Why does acne cause scars?
One of the essential elements of acne is an inflammatory immune response to the P. acnes bacterial infection. (I explain this in more depth over on my dedicated acne page.) When infection sets in, the body sends waves of white blood cells to kill off the offending bacteria. Inflammation occurs and your pores swell up, rupturing internally and spreading infected material into the surrounding tissue. Delightful, I know.
This creates an unfortunate cocktail where you have both trauma and infection in the same place. Your body’s wound-healing response kicks in, but it does so in a contaminated environment. Wound healing is one of the most complex biological processes in your body, so the more complications there are, the more likely it is that the healing will go awry. Your skin attempts to repair all this damage by sending collagen and lots of other goodies to the site, but with severe or long-lasting infection the end result is often a flawed patch repair that has either too little or too much collagen, resulting in an inconsistent skin texture, which is recognisable as a scar.
What are the different types of acne scars?
There are two main types of scarring, and acne can result in both:
Atrophic — this is where not enough collagen is produced during the wound healing process and you end up with a depression in the skin at the affected area. This is the more common type of scarring, accounting for 75 per cent of all scars. Atrophic scarring can be further broken down into three subtypes:
Ice pick – narrow (1-2mm in diameter) holes that reach deep into the dermis and taper to a point, as if someone has stuck – guess what? – an ice pick in your skin. This is the most common subtype, representing 60-70 per cent of atrophic scars;
Boxcar – wider than ice pick scars (typically 1.5-4mm in diameter), these are roughly round or oval in shape and have clear, steep, almost vertical edges. They can be shallow (from 0.1-0.5mm) or deep (more than 0.5mm). They’re very distinctive and look as if someone has punched out a section of the surface of your skin. They account for 20-30 per cent of atrophic scarring.
Rolling – wide in diameter (4-5mm) but very shallow, appearing as a slight divot in the level of the skin’s surface. These are found in 15-25 per cent of cases of atrophic scarring.
Hypertrophic scars or keloids – this is where too much collagen is produced during the wound healing process and you get a mass of raised tissue at the site. Hypertrophic scars are typically pink, linear and stay within the boundaries of the original wound. Keloid scarring is a darker purplish colour, more bulbous and extends beyond the wound’s original borders.
It’s not uncommon to have a combination of two or all of the different subtypes of atrophic scarring. You’re more likely to see hypertrophic or keloidal scarring on the body than on the face. Darker skin tones are more likely to get keloidal scars than lighter skin tones. And the worse a spot or breakout is (and, er, especially if you pick at it) the more likely it is to leave hypertrophic or keloidal scarring.
How do I prevent scarring with acne?
Scars can be stubborn and tricky to treat once they’ve appeared, so the best idea is to try and prevent the scars from appearing in the first place. There is a strong relationship between the severity and duration of inflammation and the development of scarring, so you’ll want to focus on treatments that lessen the severity and duration of the inflammation. Makes sense, right? The following steps will help:
Establish a good acne treatment regime – skincare, tweakments and lifestyle changes are all proven to help lessen the severity of acne. You’ll find lots of information about all these measures on the page all about acne.
Don’t pick, squeeze or otherwise touch your spots – I know, it’s tempting – and Dr Pimple Popper on YouTube has proven that a lot of us have a hidden fascination with doing this – however, your fingers have more bacteria and dirt than any other part of your body, so the last place you should be putting them is an infection site. I’m afraid that while it feels satisfying, you’ll only make things worse.
“But, what about if I clean my fingers and the area first?” I hear you say. OK, two things: first, unless you live in a hermetically sealed laboratory, the area’s most likely going to get dirty again, just bringing you back to square one; and second, squeezing a spot is blunt trauma and you run a high risk of damaging the surrounding tissue and irritating the skin further. So don’t do it.
If you’re not going to listen to me, then lance your spots following the steps outlined over on the acne page.
If you have acne-related scabs, leave them well alone and let them fall off naturally – absolutely no exception to this one. Scabs, though not the most sought-after fashion accessory, are incredibly clever and a lot of healing goes on behind the scenes; disrupting the process can actually make things much worse.
Be gentle with spot treatments, which can be rather aggressive. Anything too drying can kick the skin’s sebum production into overdrive. Indeed, anything that tips the balance very strongly in one direction will usually cause the skin to overcompensate in response. So be careful!
Keep your skin well moisturised – while you may be thinking that drying the skin is the best way to go for acne, it’s actually moisture that you need to focus on getting right, particularly if you want to avoid scarring as studies show that scar severity is directly correlated with moisture levels.
Cystic spots can require cortisone injections to reduce inflammation, thereby lowering the chance of scarring.
The key message is to get ahead of your acne. Minimising the severity of your outbreaks is the best way to prevent scars appearing further down the line. It’s also worth remembering that you can’t start treating scars until your acne has completely subsided and all spots have disappeared.
How can I treat acne scarring?
