Acne Scarring
A detailed discussion of acne scars includes the causes of scarring, prevention of scarring, types of scars, and treatments for scars.
Before talking about scars, you should be aware of spots that may look like acne scars but are not scars, in the sense that a permanent change has occurred. Even though they are not true acne scars and disappear in time, they are visible and can cause embarrassment.
Macules or ‘pseudo-scars’ are flat, red spots that are the final stage of most inflamed acne spots. After an inflamed acne spot reduces, a macule may remain to "mark the spot" for up to 6 months. When the macule eventually disappears, no trace of it will remain - unlike an acne scar. If you want to do something about this quicker then phone our advisors on 08701 909369 who will tell you about our acne solution, Aknicare; our scarring treatment, Terproline; or Synchrorose, which is our cure for reddening skin.
Post-inflammatory pigmentation is discoloration of the skin at the site of a healed or healing and inflamed acne lesion. It occurs more frequently in darker-skinned people, but occasionally is seen in people with white skin. Some post-inflammatory pigmentation may persist for up to 18 months, especially with excessive sun exposure. Chemical peeling may hasten the disappearance of post-inflammatory pigmentation. SkinMed offer a product called Thiospot Skin Roller which is a tried tested and safe way of reducing post-acne dark marks.
Causes of Acne Scars
In the simplest terms, acne scars form at the site of an injury to tissue. They are the 
visible reminders of injury and tissue repair. In the case of acne, the injury is caused by the body’s inflammatory response to oil, bacteria and dead cells in a plugged hair follicle duct.
When tissue suffers an injury (such as an acne lesion), the body rushes its ‘repair kit’ to the injury site. Among the elements of the repair kit are white blood cells and an array of inflammatory molecules that have the task of repairing tissue and fighting infection. However, when their job is done, they may leave a somewhat messy repair site in the form of fibrous scar tissue, or eroded tissue.
White blood cells and inflammatory molecules may remain at the site of an active acne lesion for days or even weeks. In people who are susceptible to scarring, the result may be an acne scar. The occurrence and incidence of acne scarring is still not well understood, however. There is considerable variation in scarring between one person and another, indicating that some people are more prone to scarring than others.
Scarring Management
A main aim of acne treatment is to avoid scarring – both physical and mental scars that can leave a permanent mark on a person’s life.
This section will focus on the physical acne scarring, with the emotional effects of acne being dealt with in the following section.
Acne is a temporary problem for most people, but acne scarring can be a permanent reminder of it, so any person showing signs of acne should be warned of the consequences of leaving acne untreated
Reasons for Scarring
Many people believe that you have to compulsively pick or squeeze at spots in order to scar, but it is possible to separate the reasons into the following categories:
Picking and Squeezing
This is probably the most common reason for developing acne scars. Sometimes a 
mark - as opposed to a ‘pitted acne scar’- can be left behind, which will often fade over time. In some cases, people (usually young women) may be obsessive about picking their skin, which in itself will cause a type of acne known as ‘acne excoree’, which will manifest itself in isolated spots that rarely have a ‘head’. The lack of blackheads, grease and genuine acne spots will be a clue to this type of acne. Doctors argue over how best to treat these patients – should they be ignored and referred for psychological help, or given a strong acne treatment to deal with every small imperfection?
It is important to understand therefore how picking and squeezing the wrong type of spot will cause damage.
It is not unheard of for people to use instruments such as eyebrow tweezers, metal nail files, pins, needles, scissors or even cheese graters to dig at their skin. Without appearing to ‘tell someone off’, if you feel the same then you really should be encouraged to leave your skin alone and start using our acne solution, Aknicare®.
Scarring Acne
Picking and squeezing spots causes more trauma to the area and can result in the rupture (bursting) of the hair follicle and oil duct which can cause more tissue damage and cause an acne scar. In cases where the level of bacterial involvement is high and you have a lot of pustular activity, this can cause acne scarring, and antibiotics may well be considered to reduce the damage by the high level of bacteria.
Not all acne scars will be as a result of picking or squeezing. Sometimes people will have a pre-disposition to scar easily or the types of spots they get can be very aggressive (such as nodular-cystic acne) and may cause deep pits in the skin (pitted scarring) or raised bumps (Keloid scars).
Pitted scarring. These types of acne scars may be a small depressed mark or run for a few centimetres with the appearance of a mark left behind after an ice pick has been used in the snow (unsurprisingly referred to as ‘ice pick scarring’). Some acne scars may take many years to appear, as a result of the skin loosing collagen in later years.
Keloid scarring. These are the raised types of acne scars, where the skin has laid down excessive amounts of tissue following trauma to the skin, like acne spots. These, if large and unsightly, may respond well to steroid injections, which can be very painful. Often, they do not respond well to acne treatment, although in recent years there has been the introduction of pressure plasters, transparent and painless which, if kept on the raised area, may give some excellent results over a period of many months. The results can last forever and help to reduce the severity of the acne scar.
Disguising scars
Both pitted and keloid acne scars are very hard to disguise, as light will reflect from them at different angles to the rest of the skin and therefore even the best make-up in the world will make these bumps or dips hard to cover up. For more severe pitted acne scars, doctors may cut away around the scar tissue, leaving a more even mark. They may make an incision into the scar and stitch the scar up. Both of these options will obviously not get rid of the scar, but may help improve their appearance.
