“Acne scarring occurs because infected material from follicles within the skin spills out causing inflammation and damage to the dermis of the skin,” explains David Cangello, MD of New York's Cangello Plastic Surgery. “When the dermis is injured, the response is fibrosis, which is a complex process involving deposition of collagen and other proteins. The combination of damage or thinning to the dermal layer of the skin and fibrosis causes acne scarring."
Another big player? Genetics, which greatly impact the after effects. “If your mother or father suffered from acne and scarring, you could have a 50 percent chance of also having it,” shares Manon Pilon, R&D Director of Nelly De Vuyst and author of Anti-Aging: The Cure Based On Your Body Type.
Unfortunately, all scars aren’t created equally either. “When a pimple forms, collagen is damaged, and abnormal healing of that collagen and leads to scarring. It is estimated that an individual pimple has a six percent risk of healing with a scar,” explains Joshua Zeichner, MD, dermatologist and director of cosmetic and clinical research at Mount Sinai Hospital in New York City.
To help, we’ve broken down the six most common types of scarring along with dermatologist-approved solutions.
Keloids and hypertrophic scars
"Hypertrophic scars are ‘overgrown,'" explains Dr. Cangello. "These types of scars stay within the boundary of the wound edge and typically appear to be raised or firm. Keloids go beyond the point of hypertrophic scars and they grow outside the bounds of the wound’s edges—they can grow to be very large.”
According to Elizabeth Arden’s consulting dermatologist Dendy Engelman, MD, people with darker skin are at a higher risk of keloids so prevention is key. “This can be treated with the PicoSure picosecond laser, intralesional steroids, photodynamic therapy, and scar revision, which means excising the scar with a small 'punch,' and suturing the defect closed, but this only works for isolated scars.”
Among the favorites, PicoSure laser is a treatment that rejuvenates the skin and removes skin irregularities including hyperpigmentation, acne scarring, and sun exposure, minus the excess heat produced by many previous gen lasers. “It is a very safe treatment that creates a photomechanical impact (PicoSeconds of pulse width which are so ultra short they deliver a mechanical impact) to remove damaged layers of the skin without harming the healthy skin surrounding it,” Dr. Engleman adds. “The light also helps stimulate collagen production and produces new skin cells in the underlying layers to reveal younger looking as well as scar-free skin.”
Ice pick scars
Ice pick (or pitted) scars are described as small, yet deep, holes on the surface of the skin. Pilon explains that “ice pick scars begin as a comedone: a soft plug formed in the hair follicle, blocking the pore. The pus can build up pressure, which will cause the inflammation to go deeper into the skin—revealing deep crevices with a narrow openings being formed.”
Dr. Cangello has found success in treating these types of scars with a resurfacing lasers or a method known as subscision. "Subcision (or cutting under the surface of the skin) can sometimes release depressed scars as well. There are lots of tools in the armamentarium and choosing the right ones based on the characteristics of the scar is key,” he adds.
Conversely, Dr. Zeicher has found success with a procedure called TCA Cross, where very high concentration of trichloroacetic acid is applied directly to the scar. “TCA is commonly used at lower concentrations for full face chemical peels. However, the high concentration of the acid creates a wound within the scar and leads to healing process that improves of the depth of it,” he explains.
Rolling scars
Think of rolling scars as another version of ice pick scars, but they are smooth around the edges.“They are scar tissue under the skin that gives it an uneven appearance,” explains Dr. Engelman. Per Pilon, rolling scars are almost always a result of long-term inflammatory acne. “Unfortunately, this type of scar can become more obvious and/or severe as you get older, especially when your skin loses its natural tightness and elasticity. They tend to be shallow, so if you were to stretch the skin it might be hard to tell that they are there. Laser treatments are a common way to target rolling scars, as they resurface the top layers of your skin.”
Boxcar scars
When you have inflammatory acne—think red, inflamed, irritated papules and pustules—boxcar scars are common aftermath. While shallow, they tend to have sharper edges unlike their sister rolling scars described above. “Boxcar scars look almost like someone pushed their fingernail directly into your skin. This depression in your skin holds scar tissue that becomes pulled downward into the rest of the skin,” explains Pilon. She suggests collagen-boosting laser treatments can help reduce the appearance unevenness. “Radio Frequency (RF) can also be used to help with scar tissue. For a more superficial treatment, you can choose microdermabrasion which can help improve the skin’s texture.”
Combination scars
More often than not, acne-sufferers don’t exclusively have one type of scarring—it’s usually a mix of those listed above. “Chemical peels can be a great way of addressing pigment changes and superficial scarring,” explains Michele Farber MD FAAD, a dermatologist at Schweiger Dermatology Group. “For deeper scars, microneedling and fractionated laser resurfacing can generate controlled injury to skin to stimulate controlled wound healing to rebuild collagen within indented scars,” she adds.
In terms of OTC solutions, sunscreen is always a must. “EltaMD makes great, acne-friendly sunscreen,” Dr. Farber adds. “Retinols are also great as anti-aging and helping to stimulate collagen regeneration; they are helpful for maintenance alongside in-office procedures. Skinceuticals also makes a great vitamin C serum.” She also recommends glycolic acid-based products because they “help stimulate skin turn over and thus collagen regeneration.”
Hyperpigmentation
When acne heals, it often leave behind “stains” in the skin which, despite not being true scars, can be long-lasting and have a significant psychosocial effect shares Dr. Zeichner. “In fairer complexions, when pimples heal, the skin may be left with a red spot. This is known as persistent erythema. In these cases, the fire is out, but there still are glowing embers in the skin. The best way to treat these red spots is to continue treating the face with your acne treatment.”
For darker complexions, he shares that “inflammation can rev up activity of your pigment producing cells leading to dark spots that remain even after the pimple goes away. The spots, known as post-inflammatory hyperpigmentation, do fade on their own but it can take several months.” Dr. Farber acknowledges that “Hyperpigmentation may benefit from some measures used to treat scarring, but can respond to topical creams like retinoids and vitamin c serums, and chemical peels to help even out skin.”
BTW, we polled 700 women about their acne, and this is what they had to say. Oh, and if you're currently dealing with boob zits, it's totally normal.
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