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					Title:
Acne Scarring

Word Count:
2098

Summary:
Main causes of acne scarring.


Keywords:
acne. acnes, faqs, faq, FAQ, FAQS, ACNE, ACNES


Article Body:
A detailed and comprehensive discussion of acne scars starts with causes
of scarring, prevention of scarring, types of scars, and treatments for
scars.

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

Macules or "pseudo-scars" are flat, red or   reddish spots that are the
final stage of most inflamed acne lesions.   After an inflamed acne lesion
flattens, a macule may remain to "mark the   spot" for up to 6 months. When
the macule eventually disappears, no trace   of it will remain —unlike a
scar.

Post-inflammatory pigmentation is discoloration of the skin at the site
of a healed or healing inflamed acne lesion. It occurs more frequently in
darker-skinned people, but occasionally is seen in people with white
skin. Early treatment by a dermatologist may minimize the development of
post-inflammatory pigmentation. Some post-inflammatory pigmentation may
persist for up to 18 months, especially with excessive sun exposure.
Chemical peeling may hasten the disappearance of post -inflammatory
pigmentation.

Causes of Acne Scars
In the simplest terms, scars form at the site of an injury to tissue.
They are the visible reminders of injury 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 discussed later: (1) depressed areas such
as ice-pick scars, and (2) raised thickened tissue such as keloids.

When tissue suffers an injury, the body rushes its repair kit to the
injury site. Among the elements of the repair kit are white blood cells
and an array of inflammatory molecules that have the task of repairing
tissue and fighting infection. However, when their job is done they may
leave a somewhat messy repair site in the form of fibrous scar tissue, 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 susceptible
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, indicating that
some people are more prone to scarring than others. Scarring frequently
results from severe inflammatory nodulocystic acne that occurs deep in
the skin. But, scarring also may arise from more superficial inflamed
lesions. Nodulocystic acne that is most likely to result in scars is seen
in these photos:

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

The life history of scars also is not well understood. Some people bear
their acne scars for a lifetime with 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 psychologically distressing to one person
may be accepted by another person as "not too bad." The person who is
distressed by scars is more likely to seek treatment to moderate or
remove the scars.

Prevention of Acne Scars
As discussed in the previous section on Causes of Acne Scars, the
occurrence of scarring is different in different people. It is difficult
to predict who will scar, how extensive or deep scars will be, and how
long scars will persist. It is also difficult to predict how successfully
scars can be prevented by effective acne treatment.

Nevertheless, the only sure method of preventing or limiting the extent
of scars is to treat acne early in its course, and as long as necessary.
The more that inflammation can be prevented or moderated, the more likel y
it is that scars can be prevented. (Click on Acne Treatments for more
information about treatment of mild, moderate and severe acne). Any
person with acne who has a known tendency to scar should be under the
care of a dermatologist. (Click on Find a Dermatologist to locate a
dermatologist in your geographic area).


Types of Acne Scars
There are two general types of acne scars, defined by tissue response to
inflammation: (1) scars caused by increased tissue formation, and (2)
scars caused by loss of tissue.

Scars Caused by Increased Tissue Formation
The scars caused by increased tissue formation are called keloids or
hypertrophic scars. The word hypertrophy means "enlargement" or
"overgrowth." Both hypertrophic and keloid scars are associated with
excessive amounts of the cell substance collagen. Overproduction of
collagen is a response of skin cells to injury. The excess collagen
becomes piled up in fibrous masses, resulting in a characteristic firm,
smooth, usually irregularly-shaped scar. The photo shows a typical severe
acne keloid:

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

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

Hypertrophic and keloid scars persist for years, but may diminish in size
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 than keloids and hypertrophic scars.
Scars associated with loss of tissue are:

    Ice-pick scars usually occur on the cheek. They are usually small,
with a somewhat jagged edge and steep sides—like wounds from an ice pick.
Ice-pick scars may be shallow or deep, and may be hard or soft to the
touch. Soft scars can be improved by stretching the skin; hard ice-pick
scars cannot be stretched out.

    Depressed fibrotic scars are usually quite large, with sharp edges
and steep sides. The base of these scars is firm to the touch. Ice-pick
scars may evolve into depressed fibrotic scars over time.

    Soft scars, superficial or deep are soft to the touch. They have
gently sloping rolled edges that merge with normal skin. They are usually
small, and either circular or linear in shape.

    Atrophic macules are usually fairly small when they occu r on the
face, but may be a centimeter or larger on the body. They are soft, often
with a slightly wrinkled base, and may be bluish in appearance due to
blood vessels lying just under the scar. Over time, these scars change
from bluish to ivory white in color in white-skinned people, and become
much less obvious.

