Ugh…Isn’t it bad enough that I have pimples? Why does it have to leave scars behind as well?
About 80% of patients with acne suffer from scarring. That’s a lot! It’s no surprise that I’m asked about treatment options for acne scarring daily in my clinic.
First, let’s distinguish between true acne scars versus the inflammation marks from breakouts.
Post-Inflammatory Erythema
The red spot that is flat and stays on the skin much longer than the actual pimple is something called “Post-Inflammatory Erythema”. It’s red because the blood vessels under the skin enlarged and became bigger than normal to bring the immune system to the pimple to help heal it. Those blood vessels can stay enlarged for many weeks after the actual pimple is gone.
These flat red spots are not considered true scars. And good news is these tend to fade with time!
To avoid these red spots becoming darker, be sure to protect your skin from the sun. Sun exposure on these red spots can “tan” them and then they become more difficult to resolve.
Post-Inflammatory Hyperpigmentation
Some patients heal with dark spots instead of red spots due to their skin type. This is called “Post-Inflammatory Hyperpigmentation”. These also do tend to fade with time, but they can last a lot longer than red spots. You also want to protect your skin from the sun so they don’t become even darker.
The best treatment for post-inflammatory erythema and hyperpigmentation is time. Allowing your body to heal and knowing these will improve with time and could even resolve on their own if you did nothing at all is a good way to approach these.
Also, ideally you are having your acne treated and aren’t getting as many new pimples so you don’t have as many red or brown spots behind. It’s frustrating when you get one spot resolved and you just keep getting pimples on top of them. So be sure to meet with your dermatologist to discuss treatment options for your breakouts.
There are some cosmetic treatment options that can help fade these red or brown spots if you get frustrated with them. Talk to your dermatologist about some cosmetic redness reducing creams, skin lightening creams and cosmetic laser treatment options that target red and brown spots on the skin.
Types Of Scars
True acne scars tend to stay stable over time and leave behind a more permanent indentation (divot) in the skin are considered “Atrophic Scars”.
Acne scars can also be thicker than normal skin and we refer to these as “Hypertrophic Scars.”
When the scar extends beyond the border of where the initial lesion was they are considered “Keloid Scars”.
Complete resolution of these true types of scars (atrophic, hypertrophic and keloid), even with the current technology of cosmetic treatment options, is not common. Sorry to be the bearer of bad news, but just keepin it real. Being clear about realistic results of the treatment options is key so you can decide where to invest your time and money.
Treatment for Atrophic Acne Scars
Some treatment options for atrophic acne scars (divots or indentations in the skin) include cosmetic options such as lasers, microneedling, chemical peels and dermal fillers.
Lasers
Lasers use light to target certain aspects of the skin. There are two main types of lasers that can help improve atrophic acne scars: ablative and non-ablative.
Ablative Lasers
Ablative lasers which create injury to the top layer of the skin (epidermis) and deliver heat to the underlying skin (dermis). As these areas heal, it triggers new collagen to form and new skin that is tighter, smoother and firmer.
After an ablative laser treatment, you are likely to have red, raw, tender, swollen skin in the areas that are treated. It may take several weeks for this to heal and you may have redness or pink tone to your skin for months afterwards.
However, once you start healing from your treatment you will notice immediate results in your scars.
Due to its significant downtime and potential side effects, I advise that your ablative laser treatment only be performed by an experienced board-certified dermatologist or plastic surgeon.
Non-Ablative Lasers
Non-ablative lasers deliver heat to the underlying skin (dermis) without damaging the top layer of the skin (epidermis). The injury in the dermis from this laser also triggers collagen to help rejuvenate the skin. This laser is less aggressive than the ablative laser treatments and you are likely to have a shorter recovery.
You will still experience redness, swelling, some mild tenderness but you will not have raw, open skin with this type of laser. The results of a non-ablative laser will be more gradual rather than immediate and you are likely to need several treatments.
