Addressing Acne Scarring Concerns Among Patients

Ice pick scarring on the cheeks | Image credit: DermNet

A common question I receive from patients is how to address acne scarring. This question usually comes up either when I meet with an acne patient for the first time or after a patient’s acne has cleared from treatment. As we know as clinicians, acne scars can have a significant impact on a patient's self-esteem and confidence. With all of the latest advancements in dermatology, there is a great range of treatments available to address the various types of acne scarring.

When assessing a patient with acne scars, understanding the different types of scars is critical in determining the most effective treatment approach. There are 3 common categories for acne scarring: Depressed or atrophic acne scars, raised or hypertrophic acne scars, and post-inflammatory hyperpigmentation or pigmented scars.^1,2 

1. Depressed or atrophic scars: These scars appear as depressions in the skin and are categorized into 3 subtypes: Ice pick scars, boxcar scars, and rolling scars.

When addressing atrophic scars, the key to success is stimulating collagen production. Some common procedures that we perform for this include microneedling pens, microneedling with radiofrequency (RF), and fractional lasers.

Microneedling uses tiny needles to create controlled micro-injuries in the skin, triggering collagen production and remodeling. Microneedling with radiofrequency uses heat to target deeper dermal layers of the skin and therefore can promote more collagen fiber tightening than traditional microneedling pens. Traditional microneedling pens can work effectively for treating superficial scars, but for deeper scars, RF microneedling may be needed for faster improvement.

Laser treatments, such as fractional laser resurfacing, target the damaged skin, stimulating collagen production and improving skin texture. Some fractional lasers that I recommend to patients include Clear & Brilliant and Fraxel laser. Typically for more superficial scars, I will utilize Clear & Brilliant, whereas for deeper scars, I will recommend Fraxel CO2 laser.

For laser or microneedling sessions, I usually recommend a series of treatments spaced apart monthly for the best results. Depending on the number of scars, intensity of the treatment, and how long the scars have been present, the number of treatments can vary from 3 sessions to more.

2. Hypertrophic or raised scars: These scars result from excess collagen production during the healing process, leading to raised, firm areas of skin.

For hypertrophic or raised scars, I usually initiate treatment with local corticosteroid injections, tailoring the strength and quantity to the size and firmness of the scars. This is a process that can involve as little as one session or require a series of injections depending on the types of scars and their responsiveness to treatment. Steroids work to reduce these raised scars by breaking the bonds between collagen fibers and through their anti-inflammatory properties.

Some hypertrophic scars can also respond well to certain vascular laser treatments, such as the Vbeam or Cutera Excel V laser. These options are typically used in cases where a patient has a red or pink scar. These lasers work to both reduce the pigmentation and as well as target the textural changes.

3. Post-inflammatory hyperpigmentation (PIH) or pigmented scars: These are flat spots on the skin with pigmentation, but no texture changes.

When it comes to treating post-inflammatory hyperpigmentation, my first step is to create a skincare routine. The 4 key ingredients include (1) an antioxidant, (2) sunscreen, (3) topical retinoid, and (4) moisturizer. I always recommend products that are oil-free and non-comedogenic to avoid clogging the pores and triggering any acne flares.

For antioxidants, I typically endorse products with vitamin C and vitamin E such as SkinCeuticals CE Ferulic with 15% L-Ascorbic Acid serum. For sunscreens, I recommend products with zinc oxide and titanium oxide for broad-spectrum protection, such as the Dune Mineral Melt SPF 30. For moisturizers, products with hyaluronic acid and ceramides are vital for extra hydration, such as Fig.1 Ceramide Moisturizer. When it comes to topical retinoids, this is usually a prescription medication such as Altreno (tretinoin), Arazlo (tazarotene), or Aklief (trifarotene), that is sent to a patient’s pharmacy during their office visit.

After a skin care routine has been established, I usually recommend a series of chemical peels. Chemical peels involve applying a chemical solution to the skin, causing skin turnover and exfoliation, whether on a superficial, medium, or deep depth to the skin. Some common superficial-depth peels that I perform in the office include mandelic acid and glycolic acid peels, whereas a medium-depth peel that I often perform is the VI Peel Purify with Precision Plus. The chemical peel process is crucial to stimulating skin regeneration and helping to reduce the appearance of pigmented scars. No matter the type of peel, I usually recommend a series of treatments spaced apart monthly for the best results.

Acne scars can feel like a daunting challenge to treat, but with all the advancements in dermatological techniques, there are numerous options available to treat our patients. Whether it's laser therapy, chemical peels, microneedling, or simple skin care modifications, consulting with a dermatology specialist is the first step toward patients achieving better skin.

Hailey Brickman, PA-C, is a board-certified dermatology physician assistant practicing at The Dermatology Specialists in New York, NY.

References

1. Cirino E. 5 types of acne scars and how to treat them. Healthline. Updated January 26, 2024. Accessed June 3, 2024. https://www.healthline.com/health/skin-disorders/types-of-acne-scars

2. Medical treatment for scars & keloids. NYU Langone Health. Accessed June 3, 2024. https://nyulangone.org/conditions/scars-keloids/treatments/medical-treatment-for-scars-keloids