Definition

Acne is an inflammatory condition of the nodes that produce sebum, which usually affects adolescents and young adults of both genders. Very often acne leaves behind scars, mainly on the face, but also on the body. Acne scarring is a problem leading to disappointment, especially if the scars appear on the face. However, there are available procedures to treat the scars, which also lead to self-confidence and self-esteem improvement.

What causes acne scars?

Acne scars are most often the product of an inflamed lesion, such as a papule, pustule, or cyst that has been caused by acne. Inflamed blemishes occur when the follicle, or pore, becomes engorged with excess oil, dead skin cells, and bacteria.

The pore swells, causing a break in the follicle wall. If the rupture occurs near the skin’s surface, the lesion is usually minor and heals quickly. More serious lesions arise when there is a deep break in the follicle wall, and the infected material spills out into the dermis and destroys healthy skin tissue.

To repair cutaneous wounds, the skin forms new collagen fibres. Collagen is the fibrous protein that gives skin its strength and elasticity. During the healing process, the body sometimes produces too much collagen, which creates a mass of raised tissue on the skin’s surface. This type of scarring is called hypertrophic, or keloid, scarring.

More commonly, acne causes atrophic scars. Atrophic scars develop when there is a loss of tissue. Ice pick and boxcar scars are two examples of atrophic scars.

Scar development is proportional to inflammation. The greater the inflammation on the skin, the more likely scarring is to occur. Deep breakouts that take a long time to heal also increase the chance of scarring. Blackheads, whiteheads, and other non-inflamed blemishes do not typically cause scarring because these types of lesions do not injure skin tissue. Often, what is taken to be an acne scar is not a true scar at all, but rather post-inflammatory hyperpigmentation. This temporary discoloration of the skin will eventually fade on its own.

Prevention of Acne Scars

To minimise the chance of developing acne scars, inflammatory outbreaks should be reduced as much as possible. If prompt treatment adapted to your needs is initiated using the current dermatological strategies, while avoiding the use of oral medications, then the chances of acne scarring are reduced.

Furthermore, squeezing or picking at the papules, pustules and cysts should be avoided because the infected bacteria penetrate deeper in the dermis, resulting in the spreading of the infection to other tissues, as well as worsening of the inflammation.

There are two main types of acne scars that are specified by the inflammation itself

• Scars caused by an excess of tissue – hypertrophic or keloid acne scars.
• Scars causedby a loss of tissue– atrophic acne scars.

Hypertrophic or Keloid Scars

The scars that protrude are called hypertrophic or keloid scars. Hypertrophic scars are formed by the overproduction of collagen during the healing of acne wounds, creating a raised irregular scar of fibrous firm tissue at the site of the lesion. The appearance of hypertrophic and keloid scars is less common in patients with acne as compared to atrophic scars. Certain factors can potentially determine their progress, such as acne severity and duration, genetics (heredity), and secondary infections.

Atrophic Acne Scars

Atrophic scars are the most common type of scar due to inflammatory acne. Within this category, the following main types are more common in patients with acne:

• Ice-pick Scars: A narrow scar that extends deep into the dermis. This type of scar is leaving a small, yet obvious, “hole”. The skin looks as if it has been pierced by an ice pick or other sharp instrument, hence the English name ice-pick. Ice pick scars are caused by an inflammatory breakout, such as a deep papule or cyst, that has damaged the skin’s structures. They are most common on the cheeks.
• Boxcar Scars: Round or oval depressions with steep vertical sides. They have similar appearance with chickenpox scars. Boxcar scars occur when an inflammatory breakout destroys collagen, creating a depressed area on the skin. Boxcar scars can be mild and superficial or deeper and more severe.
• Rolling Scars: Relatively wide skin depressions with round, inclined edges. If many such scars are present on the skin, they may look like a wave, hence the English name.
• Subcutaneous tunnels or large retractions: These are actually acne scars that can alter facial contour and are difficult to treat.

Treatment of Acne Scars

• Injectable collagen: The appropriate type of collagen is selected to “fill” and lift the atrophic scar so that it is in the same level with normal skin.
• Medium or deep chemical peels: When used appropriately, skin texture becomes smoother, collagen formation is stimulated, and deep scars are improved.
• Dermabrasion (mechanical dermabrasion):Depending on the invasiveness of the procedure, we can reach deep enough to the papillary dermis to treat even the most stubborn acne scars.
• Fractional lasers:
  • Invasive CO2 Lasers cause controlled tissue sublimation and activate skin regeneration – on average, three sessions are required for an optimal result to be achieved.
  • Non-invasive ERBIUM (FRAXEL, MOSAIC) Lasers. Uniform removal of the surface parts of the epidermis and dermis without severe thermal damage.
• Dermatologic surgery: Now it is only rarely required, especially for residual cysts that recur often.

Older techniques for acne scars, such as the use of injected corticosteroids or cryotherapy are now less useful, as more advanced devices have been developed and used to treat acne scars..