The Best Treatments For Each Type Of Acne Scar

Acne scars can be a lasting reminder of past breakouts, impacting not only skin health but also self-esteem. While some scars fade with time, others remain more permanent and require targeted treatment. Understanding the different types of acne scars is the first step in choosing an effective treatment plan. Each scar type is unique, and addressing them with the right interventions can lead to significant improvements in skin texture and appearance.

Types of Acne Scars

1. Atrophic Scars

Atrophic scars are depressed scars that sit below the surrounding skin. These scars result from a lack of collagen during the wound-healing process. Atrophic scars can be classified into the following subtypes:

Ice pick scars

• Description: These scars are narrow, deep, and sharply defined, resembling tiny puncture wounds or open pores. They often penetrate deeply into the skin’s surface, making them appear as if the skin has been pricked with a sharp object.
• Appearance: Due to their depth, ice pick scars cast noticeable shadows under certain lighting, making them highly visible. They often occur on areas like the cheeks and nose, where acne lesions tend to be deeper. Their vertical orientation makes them challenging to treat with superficial methods.
• Common Causes: Ice pick scars result from severe acne, particularly cystic or nodular acne, which causes deep inflammation. When an infection destroys collagen and elastin in the skin, the tissue collapses, leaving a deep pit. Delayed or improper treatment of acne increases the likelihood of developing these scars.

Boxcar scars

• Description: These scars are wider and shallower than ice pick scars, with well-defined, sharp edges. They have a box-like shape and appear as indentations in the skin, often covering larger areas.
• Appearance: Boxcar scars create a pitted or cratered look on the skin, frequently found on the cheeks, temples, and lower jawline. Their sharp edges can make the skin appear uneven and rough to the touch.
• Common Causes: Boxcar scars are typically formed when acne inflammation destroys collagen over a broader area. The loss of support from collagen creates depressions in the skin. Moderate to severe acne, especially inflammatory types like papules and pustules, is a common culprit.

Rolling scars:

• Description: Rolling scars are characterized by their wave-like appearance. They are less sharply defined than ice pick or boxcar scars, with sloping edges that blend into the surrounding skin.
• Appearance: These scars give the skin an uneven, bumpy texture, particularly noticeable under direct lighting. Rolling scars are typically spread out, creating a stretched, undulating effect that can cover larger areas.
• Common Causes: Long-term or recurrent inflammation damages the skin’s deeper structures, such as the dermis and subcutaneous layers. This results in fibrous bands forming between the skin and underlying tissue, tethering the surface and creating the rolling effect.

2. Hypertrophic Scars

Description: Hypertrophic scars are raised, firm scars that develop when the body produces excess collagen during the wound-healing process. Unlike keloids, they are limited to the original boundary of the acne lesion and do not spread into the surrounding skin. These scars often have a rubbery texture and can appear pink, red, or flesh-toned, depending on the individual’s skin tone. Over time, they may soften or flatten, but they often remain elevated without treatment.

Appearance: Hypertrophic scars are thick and noticeable, typically forming over areas where the acne lesion was most inflamed. They are most common on the chest, back, shoulders, and jawline, where the skin tends to be thicker and more prone to robust healing responses.

Common Causes: These scars result from an overproduction of collagen during the skin’s attempt to repair itself after significant trauma. Deep, inflammatory acne, such as cysts or nodules, is more likely to lead to hypertrophic scarring, especially if lesions are picked at, popped, or improperly treated. Factors like genetics, delayed wound care, and higher skin tension in certain body areas can also increase the likelihood of these scars forming.

3. Keloid Scars

Description: Keloid scars are an extreme form of scar tissue characterized by their raised and thickened appearance. Unlike hypertrophic scars, keloids grow beyond the boundaries of the original lesion, often expanding into the surrounding skin. These scars can feel rubbery or firm to the touch and are sometimes accompanied by itching, tenderness, or even pain. Keloids are typically red, pink, or darker than the surrounding skin, depending on the individual’s skin tone, and they can persist or enlarge over time if left untreated.

Appearance: Keloid scars are irregularly shaped and may appear shiny or smooth on the surface. They often develop on areas with higher skin tension, such as the chest, shoulders, back, jawline, and ears. Their prominent and overgrown nature makes them particularly noticeable, and they can sometimes cause emotional distress or self-consciousness due to their visible size and texture.

Common Causes: Keloids result from an overly aggressive healing response, where the body produces excessive collagen even after the wound has healed. This leads to the uncontrolled growth of scar tissue. People with a genetic predisposition, particularly those with darker skin tones, are more prone to keloid formation. Acne lesions that are deep, inflamed, or improperly treated, as well as trauma like picking or squeezing pimples, can trigger keloid development. Environmental factors, such as repeated irritation or friction on the scar site, can also exacerbate their growth.

