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Battle Scars

Acne is quite possibly one of the most emotional skincare journeys a person can take. There are days when you wish you could be invisible, days when you feel the burn of everyone's eyes on that new crop of pimples that showed up overnight, and days when you regret picking because now your pimples are bigger and angrier than they were before you touched them. There are also those magical days when you wake up and all of the stars have aligned and your skin is clear and bright and you feel like you could take on the world. It's a rollercoaster of emotions and I have taken the ride with so many of you; coaching you through the worst of it. We talk so much about the acne itself that it seems like we forget the scars that are often left behind and the emotional impact they have too. Acne scars are like insult to injury...it doesn't seem fair.


Scars come in different shapes and sizes, and some are pigment without texture while others are texture with no pigment. For some, its both. No matter what type of scars you have, they are unwanted reminders of the trauma acne caused your younger self. So how do you get rid of scars? The short answer is that you may never fully get rid of your acne scars, but you can certainly improve their appearance and texture with the right help.


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Textured scars often appear in the fleshy part of the cheeks and just below the jawline. They can be shallow or deep, but they all run deeper than they appear. I usually describe textured scars as having scar tissue beneath the surface of the skin that acts as a tether. It's important to understand that because if you don't address the scar tissue beneath the surface, you will not get very far in correcting texture. Most acne sufferers assume that scars appear because of picking, but in my experience that is only part of the problem. When acne bacteria is present in the skin, your body is triggered to fight the offending bacteria by flooding the area with white blood cells. When the battle ensues, some healthy cells are sacrificed in the process and the end result is a scar. This is not an okay to pick at your face! Picking pus filled lesions spreads bacteria and can make scars larger or cause additional scars to form. There are safe ways to extract or drain some pustules without damaging healthy tissue in the process, and that should be done by an experienced and licensed aesthetician.


If pigment is your main issue, count yourself lucky because treatment is fairly easy, and even with no treatment at all, your marks will eventually fade away. This type of pigment is called Post-Inflammatory Hyperpigmentation and forms as a result of increased inflammation and trauma to the skin. Just like any wound can leave pigmentation behind as an inflammatory response, so too can acne which is defined as a chronic inflammatory condition of the skin.

Because treating Pigmented scars is easier, let's talk about that first. Treating post-inflammatory hyperpigmentation or PIH usually involves some form of photo therapy such as IPL (Intense Pulsed Light) or BBL (Broad Band Light). These pulsed light therapies are applied to skin using wavelight-specific filters. Depending on the filter, the light can destroy either reds or browns in the skin, and some devices will target both. If you have other skin disorders such as melasma that are stimulated to worsen with heat, topical products containing prescription strength lighteners like hydroquinone or cysteamine hydrochloride may be more appropriate. In stubborn cases we use microneedling to drive the lightener deeper into the skin and add peel ingredients to slough off superficial pigment. There is little to no downtime with photo therapies, but avoiding unprotected sun exposure is extremely important in the weeks following treatment. When using lightening products it, again, is advisable to avoid unprotected sun exposure but will not require you to plan for downtime. In the case of needling in lighteners and peels, you should plan to be red and maybe slightly swollen the day of, and you will begin peeling 2-3 days after treatment. Proper post-care instructions and products should be given for use during your peel process.


On to textured scars! There are atrophic scars which just means that they form as a depressed area of the skin such as boxcar scars which form in box-like shapes with defined edges, much like a chickenpox scar. Icepick scars are also a form of atrophic scar. Just like the name implies they are very deep hole-like depressions that look like they could have been made by an icepick. Rolling scars are rope-like with undefined edges and make skin appear wavy in texture. Hypertrophic scars conversely build up above the surface of skin and those who are genetically predisposed may develop keloid scars which are hypertrophic scars that continue to grow beyond the space of the original scar. Treating any of these textured scars can be tricky and involve multiple therapy types and multiple visits. Atrophic scar treatment involves a combination of whittling down the surface tissue while breaking up scar tissue beneath the skin. To work from the surface down, we have options like chemical peeling, microdermabrasion, and ablative laser. In some cases, Dermal fillers are used to redensify depressed areas. As you might imagine, working on texture will almost always come with some contraindicated health issues or medications, downtime and detailed post-care instructions, so I recommend having a full consultation prior to scheduling any treatment.


To work on the tethered scar tissue below, we use deeper ablative fractional laser, Microneedling or RF microneedling (microneedling accompanied by radio frequency), and subcision which is breaking up scar tissue manually with a syringe (you are fully numbed for all of these therapies). In particularly difficult cases, it may be necessary to have the scar removed by a physician or surgeon via punch excision and then stitched together, or even grafting skin from another part of the body after punch excision. For Ice pick scars in specific, the use of trichloroacetic acid at high percentages applied directly into the divot causes the chemical reconstruction of scars. This procedure is known as TCA Cross and should only be performed by an experienced licensed aesthetician.


Hypertrophic scars can be tricky to treat, but there are certainly options. Steroid injections can be used to slowly soften and reduce scar tissue. In less severe cases prescription steroid can be applied topically after needling or fractional laser rather than injected. Fractional laser on its own can sometimes do the trick too. In more severe cases surgical removal of the scar tissue is advisable.


Newer scars are almost always easier to treat, but even old scars can be improved with time, appropriate treatment, and persistence. You do not have to live with the unsightly souvenirs of your acne. If your acne is controlled, you are ready to begin the journey of erasing the evidence that it ever happened in the first place. ALways look for a practitioner that has experience with scar revision and a practice that offers multiple treatment modalities because you will likely need several types of treatment to achieve the desired end result.


If you are local, I offer complimentary consultations by appointment. Appointments can be scheduled by calling 480.947.6788. I am also available for virtual consultations which can be scheduled via email at erin.cooper@bealsmd.com.


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