Acne is a skin problem often associated with teenage hormones and going through puberty. But over 80 percent of people ages 11 to 30 years old suffer from acne, and many of those people experience some form of acne scarring, according to a study published in The Journal of Clinical and Aesthetic Dermatology (1).
While popping the occasional zit is uncomfortable, painful and, well, gross, people with acne scarring also experience stigma and bias when it comes to their looks. Results from an online survey, which was published in the journal Dermatology and Therapy, revealed that people with acne scars were less likely to be considered attractive, happy and confident compared to those with clear skin (2).
The effectiveness of acne scar removal and acne scar treatment varies on a case-by-case basis, and not all treatments work the same way. Before embarking on a quest to get rid of acne scars, it’s important to understand what causes scarring and work closely with a dermatologist to identify the treatment and removal methods that are best suited for you and your skin.
What Causes Acne Scarring?
Acne scars usually result from inflammatory breakout, according to Dr. Kenneth Mark, a board-certified cosmetic dermatologist. “Acne scars are caused typically by inflammatory acne lesions, which are usually cystic but can also be big red bumps or pustuled like inflammatory whiteheads,” he says. “The skin gets inflamed from the lesion and then when the lesion resolves, it typically leaves some form of an indented scar.”
When breakouts penetrate deep into the skin, tissue damage below the skin’s surface may occur. As the skin tries to heal itself and repair the damage, it produces collagen. An acne scar forms when the body produces too little or too much collagen during the repair process.
Touching, picking and popping zits can exacerbate acne scars, says Dr. Tess Mauricio, CEO of M Beauty Clinic in Beverly Hills and San Diego, because these activities cause inflammation.
“The likelihood that your pimples will cause acne scars depends on your genetics, your skin type, the severity of your acne and the inflammation that occurs while you have acne,” she adds.
Types of Acne Scars
Atrophic acne scars—characterized by pits and depressions in the skin—make up the majority of acne scars. These scars form when the skin does not produce enough collagen during the healing process.
There are three types of atrophic acne scars:
Icepick scars make up 60-70 percent of atrophic acne scars and are characterized by deep, narrow depressions in the skin. Because they are the deepest type of acne scar, ice pick scars are also the most difficult to treat.
Boxcar scars account for 20-30 percent of atrophic acne scars. They are shallower and wider than ice pick scars and usually have a round or oval shape. Effectiveness of treatment for boxcar acne scars will depend on how deep or shallow they are. Shallow boxcar scars respond better to skin resurfacing treatments than deep boxcar scars.
Rolling scars are the widest and smoothest type of acne scars and they make up approximately 15-25 percent of atrophic acne scars. These shallow acne scars are characterized by their wavy look and may seem to disappear if the skin is stretched.
Acne scars that are raised instead of depressed are called keloid, or hypertrophic, scars. These thick, bumpy scars result from the skin producing too much collagen during the healing process. Keloid scars are often discolored and are most often found on the chest and back area.
It’s important to keep in mind that acne scars are different than acne marks. “Acne marks are generally flatter and appear red or inflamed,” says Dr. Paul S. Nassif, a renowned facial plastic and reconstructive surgeon in Beverly Hills. “Marks are a result of hyperpigmentation from healed acne.”
Nassif explains that acne marks typically fade on their own, and the skin usually takes three to six months to heal itself. “Scars are more permanent, and take much longer to improve in appearance,” he says.
How to Fade Acne Scars and Marks
Acne scars are considered a medical problem, and Mauricio explains that it’s best to work with a professional dermatologist for treatment. Do-it-yourself topical solutions, she says, can actually exacerbate acne inflammation and cause more scarring.
If you’re dealing with active breakouts at home, Mauricio says that—if used regularly—products with glycolic acid, salicylic acid, benzoyl peroxide and tretinoin can effectively help acne and prevent scarring. Spot treatments are also an option for addressing active acne. “Spot treating with benzoyl peroxide, glycolic acid and salicylic acid decreases inflammation, dries out pimples and can accelerate resolution,” says Mauricio. But she warns that using spot treatments too often can overdry the skin and cause irritation.
Mark also recommends salicylic acid to his patients because it exfoliates and can help fade acne marks. “It also has an anti-inflammatory effect on oil glands,” he says. “This, therefore, treats—and, at the same time, prevents—new acne lesions.”
