on them best.
- Cosmetic fillers add volume to atrophic scars. A substance is injected into the scar in order to raise it to the level of the skin surrounding it. Commonly used cosmetic fillers include hyaluronic acid, calcium hydroxyapatite, poly-L-lactic acid, and polymethacrylate. Some of these have collagen-stimulating properties that spur the body itself to plump up the scars. This is not as invasive as other procedures, but the effect may not last as long and most will require repeated injections.
- Dermabrasion refers to the process of removing the top layers of the skin in order to smoothen out the texture. If you’ve ever sanded wood, you’d get the idea. This can be done chemically with hydrogen peroxide, or manually using motorized handheld devices with abrasive surfaces. You will be given anesthesia because this procedure is quite painful. You’ll have to deal with the pain for a couple of weeks, but it can give significant improvement in shallow boxcar and rolling scars after just one or two sessions.
- Microneedling uses tiny needles to puncture the skin and spur collagen production as it heals. You have to do multiple sessions spaced every month or so to help improve the appearance of shallow atrophic scars.
- TCA CROSS involves administering high concentrations of trichloroacetic acid on icepick scars to cause damage to the skin that will eventually lead to collagen synthesis and healing. You will need multiple sessions to see significant results, but this is among the most effective ways to deal with icepick scars.
- Laser therapy is a popular option for atrophic scars of all kinds, but particularly effective for boxcar and rolling scars. There are ablative lasers that damage the dermis and epidermis in order to spur collagen synthesis and non-ablative lasers that damage only the dermis. Because lasers work by injuring the skin, you can expect it to get worse before it gets better. Do this if you can spare a couple of days post-operation for downtime as you will experience pain, tenderness, and redness. The color will remain for a couple of weeks, but many people are happy with the results in the long-term.
- Radiofrequency is similar to lasers in that they also target tissues under the skin to promote healing and rejuvenation. This method uses electromagnetic radiation to damage the skin with heat. With less risk of infection and a shorter downtime, this emerging technology is fast gaining traction among those who want to improve their skin texture.
- Surgical procedures are more expensive and invasive, but these provide long term improvement. Subcision is best for rolling scars, punch excision is popular for icepick scars, and punch elevation is often used for shallow and deep box scars. Note that acne reparation surgery is a distinct medical specialization, so make sure the doctor that you pick has the proper credentials.
Scientific studies show that combining different scar treatments can improve results. Do your research to have an idea of what’s available, and discuss your options with a licensed dermatologist. All the treatments for acne scarring will have side effects, and you will need expert guidance in order to minimize them. More importantly, a thorough examination of your skin and medical history will allow the doctor to give you options tailor fit for you.
Conclusion
Acne scars can be just as frustrating as active acne, if not more so because of their duration. There are treatments that can help improve the texture of skin, but in this case, an ounce of prevention is worth much more than a pound of cure.
Treating acne early, consistently using sun protection, and (this is important) refraining from picking at pimples are all great ways to avoid the headache of dealing with scars.
This content is for general information only and is not a substitute for medical advice.
Resources:
Boen, M., & Jacob, C. (2019). A Review and Update of Treatment Options Using the Acne Scar Classification System. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.], 45(3), 411–422. https://doi.org/10.1097/DSS.0000000000001765
Fabbrocini, G., Annunziata, M. C., D'Arco, V., De Vita, V., Lodi, G., Mauriello, M. C., Pastore, F., & Monfrecola, G. (2010). Acne scars: pathogenesis, classification and treatment. Dermatology research and practice, 2010, 893080. https://doi.org/10.1155/2010/893080
Ulrich, D., Ulrich, F., Unglaub, F., Piatkowski, A., & Pallua, N. (2010). Matrix metalloproteinases and tissue inhibitors of metalloproteinases in patients with different types of scars and keloids. Journal of plastic, reconstructive & aesthetic surgery : JPRAS, 63(6), 1015–1021. https://doi.org/10.1016/j.bjps.2009.04.021
