Different types of acne scarring and how to treat it

Acne scarring is so much more than simply a negative side effect of severe acne, as it can cause significant confidence issues in both adolescents and adults. Improving the appearance of scarring can dramatically improve self-esteem and reduce social anxiety. Although it is challenging to treat, major improvement can be achieved with clinical modalities, active cosmeceuticals and sun protection. One small change on the outside can make a dramatic difference on the inside, and that’s why I love being a cosmetic chemist!

Ideally scarring should be prevented by successfully treating and controlling the acne until hormonal regulation is achieved. However, some individuals are more prone to scarring, particularly those with darker skin tones.

The levels of acne scarring

Low-level scarring – superficial and only affects the epidermal layer. These scars are often simply highlighted by redness or slight pigmentation (Post inflammatory hyperpigmentation) and are not technically scars. They will generally heal with topical skin care, low-level chemical peels, IPL, LED therapy and lasers designed to treat redness and pigmentation.

Mild scarring – can be successfully treated with skin needling, fractional laser, radiofrequency (RF) therapy and dermal fillers combined with daily topical skin care.

Moderate scarring – treated with ablative CO2 lasers, Fractional laser, skin kneeling, RF and dermal fillers combined with topical skin care.

Severe scarring – treated with CROSS therapy with concentrated trichloracetic acid (TCA) placed directly on the scar to create a controlled acid burn, with punch techniques where the scar is excised often with skin grafts, with fat transfer, or with dermal filler.

Classifying scars

Ice pick scars – these scars are under 2mm wide with defined edges usually due to acne. They are conical or cylindrical in shape and appear as large, empty pores. These scars are difficult to camouflage.

Box scars – these scars can appear like rolling scars but have clearly defined margins with vertical box-shaped profile in cross-section. Box scars can be shallow or deep and can resemble chicken pox scars.

Rolling scars – these are generally over 5mm wide and have rounded sloping edges giving the skin a rippling texture.

There is also a category of severely raised scars called keloid or hypertrophic scars. This is often the result of injury or surgery rather than acne and is treated with local steroid therapy and/or vascular laser. These scars result from overproduction of collagen in an abnormal response to healing.

Clinical Treatment

Skin needling

Skin needling creates a controlled injury to the deeper dermis. Only a fraction of the skin is injured but a significant healing response is triggered to produce collagen production and textural improvement. All skin types can be treated, there is little social downtime and side effects are minimal. Eight to ten fortnightly to monthly treatments are recommended with optimal results achieved after twelve months when new collagen has matured. This treatment will reduce the surface depressions and is recommended for icepick, rolling and box scars.

Fractional laser

This is a non-invasive treatment and leaves the skin surface intact. Fine targeted lasers cause channels of heat injury to the epidermis and dermis resulting in collagen remodelling. The skin surface will be inflamed and swollen for around five days. Ice pick scars are successfully treated with approximately five treatments every four weeks.

Ablative laser (CO2 laser)

There is significant downtime with this treatment as the entire skin surface is injured and resurfaced. CO2 laser causes total tissue vaporization and can improve acne scarring by up to 80% due to the new collagen stimulation and reducing surface defects.

Complications of this treatment can include infection, milia formation and post-inflammatory hyperpigmentation (PIH) in darker skinned patients which presents around 4 weeks after treatment.

Cosmeceutical treatment

Clinical scar therapy must be coupled with topical skincare to achieve optimal results. Cosmeceutical ingredients should be targeting collagen production, reducing inflammation and promoting barrier repair. I would recommend:

Vitamin B serum – for barrier strengthening and healing (such as Vitamin B)

Vitamin B stimulates the production of the major skin barrier proteins to promote healing and protect the skin surface from inflammation. It also promotes collagen regeneration for remodelling of scars and reduces hyperpigmentation which may be a side effect of scarring or scar treatment.

Vitamin A serum – for collagen production (such as Ultimate A)

Vitamin A, particularly in the form of stabilised retinol aids in collagen production and promotes the production of new surface cells which is important in the healing process. Vitamin A helps with the production of healthy blood vessels in the dermis to enable vital supply of skin nutrients and removal of toxins during scar healing and treatment.

L-ascorbic acid – for wound healing (such as Pure-C crystals or Suprema-C)

L-ascorbic acid is essential for wound healing due to its ability to stimulate collagen, reduce redness and lighten pigmentation. Vitamin C is often used in scar therapy following fractional laser and ablative laser which may produce significant inflammation.

Physical sunscreen – for sun protection (such as ÜberZinc)

UV light is a scar’s worst enemy as it basically reverses healing. Furthermore, if the skin is healing both during scarring and following scar treatment, it is more susceptible to solar damage and exposure increases the chance of development of skin cancer. It is imperative to protect the skin, preferentially with mineral zinc oxide which provides natural UVA/UVB and Infrared protection. Zinc oxide is also a natural anti-inflammatory to aid the healing process. Mineral makeup such as Synergie Minerals foundations can be applied once the skin surface has commenced healing.

Pre-treatment prior to scar therapy
  • Pure-C crystals or Suprema-C – will prepare the skin with protective antioxidants
  • Ultimate A and Vitamin B – will help to lighten uneven skin tone and reduce the incidence of post-inflammatory hyperpigmentation
  • ÜberZinc – your sun protection is essential
Post-treatment following scar therapy
  • Pure-C crystals or Suprema-C – reduces redness and inflammation while the skin is in its healing phase.
  • Vitamin B – restores protective barrier on the skin
  • Occlusiderm – provides a protective moist cover on the skin and is recommended until the skin surface has been regenerated. Occlusive products are similar in texture to petroleum jelly but it is better to use a botanical occlusive such as Occlusiderm that has added healing agents such as castor bean oil, squalene, shea butter, sea buckthorn oil and propolis.
  • ÜberZinc – don’t undo the healing! Sun protect.

Alternatively, the Synergie Skin Post-Treatment Kit is a perfect mini set of these soothing post-treatment products.

During the healing phase, avoid retinoids and strong acids as this may cause further inflammation. Of course, sun protection is vital at all stages of scar treatment. A normal skin care routine may be resumed when all signs of skin redness and inflammation are resolved.