Dealing with Acne Scars: Practical Approaches for Removal and Restoration

Acne is a chronic inflammatory skin condition that involves the pilosebaceous unit (hair follicles and oil glands). Acne affects the skin of the face, neck, shoulders, chest and back. Acne is caused by three main factors- overproduction of sebum (oil) by sebaceous glands, abnormal skin cell turnover and overgrowth of bacteria (Proprionibacterium Acnes). 

Acne severity is graded as mild, moderate, severe and nodulocystic. 

Mild  acne is characterised by whiteheads and blackheads. In moderate acne, there is presence of papules and pustules. In severe acne, there is the presence of papules, pustules and nodules. Nodulocystic acne is the most severe form of acne characterised by numerous nodules, cysts, severe inflammation and high risk of scarring. 

Types of Acne Scars

Rolling scars, boxcar scars, ice pick scars and hypertrophic/keloid scars. Acne patients also suffer from post inflammatory erythema and hyperpigmentation.

Rolling, Boxcar and ice pickscars are classified as atrophic scars. Rolling scars are depressed with gently sloping edges. Box car scars are depressed with sharp distinct edges. Ice pick scars are V shaped, narrow with sharp edges. 

A hypertrophic scar is the same size as the acne lesion that caused it, while a keloid scar is an excessive scar formation often larger than the causative lesion. Hypertrophic and keloid scars are more common on areas such as the jawline, chest, back, and shoulders. People with a darker skin color are more likely to develop this type of scarring.

Post-inflammatory erythema hyperpigmentation:

After the inflammation from acne fades, it often leaves behind reddish and darker patches of skin. This is due to increased vascularity and pigmentation of the skin. Risk factors for developing post inflammatory erythema/hyperpigmentation include: severe acne, picking or squeezing acne and darker skin types. The skin gradually returns to its normal state in several months.

Understanding Acne Scars

Acne scars form as a result of inflammation of the sebaceous gland affecting the surrounding skin, resulting in tissue loss (causing indentations) and scar formation (causing tethering or hypertrophic/keloid scars). About one in two people with acne will develop acne scars. 

Acne scars often co-exist with post inflammatory erythema/hyperpigmentation- they can be differentiated based on their appearance.

Factors affecting severity of acne include:

• Genetic factors 
  • Family history of severe acne
• Hormonal factors 
  • Polycystic ovaries  
  • Stress
  • Hormonal imbalances (starting/stopping birth control pills, bodybuilders using testosterone)
• Environmental factors 
  • High humidity causing swelling of the skin
  • Cosmetics – oil based skincare clog pores
  • Food: Excessive dairy products, meat protein and refined sugars in the diet. 
• Medications
  • Corticosteroids, antiepileptics, antidepressants

Prevention and Early Intervention

Early treatment of active acne would reduce the risk of development of severe acne breakouts, acne scars and post inflammatory erythema/hyperpigmentation. In turn, this will reduce the chance of emotional distress from acne.  Lifestyle changes include: avoiding foods that trigger acne (eg dairy, deep fried oily food), reducing stress. Skincare routines include UV protection, using skincare containing actives such as retinol salicylic acid or lactic acid, going for regular exfoliation facials, avoiding excessive makeup.

Skincare and for acne treatment

Cleansers/face wash- for acne prone oily skin, it is important to choose a cleanser or face wash that gently exfoliates, removes sebum and unclogs pores, while not being excessively harsh and stripping the skin of essential lipids. Ingredients to look for include: salicylic acid, glycolic acid and lactic acid. Cleansers and face washes for acne prone skin often are labelled “oil free” and “non comedogenic”.

Benzoyl peroxide- This over the counter antiseptic acts by reducing excess sebum, increasing skin cell turnover, reducing inflammation and killing acne bacteria. Benzoyl peroxide is available as gels, cleansers and spot treatments. Benzoyl peroxide is used once or twice a day. Side effects include irritation, redness, dryness, photosensitivity and staining of clothes and hair. 

