Acne and acne scarring

Skin Issues: acne and acne scarring

Learn more about methods of treating acne and acne scarring in Book 1: Face and Skin.


Acne occurs when the oil-secreting glands in the skin are clogged and become inflamed or infected. This can be caused by or exacerbated by –

  • hormones
  • stress
  • birth control pills
  • not enough rest

Symptoms of acne include whiteheads (closed, plugged oil glands), blackheads (open, plugged oil glands), pustules and cysts (large fluid-filled bumps).
The first step in resolving this issue is to clear acne lesions, reduce inflammation and encourage the healing process. This initial stage may take 4—6 weeks depending on the type and frequency of treatments required. Home-care topical formulations, oral vitamin supplements and monthly maintenance treatments should continue to keep the skin clear.

Acne Scarring

Even with the most cautious and painstaking therapy, acne scars may still be left behind after acne lesions have been successfully treated. Discolorations are not really acne scars but post-inflammatory hyperpigmentation, which fades as time goes on.
Acne scars can be addressed with a range of non-surgical techniques, depending on the type of scar. For more serious cases, surgery may be necessary. It is vital that you ask your clinician to assess the type of scarring and plan a program specifically for you.

The following risk factors may lead to acne scarring—

  • A genetic tendency to scar
  • Large size and depth of the lesion
  • Naturally slow healing of the skin
  • Smoking
  • Drinking alcohol
  • Poor nutrition
  • Poor hydration
  • Excess weight/obesity
  • Not enough rest
  • Improper wound care
  • Being slow to identify infection
  • Chronic illness
  • Stress on your acne lesion wound
  • Exposure to sunlight

In general, acne scars can be classified in two categories:

  • Indented or depressed – those caused by a loss of tissue (atrophic).
  • Raised or thickened – those caused by an excess of tissue (hypertrophic).
  • Within these categories, acne scars can be sorted into four types: ice pick, boxcar, rolling (which are indented) and keloid scars (which are raised).

Types of acne scars

Ice Pick Scars

These are deep, very narrow scars that delve into the dermis. The skin looks as if it has been scored by an ice pick or other sharp instrument. Ice pick scars appear to make a small, deep hole in the skin. Some may resemble large, open pores.
Ice pick scars develop after an infection from a cyst or other deep inflamed blemish works its way to the surface. The bacteria destroy skin tissue, resulting in a long column-like scar.
This type of scar can be treated with punch excision or punch grafting. With punch excision, the surgeon cuts into the skin with a special punch tool matched to the size of the acne scar, to remove the scar before closing the wound with stitches. The punch tool is somewhat different from conventional plastic surgery cutting tools. It can actually remove tiny fragments of tissue without stretching or affecting the surrounding skin. In punch grafting a skin graft, generally removed from behind the ear, is used to stop up the hole in the skin.

Boxcar Scars

Boxcar scars are round or oval dents with steep vertical sides. Wider than ice picks, boxcar scars give the skin a pitted appearance.
When an inflammatory breakout destroys collagen, tissue is lost. The skin over this area is left without support; it sinks and a depressed area appears. Boxcar scars may be superficial to severe, depending on the amount of tissue lost.
Treatments for boxcar scars include punch excision (see above) or punch elevation (see below), dermal fillers, and laser resurfacing.
Punch elevation is a microsurgical method that can be performed in the surgeon’s rooms. Using the punch tool, the surgeon commences pinching the scar tissue base. The action of the punch tool resembles pinching-off the scar tissue in a controlled way, to make sure that the underlying skin is minimally affected. When the scar tissue base is sufficiently punched, the base of the acne scar will be level with the outer walls surrounding the scar, i.e. the scar base is ‘elevated’. This ‘raising’ effect makes the scar appear shallower.
Next, the surgeon puts sutures (stitches) into the scar site. Tiny pieces of the surrounding skin are incorporated into the sutures. The result is that the scar site is overlaid by new skin, which in turn triggers the skin’s healing.

Rolling Scars

This type of scarring causes ‘rolling’ or ‘wave-like’ undulations across skin that otherwise looks normal.
Rolling scars arise when fibrous bands of tissue develop between the skin and the subcutaneous tissue below. These bands pull on the epidermis, binding it to deeper structures of the skin. It is this pulling of the epidermis from within that creates the rolling appearance of the skin.
Rolling scars are best treated with subcision, which is a relatively simple and low risk surgery procedure that can be performed in a day surgery. It is used to treat indented acne scars and may be combined with other therapies such as laser, skin microneedling (e g. ‘dermaroller’), punch grafting of the skin (see above), dermabrasion etc.

Hypertrophic or Keloid Scars

A hypertrophic scar looks like a raised, firm mass of tissue. These kinds of scars frequently grow bigger than the original wound. Hypertrophic scars caused by acne are most often found on the torso, especially in men.
Unlike ice pick or boxcar scars, hypertrophic scars are not caused by a loss of tissue. Instead, they develop because of an overproduction of collagen. Steroid (cortisone) creams, tapes, or injections are used to help shrink and flatten the scar. Interferon injections may also be used to soften scar tissue.

In Book 1: Face and Skin you can find out about

  • Traditional acne medications and their side effects and alternatives
  • Minimally invasive acne and scarring treatments
  • Non-surgical acne and scarring treatments
Page Hierarchy: Acne and acne scarring