As mentioned above, scars are the result of either too much or not enough collagen being produced during the wound healing process. Fortunately, there are a number of tweakments which can help, either by kick-starting your body’s collagen production, stimulating the remodelling of existing collagen structures, or plumping up the skin to effectively hide the uneven texture:
Radiofrequency with microneedling – a combination of microneedling and radiofrequency that both perforates and heats up the dermal-epidermal junction – where the upper layers of your skin meet the lower layers – stimulating the production of collagen. Over time, this will lead to more level skin. While most acne scarring treatments require you to wait until the acne has completely gone, this tweakment can usually be done on active acne, just as long as your acne is not in the middle of a major flare-up.
Laser skin resurfacing – both ablative and non-ablative lasers have been shown to help with acne scarring by stimulating the regeneration and remodelling (i.e. making new collagen and structuring it better) of collagen fibres in the skin. This tends to be the only viable option for hypertrophic scarring, which is the result of too much collagen, as the right laser will stimulate remodelling without adding much in the way of new collagen to the area.
Laser facials – a gentler option than a full resurfacing, this will brighten your skin and improve its texture. Only really suitable if you have low-level scarring.
Clinical microneedling – by creating channels of damage down to the dermal-epidermal junction, the body’s wound-healing response kicks in again, resulting in more collagen being produced. Because the damage created by each needle-puncture is tiny, the collagen is structured effectively, leading to more even skin texture.
Microneedling facial – as above with your straightforward microneedling, the microneedling facial will involve additional serums and often a complementary treatment such as light therapy. Again, this is all about getting your collagen production underway, though this is usually gentler than clinical microneedling on its own, and won’t produce the same wound-healing response, so it’s not going to suit deeper scarring.
Skin peels – the deeper types of skin peel are designed to trigger collagen growth, making it a good option for acne scarring. ‘Light peels’ are unlikely to be effective, although they may help if there is any hyperpigmentation accompanying the scar, which is not uncommon.
Clinical red-light therapy — a course of sessions under a clinical-strength LED canopy delivering red and infrared light will regenerate the skin from within, producing collagen, growth factors, elastin and improving the hydration of the skin on the inside in a way that will lead to a smoother-looking surface on the outside. A ‘course’ will mean two sessions a week, for eight to 12 weeks.
Which one will be best for you depends on a number of factors, so if it’s something you really want to tackle then find yourself a good practitioner and go for a consultation – a professional will need to take a good look before you know for sure which way to go.
Does acne scarring fade?
If you’re not sure whether you need treatment and you’re wondering whether your scarring might just fade away naturally, then there are two visual elements to a scar you need to consider: colour and texture.
- Discolouration will often diminish over time –not particularly speedily, mind you; we’re talking about anywhere from six months to five years for hyperpigmentation or hypopigmentation to start to fade, depending on the size of the scar. However, it doesn’t always fade and, even if it does, it will almost never be a perfect match for the surrounding skin tone.
- Texture – by which I mean the depressions of atrophic scarring or the raised bumps of hypertrophic and keloidal scarring – will begin to improve over time, but again we’re talking about many months or sometimes years before you start to see a difference.
Then there’s your age to consider. If you are 19 and your skin is functioning at its youthful best, its own regeneration processes, growing new collagen and elastin and remodelling the skin’s surface, will do a good deal to lessen the scarring. But the older you are, the less efficient your skin becomes at self-repair.
So, will they fade? Yes, but it takes a long time. Will they fade away completely? Well, that’s in the next section…
Do acne scars go away?
While scars will usually fade or diminish over time, if left to their own devices, they will almost never disappear from view completely, particularly in cases of more severe scarring. The discolouration of a scar will fade, but it’s highly unlikely to match the surrounding skin tone completely, no matter how long you wait. The same goes for the texture of a scar: the difference between the scar and the surrounding skin will diminish over time, but it’s not going to go away completely.
The good news is that tweakments can help with the last leg of the healing process, bringing both skin tone and texture more into line. While severe scars may never go away completely, even with the help of tweakments, the treatments recommended here will get you much further than just letting scars run their course naturally.
Can plastic surgery help with acne scarring?
In the world of plastic surgery, skin grafts are often used to treat severe scarring, for example in burn victims. It’s a little trickier to make this work with acne scarring, however, because acne scars tend to cover quite a wide area but don’t go very deep. Bear in mind that skin grafted onto the face from elsewhere on the body will be inconsistent in texture and tone, like the scar you’re trying to cover up, so it’s only really suitable for extremely severe scarring. Acute cystic lesions may result in the sort of scarring that’s limited to a small, distinct area and might be suitable for a skin graft—however, in the majority of atrophic acne scarring, personally, I’d prefer to rely on tweakments.
Home remedies for acne scarring overnight?
Since acne scarring is an issue with the actual structure of the skin cells, you need something that’s going to physically remodel the skin. No home remedy is going to do that, particularly not overnight. If you want something you can do at home which will move your skin’s surface in the right direction, exfoliation is your best bet.
I’m not a big fan of exfoliating face scrubs; what I prefer to use is an acid-based product that will exfoliate the skin and give it a light peel. The ones you can get for home use are not clinic-strength, but they’ll still get into the epidermis and loosen up the dead skin cells on the surface, leaving a fresher, more even surface. You want to look for a product containing alpha-hydroxy acids (AHAs), such as glycolic acid or lactic acid. One of my long-term favourites is Paula’s Choice 8% AHA Lotion, which I’d suggest using twice a week, which is plenty to see an improvement.