Even after lesions have healed, they can leave behind permanent reminders. While it’s difficult to avoid acne scarring completely, understanding the inner workings of your skin can help you minimize long-term damage.
What causes acne scarring? In the simplest of terms, acne scars are visible reminders of injury and tissue repair. When tissue suffers an injury, the body rushes its “repair team” to the injury site. This specialized team includes white blood cells and an array of inflammatory molecules that work to fight infection and heal damaged tissue. Once the infection is gone, however, the tissue can’t always be restored to its former state.
Who is most susceptible to acne scars? How and why people end up with acne scars is not completely understood. There is considerable variation between individuals, suggesting that some people are simply more prone to acne scarring than others. Acne Scar-susceptible people often find a genetic connection, as well — both the degree to which you scar and the kind of scar you get can "run in the family." There is also considerable variation in the “life history” of individual scars; some people bear acne scars for a lifetime with little change, while others watch their scars diminish with time. We do know that scarring occurs most frequently in patients with the most severe forms of inflammatory acne, involving deep nodular lesions.
How can I avoid acne scarring? Because we know so little about what causes one person to scar more easily than the next, the best way to avoid scarring is to prevent acne. It's important to treat the condition early in its course, and for as long as necessary. The more inflammation you can prevent, the less likely you are to scar. In the event that you do get acne lesions, it’s important to treat them with the proper medication rather than squeeze or pick at them. Handling the skin — squeezing with your fingernails, poking pimples with a pin, or whatever — significantly increases damage to surrounding tissue, and thereby increases the chance that the lesion will leave a permanent scar and acne scar treatment will be necessary.
Remember: A pimple that's bothering you today will go away soon if you let it be; if you pick at it, it could stick around forever. If you have a particularly troublesome lesion, see your dermatologist or aesthetician for safe, professional scar treatment or extraction.
Another thing to remember: A healthy body heals faster and more completely, so never underestimate the power of a healthy lifestyle. Eat a balanced diet, get plenty of rest and drink lots of water. If your work or play takes you out in the sun, protect yourself against harmful UVA and UVB rays with oil-free sunscreen; too much sun exposure can make scars stick around longer. Another habit that you know is bad — smoking — depletes your skin's valuable oxygen collagen reserves, causes free radical damage and deposits toxins, making it more vulnerable to aging and acne scarring.
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Types of acne scars
First, some good news about the healing process. As an acne blemish heals, the inflamed area flattens, leaving behind a reddish spot. Though it may look like an acne scar, it’s actually a macule — the final stage of an acne lesion. Macules may last for up to six months, but leave no permanent acne scar.
The same holds true for post-inflammatory hyperpigmentation, a darkening of the skin at the site of a healing acne lesion. Most prevalent in African-American, Asian and Latino populations, these spots can last up to 18 months — but may disappear more quickly if you stay out of the sun. Both macules and post-inflammatory hyperpigmentation are considered "pseudo-scarring" because they eventually disappear completely.
There are two kinds of true scars left behind by acne: acne scars caused by increased tissue formation, and acne scars caused by tissue loss. The former, called keloid or hypertropic scars, are less common and appear to be hereditary. These are found primarily in African-American, Asian and Latino patients. Keloid scarring occurs when the skin cells respond to injury by producing an excess of collagen, which forms into lumpy fibrous masses most frequently along the jaw line and on the back or chest. These acne scars appear firm and shiny, and may persist for years.
Acne scars caused by tissue loss are much more common, and may take many forms:
Soft acne scars have gentle sloping rolled edges that merge with the surrounding skin. They are usually small, circular or linear in shape, and soft to the touch.
Ice-pick acne scars. Most often found on the cheek, ice-pick scars are usually small but deep, with a jagged edge and steep sides. If they are soft to the touch, they may be improved by stretching the skin; hard ice-pick scars are difficult to treat.
Depressed fibrotic acne scars. Over time, ice-pick scars may evolve into depressed fibrotic scars. These also have sharp edges and steep sides, but are larger and firm at the base.
Atrophic macules, a form of acne scarring most common in Caucasians, are soft with a slightly wrinkled base. Blood vessels just below the surface of the scar may make them appear purplish when they are recent, but this discoloration may fade over time to a pale ivory. Atrophic macules are usually small when they occur on the face, but may be a centimeter or larger elsewhere on the body.
Follicular macular atrophy is more likely to occur on the chest or back of a person with acne. These small, soft white lesions resemble whiteheads that didn’t fully develop; they may persist for months or years.
Can my acne scars be treated?
The short answer is yes - acne scar treatment is available. Post-inflammatory hyperpigmentation and macules can be improved with bleaching agents. Some superficial acne scarring can be treated with topical resurfacing agents, like Retinol, which is available in many over-the-counter forms, as well as in prescription medications such as Retin-A and Renova. Other forms of scarring can be improved with microdermabrasion (a minimum of 6–8 treatments are typically required) or dermatologic surgery. It may not be possible to restore your skin to its pre-acne appearance — but if your scars have a significant effect on your emotional well-being, it’s worth considering. There are a number of different scar treatments available; consult your dermatologist to find out if your particular situation may be improved, and how.