Physical Scars

The bad news is that acne can have lingering long-term effects — it can scar! The good news is that there are lots of ways to stop acne from scarring, and many of them are presented here. But if you already have scars, I have more good news — something can be done about them.

I delve even more deeply into the dermatology tool chest in search of some heavy-duty and “light” tools that may help you with your acne scars. The treatments described here are considered to be “surgical” in nature because they often involve cutting, abrading moving, building up, and destroying tissue (skin).

Examining Acne Scars

Acne scars are caused by the body’s response — and sometimes, overresponse — to injury caused by inflammatory acne lesions. Most often, scarring results from severe nodular acne that occurs deep in the skin. But, scarring also may arise from more superficial inflamed lesions.

The term scarring technically refers to a process in which new collagen is laid down to heal an injury. Collagen is a protein that gives the skin its rigidity and strength and is produced by skin cells called fibroblasts.

Scars can take on a number of different appearances: They may be flat; or sometimes, fibroblasts may work overtime and produce too much collagen that results in scars that bulge out like lumps. They can also form indentations (or pits) when there’s a loss of skin that is replaced by collagen.

Scars can be skin colored, whitish, purple, red, or even darker than a person’s normal skin color. There are times when “scars” aren’t really scars. After an acne lesion has healed or even while healing, it can leave a pink, red, purple, or a darkly pigmented mark on your skin.

These marks are actually macules, spots that indicate a temporary color change of the skin. These areas of remaining inflammation or post-inflammatory change aren’t scars because no permanent change has occurred.

Sometimes, especially in darker-skinned people, the spots tend to be darker than the normal skin color and they tend to hang around longer. This is known as postinflammatory hyperpigmentation (PIP), an after-effect from a healing acne lesion itself.

These lesions also tend to fade in time, unless the pigment winds up deep in the dermis (dermal melanosis). Dermal melanosis is a type of PIP that is much harder to treat and may never fade away completely. I cover PIP and options for stepping up the speed at which these lesions fade in earlier.

Some people endure their acne scars all their lives with little change in them. Other people are luckier — their skin improves and the scars undergo some degree of improvement over time, and they sometimes transform (remodel) themselves and decrease in size.

I guess time does heal some, if not all, wounds. I characterize the different types of scars next. Keep in mind that some people have a combination of different types of scars so that one treatment may not work on them all.

Scars caused by loss of tissue

Some acne scars appear as holes, pits, or craters in the skin. Called atrophic scars or crateriform scars, these depressed, cavity-like, inward-directed scars are associated with a lack of tissue that occurs when the inflammation from healed acne causes destruction to the skin (similar to scars that often result from chickenpox).

The scar tissue contracts and binds the skin down. Terms and descriptions related to this type of scarring will be helpful when talking with your dermatologist and reviewing treatment options, because some treatments work better than others for different scars. Here are some more descriptive names:

  • Ice-pick scars: These scars are the most common acne scars that occur on the cheeks. They’re most often small, with a somewhat jagged edge and steep sides — like wounds from an ice pick. They can be shallow or deep. Ice-pick scars may evolve into depressed fibrotic scars over time.
  • Depressed fibrotic scars: These scars are usually quite large, with sharp edges and steep sides.
  • Boxcar scars: These scars are angular and usually occur on the temple and cheeks, and can be either superficial or deep. They are similar to chickenpox scars. Rolling “hill and valley” scars: These scars give the skin a wavelike appearance. They have gently sloping rolled edges that merge with normal skin.

Collagen running amok

Scars that bulge out and look like lumps are associated with an exaggerated formation of scar tissue due to excessive amounts of collagen production. These are the two most common of this type:

  • Hypertrophic scars: These scars bulge outward like lumps.
  • Keloids: A keloid is a scar whose size goes far beyond what would be expected from what seems to be a minor injury. It’s kind of an “over-scarring.”

Both hypertrophic scars and keloids occur more commonly in dark-skinned individuals. They also tend to run in families — that is, growth of scar tissue is more likely to occur in people whose relatives have similar types of scars.

These scars persist for years, but may diminish in size over time. They’re notoriously difficult to treat and impossible to completely eradicate. A single, optimal treatment technique for hypertrophic scars and keloids hasn’t been developed, and the recurrence rate of these scars after treatment is high.

Surgical management is reserved for cases that are unresponsive to a conservative treatment, such as injecting cortisone into the scars themselves. The cortisone injections often help to shrink thickened, raised scar tissue. This procedure is similar to the procedure that is used to treat acne nodules.

Surgical treatment is a last resort because any person whose skin has a tendency to form these types of scars from acne damage may also form larger scars in response to any type of aggressive skin surgery.