    Follicular macular atrophy is more likely to occur on the chest or
back of a person with acne. These are small, white, soft lesions, often
barely raised above the surface of the skin—somewhat like whiteheads that
didn’t fully develop. This condition is sometimes also called
"perifollicular elastolysis." The lesions may persist for months to
years.

Treatments for Acne Scars
A number of treatments are available for acne scars through dermatologic
surgery. The type of treatment selected should be the one that is best
for you in terms of your type of skin, the cost, what you want the
treatment to accomplish, and the possibility that some types of treatment
may result in more scarring if you are very susceptible to scar
formation.

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

    * The way you feel about scars. Do acne scars psychologically or
emotionally affect your life? Are you willing to "live with your scars"
and wait for them to fade over time? These are personal decisions only
you can make.

    * The severity of your scars. Is scarring substantially disfiguring,
even by objective assessment?

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

Before committing to treatment of acne 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 dermatologist needs to conduct a full
examination and determine whether treatment can, or should, be
undertaken.

The objective of scar treatment is to give the ski n a more acceptable
physical appearance. Total restoration of the skin, to the way it looked
before you had acne, is often not possible, but scar treatment does
usually improve the appearance of your skin.

The scar treatments that are currently available include:

    Collagen injection. Collagen, a normal substance of the body, is
injected under the skin to "stretch" and "fill out" certain types of
superficial and deep soft scars. Collagen treatment usually does not work
as well for ice-pick scars and keloids. Collagen derived from cows or
other non-human sources cannot be used in people with autoimmune
diseases. Human collagen or fascia is helpful for those allergic to cow-
derived collagen. Cosmetic benefit from collagen injection usually lasts
3 to 6 months. Additional collagen injections to maintain the cosmetic
benefit are done at additional cost.

    Autologous fat transfer. Fat is taken from another site on your own
body and prepared for injection into your skin. The fat is injected
beneath the surface of the skin to elevate depressed scars. This method
of autologous (from your own body) fat transfer is usually used to
correct 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 to be the most effective treatment for
acne scars. Under local anesthetic, a high-speed brush or fraise used to
remove surface skin and alter the contour of scars. Superficial scars may
be removed altogether, and deeper scars may be reduced in depth.
Dermabrasion does not work for all kinds of scars; for example, it may
make ice-pick scars more noticeable if the scars are wider under the skin
than at the surface. In darker-skinned people, dermabrasion may cause
changes in pigmentation that require additional treatment.

    Microdermabrasion. This new technique is a surface form of
dermabrasion. Rather than a high-speed brush, microdermabrasion uses
aluminum oxide crystals passing through a vacuum tube to remove surface
skin. Only the very surface cells of the skin are removed, so no
additional wound is created. Multiple procedures are often required but
scars may not be significantly improved.

    Laser Treatment. Lasers of various wavelength and intensity may be
used to recontour scar tissue and reduce the redness of skin around
healed acne lesions. The type of laser used is determined by the results
that the laser treatment aims to accomplish. Tissue may actually be
removed with more powerful instruments such as the carbon dioxide laser.
In some cases, a single treatment is all that will be necessary to
achieve permanent results. Because the skin absorbs powerful bursts of
energy from the laser, there may be post-treatment redness for several
months.

    Skin Surgery. Some ice-pick scars may be removed by "punch" excision
of each individual scar. In this procedure each scar is excised down 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
technique in which a surgical probe is used to lift the scar tissue away
from unscarred skin, thus elevating a depressed scar.

    Skin grafting may be necessary under certain conditions—for example,
sometimes dermabrasion unroofs massive and extensive tunnels (also called
sinus tracts) caused by inflammatory reaction to sebum and bacteria in
sebaceous follicles. Skin grafting may be needed to close the defect of
the unroofed sinus tracts.

    Treatment of keloids. Surgical removal is seldom if ever used to
treat keloids. A person whose skin has a tendency to form keloids from
acne damage may also form keloids in response to skin surgery. Sometimes
keloids are treated by injecting steroid drugs into the skin around the
keloid. Topical retinoic acid may be applied directly on the keloid. In
some cases the best treatment for keloids in a highly susceptible person
is no treatment at all.

In summary, acne scars are caused by the body’s inflammatory response to
acne lesions. The best way to prevent scars is to treat acne early, and
as long as necessary. If scars form, a number of effective treatments are
available. Dermatologic surgery treatments should be discussed with a
dermatologist.

				
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