There are various types of acne lesions, and there are also various types of acne scars. To understand the types of acne scarring,skin care professionals need to be aware of the types of acne lesions there are. It is also important to explore not only the physical but also the psychological effects of acne lesions and the associated scarring.

When most of the general population think about acne, it is a common belief that once the acne is controlled or eliminated, the skin will appear clear and healthy and all problems will be over. What many fail to consider is the unsightly scarring that can remain after the acne disappears and the many areas of the body that can be affected.

PSYCHOLOGICAL EFFECTS

The majority of acne sufferers are teenagers and young adults; however, it can affect any age group. 80% of acne sufferers are in the teenage demographic, and the long-term psychological effects can last a lifetime. It is already a challenge to navigate through this critical stage leading to adulthood. Coupling this with acne and acne scarring compounds the stress teenagers already experience. This can lead to devastating psychological ramifications, such as depression, introversion, and low self-esteem. Although bullying and cyber-bullying is addressed more and more, it does continue and looks are often the subject matter of choice, making anyone with skin concerns an easy target. It can affect many aspects of one’s life, from reduced social interaction to limiting career choices. Although it is unfair, there are still those that make judgements based on appearance which is why acne scarring can be devastating.

PHYSICAL EFFECTS

There are many types of acne that transpire into many types of acne scarring. As various forms of acne require specific treatments, acne scarring is also addressed based on the form presented. Acne is caused by bacterial proliferation in pores that have become blocked with oils and dead skin cells. The propioni bacteria (c.acne) that causes acne is anerobic, meaning it survives in a non-oxygenated environment, making the blocked pores a perfect breeding ground. Introducing oxygen to the propioni bacteria eliminates it, which is why many products that treat acne contain benzoyl peroxide.

FORMS OF ACNE

Pustules and papules are sometimes referred to as closed comedones. Pustules are pus-filled acne lesions that present with some redness at the base and are either white oryellow on the surface. Papules are reddened bumps that are tender to the touch. Squeezing pustules and papules may lead to scarring and hyperpigmentation.

 Blackheads are often referred to as open comedones, as they are trapped oils in the pore that have oxidized, hardened, and turned black. It is common to squeeze a blackhead to eliminate it; however, blackheads do not typically leave scars. They can, however, extend a pore leaving a more pronounced opening on the surface of the skin.

These large, inflamed, and circular protrusions on the skin are extremely painful. They can easily leave scars, especially if picked or squeezed.This painful, inflamed, and pus-filled form of acne should not be picked or squeezed, as it can easily leave scars.This type of acne presents more on the body, namely on the chest, neck, buttocks, and arms. It consists of many nodules that are interconnected under the skin and is prone to scarring.

Many athletes experience this type of acne from the headgear they wear, as it is caused from pressure upon the skin, heat, and friction. This has more recently been referred to as maskne, occurring in the areas covered by protective face masks that make contact with skin. Scarring is not as common with this form of acne; however, picking and squeezing could produce scars.

THE CAUSE OF ACNE SCARRING

An acne scar occurs from acne inflammation and the resulting breakdown in the pore wall. The severity of the scar depends on the amount of inflammation and the degree of damage to the surrounding tissue caused from the release of the pore content when it is ruptured. Picture a hose that has a knot in it. If the hoseis turned on, the waterline is building and building; however, the water is unable to pass due to the blockage. The sides of the hose will begin to expand until it can no longer withstand the pressure, at which point one wall of the hose will burst to release the water. That is the same scenario with acne. If a client squeezes a small pustule and the contents are released on the surface of the skin, the damage to the surrounding tissue is minimal and usually will heal rather quickly. If skin care professionals think about a cyst or a nodule, they are usually larger than a pustule, and therefore, they contain more infected fluid. Squeezing them by exerting pressure on the surface can force the contents to be released within the skin, causing deeper scars. The rupturing of the pore wall can occur from the pressure build-up of the infected fluid in pustules, papules, cysts, and nodules with no interference. In an effort to repair the scars, new collagen fibers are formed.

TYPES OF ACNE SCARS

Acne scars fall into two categories – hypertrophic or atrophic. Many individuals have both types of scarring especially in cases of severe acne.

Hypertrophic scars appear as raised tissue often referred to as keloids. These scars occur when the body over-produces collagen in the healing process. Although keloids are more common in darker skin, anyone can develop them.

Atrophic scars appear as indents in the skin. This type of scar occurs when the body does not produce enough collagen in the healing process to fully restore the damaged tissue. Icepick, boxcar, and rolling scars are all types of atrophic scars. Icepick scars are common and quite difficult to heal. They appear on the surface as round holes in the skin and narrow as they godeeper into the skin; the shape is similar to that of an icepick. Boxcar scars have a square appearance with sharper edges, whereas rolling scars have more rounded edges.

DIAGNOSING ACNE SCARS

Some physicians use a grading system to categorize acne scarring.Grade one is a flat scar that is generally red in color.Grade two is a scar that is evident; however, it can be covered with makeup.Grade three is visible and not easily covered with makeup.Grade four is severe scarring that is immediately evident when within 1.64 feet of the individual.

TREATMENT OF ACNE SCARS

The treatment of acne scars can be somewhat of a conundrum as the skin should be acne-free before proceeding with scarring treatments. There are various topical and oral acne medications that if utilizedwould contraindicate a variety of scarring treatments. Imagine having acne that is not yet controlled and the associated scarring simultaneously, which occurs in many cases. There are, however, some topical treatments for acne that can also assist with scarring. Salicylic acid, alpha hydroxy acids, and retinoids are often prescribed to help prevent acne breakouts, as they increase cellular turnover. These lessen the build-up on skin that clogs the pores, thus reducing acne lesions.