In some cases, the best treatment for keloids in a person who is highly likely to develop them is no treatment at all. Certain lasers as well as intense pulsed light (IPL) devices may prove to be effective for these stubborn scars, but long-term studies are necessary to see how effective they will prove to be.

Taking Initial Treatment Steps

The oral and topical treatments used to treat acne don’t do very much to improve the appearance of acne scars. However, dermatologists and plastic surgeons do offer a number of treatment options if you have scars.

The type of treatment you decide upon should be the one that is best for you in terms of your type of skin, the cost of the treatment, and what you want it to accomplish.

Deciding whether you want to do anything about it

A decision to seek treatment for acne scars, and the specific treatments that you may choose, depend on a number of factors that you and your doctor can discuss and weigh:

  • How do you feel about your scars? You may have scars and could care less about them or they may be psychologically distressing to you. Do the scars emotionally affect your life? Are you willing to live with your scars and wait for them to fade over time?
  • What’s your age, overall health, and medical history? If you’re a teenager or healthy adult, you’d probably want to wait until your acne is no longer active. If you’re an adult or senior who has medical problems and are taking several medications, consult with your primary care provider before embarking on any surgical procedure.
  • How bad are your scars? Are they disfiguring? The severity of the scars can affect whether you’re willing to go through treatment.
  • What kind of scars do you have? Some scars respond more readily to treatment, and others, like keloids, indicate that treatment could actually cause more scarring.
  • What’s your doctor’s opinion? An expert opinion as to whether scar treatment is justified in your particular case may help you decide upon the most effective treatment for you.
  • What do you want to accomplish? Maybe you just want to diminish the appearance of deep scars or maybe you’re trying out for a part in a feature film.
  • How will you pay for treatment? Get a handle on your finances and insurance coverage before you make any decisions. You need to determine the costs that you’ll have to pay out of pocket and whether you can afford to do so. A significant investment of time and money is often needed.

Most of these procedures aren’t covered by health insurance plans because they’re generally considered to be cosmetic in nature. It may go without saying, but I’ll say it anyway: They’re all pretty expensive. Just to give you an idea, a laser skin resurfacing can cost from $4,000 to $5,000 or more!

Also be aware that acne scars are particularly difficult to treat and they can’t always be effectively corrected by one single treatment method. In fact, using more than one method may yield better results. Before committing to treatment of acne scars, you should have a discussion with your doctor.

Finding a physician

When you turn your attention to the treatment of acne scars, it’s especially important that you find a doctor who is trained and experienced in the procedures that I describe here, for a number of reasons:

  • Many of the treatments have sometimes been offered by inadequately trained practitioners, sometimes with devastating, disfiguring results.
  • Some of the treatments may result in more scarring if you have a propensity to develop hypertrophic scars or keloids. You need a reputable, experienced physician to help you weigh the pros and cons with this type of scarring.

With the exception of microdermabrasion and most chemical peels, which can be performed by a physician, nurse, or licensed aesthetician, the procedures described here are performed by a dermatologist or plastic surgeon in her office.

If your doctor or dermatologist doesn’t treat acne scars, check earlier article where I tell you how to find a dermatologist who does. You can also go to the Web sites of The American Academy of Dermatology and The American Society for Dermatologic Surgeons.

These sites can help you locate a dermatologist who has specialized training in cosmetic and other types of skin surgery. To find a plastic surgeon who performs these procedures, visit the online referral service of the American Society of Plastic Surgeons (ASPS). This is the largest plastic surgery organization in the world and the foremost authority on cosmetic and reconstructive plastic surgery.

Treating Your Scars

Don’t start any treatment for scarring until your acne is completely gone and unlikely to come back. If you go to all the trouble and expense to undergo a procedure (or multiple procedures) and then get more acne, and thus more scarring, you have to go through it all again.

Just imagine how expensive that would be! Skin resurfacing techniques (like dermabrasion), surgical excision, and fillers have been used to diminish acne scarring for years with mixed results.

Currently, laser therapy has assumed a more important role in the treatment of acne scars, and other newer surgical methods featuring light and radio waves are an option to treat your acne. Most scar treatment focuses on facial scars. Generally, scars on the chest and back don’t respond as well to the treatments mentioned hereafter.

Because these scars are so hard to treat, the best approach is to try to prevent them in the first place. If the prevention route fails, the intralesional cortisone (steroid) injections that I describe in the “Growing out: Collagen running amok” section, may help to shrink them.

One remnant of the recent past in treating acne scars is the chemical acid peel. Peels are sometimes used in the treatment of acne and dark spots, and you may still hear about them in conjunction with treating shallow acne scars.

But, for the most part, the results of chemical peels in treating scars are disappointing, and the method has been replaced by others, notably lasers, that I discuss.

