A detailed
and comprehensive discussion of acne scars starts with causes
of scarring, prevention of scarring, types of scars, and
treatments for scars.
Before
talking about scars, a word about spots that may look like
scars but are not scars in the sense that a permanent change
has occurred. Even though they are not true scars and disappear
in time, they are visible and can cause embarrassment.
Macules
or "pseudo-scars" are flat, red or reddish spots
that are the final stage of most inflamed acne lesions.
After an inflamed acne lesion flattens, a macule may remain
to "mark the spot" for up to 6 months. When the
macule eventually disappears, no trace of it will remain
- unlike a scar.
Post-inflammatorv
piqmentation is discoloration of the skin at the site
of a healed or healing inflamed acne lesion. It occurs more
frequently in darker-skinned people, but occasionally is
seen in people with white skin. Early treatment by a dermatologist
may minimize the development of post-inflammatory pigmentation.
Some post-inflammatory pigmentation may persist for up to
18 months, especially with excessive sun exposure. Chemical
peeling may hasten the disappearance of post-inflammatory
pigmentation.
In the
simplest terms, scars form at the site of an injury to tissue.
They are the visible reminders of injury and tissue repair.
In the case of acne, the injury is caused by the body's
inflammatory response to sebum, bacteria and dead cells
in the plugged sebaceous follicle. Two types of true scars
exist, as discussed later: (1) depressed areas such as ice-pick
scars, and (2) raised thickened tissue such as keloids.
When
tissue suffers an injury, the body rushes its repair kit
to the injury site. Among the elements of the repair kit
are white blood cells and an array of inflammatory molecules
that have the task of repairing tissue and fighting infection.
However, when their job is done they may leave a somewhat
messy repair site in the form of fibrous scar tissue, or
eroded tissue.
White
blood cells and inflammatory molecules may remain at the
site of an active acne lesion for days or even weeks. In
people who are susceptible to scarring, the result may be
an acne scar. The occurrence and incidence of scarring is
still not well understood, however. There is considerable
variation in scarring between one person and another, indicating
that some people are more prone to scarring than others.
Scarring frequently results from severe inflammatory nodulocystic
acne that occurs deep in the skin. But, scarring also
may arise from more superficial inflamed lesions. Nodulocystic
acne that is most likely to result in scars.
The
life history of scars also is not well understood. Some
people bear their acne scars for a lifetime with little
change in the scars, but in other people the skin undergoes
some degree of remodeling and acne scars diminish in size.
People also have differing feelings about acne scars. Scars
of more or less the same size that may be psychologically
distressing to one person may be accepted by another person
as "not too bad." The person who is distressed
by scars is more likely to seek treatment to moderate or
remove the scars.
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As discussed
in the previous section on Causes of Acne Scars, the occurrence
of scarring is different in different people. It is difficult
to predict who will scar, how extensive or deep scars will
be, and how long scars will persist. It is also difficult
to predict how successfully scars can be prevented by effective
acne treatment.
Nevertheless,
the only sure method of preventing or limiting the extent
of scars is to treat acne early in its course, and as long
as necessary. The more that inflammation can be prevented
or moderated, the more likely it is that scars can be prevented.
Any person with acne who has a known tendency to scar should
be under the care of a dermatologist.
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There
are two general types of acne scars, defined by tissue response
to inflammation: (1) scars caused by increased tissue formation,
and (2) scars caused by loss of tissue.
Scars
Caused by Increased Tissue Formation
The
scars caused by increased tissue formation are called keloids
or hypertrophic scars. The word hypertrophy means "enlargement"
or "overgrowth." Both hypertrophic and keloid
scars are associated with excessive amounts of the cell
substance collagen. Overproduction of collagen is a response
of skin cells to injury. The excess collagen becomes piled
up in fibrous masses, resulting in a characteristic firm,
smooth, usually irregularly-shaped scar. The photo below
shows a typical severe acne keloid:
The
typical keloid or hypertrophic scar is 1 to 2 millimeters
in diameter, but some may be 1 centimeter or larger. Keloid
scars tend to "run in families"-that is, abnormal
growth of scar tissue is more likely to occur in susceptible
people, who often are people with relatives who have similar
types of scars.
Hypertrophic
and keloid scars persist for years, but may diminish in
size over time.
Scars
Caused by Loss of Tissue
Acne
scars associated with loss of tissue-similar to scars that
result from chicken pox-are more common than keloids and
hypertrophic scars. Scars associated with loss of tissue
are:
Ice-pick
scars usually occur on the cheek. They are usually
small, with a somewhat jagged edge and steep sides-Iike
wounds from an ice pick. Ice-pick scars may be shallow
or deep, and may be hard or soft to the touch. Soft scars
can be improved by stretching the skin; hard ice-pick
scars cannot be stretched out.
Depressed
fibrotic scars are usually quite large, with sharp
edges and steep sides. The base of these scars is firm
to the touch. Ice- pick scars may evolve into depressed
fibrotic scars over time. Soft scars. superficial or deep
are soft to the touch. They have gently sloping rolled
edges that merge with normal skin. They are usually small,
and either circular or linear in shape.
