Acne and scarring: why prevention is better than the cure
Acne is such a common condition in puberty that it is often thought of as a temporary phase that most will have to go through, almost like a rite of passage. However, not only does acne continue into adulthood for some, but its effects can persist in ways that people do not expect, namely in the form of permanent scarring. In fact, as many as 20% of people with acne will go onto develop some form of scarring.
This may not be that apparent to acne sufferers while they have active acne, as they are more troubled by a cycle of painful and inflamed skin lesions, followed by transient redness and hyperpigmentation. Unfortunately, as these features fade, true scarring can become evident and, with loss of collagen as we grow older, all the more obvious.
To some extent, the presence of acne scarring can depend on acne severity and on how deep the inflammation is in the skin. Picking and squeezing spots can also result in an increased risk for scarring. However, some patients with seemingly mild acne can also unfortunately scar. A tendency to scarring is more complicated than initially thought, with genetics being a factor.¹
What types of acne scarring are there?
Many people will get discolouration in an area previously affected by inflamed acne spots, presenting as either redness or hyperpigmentation. In most cases, this post inflammatory hyperpigmentation tends to resolve with time and is not considered to be true scarring.
There can be a tendency for atrophic scarring on the face. This is scarring resulting in indentations, especially in areas such as the forehead and cheeks. There are different types of atrophic scars, classified according to the type of indentation they leave in the skin, and these include ice pick scars, boxcar scars and rolling scars.
Raised, thickened scars, known as hypertrophic and keloid scars are more at risk of developing if acne is affecting the chest, shoulders and back.
Perifollicular elastolysis (PFE) is a less commonly recognised type of scarring, which appears as skin coloured white or yellowish papules in previously affected acne sites on the upper torso, chin and jawline.
Treatments for acne scarring
So, what treatments do we have for acne scarring? Post inflammatory hyperpigmentation does settle with time but can be helped along with topical retinoids, which are also commonly used in the treatment of acne. There is also evidence to suggest that topical retinoids, specifically adapalene 0.3%, can improve the appearance of minor atrophic (indented) scars.²
Chemical peels can also improve hyperpigmentation and relatively superficial scarring, though several courses are needed. Results and downtime both depend on the depth of the peel used. For example, you might experience some skin brightening and lessening in hyperpigmentation with superficial peels, but should not expect the level of improvement a medium or deep peel can achieve. Dermabrasion, where the top layer of the skin is abraded, is thought to result in mild improvement.
Hypertrophic and keloid scars can be flattened with the use of potent topical steroids, though mostly these would need to be injected directly into the scar, and often more than one session may be needed. In the past few years, pulse dye laser (PDL), has been used successfully in the treatment of keloid scars.
Atrophic or indented scarring can be particularly difficult to treat. Full ablative laser such as CO2 or erbium: YAG laser, is where the top layers of skin are injured and destroyed, stimulating recovery and collagen production in deeper layers. This is often thought to be the gold standard of treatment, with significant improvement of up to 70%. There is significant downtime, with costs and potential complications, and this treatment should only be undertaken by trained medical specialists.
Fractional laser, which leaves columns of skin between treated areas unaffected, initially promised to give similar benefits to ablative laser with less downtime. A course of three to five may be required, and results may not quite reach the same levels of efficacy as ablative laser, but it has a excellent safety profile.
Some types of atrophic scarring such as rolling and boxcar scars can be treated via a technique known as subcision. This requires a skilled medical operator to manipulate a needle within numbed skin, in order to break up fibrous bands causing tethering of these scars to the deeper skin layers. Ice pick and other deeply indented scars can also be treated through punch excision, whereby the scars are removed and the wound stitched, or by punch elevation, whereby scars are punch excised, elevated and stitched closer to the surface of the skin. Again, these techniques require a highly trained specialist, involve a minor procedure and have some expected downtime.
Microneedling, otherwise known as collagen induction therapy, is an increasingly popular treatment where multiple needles are passed over affected areas in an automated way, inducing micro-injuries and collagen production as the skin heals. Some studies have shown this technique to boost collagen production by up to 400%.³ Though a course of multiple treatments may be required, this is a relatively inexpensive procedure, with very little downtime, that may be useful in mild atrophic scarring or hyperpigmentation.
Other treatments for atrophic scars include injection of fillers, and a procedure known as TCA CROSS, where trichloroacetic acid is added to the centre of depressed scars, inducing injury and collagen stimulation.
Prevention is better than the cure
So, what should we be taking away from the above information? Mainly that, unless scarring is very mild/superficial, treatment of most types of acne scarring can be costly, with potential complications and significant downtime depending on the treatment picked, requiring the skills of highly trained medical professionals. Improvement can range from mild to significant depending on the treatment undertaken, but it would be unrealistic to expect complete resolution of the scarring.
When it comes to acne scarring, all dermatologists will tell you that this is a case of “prevention is better than the cure”. Certainly, to me, any evidence of early scarring in a patient is a strong indication that this person’s acne should be treated without any further delay. This is crucial to ensure that any active acne is shut down, in order to prevent any further scarring, which is harder to treat than the acne itself.
If you are suffering with acne and are have noticed evidence of scarring, I would urge you to seek the help of your GP or a consultant dermatologist. Visit my website for more information on acne and specific treatment options.
References
- English RS, Shenefelt PD. Keloids and hypertrophic scars. Dermatologic Surgery. 1999;25(8):631–638.
- Loss MJ, Leung S, Chien A et al. Adapalene 0.3% Gel Shows Efficacy for the Treatment of Atrophic Acne Scars. Dermatol Ther (Heidelb). 2018 Jun; 8(2): 245–257.
- Aust MC, Fernandes D, Kolokythas P, Kaplan HM, Vogt PM. Percutaneous collagen induction therapy: an alternative treatment for scars, wrinkles, and skin laxity. Plast Reconstr Surg. 2008 Apr; 121(4):1421–9.
