As if acne breakouts aren’t annoying enough, the leftover acne scarring and daily reminder can be further exasperating to anyone who has experienced this cycle. Want to hear the good news? There are a wide array of treatments that exist for acne and specifically for the sake of this article, acne scarring. Prior to addressing the multiple types of acne scarring and the diverse treatments that exist, it is vital to discuss the importance of treating acne first.
Without that first step, one is bound to experience continued cycles of breakouts leading to further frustration, which is self-defeating in addition to not being cost effective. Treatment should be different depending on the situation, because acne comes in a variety of different flavors, including occlusive acne or acne mechanica, comedonal acne (think blackheads and whiteheads), inflammatory acne (pustules and papules), hormonal acne (the dreaded monthly acne), and nodulocystic acne (larger cystic lesions most likely to leave scarring). Treatment often involves a combination of topicals, antibiotics, hormonal options, oral retinoids, lasers, chemical peels, and other cosmetic procedures.
Delving into acne-scarring and treatments requires understanding the different types of acne scarring that exist in addition to understanding the most crucial aspect in my opinion: prevention. Prevention should be addressed two fold-one treatment as addressed above, in addition to the importance of sunscreen every day. UV radiation especially from the sun plays a large role in scarring, especially pigmentary changes. A daily sunscreen that is broad spectrum (covering both UVA and UVB radiation) in addition to SPF 50+ will play a large role in acne scar prevention.
Acne scars can be broadly categorized in three different categories: atrophic scars, hypertrophic scars, and pigmented scars. Atrophic scars are flat or depressed areas that have healed below the normal level of skin. Furthermore, these can be categorized as boxcar scars, icepick scars, and rolling scars. Boxcar scars get their name due to their wide appearance with vertical edges on either side, resembling a box. Icepick scarring is categorized as deep and narrow channeling of the skin. Rolling scars can be rather deep as well however tends to have more sloped edges. All three are often treated with a multi-modality approach. The treatment of choice for such scarring is often a combination of acne scarring surgery, rejuvenation with fillers, microneedling, chemical peels, ablative laser therapy, and/or subcision (which does not call for incision).
Hypertrophic scarring and keloidal scarring is often more common in those with darker skin types and therefore is very relevant to the South Asian community. Both of these scar types extend on top of the skin itself and can be hyperpigmented in a variety of purple, red, pink, or darker tones and often accompanied by cystic acne. Treatments of choice include intralesional steroids, laser therapy, prescription medications to treat any ongoing acne, topicals for hyperpigmentation, and acne scar surgery.
The most common complaint related to acne scarring in South Asian skin is hyperpigmentation associated with acne. Fading acne scars often requires understanding whether the scarring is due to true post-inflammatory hyperpigmentation or post-inflammatory erythema (reddening caused by irritation, injury or blood vessel dilation). Post-inflammatory hyperpigmentation (PIH) is often categorized by brown or tan areas versus post-inflammatory erythema (PIE) is often seen as resultant red or pink areas. Again, sunscreen is the most crucial aspect in treatment in both scenarios.
Several topical ingredients play a role in treatment of PIE, including niacinamide, azelaic acid, green tea, and the standard of acne treatment, topical retinoids. Topical agents most commonly used in PIH include hydroquinone (higher percentages available via prescription with a board certified dermatologist), retinoids, vitamin C, kojic acid, arbutin, azelaic acid, alpha hydroxy acids, and/or tranexamic acid. Chemical peels are often a great adjunctive treatment for PIH and often some laser therapy (PDL/IPL) can play a role in treatment of both categories.
Topical treatments can be found as ingredients in over the counter formulations however often one prescribed by a dermatologist involves higher percentages and more stable formulations emphasizing better results. Chemical peels range from a variety of superficial to deeper peels which help remove the outer layers of the skin, also known as exfoliation, and can be used in a wide array of different scarring. Dermal fillers, are best for atrophic scarring where a substance, often hyaluronic acid, are injected into the scar itself to even out the level. Microneedling, a procedure with minimal downtime, will create small localized injuries across the skin stimulating the skin to produce collagen in a targeted fashion. Very deep atrophic scarring often requires well to subcision which entails breaking through the scar tissue that is often tethered down onto the skin. Laser therapy can be broadly broken down into two categories: ablative vs non ablative therapy.
All of the above are done best in conjunction with a professional such as a board certified dermatologist. Remember, not all treatments are created equally as every individual’s skin type responds best to an individualized approach. Patience and compliance are often the most important aspects of all acne and acne scarring treatments.
Mona Mislankar, MD, FAAD is a board certified dermatologist. For more details, visit Dr. Mislankar on Instagram @drmislankar.
This article is for informational purposes only and should not be construed as medical advice.