But if you suffer from acne scarring, professional dermatologic intervention is often necessary. Common professional treatments for acne scars include:
Dermabrasion: This is an intense procedure that uses a rotating tool to remove the outer layer of skin. It can be effective in treating acne scars because it stimulates new skin growth and softens scar edges. But dermabrasion requires anesthesia, and recovery from dermabrasion is a long, often painful, process. Recovery times may last up to one month. Dermabrasion is also not recommended for people with dark skin tones, because it can cause permanent discoloration. Because of the intensity of the treatment and the downtime involved, many dermatologists recommend microdermabrasion or laser treatments over traditional dermabrasion procedures.
Microdermabrasion: Microdermabrasion is a procedure that abrades the skin with aluminum oxide crystals and removes the very top layer of skin through a vacuum tube. This procedure is much milder than traditional dermabrasion techniques and has proven effective at minimizing and fading acne scars. Multiple microdermabrasion sessions are often recommended. Patients who undergo microdermabrasion have virtually no downtime and can proceed with their usual activities following treatment—though sun protection is very important after microdermabrasion sessions.
Laser treatments: There are several different types of laser treatments available to help minimize and fade acne scars. But the majority of lasers for acne scar treatment fall into two categories: fractional ablative and fractional non-ablative. Both types of lasers help resurface the skin and stimulate collagen production. Fractional ablative lasers are stronger and tend to have better results than fractional non-ablative lasers. “For severe cases,” says Mark, “the most dramatic improvement can be achieved by an ablative laser, which heats up the skin to the point of causing peeling.” Patients treated with ablative lasers may experience redness and swelling around the treatment area and have more downtime following treatments.
Fractional non-ablative lasers are useful in treating mild and moderate acne scars, but the results from treatment are generally more gradual in nature. Patients often need at least three to five treatments with non-ablative lasers to see impactful results, but recovery time is faster compared to ablative laser treatments.
Subcision: Subcutaneous incisionless surgery, known as subcision, is a minor surgical procedure used to treat acne scars. During subcision, a needle is inserted into a puncture in the skin surface and moved back and forth in a fan-like motion. The procedure breaks up the fibrotic strands that attach the scar to the skin’s subcutaneous tissue. Breaking up the fibrotic strands allows dermatologists to “lift” the scar. Subcision also “stimulates the body to produce collagen at the site,” says Mark, who adds that when this method works, the correction is permanent. Patients may experience some swelling and bruising following this procedure and may be given antibiotics and anti-inflammatory medications and asked to ice the area following treatment.
Skin needling: Microneedling is a procedure where small, fine needles puncture acne-scarred skin. It is often done with a small, handheld device. Microneedling helps to stimulate collagen production and thicken the epidermis and dermis. These treatments require minimal recovery time and often show moderate but noticeable improvements in the overall appearance of acne scars.
Treating and fading acne scars and marks is an individualized process that may require a combination of treatment methods based on your skin and the types of scars you have. It’s important to work closely with a board-certified dermatologist to determine a treatment plan that fits your needs.
Preventing Acne Scars
Since the effective treatment of acne scars requires dermatologic intervention, preventing acne scars before they form is the most effective way to maintain smooth, clear skin.
Look for skincare products with glycolic acid, salicylic acid and benzoyl peroxide. Glycolic and salicylic acid exfoliate the skin and help unclog pores, while benzoyl peroxide is used to kill bacteria. Tretinoin is a topical medication that may be prescribed by your doctor to help manage acne. It stimulates skin growth, lightens pigmentation and reduces oiliness. If using tretinoin for acne, follow your doctor’s instructions and avoid using acid treatments and benzoyl peroxide with it unless instructed by your doctor to do so.
Avoid touching, popping or picking active breakouts. “This will only cause more inflammation and the more inflammation there is, the more likely you will be left with scars,” says Mauricio.
If you do have a particularly inflamed acne breakout, says Nassif, it’s important to act fast. Gently remove makeup and apply a sanitized cold compress or soaked cotton pad. “A spot treatment with honey can also help reduce inflammation and redness,” he adds.
For breakouts that do not respond to at-home treatments, a visit to the dermatologist for an anti-inflammatory injection with saline solution may be enough to effectively treat the acne and prevent scarring, says Mark.
Besides developing a solid skincare regimen, Mauricio explains that good skin often starts with a high-quality diet. “Eating healthy and avoiding lots of inflammatory foods high in sugar can help acne,” she says. “Taking probiotics can also help, as the skin’s microbiome is important to the pathogenesis of acne and acne treatments.”
Mauricio also recommends stress reduction as a key component in preventing breakouts and decreasing inflammation. “Finding ways to get better sleep and reduce stress with exercise will calm the immune system and the skin,” she says.