Acne Scarring: Finding the Best Treatment Based on Scar Type

For most people, acne is a condition with psychological and social implications, but is ultimately confined to the teenage years; however, some unfortunate acne sufferers have an extreme immune response to acne, which leads to excessive collagen loss and scarring.

Acne scarring is a unique type of scarring, so traditional cosmetic surgery won’t necessarily be effective. In fact, based on reading the most current research and thousands of forum posts by real acne scar sufferers, my top two recommendations are

Don’t just go to the first dermatologist you find online. Find a dermatologic surgeon or a cosmetic surgeon who specializes in acne scars. It will require some time and research.

Get educated on acne scarring and its treatment. I’ve heard stories of doctors who specialize in acne scarring but aren’t familiar with certain treatment possibilities. The treatment of ance scars is a relatively young, dynamic science. For example, the two main classification systems for acne scarring were just created in 2001 and 2007.

Treatment is based on the scar type, so the first thing to learn is the type of scars you have. In the rest of this article, I’ll discuss the classification system devised in 2001 and published in the Journal of the American Academy of Dermatology.

You’ve probably heard these terms before, but I believe I can add some depth and clarity to the classification system. The above-mentioned article first proposed that scars be classified as rolling, boxcar, or ice-pick and recommended standard treatments for each.

Rolling scars are wavy, poorly defined scars that are usually wider than 5 millimeters.

Boxcar scars are round or oval depressions with well defined edges and flat bases; they can be either shallow or deep.

Icepick are less than 2 millimeters wide and extend deep under the skin’s surface, usually tapering to a point at the base.

Treatment Options

Rolling scars: The most important feature of rolling scars is tethering, which refers to the presence of fibrous strings that connect the scar to deeper tissue. A simple test for tethering is stretching the rolling scars. If they flatten, then they’re probably not tethered; if they won’t flatten, then they’re probably tethered. Of course, your dermatologist will need to make the final determination.

If the rolling scars are tethered, then treatment won’t be effective until the tethers are cut in a procedure called subcision. In many cases, subcision is the only procedure necessary for rolling scars; however, laser resurfacing and filler substances are sometimes beneficial.

Boxcar scars: Swallow boxcar scars can be treated with a couple of rounds of laser resurfacing.

Deep, smaller, boxcar scars can be treated with a punch excision, in which a small, cookie-cutter like tool is pushed into the skin to excise the entire scar, creating an incision that can be sutured to heal without a scar.

Deep, large boxcar scars can be treated with punch elevation or with an elliptical excision. Punch elevation means the bottom of the scar is punched and allowed to float to the surface where its glued or sutured in place, so basically the bottom of the scar is lifted to be one the new skin surface. An elliptical excision is a football shaped excision.

Icepick scars are treated using punch excision or a method called TCA Cross, which involved using high concentrations of trichloroacetic acid on just the bottom of the scar causing collagen damage and resulting in new collagen growth. As the new collagen grows, it lifts the bottom of the scar. TCA Cross isn’t recommended in the article mentioned above because it wasn’t a published method until 2002.

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