SPA TREATMENTS FOR ACNE SCARRING

There are many in-spa treatments available to treat acne scarring depending on the type of scarring presented. It is common to have more than one type of acne scarring, and it is also common to use more than one type of protocol to treat the scars. 

Skin resurfacing involves the removal of the layers of the skin; the number of layers removed is dependent on the product or the modality used. Removal of the upper layers stimulates the process of cellular renewal, in other words, speeding up the process making resurfacing treatments a popular choice to minimize the acne scars. Resurfacing treatments should be done in a series to achieve the best results.

Chemical peels are often used in the treatment of scarring. Aestheticians are licensed in most states to use up to a 30% concentration with a pH of three; however, higher concentrations of peels are available in medical spas. Salicylic acid is a gold standard in the treatment of acne, and this beta hydroxy acid is often used in combination with alpha hydroxy acids in peels for acne scarring treatments. There is generally no down-time with peels at a 30% concentration; however, those with higher concentrations, such as Jessner Peels, may require a couple of down days. These can be used for ice pick, boxcar, and rolling acne scars.The series of treatments will be recommended after the acne scarring is evaluated.

Dermabrasion andmicrodermabrasion both use a modality that removes layers of the skin with a sanding like tool. Some older dermabrasion machines used a circular wire tool that rapidly rotated and removed several layers of the skin, leaving the skin exposed and almost raw looking. When the resurfacing is deep, special care must be taken to keep the skin clean, as the risk of infection increases with deep resurfacing. This type of treatment is not normally used on darker skins because there is risk of demarcation. Microdermabrasion is normally not as deep as dermabrasion and suitable for most individuals. The skin will appear slightly reddened; however, with only a few hours of downtime, it is the more popular of the two unless the scarring is widespread and severe. This treatment option can be used for ice pick, boxcar, and rolling acne scars, as well.

Laser resurfacing has become extremely popular. There are two types of resurfacing lasers, ablative and non-ablative. Non-ablative laser treatments are used to treat mild to severe skin conditions without tissue vaporization and require little to no downtime. Several treatments may be necessary with non-ablative laser treatments to achieve results. Ablative laser treatments are also known as fractional carbon dioxide (CO2) and treat the most severe skin conditions by vaporizing the top layers of damaged skin. While ablative treatments yield the most dramatic results in grade one treatment, more downtime is typically needed so skin can heal. Lasers can be used for ice pick, boxcar, and rolling acne scars.The series of treatments will be recommended after the acne scarring is evaluated; however, deep icepick or boxcar scarring may require other methods such as excision or punch grafting.

Microneedling utilizes small needles to injure the skin causing the skin to go into repair mode and increase the production of collagen. The longer the needles, the more the skin is damaged.More collagen production leads to skin healing itself. The length of the needles varies and is not only dependent on the condition being treated but also the practitioner performing the treatment. According to Skin.com, “Although microneedling has proven to be an efficacious procedure for improving the skin, it is ‘fraught with legal issues.’ In short, under FDA guidelines, aestheticians can only use microneedling devices of less than 0.3 millimeters and only those that do not make medical claims.”

 There are also dermarollers and microneedling pens. Dermarollers have cylinders with needles embedded in them that are manually rolled over the skin. Microneedling pens are motorized and utilize special cartridges with the needles grouped on the end. Both types of devices are available with various needle lengths, making them suitable for both aestheticians, medical spas, and physicians. Microneedling is often used on areas that othermodalities are unable to treat, such as the eye and mouth area. The needles can also be changed during the treatment, with smaller ones being used on the more delicate eye area and longer ones being used on the cheeks or the areas where the acne scarring is more severe. They may also be adjusted depending on the skin tolerance. If longer needles are used in a medical spa, often lidocaine is applied prior to the treatment to minimize any discomfort. Downtime is normally one day, making it an easy treatment to fit into anyone’s schedule. Microneedling can be used for ice pick, boxcar, and rolling acne scars, and the series of treatments will be recommended after the acne scarring is evaluated.

Dermal fillers are injected under the scar to force the tissue up, thus minimizing the appearance of the scar by leveling the skin surface, and there is no downtime. Rolling and boxcar scars can be effectively treated with dermal fillers; however, they are not permanent and need to be reinjected to keep the skin volume plumped.

Cryosurgery utilizes liquid nitrogen to treat raised scars. It freezes the tissue causing it to die and then fall off. Although there is no downtime, the treated tissue will initially turn red, then begin to darken before it turns black and falls off. Keloids respond well to this type of treatment; however, the thickness of the keloid can affect the outcome. The earlier they are treated, the more successful the results.

Punch excision uses a punch the size of the scar to remove it.The skin is then sutured. It takes approximately one week for recovery butone to two months for the punch excision scar to diminish. Punch grafting is another method when deeper and larger areas of scarring are being treated. The scars are excised with the punch; then, skin is grafted onto the area treated. Punch excision is a method often used for deep icepick and boxcar scars.

There are many methods to effectively treat acne scarring. To reduce the risk of acne scarring, it is important to begin treatment immediately when acne begins to develop.Clients should be advised to avoid picking or squeezing the lesions. The longer the acne is present, the more increased risk of acne scarring.

In conclusion, there are many homecare and in-spa treatments to minimize and, in some cases, eliminate acne scars allowing everyone to put their best face forward.

Karen Asquith is recognized as an honored member of the Stanford International “Who’s Who” of business executive professionals. Currently, she is the national director of education for G.M. Collin Skin Care, based in Montreal, Canada and in Plattsburgh, New York, where she provides skincare training programs and guidance for an international staff of 140.For the past decade, Asquith has consistently been featured as a guest lecturer at skincare industry forums, presenting cutting-edge skincare protocols and topics throughout North America. She may be reached at This email address is being protected from spambots. You need JavaScript enabled to view it..