Lasers and Chemical Peels
This is the modern way of treating acne scars on a large area of the face. By removing damaged tissue and stimulating new skin growth one can effectively resurface the skin thereby reducing acne scars significantly. This should not be taken lightly however, and an experienced practitioner who is knowledgeable of the right types of acid or laser is essential. Pyruvic Acid and Salicyclic Acid have both been shown to be useful in acne management and also in acne scarring as they both have been shown to have a sebo-static effect (they slowdown oil production) and hence can have a dual benefit in acne and scar management
The best way of finding out if lasers chemical peels are suitable is to have a consultation with a specialist.
Ethnic Skin and Acne
Acne will not discriminate against race or age, the darker the skin, the more likely it is
to lay down extra pigmentation as spots heal. This can be the cause of great distress for some people and may, in fact, make even a mild case of acne one long to remember simply because of the dark, flat marks left behind.
Darker skin types have more oil glands than fair skin types and the normal response in white skin to injury is to turn red, where dark skin will turn darker.
The dark spots left behind as a result of acne are known as post inflammatory hyper-pigmentation. This is common in any dark skin types. The inflammation from acne causes the pigment cells in the skin to be stimulated. It is these pigment cells that are responsible for making our melanin, the skin’s natural colouring; therefore this stimulation will result in the dark marks left behind.
Treating these marks is not easy and will often be made worse by picking spots. Therefore in dark skin types the following is recommended:
- Don’t pick at the skin. Trauma to the skin will result in it laying down more layers of the skin’s natural skin-colouring cells. Treat the acne and leave the spots alone.
- Cover the marks with camouflage. See the section on acne scarring for further information on cosmetic camouflage. Every possible skin colouring has been considered in the modern cosmetics designed to disguise birth marks and discolouration.
- Avoid skin-bleaching kits. These may cause a host of other problems in themselves. If the skin is left alone, with marks disguised with camouflage it is likely that in time, they will heal well on their own.
- Avoid hair pomades. These can cause a type of acne known as ‘pomade acne’ and is as a direct result of the heavy hair styling oils coming into contact with the skin. Recommend that if they are to be used, that the skin is protected whilst it is applied and the area around the scalp be kept free of contact with the oil as much as possible
Pigmentation changes as a direct result of acne, or through the use of lasers and peels can be managed in most cases. One should avoid hydroquinone, arbutin and bearberry containing products as there is data emerging about potential carcinogenic side effects. There are safer products just as effective on the market now. (See the Thiospot section or read our acne clinical protocol).
Cosmetic Camouflage
This is a fantastic and often highly efficient way of disguising flat acne scars and marks or facial redness (Rosacea). The British Red Cross runs a cosmetic camouflage service and patients can be referred via their GP to their local clinic to have a ‘lesson’ in how to apply these disguising creams. They will take time to select a near perfect skin colour match (suitable for any skin colourings) and they will be shown how to apply and maintain the disguising effects of these advanced ‘foundations’.
Customers should be advised to ask their GP for a referral. They are usually run from local dermatology clinics and may take some time to come through. Anyone still showing signs of active acne should be encouraged to continue treating their acne, as these types of camouflage creams are not designed to disguise acne spots. If they cannot get a referral, they should contact their local British Red Cross for further information.
Psychological Scarring of Acne
Some people may appear to be relaxed and outwardly unconcerned about their acne, whilst another may seem distraught over a few spots. Acne is a visual condition, most commonly affecting the face. Therefore, it is understandable that many people will feel embarrassed and self-conscious, adopting body language aimed at stopping stares i.e., head down, avoiding eye contact and growing a long fringe.
It may be very tempting to suggest that a long, perhaps greasy fringe is swept away from the face, but it is likely to make someone feel very self-conscious if they are using it as a mask from the world. It might be more helpful to suggest keeping their face free from hair and hair products as much as possible, and to ensure hair is kept back from the face at least at night time as this can help to prevent oily skin.
A survey revealed the following:
- Up to 75% feel depressed as a direct result of having acne
- 15% feel suicidal as a direct result of having acne
The most common age group to develop acne is from age 12 – 16. These are the most formative years for girls and boys alike; a change from childhood into adult life. It seems ironic that this is the one time when acne is most likely to occur – almost as if it is a test, to make this turbulent time seem even harder! Boys are usually more severely affected than girls. However, boys are usually more reluctant to discuss their ‘feelings’ or admit to feeling embarrassed or ashamed or even to ask for help. Sometimes a child will require unbiased support from a parent, preferably without criticism or blame. This is when understanding the cause of acne is very helpful.
Counselling may help in some cases, and this is usually available through GP’s. However, the waiting lists may be long and usually the course of counselling is restricted to six weeks. This may not be suitable for someone feeling very depressed. They may have to seek private counselling which is available through the British Association of Counsellors. One can also phone agencies such as Child Line and the Samaritans.
In most cases, if the depression is directly related to acne, once the acne has been successfully controlled, the patient will automatically feel better about themselves.
