By Dr. Thomas Griffin
Acne is an extremely common skin problem. Affecting about 80% of people ages 11-30, acne affects more than the visual, and cosmetic appearance of the skin, but the mental well-being of those affected as well. While not every person affected by acne will have signs of the acne left on their skin, about 1 in 5 who have had acne will have some degree of scarring. Acne scars are permanent marks left on the skin.
In general, acne is an inflammatory skin condition. The oil-making glands of the skin, sebaceous glands, get clogged and the increased oil production backs up. The body’s immune system reacts to this build-up and creates a pimple. In acne scarring, this inflammation and the wound healing that results is the root of the problem. Those who are predisposed to acne scarring have a more robust inflammatory response that not only attacks the acne lesion but the surrounding skin as well.
Types of Acne Scars
There are 3 types of acne scars; icepick, boxcar, and rolling.
- Icepick scars are deep, narrow, scars that appear like large pores.
- Boxcar scars are shallow depressions in the skin with fairly sharp, vertical, borders.
- Rolling scars are deeper, wider, and less defined.
Most patients will have a combination of multiple types of these scars.
Treatment of acne scarring begins with its prevention.
Early, aggressive, treatment of active acne with a dermatologist is important.
There are a number of different topical and oral medications which can be prescribed to help control acne early. A good prescription treatment regimen often involves multiple medications to target the clogged pore, reduce oil production and help control the inflammation. I am a huge advocate of chemical peels and laser treatments to help further improve the results of prescription medications.
Chemical peels, of which there are multiple types, can help directly break down the clogs in the pores and exfoliate the superficial skin. They help to reduce the number of acne bacteria on the skin. In the active acne stage, laser energy can be very helpful as well. Devices like BBL, clear silk, aerolase, and genesis heat the skin gently and help to reduce the inflammation and blood vessel dilation that causes collagen damage. Although these devices take multiple treatments and upkeep, they are non-invasive, have no downtime required, and are very tolerable.
In addition to prescription and laser prevention of acne scarring, it’s important that those people affected by acne don’t make their risk of getting scarring any worse. Picking and popping acne only makes things worse. I like to use the analogy of an iceberg. The whitehead we see on top of the skin is only about 10% of the actual pimple. When we pop that whitehead we actually burst the puss under the skin as well. The body responds very strongly to that and tries to clean it up with a stronger inflammatory response. This makes the pimple last longer and increases the risk of scarring. Instead, of popping, use a pimple sticker. The cover will help to keep your fingers off of them and helps to dry the lesions out faster.
Once a person has scars and their active acne is controlled treatment of acne scarring depends on the type of scars that a person has. As stated earlier, there are 3 basic types of scars and most patients have a combination of scar types.
Treatment should target the different scar types and therefore a combination of different treatments is nearly always employed.
Boxcar Scars: The most treatable scar type.
This kind of scar is shallow and has sharp vertical borders. Laser resurfacing is the best approach to boxcar scars. There are a number of different lasers which are capable of improving boxcar scars. Multiple treatments with non-ablative fractionated lasers like halo and Fraxel do a fine job without sacrificing much in healing time. Ablative fractionated lasers like a CO2 or erbium-based pro fractional will add some more recovery time but are a bit more effective than a non-ablative laser. The ultimate treatment for boxcar scars, if healing time is not an issue, is fully ablative resurfacing. This treatment is aggressive, the laser removes full layers of skin like a controlled burn, but the results are amazing often in one treatment.
Icepick scars: Narrow, vertical, and deep scars.
These lesions tend to be quite difficult to treat. There are several approaches to icepick scars. The first is a modified chemical peel called TCA cross. In this method, a very high-strength acid is applied directly to the scar with a narrow sharp tool like a toothpick. The idea is to injure the sides of the scar within the depression and get the hole to fill in. It generally takes 6-8 sessions but doesn’t hurt. Each session has some healing around the sites. Some physicians will do small surgical procedures called punch excisions to remove and stitch the ice pick scars. Once either the TCA cross or punch excisions are complete the skin can be resurfaced with a laser to blend it all in. I have found these methods to be extremely effective for ice pick scars, however many of my patients are not excited about having a surgical procedure on their scars. In this case,
“I find radio frequency micro-needling in combination with superficial laser resurfacing to be an effective means of improving ice pick scars.” Dr. Thomas Griffin is a board-certified dermatologist in Philadelphia where he specializes in cosmetic dermatology. According to him, “Radio frequency is basically heat applied to the deep levels of the skin. This heat is released from the tips of the microneedle. Heat functions to boost collagen production and tighten the skin. The benefit of RF micro needling is that microneedles can get very deep, millimeters, in the skin with almost no healing time.” Trying to get a laser millimeter into the skin would result in a massive recovery. This depth is important in icepick and rolling scars to improve the dull depth of collagen damage. I love to combine RF micro needing with a superficial CO2 resurfacing so that not only are we treating the depth of the scars, but the top layers of the skin as well. The C02 improves the superficial texture irregularities and is wonderful for pore improvement.
Atrophic or Rolling Scars: result from large-scale, deep, degradation of collagen.
The superficial skin is, for the most part, normal in appearance and texture but the dermal collagen is thinner and sometimes bound down. As with all acne scarring, a combination of treatments is necessary to improve rolling scars. “Bound down” refers to small, fibrous bands that tether the skin down. These bands can be freed up with a process called subscission where the physician takes a small needle and uses it under the skin to cut the bands. Subscission is often combined with laser and energy techniques. Because of the depth of the damage to the collagen in rolling scars, superficial resurfacing techniques are usually not very effective. Lasers that safely penetrate into the deep dermis are preferred. For this type of scar, I prefer to use picosecond lasers. As opposed to ablative or non-ablative fractionated lasers which essentially bore a hole through the top of the skin, picosecond lasers focus their energy under the skin where they make tiny burst injuries. Fractionated picosecond devices can be very effective for rolling scars while minimizing recovery time.
Treating Acne Scars: Be Patient
Most treatments heal completely in just a few days and they are safe for all skin types. While boxcar and icepick scars are not generally amenable to injectables, rolling scars can be effectively injected with fillers and collagen-boosting products like sculptra. While fillers are not permanent, they can make a huge impact quickly and easily. In general, fillers would be the last step in the process after lasers.
Treatment of acne scarring is a complex process. While it’s important to note that having an expectation of 100% pristine skin is often not a reality, a knowledgeable aesthetic physician can make a huge impact on scarred skin. As with any kind of scar, early intervention is the key and gives the best results. However, if a patient has had scars for a number of years all is not lost.
Understand that treatment is a process, be patient. Multiple treatments with various tools over time is the best approach. Look for a provider who specializes in laser medicine. This provider should have a number of lasers and can offer multiple treatment options and approaches to fit your specific needs.
About the Author:
Dr. Thomas Griffin is a board-certified dermatologist specializing in cosmetic, medical, and surgical dermatology. He is the Department Chair of the Laser and Aesthetics Surgery Center at Dermatology Associates of Plymouth Meeting where he treats patients from throughout the tri-state area. Dr. Griffin believes in a patient-centered approach to dermatologic care.
The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.