Laser skin resurfacing

There are many types of lasers and there are a number of new procedures now available that complement or even surpass previous scar revision techniques such as those that I describe later.

Treatment with some of these devices can be used to help improve and treat acne itself, and as a simultaneous benefit, they can stimulate collagen remodeling and result in the improvement of the appearance of acne scars.

Laser resurfacing can result in uneven skin tones in people with darker skin. Treatment with laser resurfacing takes place in an office setting. Typically three sessions are performed. For a “full-face” resurfacing, the cost can be $3,000 to $8,000 and up! Sometimes, laser resurfacing and other surgical treatments for acne scars are combined.

The surgical treatment is usually completed 6 to 12 weeks before the laser is called into action. This waiting period gives your skin time to heal and remodel itself. The two major categories of lasers that are used in acne scar therapy are the resurfacing (ablative) lasers and the non-ablative lasers.

Ablative lasers

The powerful ablative lasers literally remove the outer layers of the skin by using high-energy light to burn away scar tissue, and stimulate the dermal collagen to tighten, reducing the amount of scar visibility. This procedure is used for deeper scars and carries the risk of further scarring.

Because the skin is injured and unprotected tissue is exposed, great effort must be put into post-operative wound care and infection prevention. The skin may remain reddened for several months or a year afterwards.

Non-ablative lasers

At first, ablative lasers were used to recontour or vaporize the skin’s surface. Now, techniques involving non-ablative lasers have taken over because of their ability to promote collagen growth beneath an acne scar without creating an external injury.

The non-ablative lasers produce a controlled injury to certain target structures in the dermis, while completely sparing the epidermis from damage. The laser beams can penetrate into the dermis without injuring the epidermis. By heating dermal collagen, they help to “tighten” the dermis and result in less visible scarring.

The theory is that the thermal injury caused by the laser triggers a wound repair response, including fibroblast activation and new collagen formation. Non-ablative laser resurfacing can be effective for treating shallow boxcar scars, as well as for smoothing and tightening scars that have been treated previously.

It is not very effective for deep, depressed, craterlike scars. A topical anesthetic is applied by a doctor or his medical assistant about an hour before performing these procedures to make the pain tolerable.

The surface of the skin is cooled to prevent the laser from damaging the epidermis. A patient will feel both the cold spray as well as some amount of stinging and heat during the session.

Considering other surgical treatment options

Atrophic scars, such as ice-pick scars, boxcar scars, and small depressed fibrotic scars, may be removed or improved by a punch excision of each individual scar.

Excising scars

In this procedure, each scar is cut down to the layer of subcutaneous fat; the resulting hole in the skin may be repaired with sutures or with a small skin graft. Alternatively, the punch may simply be elevated. There are three techniques:

  • Punch excision: Your doctor removes the pitted scar with a cookie-cutter-like tool that punches out small portions of skin. The surrounding healthy skin is joined together by suturing.
  • Punch replacement: As with the punch excision, the scar is removed and then replaced with a skin graft of unscarred skin, usually harvested from behind the ear. This method is usually the most successful for treating deep scars.
  • Punch elevation: Here the scar is punched out, but not discarded. It is allowed to float up to the level of surrounding skin.

Your dermatologic or plastic surgeon may allow the scar from punch techniques to fade on its own. Or she may perform the procedure before a more generalized resurfacing technique such as laser resurfacing is performed.

Less commonly, dermabrasion, microdermabrasion, and chemical peels are sometimes used in conjunction with punch techniques. The prices of these procedures vary and depend upon the number of grafts or punches that are done. Punch grafting can run $50 to $150 per graft or $1,000 to $2,500 per session.

Subscising scars

Subcision helps to restructure and remodel scar tissue by breaking fibrous bands that are creating tension between the epidermis and deeper structures. It also helps induce new collagen formation. This method is useful for indented, rolling scars that result from scar tissue holding the skin down.

This is a very specialized procedure that is performed by a qualified dermatologic or plastic surgeon. To perform this technique, a sharp instrument such as a tiny scalpel or needle is used to undercut and lift the scar tissue away from unscarred skin, elevating the skin to make it even.

The subscising procedure breaks down adhesions (old bands of scar tissue), which helps to reorganize the formation of new collagen and elastic tissue for a smoother skin surface. The overlying skin isn’t cut, so sutures aren’t needed. This breaking down of scar tissue helps to level the playing field.

After the wounds heal, an injection with a filler material under the scar can help to replace any remaining defects and bring them to surface level. The filler can be made of one’s own fat or a collagen or other synthetic substance: Fill ’er up!” The procedure can cost between $200 and $1,000 depending on the number of lesions treated.

Contouring the defects: Fill ’er up!