Retinols- Retinols are a group of medications derived from Vitamin A that acts by reducing excess sebum, increasing skin cell turnover and reducing inflammation. They come in various strengths- ranging from off the counter to prescription, common examples include adapalene and tretinoin. Retinols applied once daily at night. Side effects include: irritation, redness, dryness and photosensitivity.

Azelaic acid- this medication is suitable for sensitive skin and in pregnancy/breastfeeding. It acts to reduce inflammation, kill acne bacteria, reduce sebum production and increase skin cell turnover. It also reduces post inflammatory erythema and hyperpigmentation. Azelaic acid 15-20% require prescription, 10% is available over the counter.

Antibiotics- topical or oral antibiotics act by killing acne bacteria and reducing inflammation. Commonly prescribed antibiotics include clindamycin and doxycycline.

Oral Isotretinoin- This is a treatment is reserved for severe acne that has not responded to medical treatment. This vitamin A derivative, when taken orally, reduces sebum production, increases skin cell turnover, reduces inflammation and kills acne bacteria. Over 80% of patients see a long term improvement in acne after a 3-4 month course of treatment. This medication carries potentially severe risks in pregnant patients- including risk of birth defects, miscarriage, and stillbirth- which is why female patients taking isotretinoin need to use two forms of birth control and have negative pregnancy tests. Other rare adverse events include: liver injury, bone marrow suppression and deranged lipid profiles. Common side effects include photosensitivity and dry skin/lips/eyes/mouth. Regular monitoring with blood tests and pregnancy tests is required.

Non-Invasive Acne Scar Treatment Options

A HydraFacial is a multi-step facial treatment that includes exfoliating, extracting, and then hydrating the skin. Using patented hydra-dermabrasion technology, a combo of hydration and microdermabrasion, it resurfaces the skin, clears dirt and impurities from clogged pores and infuses nourishing serums. Suitable for all skin types, HydraFacials are particularly suitable for people with acne prone and oily skin.

Lasers (PicoSure, MOXI Laser) and BBL HERO treatments are useful in the treatment of active acne and superficial acne scars– they act to reduce post inflammatory erythema and hyperpigmentation and resurface the skin. PicoSure treatments target post inflammatory erythema and hyperpigmentation, speeding up the resolution or red and brown marks. At Bay Aesthetics Clinic- a tailored treatment plan using all 3 devices will be customised to the patient. 

MOXI Laser is a potent resurfacing laser, triggering skin rejuvenation and improving superficial acne scars and open pores. 

 Active acne lesions can be addressed with the BBL HERO Forever Clear protocol- that destroys acne bacteria and reduces inflammation in active acne lesions.

SecretDUO: RF microneedling with Erbium Glass laser is the treatment of choice for deeper acne scars- this treatment uses fine gold tipped needles that emit radiofrequency energy (“RF microneedling”) that bypass the superficial layer of skin (epidermis) to reach the deeper layer (dermis) to remodel existing scar tissue and stimulate collagen production. This is combined with the Erbium Glass laser- a non ablative laser that tightens skin. 

For very deep acne scars- subcision with injection of collagen stimulator such as Sculptra is required. The subcision procedure uses a fine needle to break up the acne scar tissue that is tethering the skin, with the collagen stimulator acting to improve the skin thickness.

Post-Treatment Care and Maintenance

Hydrafacial and BBL HERO treatment have no downtime and clients can return to usual activity right away. After resurfacing laser and RF microneedling treatments, the skin would be red and sensitive for 2-3 days. Clients should stop skincare products which may cause irritation such as Vitamin C, retinols and alpha hydroxyl acids for 5-7 days after a treatment, use a post laser/treatment serum that contains stem cell derived growth factors and exosomes and apply SPF 50 sunblock when going out. Direct sun exposure should be minimized.