Acne scarring, which may result from severe cases of acne or from undue delay in getting appropriate treatment, is estimated to affect to a greater or lesser extent some 95 percent of acne sufferers.

All types of acne, from simple pimples and pustules to the deep painful cystic varieties, can cause scarring. Therefore, appropriate anti-acne treatments must be started early enough to prevent this. Happily, these days, should scarring occur, one need not despair. A number of new and refined cosmetic dermatologic surgical procedures are available for dealing with even the toughest and most disfiguring forms of post-acne scarring.

Scarring from acne is a direct result of acne inflammation within hair follicles (pores) and of the tissue destruction and loss that often follows.

By far the majority of acne scars are of the atrophic type, meaning that there is a loss of underlying tissue. As scars mature and contract they draw in the surface layers of the skin leading to the appearance of indentation. This sunken appearance is commonly referred to as a pock scar. When the scar is very narrow but deeply penetrating, it is called an ice-pick scar.

In general, the more severe and extensive the inflammation and the longer it persists before treatment, the more tissue is destroyed and the wider and deeper is the resulting scar. Scars typically become increasingly visible and disfiguring with time as age-related losses of dermal and fat tissue accentuate the defects.

Scars appear as abnormalities in color, shape, contour, and texture. Cosmetic procedures are directed to remedying each of these variables to the extent possible.

Although each patient and each scar must be treated individually, it is generally the type of scar and its location that most determine the specific kind of treatment.

Superficial scars, those that affect only the epidermis and the uppermost layers of the dermis, can appear as reddish, or more commonly brownish, blemishes of the skin. If protected from the sun, most of these superficial scars/discolorations will fade significantly or completely within three to 18 months. In some individuals, particularly those with olive-toned or darker skin, nightly home applications of tretinoin (Retin A), coupled with morning applications of a noncomedogenic combination of alpha hydroxyacid and SPF 15 sunscreen may be sufficient to improve the appearance of these scars after several weeks to months of continued use. Others may additionally benefit from an in-office series of light glycolic acid or beta hydroxyacid peels or microdermabrasion to hasten the fading of the lesions and to promote collagen synthesis.

For more extensive superficial scarring, where scores of lesions may be present, dermasanding or laser resurfacing may be needed. Medium depth chemical peeling, on the other hand, has not proven useful for anything more severe than the mildest forms of acne scarring and is thus seldom used anymore for these purposes.

Not uncommonly, after a group of deep cysts heal, multichanneled tracts, known as sinus tracts, may form below the skin surface. These are often best treated by direct surgical excision of the scar and subsequent buffing (scarabrasion) of the area sometime between six and ten weeks later. Where still more extensive inflammation and deep tissue destruction have resulted within the dermis or even further down within the fatty layer, troughed scars may ensue. Such instances are best benefited by the injection of filling substances, such as Juvederm or Radiesse or deeper filling agents like Radiesse.

Dermaspacing to promote native collagen synthesis has also proven quite useful. And as long as the acne problem remains under strict control and further tissue destruction prevented, the latter method possesses the additional advantage that the cosmetic improvements achieved can be anticipated to be permanent. All other therapies are likely to need periodic touch-ups to maintain the desired degree of correction.

Ice-pick scars, which are often numerous, typically are very narrow and penetrate quite deeply. These present perhaps the most difficult therapeutic challenge. Ice-pick scars are best treated by either punch excision, punch elevation, or punch replacement. The word punch refers to the razor-sharp circular cutting instrument used by the dermatologic surgeon to core out the scar. In punch excision, the ice-pick scar is cored out and the resulting wound either simply sutured closed or, if small enough, allowed to heal on its own. In punch elevation, the cored sample is not removed, but elevated up toward the surface to eliminate the depression, and then allowed to heal on its own. In punch replacement, a small graft of normal color-matching tissue, usually taken from skin overlying the bone directly behind the ear, is used to replace the cored out scar.

The CROSS  (Chemical Reconstruction of Skin Scars) method is another option for treating ice pick scars. Here an extremely high concentration of trichloroacetic acid is placed into the depth of the ice pick scar. The resulting irritation leads to closure of the scar. One or more treatments may be necessary.

It is not unusual for individuals with post-acne scarring to have a number of different types of lesions, for which the combined or sequential use of any of the above therapies is indicated.

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