Acne Scarring

							Title:
Acne Scarring

Word Count:
2098

Summary:
Main causes of acne scarring.


Keywords:
acne. acnes, faqs, faq, FAQ, FAQS, A
CNE, ACNES


Article Body:
A detailed and comprehensive discus
sion of acne scars starts with caus
es of scarring, prevention of scarr
ing, types of scars, and treatments
 for scars.

Before talking about scars, a word
about spots that may look like scar
s but are not scars in the sense th
at a permanent change has occurred.
 Even though they are not true scar
s and disappear in time, they are v
isible and can cause embarrassment.

Macules or "pseudo-scars" are flat,
 red or reddish spots that are the
final stage of most inflamed acne l
esions. After an inflamed acne lesi
on flattens, a macule may remain to
 "mark the spot" for up to 6 months
. When the macule eventually disapp
ears, no trace of it will remain—un
like a scar.

Post-inflammatory pigmentation is d
iscoloration of the skin at the sit
e of a healed or healing inflamed a
cne lesion. It occurs more frequent
ly in darker-skinned people, but oc
casionally is seen in people with w
hite skin. Early treatment by a der
matologist may minimize the develop
ment of post-inflammatory pigmentat
ion. Some post-inflammatory pigment
ation may persist for up to 18 mont
hs, especially with excessive sun e
xposure. Chemical peeling may haste
n the disappearance of post-inflamm
atory pigmentation.

Causes of Acne Scars
In the simplest terms, scars form a
t the site of an injury to tissue.
They are the visible reminders of i
njury and tissue repair. In the cas
e of acne, the injury is caused by
the body’s inflammatory response to
 sebum, bacteria and dead cells in
the plugged sebaceous follicle. Two
 types of true scars exist, as disc
ussed later: (1) depressed areas su
ch as ice-pick scars, and (2) raise
d thickened tissue such as keloids.

When tissue suffers an injury, the
body rushes its repair kit to the i
njury site. Among the elements of t
he repair kit are white blood cells
 and an array of inflammatory molec
ules that have the task of repairin
g tissue and fighting infection. Ho
wever, when their job is done they
may leave a somewhat messy repair s
ite in the form of fibrous scar tis
sue, or eroded tissue.

White blood cells and inflammatory
molecules may remain at the site of
 an active acne lesion for days or
even weeks. In people who are susce
ptible to scarring, the result may
be an acne scar. The occurrence and
 incidence of scarring is still not
 well understood, however. There is
 considerable variation in scarring
 between one person and another, in
dicating that some people are more
prone to scarring than others. Scar
ring frequently results from severe
 inflammatory nodulocystic acne tha
t occurs deep in the skin. But, sca
rring also may arise from more supe
rficial inflamed lesions. Nodulocys
tic acne that is most likely to res
ult in scars is seen in these photos:

(Photos used with permission of the
 American Academy of Dermatology
National Library of Dermatologic Tea
ching Slides)

The life history of scars also is n
ot well understood. Some people bea
r their acne scars for a lifetime w
ith little change in the scars, but
 in other people the skin undergoes
 some degree of remodeling and acne
 scars diminish in size.

People also have differing feelings
 about acne scars. Scars of more or
 less the same size that may be psy
chologically distressing to one per
son may be accepted by another pers
on as "not too bad." The person who
 is distressed by scars is more lik
ely to seek treatment to moderate o
r remove the scars.
Prevention of Acne Scars
As discussed in the previous sectio
n on Causes of Acne Scars, the occu
rrence of scarring is different in
different people. It is difficult t
o predict who will scar, how extens
ive or deep scars will be, and how
long scars will persist. It is also
 difficult to predict how successfu
lly scars can be prevented by effec
tive acne treatment.

Nevertheless, the only sure method
of preventing or limiting the exten
t of scars is to treat acne early i
n its course, and as long as necess
ary. The more that inflammation can
 be prevented or moderated, the mor
e likely it is that scars can be pr
evented. (Click on Acne Treatments
for more information about treatmen
t of mild, moderate and severe acne
). Any person with acne who has a k
nown tendency to scar should be und
er the care of a dermatologist. (Cl
ick on Find a Dermatologist to loca
te a dermatologist in your geograph
ic area).
Types of Acne Scars
There are two general types of acne
 scars, defined by tissue response
to inflammation: (1) scars caused b
y increased tissue formation, and (
2) scars caused by loss of tissue.