Microneedling
Microneedling is the use of several small needles injected shallowly into the skin. The injury from the needles forms a wound and as the wound heals it builds collagen under the surface. Your skin will be red and some plump swelling after your treatment and recovery is a few days. You will likely need multiple treatments to improve the appearance of your skin.
“Vampire Facials”
Performing microneedling with added platelet rich plasma (PRP) aka “Vampire Facial” has the benefit of microneedling plus the nutrients of your own PRP. To obtain your PRP, you will have your blood drawn and then they will spin it down in a centrifuge that separates out the different parts of the blood so that only the PRP part of your blood is separated. Your PRP is then placed on your skin and when the microneedling is done the PRP is injected into the skin with the microneedles.
There are other variants of this type of procedure using different serums on the skin and stem cells and this procedure is being done with microneedles and PRP can also be used with lasers. Meet with your local experienced board-certified cosmetic dermatologist or plastic surgeon to discuss the options.
Chemical Peels
Chemical peels are when a solution is placed on your skin that causes it to exfoliate and peel off. There are several different types of chemicals that can be used and there are various strengths and combinations of the different chemicals.
The depth of how far the chemical goes into the skin layers is graded as superficial (top layer only, epidermis), medium (epidermis and upper dermis) and deep (epidermis and deep dermis). To improve acne scars, you may need a stronger chemical peel since this is where the scar tissue is located in the skin.
Superficial peels may improve some of your acne breakouts and some surface discoloration, but not likely to improve your scars as the peel is only the top layer of the skin. Medium peels will help improve some of your scarring and deep peels would have the most impact. However, deep chemical peels can lead to permanent scarring, skin damage and color/pigment changes. I advise that if you chose to undergo a deep chemical peel that you ensure that is being performed by either an experienced board-certified dermatologist or plastic surgeon. My personal preference would to not pursue a deep peel for scarring due to its potential complications.
Dermal Fillers
Fillers are gel-like substances that are injected into the deeper dermis layer of the skin to fill spaces that are indented.
There are several different types and brands of dermal fillers. Some fade with time and you will need repeat injections and others are more permanent. I advise starting with fillers that fade first to make sure you like the results. Meet with your board-certified cosmetic dermatologist to discuss which type of filler is best for your type of scarring.
Treatment for Hypertrophic & Keloid Acne Scars
Hypertrophic and keloid scars occur are when the body’s response to healing with scar tissue went a little overboard. These types of scars tend to occur more frequently in areas of acne on the chest and shoulders and sometimes one the face, usually around the jawline. These can be itchy and painful as well. The goal of treating these types of scars is to flatten them and make them less red.
Your dermatologist can do injections of a medication to help thin the skin where you have a thicker scar. You will likely need a series of injections several weeks apart. Realistic outcomes are a flatter scar and sometimes you can get an indentation in the skin. Sometimes these types of scars come back over time and you can repeat the injections.
Cutting out the thicker scar by a dermatologic surgeon or plastic surgeon is another option, however you may just re-create another thick scar when it heals. Doing an injection of a corticosteroid in conjunction with the removal of the scar and/or laser treatments and close follow up with possible repeated injections is another strategy.
Sometimes applying a silicone bandage to a thicker scar can also help it flatten. Lasers can also help flatten these scars as well and certain lasers targeting redness can help lessen the red color of these scars.
Next steps…
Some patients suffer from a few different types of acne scarring. Schedule an appointment with your dermatologist to review which type of scarring you have and what your treatment options are. Your dermatologist may be trained in cosmetic dermatology and have some of these cosmetic options in their office. If your dermatologist is a medical dermatologist and does not specialize in cosmetics, they may refer you to a cosmetic dermatologist or plastic surgeon for a consult to discuss treatment options.
If you are just starting to get pimple breakouts, start acne treatments early with your dermatologist to minimize your likelihood of developing acne scarring.