Acne scarring is a common and distressing consequence of acne. Post-acne scarring is the body’s attempt to repair the damage caused by acne. The skin attempts to repair these lesions by forming new collagen fibers, but these repairs aren’t as smooth and flawless as the original skin which creates scarring. Too little collagen creates depressed or pitted scars. Too much collagen creates raised acne scars. As we age and the production of collagen slows, acne scars can become more prominent.

What determines whether someone develops acne scarring?

The development of acne scarring is influenced by a combination of factors, including:

• Type and Severity of Acne: Inflammatory acne (including papules, pustules, nodules, and cysts) is more likely to cause scars especially if not treated promptly or is subjected to picking or squeezing. This is because of the deep skin inflammation and damage it can cause.
• Genetics: Some people are more prone to scarring because of their genetic makeup. If close family members have acne scars, there’s a higher chance you might develop them too.
• Skin Type: People with darker skin tones are often more susceptible to hyperpigmentation (dark spots) following an acne breakout, while those with lighter skin might see red or purple marks (post-inflammatory erythema).
• Picking and Squeezing: Popping pimples or picking at acne can increase the risk of scarring. This can introduce more bacteria into the lesion, increase inflammation, or push the inflammation deeper into the skin.
• Delayed Treatment: The longer acne remains untreated or inadequately treated, the higher the risk of scarring.
• Collagen Production: The way your skin heals and produces collagen plays a role. Too much collagen results in raised scars (hypertrophic or keloid scars), while too little leads to depressed scars.
• Infection: Bacterial growth can exacerbate acne and increase inflammation, potentially increasing the likelihood of scarring.
• Hormones: Hormonal imbalances, particularly androgens, can intensify acne, making it more severe and increasing the potential for scars.
• Other Skin Conditions: Conditions like Ehlers-Danlos syndrome can affect skin’s healing capability and may contribute to the development of scars.
• External Aggravators: Exposure to harsh environmental factors like excessive sun can exacerbate post-inflammatory hyperpigmentation, making the scars appear more noticeable.

Preventing scars often involves treating acne early, resisting the urge to pick or squeeze, and consulting a dermatologist about effective acne treatments. If scars do develop, there are various treatment options available to reduce or eliminate their appearance.

What are the types of Acne Scars?

Atrophic Scars

These scars are the most common type and appear as depressions in the skin. They occur when not enough collagen is produced while the wound is healing. There are several subtypes of atrophic scars:

• Ice pick scars: Small, deep holes that look as if the skin has been punctured with a sharp object.
• Boxcar scars: Broad, rectangular depressions with steep, defined edges.
• Rolling scars: Wide, shallow depressions that make the skin appear wavy.

Hypertrophic Scars

These are raised scars that stand above the surface of the skin. They’re caused by an overproduction of collagen as the acne wound heals. They’re typically found on the chest and back, but they can also appear on the face.

Keloid Scars

Like hypertrophic scars, keloid scars are raised, but they’re larger than the original wound. They can continue to grow and expand over time. Keloids are more common in people with darker skin tones.

How are acne scars treated?

Here are some safe and effective scar treatments that can diminish the appearance of the scars. The treatment choice will depend on the type of scar. Combinations are common.

Treatments for depressed scars include:

• Topical Treatments: These may include retinoids and chemical peels. They can help reduce the appearance of mild scarring.
• Microneedling (Collagen-induction Therapy): Tiny needles are used to prick the skin, which stimulates collagen production and can help reduce the appearance of scars.
• Laser Resurfacing: This is a procedure that uses lasers to remove surface layers of skin which stimulates the production of healthy new skin cells. It treats widespread depressed acne scarring, can recontour scar edges to make them less noticeable and treat minor facial flaws.
• Filler Injections: Fillers can be used to fill in the indentations left by deep acne scars, but not icepick scars.
• Skin Tightening with radiofrequency energy. This tightens the skin and makes depressed scars less noticeable.

Treatments for raised scars include:

• Steroid Injections: These can be used to treat raised acne scars like keloids or hypertrophic scars.
• Minor surgery: In some cases, scars might need to be removed surgically.
• Laser and light therapy using a pulsed dye laser.
• Freezing or Cryotherapy.
• Scar creams, gels and silicone dressings can help fade raised scars and reduce itching.

Scar treatments are available only after your acne has cleared because current inflammation will reduce the effectiveness of these treatments.

Dr. Michael Rains is a board-certified dermatologist and the founder of Beacon Dermatology in Asheville, North Carolina. His approach to aesthetic and dermatologic treatments is holistically focused on revealing and enhancing a patient’s natural beauty. Dr. Rains is known for his caring and compassionate approach to medicine, listening to patients’ concerns and goals and ensuring they receive excellent care and education so that they can make informed decisions about their care.