Scars Caused by Increased Tissue For
mation
The scars caused by increased tissu
e formation are called keloids or h
ypertrophic scars. The word hypertr
ophy means "enlargement" or "overgr
owth." Both hypertrophic and keloid
 scars are associated with excessiv
e amounts of the cell substance col
lagen. Overproduction of collagen i
s a response of skin cells to injur
y. The excess collagen becomes pile
d up in fibrous masses, resulting i
n a characteristic firm, smooth, us
ually irregularly-shaped scar. The
photo shows a typical severe acne k
eloid:

(Photo used with permission of the
American Academy of Dermatology
National Library of Dermatologic Tea
ching Slides)

The typical keloid or hypertrophic
scar is 1 to 2 millimeters in diame
ter, but some may be 1 centimeter o
r larger. Keloid scars tend to "run
 in families"—that is, abnormal gro
wth of scar tissue is more likely t
o occur in susceptible people, who
often are people with relatives who
 have similar types of scars.

Hypertrophic and keloid scars persi
st for years, but may diminish in s
ize over time.

Scars Caused by Loss of Tissue
Acne scars associated with loss of
tissue—similar to scars that result
 from chicken pox—are more common t
han keloids and hypertrophic scars.
 Scars associated with loss of tiss
ue are:

    Ice-pick scars usually occur on
 the cheek. They are usually small,
 with a somewhat jagged edge and st
eep sides—like wounds from an ice p
ick. Ice-pick scars may be shallow
or deep, and may be hard or soft to
 the touch. Soft scars can be impro
ved by stretching the skin; hard ic
e-pick scars cannot be stretched out.
    Depressed fibrotic scars are us
ually quite large, with sharp edges
 and steep sides. The base of these
 scars is firm to the touch. Ice-pi
ck scars may evolve into depressed
fibrotic scars over time.

    Soft scars, superficial or deep
 are soft to the touch. They have g
ently sloping rolled edges that mer
ge with normal skin. They are usual
ly small, and either circular or li
near in shape.

    Atrophic macules are usually fa
irly small when they occur on the f
ace, but may be a centimeter or lar
ger on the body. They are soft, oft
en with a slightly wrinkled base, a
nd may be bluish in appearance due
to blood vessels lying just under t
he scar. Over time, these scars cha
nge from bluish to ivory white in c
olor in white-skinned people, and b
ecome much less obvious.

    Follicular macular   atrophy is m
ore likely to occur on   the chest or
 back of a person with   acne. These
are small, white, soft   lesions, oft
en barely raised above   the surface
of the skin—somewhat like whitehead
s that didn’t fully develop. This c
ondition is sometimes also called "
perifollicular elastolysis." The le
sions may persist for months to years.

Treatments for Acne Scars
A number of treatments are availabl
e for acne scars through dermatolog
ic surgery. The type of treatment s
elected should be the one that is b
est for you in terms of your type o
f skin, the cost, what you want the
 treatment to accomplish, and the p
ossibility that some types of treat
ment may result in more scarring if
 you are very susceptible to scar f
ormation.

A decision to seek dermatologic sur
gical treatment for acne scars also
 depends on:

    * The way you feel about scars.
 Do acne scars psychologically or e
motionally affect your life? Are yo
u willing to "live with your scars"
 and wait for them to fade over tim
e? These are personal decisions onl
y you can make.
    * The severity of your scars. I
s scarring substantially disfigurin
g, even by objective assessment?

    * A dermatologist’s expert opin
ion as to whether scar treatment is
 justified in your particular case,
 and what scar treatment will be mo
st effective for you.

Before committing to treatment of a
cne scars, you should have a frank
discussion with your dermatologist
regarding those questions, and any
others you feel are important. You
need to tell the dermatologist how
you feel about your scars. The derm
atologist needs to conduct a full e
xamination and determine whether tr
eatment can, or should, be undertaken.