Another option for improving the appearance of certain acne scars is known as soft tissue augmentation. These procedures have a very limited use, and at most, they can help with some of the shallow “hill and valley” soft scars with gentle sloping edges. They don’t work well for ice-pick, deep boxcar, or depressed fibrotic scars.

Materials, including your own fat, can be injected into the depressed area of the scar to elevate it to the level of the normal surrounding skin.

The material is injected under the skin to stretch and fill out superficial and deep “soft” scars. Many substances are available and many new ones continue to be introduced. Most doctors have a variety of fillers to choose from, including the following:

  • Collagen: Collagen injections are intended to replenish your natural collagen and minimize surface unevenness by lifting and filling depressed lines and scars. The original bovine collagens Zyplast and Zyderm can’t be used in people with autoimmune diseases.

Skin testing to look for possible allergic reactions is necessary before they’re injected. The newer human-derived collagen products such as Cosmoderm and Cosmoplast offer alternatives to those who are allergic to the bovine derived collagen.

No skin testing is required with these agents. Collagen injections are temporary, and last about six months (give or take a few months), so ongoing touch-ups are necessary.

  • Fat: To correct deeper defects caused by scarring from nodular acne, fat transplantation utilizes your own fat. The fat is taken from another site on your own body and injected beneath the surface of the skin to elevate depressed scars. Because the fat is reabsorbed into the skin over a period of 6 to 18 months, the procedure usually must be repeated.
  • Newer fillers: There has been an increase in the number and quality of filler substances used to help plump up acne scars. Restylane and Hylaform are now available and there are many more to come. Longer-lasting results are expected from these materials.

Unless the borders of atrophic scars are soft, there is little place for fillers in the treatment of acne scars. They’re probably best used as a complementary procedure with other surgical treatments described here. Depending on the type and amount of filler used, treatment can cost between $400 and $750 and $1,000 and $1,200.

Trying out dermabrasion

Before there were lasers, superficial acne scars were smoothed out with a procedure known as dermabrasion. Dermabrasion was used to minimize small acne scars. As the name implies, dermabrasion involves removing the top layers of skin. Dermabrasion has been around for many decades.

Initially, sandpaper was used to remove damaged skin and allow new skin to grow in its place — yes, I’m serious. But now, electrical machines are used to abrade the skin. These gadgets have quickly rotating wheels that have a rough wire brush (fraise), or a burr containing diamond particles.

The wheel is attached to a motorized handle. Dermabrasion may make ice-pick scars and depressed fibrotic scars more noticeable if the scars are wider under the skin than at the surface. Dermabrasion is used mainly for the “softer” scars. It’s rarely used for hypertrophic scars.

Over the past decade, this procedure has fallen out of favor with the availability of newer, easierto- use techniques such as lasers. I no longer recommend it. A qualified dermatologic or plastic surgeon performs dermabrasion on a single visit as an office procedure. First she anesthetizes your skin with a numbing spray, such a Freon.

You may also be given a sedative to make you drowsy before she sheers away your scar tissue. A full-face dermabrasion can be as costly as a laser resurfacing procedure. It can cost $2,500 to $4,500. In darker-skinned people, dermabrasion may cause dramatic changes in pigmentation and worsen hypertrophic or keloidal scars.


This technique is a surface form of dermabrasion. I call it “dermabrasion lite.” Rather than a high-speed brush, microdermabrasion uses aluminum oxide crystals passing through a vacuum tube to remove surface skin. The crystals are literally blasted onto the skin and then vacuumed away accompanied by surface skin cells.

Microdermabrasion can be performed by anybody — your Aunt Gertrude, a physician, a nurse, or an aesthetician. At most, microdermabrasion is effective in reducing fine lines, “crow’s feet,” and age spots, but this treatment isn’t effective for diminishing acne scars. That’s because only the very surface cells of the skin are removed and a mild exfoliation takes place.

Microdermabrasion runs from $150 to $300 per treatment. Dermabrasion may result in pigmentary streaking in people with dark skin types. If you have dark skin, make sure your doctor has extensive experience (and success) at treating others with your skin type.

Considering emerging technologies

Many technologies that were initially developed as anti-aging wrinkle treatments are now becoming useful in treating the scars associated with acne, including radio waves. This novel treatment, referred to by the brand name Thermage, uses radiofrequency (RF) emissions to deliver controlled amounts of energy (heat) into the collagen layers of the skin.

It has a cooled application tip to protect the epidermis from heating up. It’s supposed to penetrate deeper in the skin than other methods and cause thermal injury to sebaceous glands.

Currently, it’s being used to tighten the skin as a noninvasive face-lift. More research is needed to see if it works on acne and acne scars. The procedure can cost between $2,000 and $5,000.