A Complete Review of Acne Scar Treatments

Why do some pimples leave such horrible scars?

Acne scars occur in 30% of people afflicted with moderate to severe acne vulgaris.

Acne is a manifestation of inflamed skin pores, engorged with excess sebum, dead skin cells and bacteria. When the infection is severe, the follicle wall breaks down and infected material spills out into surrounding tissues, leading to deeper and more prolonged inflammation. If the infection causes a full-thickness dermal injury, that is when scarring occurs.

The skin attempts to repair these dermal injuries through a fibrous process in which new collagen is formed and laid down to heal these lesions. But these repairs are never as smooth and flawless as original skin. They are in fact textural scars.

The highest incidence of scarring occurs after nodulocystic acne, acne conglobate and acne fulminans. In such cases, patients should seek early acne treatment to prevent gross permanent scarring.

Does the type of scar matter?

Yes very much. Identifying the type of scar is the first step in deciding treatment options. 

Pigmented scars

These can be red scars (post inflammatory erythema) or brown scars (post inflammatory hyperpigmentation). They can be self-limiting, but in most patients the discolouration tends to persist for months. Some studies have shown that prolonged red scars can lead to depressed permanent scarring.

These are the easiest acne scars to treat. Brown scars can be lightened with pigmentation creams, and lasers like PicoSure or Q-Switched Nd Yag. Red marks can be treated using medical grade creams containing azelaic acid and niacinamide, or lasers like Fotona Long-Pulsed Nd Yag or Dual Yellow Laser. Lasers are considered the mainstay treatmen. Effects of creams can be slow, hence best used as an adjunct to lasers.

Atrophic or Depressed scars

These are commonly found at the cheeks and temples, and typically result when the body does not produce enough fibroblasts and collagen during the healing process.

Types of Depressed Scars
  1. Ice pick scars are narrow but they go deep in the skin. These are usually the result of pustules – small, white and pus-filled pimples, surrounded by redness. Ice pick scars look like small round or oval holes. These are the most difficult scars to treat because they can extend far under the skin surface.
  2. Boxcar scars are broader U-shaped depressions, with sharp defined edges, almost like a crater. They can be shallow or deep. Shallow scars tend to respond better to skin resurfacing treatments.
  3. Rolling scars are wide depressions with sloping edges. As the name suggests, they typically have rounded irregular edges and a rolling appearance.

Hypertrophic or Raised scars

These occur when the body goes into “hyperdrive” during the inflammation and healing process, resulting in over-production of collagen. Hypertrophic scars are raised, and harder than usual skin texture.

If the scar tissue grows beyond the original boundary of the pimple, they are known as keloid scars. Keloids can be thicker and darker than the surrounding skin, and can occasionally be hypersensitive, painful or itchy.

While unsightly, these are relatively easy to treat. Monthly injections of triamcinolone (steroid), mixed with botox, will shrink and flatten out these scar over a few sessions.

These scars are the bane of my life!!

Many of my patients express regret at how they should have sought treatment for acne during their teenage years, not realizing the prolonged inflammation will lead to such severe permanent textural defects.

With the evolution of modern medicine and technology, these scars can now be lighted and restored. Many studies have shown how treatment of acne scars can lead to improved appearance and self-esteem in the long run.

So many different types of treatments! Which is best for me?

As I often tell my patients, there is no one way to skin the cat. Each patient will usually have a mixture of different types of scars, requiring various methods of treatment. So here’s an overview of the management options which can be tailored for specific types of scars.

Energy-based devices for acne scar removal treatment

Treating depressed acne scars is not a straightforward process. Some patients have on-going acne flares which needs to be addressed first, so as to prevent new scars from forming. I start off with a thorough initial consultation, involving accurate diagnosis of the various types of scars, then customizing an individualised treatment plan which may span several months and multiple sessions. It is also important to manage patients’ expectations of the eventual outcome.

Acne scars can be an unwanted reminder of acne and may reduce self-esteem in the long run. But these do not have to be permanent. In recent years, increased awareness and improved techniques have shown that even severe acne scars can be treated with good results. But treatments can be intensive – both time and financially. In Singapore, a comprehensive course of treatment for acne can range from $2000 – $6000. Hence prevention is always better than cure! Treat acne vulgaris with respect and seek treatment promptly, before they leave depressed scars!

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