The objective of scar treatment is
to give the skin a more acceptable
physical appearance. Total restorat
ion of the skin, to the way it look
ed before you had acne, is often no
t possible, but scar treatment does
 usually improve the appearance of
your skin.

The scar treatments that are curren
tly available include:

    Collagen injection. Collagen, a
 normal substance of the body, is i
njected under the skin to "stretch"
 and "fill out" certain types of su
perficial and deep soft scars. Coll
agen treatment usually does not wor
k as well for ice-pick scars and ke
loids. Collagen derived from cows o
r other non-human sources cannot be
 used in people with autoimmune dis
eases. Human collagen or fascia is
helpful for those allergic to cow-d
erived collagen. Cosmetic benefit f
rom collagen injection usually last
s 3 to 6 months. Additional collage
n injections to maintain the cosmet
ic benefit are done at additional cost.

    Autologous fat transfer. Fat is
 taken from another site on your ow
n body and prepared for injection i
nto your skin. The fat is injected
beneath the surface of the skin to
elevate depressed scars. This metho
d of autologous (from your own body
) fat transfer is usually used to c
orrect deep contour defects caused
by scarring from nodulocystic acne.
 Because the fat is reabsorbed into
 the skin over a period of 6 to 18
months, the procedure usually must
be repeated. Longer lasting results
 may be achieved with multiple fat-
transfer procedures.

    Dermabrasion. This is thought t
o be the most effective treatment f
or acne scars. Under local anesthet
ic, a high-speed brush or fraise us
ed to remove surface skin and alter
 the contour of scars. Superficial
scars may be removed altogether, an
d deeper scars may be reduced in de
pth. Dermabrasion does not work for
 all kinds of scars; for example, i
t may make ice-pick scars more noti
ceable if the scars are wider under
 the skin than at the surface. In d
arker-skinned people, dermabrasion
may cause changes in pigmentation t
hat require additional treatment.

    Microdermabrasion. This new tec
hnique is a surface form of dermabr
asion. Rather than a high-speed bru
sh, microdermabrasion uses aluminum
 oxide crystals passing through a v
acuum tube to remove surface skin.
Only the very surface cells of the
skin are removed, so no additional
wound is created. Multiple procedur
es are often required but scars may
 not be significantly improved.

    Laser Treatment. Lasers of vari
ous wavelength and intensity may be
 used to recontour scar tissue and
reduce the redness of skin around h
ealed acne lesions. The type of las
er used is determined by the result
s that the laser treatment aims to
accomplish. Tissue may actually be
removed with more powerful instrume
nts such as the carbon dioxide lase
r. In some cases, a single treatmen
t is all that will be necessary to
achieve permanent results. Because
the skin absorbs powerful bursts of
 energy from the laser, there may b
e post-treatment redness for severa
l months.

    Skin Surgery. Some ice-pick sca
rs may be removed by "punch" excisi
on of each individual scar. In this
 procedure each scar is excised dow
n to the layer of subcutaneous fat;
 the resulting hole in the skin may
 be repaired with sutures or with a
 small skin graft. Subcision is a t
echnique in which a surgical probe
is used to lift the scar tissue awa
y from unscarred skin, thus elevati
ng a depressed scar.

    Skin grafting may be necessary
under certain conditions—for exampl
e, sometimes dermabrasion unroofs m
assive and extensive tunnels (also
called sinus tracts) caused by infl
ammatory reaction to sebum and bact
eria in sebaceous follicles. Skin g
rafting may be needed to close the
defect of the unroofed sinus tracts.

    Treatment of keloids. Surgical
removal is seldom if ever used to t
reat keloids. A person whose skin h
as a tendency to form keloids from
acne damage may also form keloids i
n response to skin surgery. Sometim
es keloids are treated by injecting
 steroid drugs into the skin around
 the keloid. Topical retinoic acid
may be applied directly on the kelo
id. In some cases the best treatmen
t for keloids in a highly susceptib
le person is no treatment at all.

In summary, acne scars are caused b
y the body’s inflammatory response
to acne lesions. The best way to pr
event scars is to treat acne early,
 and as long as necessary. If scars
 form, a number of effective treatm
ents are available. Dermatologic su
rgery treatments should be discusse
d with a dermatologist.