Atrophic
macules are usually fairly small when they occur on
the face, but may be a centimeter or larger on the body.
They are soft, often with a slightly wrinkled base, and
may be bluish in appearance due to blood vessels lying
just under the scar. Over time, these scars change from
bluish to ivory white in color in white- skinned people,
and become much less obvious.
Follicular
macular atrophy is more likely to occur on the chest
or back of a person with acne. These are small, white,
soft lesions, often barely raised above the surface of
the skin-somewhat like whiteheads that didn't fully develop.
This condition is sometimes also called "perifollicular
elastolysis." The lesions may persist for months
to years.
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A number
of treatments are available for acne scars through dermatologic
surgery. The type of treatment selected should be the one
that is best for you in terms of your type of skin, the
cost, what you want the treatment to accomplish, and the
possibility that some types of treatment may result in more
scarring if you are very susceptible to scar formation.
A decision
to seek dermatologic surgical treatment for acne scars also
depends on:
The
way you feel about scars. Do acne scars psychologically
or emotionally affect your life? Are you willing to "live
with your scars"and wait for them to fade over time?
These are personal decisions only you can make.
The
severity of your scars. Is scarring substantially disfiguring,
even by objective assessment?
A
dermatologist's expert opinion as to whether scar treatment
is justified in your particular case, and what scar treatment
will be most effective for you.
Before
committing to treatment of acne scars, you should have a
frank discussion with your dermatologist regarding those
questions, and any others you feel are important. You need
to tell the dermatologist how you feel about your scars.
The dermatologist needs to conduct a full examination and
determine whether treatment can, or should, be undertaken.
The
objective of scar treatment is to give the skin a more acceptable
physical appearance. Total restoration of the skin, to the
way it looked before you had acne, is often not possible,
but scar treatment does usually improve the appearance of
your skin.
The
scar treatments that are currently available include:
Collagen
injection. Collagen, a normal substance of the body,
is injected under the skin to "stretch" and
"fill out" certain types of superficial and
deep soft scars. Collagen treatment usually does not work
as well for ice-pick scars and keloids. Collagen derived
from cows or other non-human sources cannot be used in
people with autoimmune diseases. Human collagen or fascia
is helpful for those allergic to cow-derived collagen.
Cosmetic benefit from collagen injection usually lasts
3 to 6 months. Additional collagen injections to maintain
the cosmetic benefit are done at additional cost.
Autologous
fat transfer. Fat is taken from another site on your
own body and prepared for injection into your skin. The
fat is injected beneath the surface of the skin to elevate
depressed scars. This method of autologous (from your
own body) fat transfer is usually used to correct deep
contour defects caused by scarring from nodulocystic acne.
Because the fat is reabsorbed into the skin over a period
of 6 to 18 months, the procedure usually must be repeated.
Longer lasting results may be achieved with multiple fat-transfer
procedures.
Dermabrasion.
This is thought to be the most effective treatment for
acne scars. Under local anesthetic, a high-speed brush
or fraise used to remove surface skin and alter the contour
of scars. Superficial scars may be removed altogether,
and deeper scars may be reduced in depth. Dermabrasion
does not work for all kinds of scars; for example, it
may make ice-pick scars more noticeable if the scars are
wider under the skin than at the surface. In darker-skinned
people, dermabrasion may cause changes in pigmentation
that require additional treatment.
Microdermabrasion.
This new technique is a surface form of dermabrasion.
Rather than a high-speed brush, icrodermabrasion
uses aluminum oxide crystals passing through a vacuum
tube to remove surface skin. Only the very surface cells
of the skin are removed, so no additional wound is created.
Multiple procedures are often required but scars may not
be significantly improved.
Laser
Treatment. Lasers of various wavelength and intensity
may be used to recontour scar tissue and reduce the redness
of skin around healed acne lesions. The type of laser
used is determined by the results that the laser treatment
aims to accomplish. Tissue may actually be removed with
more powerful instruments such as the carbon dioxide laser.
In some cases, a single treatment is all that will be
necessary to achieve permanent results. Because the skin
absorbs powerful bursts of energy from the laser, there
may be post-treatment redness for several months.
Skin
Surqerv. Some ice-pick scars may be removed by "punch"
excision of each individual scar. In this procedure each
scar is excised down to the layer of subcutaneous fat;
the resulting hole in the skin may be repaired with sutures
or with a small skin graft. Subcision
is a technique in which a surgical probe is used to lift
the scar tissue away from unscarred skin, thus elevating
a depressed scar.
Skin
qrafting may be necessary under certain conditions-for
example, sometimes dermabrasion un-roofs massive and extensive
tunnels (also called sinus tracts) caused by inflammatory
reaction to sebum and bacteria in sebaceous follicles.
Skin grafting may be needed to close the defect of the
unroofed sinus tracts.
Treatment
of keloids. Surgical removal is seldom if ever used
to treat kelodis. A person whose skin has a tendency to
form keloids from acne damage may also form keloids in
response to skin surgery. Sometimes keloids are treated
by injecting steroid drugs into the skin around the keloid.
Topical retinoic acid may be applied directly on the keloid.
In some cases the best treatment for keloids in a highly
susceptible person is no treatment at all.