4. Post-inflammatory Hyperpigmentation (PIH)

Description: Post-inflammatory hyperpigmentation (PIH) appears as flat, discolored spots that remain on the skin after an acne lesion has healed. Unlike scars, PIH does not affect the texture of the skin but is instead characterized by changes in pigmentation. The discoloration can range from pink, red, or purple in lighter skin tones to brown, gray, or black in darker skin tones. PIH is especially common in individuals with medium to dark skin, as their skin produces more melanin, the pigment responsible for skin color.

Appearance: PIH typically appears as round or irregularly shaped patches on the areas previously affected by acne. These marks are most visible under natural or bright lighting and can persist for weeks, months, or even years, depending on their severity and whether they are treated. While PIH may fade over time without intervention, its persistence often depends on sun exposure and the depth of pigmentation.

Common Causes: PIH occurs when inflammation from acne lesions triggers an overproduction of melanin, the pigment responsible for skin color. This response is the skin’s attempt to heal itself after inflammation or injury. Factors that can exacerbate PIH include:

• Picking, squeezing, or popping pimples, which worsens inflammation.
• Exposure to UV rays, which can darken the spots further.
• Hormonal changes or imbalances that increase skin sensitivity and melanin production.

Best Treatment Options for Each Type

1. For Atrophic Scars

• Ice pick scars:
  • TCA cross: A chemical reconstruction technique using trichloroacetic acid to stimulate collagen production.
  • Subcision: A minor surgical procedure that releases fibrous scar tissue under the skin.
  • Laser resurfacing: Ablative and non-ablative lasers to stimulate new collagen.
• Boxcar scars:
  • Dermal fillers: Hyaluronic acid or collagen fillers to plump the skin and reduce scar depth.
  • Microdermabrasion: A gentle exfoliation technique to improve skin texture over time.
  • Microneedling: A procedure that uses tiny needles to stimulate collagen production.
• Rolling scars:
  • Subcision: A surgical approach that releases the bands of tissue causing the wave-like appearance.
  • Fractional laser therapy: Targets deep skin layers to stimulate collagen.

2. For Hypertrophic Scars

• Steroid injections: Reduces scar size by flattening the raised tissue.
• Silicone gel sheets: Helps soften and flatten scars over time.
• Laser treatments: IPL or fractional lasers to reduce redness and flatten scars.

3. For Keloid Scars

• Cryotherapy: Freezing the scar tissue to reduce its size.
• Steroid injections: Used to shrink the scar and reduce inflammation.
• Pressure dressings: Helps prevent further growth of the keloid.
• Surgical removal with radiation: For severe cases, surgical excision followed by radiation to prevent recurrence.

4. For PIH

• Chemical peels: Exfoliates the top layers of skin to fade pigmentation.
• Topical retinoids: Promotes cell turnover and reduces discoloration.
• Vitamin C serums: Brightens skin and inhibits melanin production.
• Sunscreen: Prevents darkening of spots and promotes overall skin healing.

Factors to Consider When Choosing a Treatment

Choosing the right treatment requires careful consideration of several factors:

• Skin type and tone: Some treatments, like laser therapy, may not be suitable for darker skin tones due to the risk of hyperpigmentation.
• Severity and type of scarring: Different scar types respond to specific treatments.
• Patient expectations and budget: Cost and potential outcomes should align with patient goals.
• Professional consultation: A dermatologist’s expertise is essential to develop a customized treatment plan.

Prevention Tips to Minimize Acne Scars

Preventing acne scars starts with proactive skin care and healthy habits:

• Early and effective acne treatment: Address acne promptly to minimize inflammation and reduce scarring risk.
• Avoid picking or popping pimples: Manipulating acne can worsen inflammation and increase the likelihood of scarring.
• Use sunscreen: Protects healing skin and prevents discoloration from worsening.

Acne scars can feel like a permanent reminder of past skin troubles, but effective treatments are available for every type of scar. Understanding the unique characteristics of atrophic, hypertrophic, keloid scars, and PIH helps in selecting the right interventions. With advances in dermatological treatments and proper preventive measures, achieving smoother, healthier skin is within reach. Consult a dermatologist to explore the best options tailored to your skin’s needs.

Helyn Alvarez, MD, FAAD is a board-certified Dermatologist. Dr. Alvarez completed her undergraduate studies at Boston University in Boston, Massachusetts. She earned her medical degree and internship training from Loyola Stritch School of Medicine in Chicago, Illinois, and went on to complete her dermatology residency at the University of Alabama-Birmingham. Passionate about delivering natural-looking results, she is highly trained and experienced in aesthetic dermatology, specializing in advanced cosmetic procedures. Dr. Alvarez excels in injectables, fillers, neuromodulators like Botox, state-of-the-art laser treatments, skin tightening procedures, and non-invasive facial rejuvenation.