Source: Advanced Skin Technology, 05 Jul 2019,  5 min read

Acne scars may develop as a side effect of acne, with it being one of the most common causes of facial scarring. Acne scars can be disfiguring and may lead to social withdrawal, low self-esteem and be physically disabling for some people.  Studies indicate that males tend to suffer form more severe and persistent forms of acne from an inflammatory perspective, hence the degree of scarring in this population tends to be greater.

Acne scars develop as a result of an abnormal healing process occurring within the skin following inflammatory forms of acne.  When the skin undergoes a severe inflammatory reaction with acne lesions, it leads to changes within the section of the skin called the dermis.  The dermis is where collagen is located, and during the severe inflammatory reaction it is destroyed.

Collagen forms a large part of the structural framework within the skin, hence when it is destroyed it does not provide the skin with the architecture it needs to sit smoothly.  In the case of acne scars, the extensive destruction of collagen results in the formation of a pitted scar due to the loss of dermal skin tissue which is not replaced in great enough volumes to fill the pitted scar void.

The degree of acne scarring directly correlates with the severity of the grade of acne experienced and the duration that the condition was present in the patient, with persistent moderate to severe forms producing a greater degree of scarring.  A delay in the treatment of acne lesions when they present can also lead to the development of acne scarring.

Acne scars are described as being atrophic, which is a depressed or pitted form of scar that sits below the normal height of the skins surface.  They may appear in three main forms:

Icepick sharp and depressed scars V-shaped scars that are very narrow at the base and are generally less than 2mm wide at the skins surface

Rolling have gently sloping edges and are up to 4-5mm wide

Boxcar can be shallow or deep scars that are wide based and have a ‘punched out’ appearance

Acne scars may then be further classified into grades based on their severity.

GRADE OF POST ACNE SCARRING

PHYSCIAL APPEARANCE

Grade 1

      Scars that appear flat on the skins surface and may be coloured brown, red or white

      Redness may or may not be present

      Actual scar tissue may not be present, rather the client perceives the macular markings to be a form of scar

Grade 2

      Mildly pitted scarring that is not obvious at social distances of >50cm

      Easily covered by make-up or facial/beard hair growth

      Mild rolling atrophic type scars

      Mild papular scars

Grade 3

      Moderate acne scarring that is obvious at social distances of >50cm

      Not easily covered by makeup or facial/beard hair

      Able to be flattened by manual stretching

      Rolling scars, shallow boxcar scars

      Mild to moderate hypertrophic and papular scars

Grade 4

      Severe pitted scarring that is obvious at social distances of greater than 50cm

      Not covered easily by makeup or facial/beard hair

      Not flattened by manual stretching of the skin

      Deep pitted scars: ice pick and box car, bridges, tunnels

      Hypertrophic scars and keloid scars may be present (scars that sit above the surface of the skin)

Adapted From: Goodman, G.J., & Baron, J.A. (2006a). Postacne scarring: a qualitative global scarring grading system. Dermatologic Surgery, 32(12), 1458-1466. doi: 10.1111/j.1524-4725.2006.32354.x

As patients age, the physical appearance of the acne scars tend do decline due to internal and external ageing influences altering dermal structure and function, hence the appearance may become worse with age. Due to this reason, treating acne scars from may earlier age may yield better results long term.

An improvement in acne scars can lead to a positive improvement in self-esteem11.  The most effective treatment of acne scars occurs during the active acne phase, with early intervention and treatment of the condition reducing the development of the scars.  Treatment of acne scarring can be challenging with success depending on the type and grade of scarring present. Higher grades of scarring with a high density of icepick scarring tends to be the most difficult to treat, however grades 1-3 with a high density of rolling and boxcar scar types may achieve a more desirable outcome, especially if treated within 1 year of formation.

References:

Asif, M., Kanodia, S., & Singh, K. (2016). Combined autologous platelet-rich plasma with microneedling versus microneedling with distilled water in the treatment of atrophic acne scars: a concurrent split-face study. Journal of Cosmetic Dermatology, 15(4), 434-443. doi: 10.1111/jocd.12207

Chawla, S. (2014). Split face comparative study of microneedling with PRP versus microneedling with vitamin C in treating atrophic post acne scars. Journal of Cutaneous and Aesthetic Surgery, 7(4), 209-212. doi: 10.4103/0974-2077.150742

Connolly, D., Vu, H. L., Mariwalla, K., & Saedi, N. (2017). Acne scarring: pathogenesis, evaluation and treatment options.  Journal of Clinical and Aesthetic Dermatology, 10(9), 12-23.

Dogra, S., Yadav, S., & Sarangal, R. (2014). Microneedling for acne scars in Asian skin types: an effective low cost treatment. Journal of Cosmetic Dermatology, 13(3), 180-187.

El-Domyati, M., Barakat, M., Awad, S., Medhat, W., El-Fakahany, H., & Farag, H. (2015a). Microneedling therapy for atrophic acne scars an objective evaluation. Journal of Clinical and Aesthetic Dermatology, 8(7), 36-42.

Ibrahim, Z.A., El-Ashmawy, A.A., & Shora, O.A. (2017). Therapeutic effect of microneedling and autologous platelet-rich plasma in the treatment of atrophic scars: a randomised study. Journal of Cosmetic Dermatology, 16(3), 388-399. doi: 10.1111/jocd.12356

Goodman, G. J. (2001). Post-acne scarring: a short review of its pathophysiology. Australasian Journal of Dermatology, 42(2), 84-90.

Goodman, G.J., & Baron, J.A. (2006). Postacne scarring: a qualitative global scarring grading system. Dermatologic Surgery, 32(12), 1458-1466. doi: 10.1111/j.1524-4725.2006.32354.x

Goodman, G. J., Baron, J. A. (2007). The management of postacne scarring. Dermatologic Surgery, 33(10), 1175-1188. doi: 10.1111/j.1524-4725.2007.33252.x

Majid, I. (2009). Microneedling therapy in atrophic facial scars: an objective assessment. Journal of Cutaneous and Aesthetic Surgery, 2(1), 26-30. doi: 10.4103/0974-2077.53096

Rana, S., Mendiratta, V., & Chander, R. (2017). Efficacy of microneedling with 70% glycolic acid peel vs microneedling alone in treatment of atrophic acne scars – a randomised controlled trial. Journal of Cosmetic Dermatology, 16(4), 454-459.

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