Types of Acne Scars
Acne scars can be difficult to treat—and it takes time. Scars can be discolored, and may be raised, flat, or pitted. Some scars fade or disappear, but others may be permanent.
The best way to prevent acne from scarring is to treat it early and not pick at it. But if you do end up with acne scars, your dermatologist can recommend various types of treatments based on the type of scars you have.
It’s very important to wear sunscreen when being treated for acne scars—it helps the skin heal and prevent more discoloration.
A common misconception is that scars won't improve. Many people don’t come in for a visit because they were told by family or friends that nothing can be done to treat scars. —Dr. Lauren Levy
What causes acne scarring?
When there is a pimple or cyst on the skin, the bump is filled with bacteria, oil (sebum), and dead skin cells. White blood cells try to fight the infection, causing pus and inflammation. Damage to the skin layers can lead to scarring.
Acne scars form for many different reasons.
- The inflammation can trigger a release of certain substances that break down collagen (the connective tissue in skin) and other skin tissue, causing a pitted (atrophic) scar.
- Raised scars, also called hypertrophic scars or keloids, develop when your body produces too much collagen during the healing process.
- Flat scars include post-inflammatory erythema (PIE) and post-inflammatory hyperpigmentation (PIH). They are caused by dilated blood vessels, which make your skin red, and melanin (the pigment that makes skin darker). Exposure to sunlight can make them darker, so it’s really important to wear sunscreen.
Can acne scars be removed?
There are treatments available for all types of acne scars. Your dermatologist will recommend the best option based on the type of scar you have.
Flat acne scars, or acne marks, often fade on their own over time. You can speed up the process with topical medications (such as retinoids) or a scar gel, like Pracasil, to help rebuild collagen. Your dermatologist may also do chemical peels or laser treatments.
Treatment of acne scars is not just one and done. It often requires several different treatments and may take 4 to 6 months. Several sessions of laser, microneedling, or peels may be needed. —Dr. Levy
Raised and pitted acne scars are permanent and only go away with treatment. Some of the treatments for flat scars are also used to treat raised and pitted scars. For the best results, you may need additional types of in-office procedures, such as steroid injections or even surgery.
Acne marks vs. acne scars
Acne marks are flat discolored spots caused by PIH or PIE that usually fade on their own over time. Acne scars are those that are raised or pitted. These are permanent and will only go away with treatment.
Types of acne scars
Post-inflammatory erythema (PIE) is a red circle or mark that remains after a pimple has gone away. These marks develop when your blood vessels dilate (widen) from the inflammation.
PIE usually goes away on its own without any treatment, typically in about 3 to 6 weeks. But there are several treatments that can fade it faster:
- Pulse dye laser treatments target the affected blood vessels to reduce redness.
- Topical medications such as vitamin C, niacinamide, or azelaic acid can help reduce inflammation and fade the mark. They are available by both over-the-counter or prescription.
- Wearing sunscreen is very important if you have PIE, as ultraviolet light can make the redness worse.
Post-inflammatory hyperpigmentation, or PIH, is a flat, brown mark that remains after a pimple has gone away. The mark occurs when inflammation triggers the release of melanin, a natural pigment found in your skin.
Just like PIE, PIH will fade over time. Several treatments may help them go away faster:
- Prescription topical treatments to lighten the marks such as retinoids, vitamin C, hydroquinone, glycolic acid, or azelaic acid.
- In-office procedures such as laser treatments and chemical peels with salicylic or glycolic acid may be recommended in some cases.
Not picking at acne lesions can help reduce the chance of causing a permanent scar. You may still get a dark hyperpigmented mark (PIH) even if you do not pick, but this will fade with time. —Dr. Levy
Raised acne scars
Raised (hypertrophic) scars are hard, pink or brown bumps that form over the area of the healed pimple. When the scar grows beyond the location of the pimple, it is called a keloid.
Raised scars develop when the skin produces too much collagen during the healing process. They are often on the chest, back, and shoulders. Some people are more likely to develop them due to genetics. Raised scars or keloids are more common in Black people.
These scars don’t go away on their own, but there are several very effective treatments that help flatten them:
- Steroid injections into the scar
- Wearing a silicone patch over the scar
- Laser therapy
- Topical prescription medications, including 5-fluorouracil and imiquimod
Pitted acne scars
Pitted (atrophic) acne scars develop when inflammation causes a breakdown of tissue and collagen, creating small pits or indents. There are three types of atrophic acne scars: ice pick, boxcar, and rolling.
Ice pick scars
These are the smallest, narrowest pitted scars. Ice pick scars are widest at the top layer of your skin and narrow as they go deeper into your skin. They usually appear in areas where your skin is thinner, like your forehead and upper cheeks.
Ice pick scars are one of the more difficult acne scars to treat because they can be quite deep. But there are several in-office procedures that can help build collagen and improve their appearance. These include:
- TCA CROSS (chemical reconstruction of skin scars). A strong concentration of trichloroacetic acid (TCA) is deposited into the scar, causing new collagen to grow and reduce the depth of the scar. Multiple treatments may be needed.
- Chemical peels. Deeper chemical peels can trigger new collagen formation to help fill in the scar. This treatment is best for shallow ice pick scars.
- Punch excision (also called a punch biopsy). In this procedure, the dermatologist uses a circular instrument that looks like a tiny cookie cutter to cut out the scar, then stitches the hole to create a new flat scar.
- Punch elevation. In this procedure, the punch biopsy instrument is used to collect a small amount of tissue from the deepest part of the scar, which is then used to raise the base of the scar so it’s level with the rest of your skin.
- Punch graft. Your dermatologist removes the scar with the punch biopsy instrument, then sews a piece of skin of the same size (taken from your neck or behind the ear, for example) over the pit to make the area appear flat.
- Dermabrasion. Your dermatologist uses a device to remove the top layer of your skin, which makes the scar more level. It may require 2 to 6 treatments.
- Microneedling. A device with several small needles in it is used to prick shallow holes in the skin, which causes new collagen to grow, filling in the scar. Microneedling may require 2 to 6 treatments.
- Platelet-rich plasma (PRP) treatments. In this procedure, your dermatologist uses plasma from your own blood to treat your scars. Platelet-rich plasma contains a lot of growth factors that, when injected into the skin, can trigger new collagen production.
- Laser treatments. Depending on the depth of your scarring, different lasers can be used to treat it. Ablative lasers remove the outer layer of the skin and heat up the deeper layers to promote new tissue growth, making skin smoother and tighter. Nonablative lasers simply heat up the deeper layers to promote new tissue growth. Several treatments may be required.
These round or oval scars are wider than ice pick scars and have sharp, well-defined edges. Boxcar scars occur mostly on your lower cheeks and jawline, where your skin is thicker.
Your dermatologist may treat these scars with a procedure called subcision. A needle is used to separate the top layer of skin from the scar tissue below, which causes new collagen to form and push the scar up so it’s level with the rest of your skin.
Chemical peels, microneedling, dermabrasion, and laser therapy can also be used to treat boxcar scars. Or your dermatologist may suggest injecting a filler, such as hyaluronic acid or polymethyl methacrylate, to fill in the scar.
Like boxcar scars, rolling scars are wide and commonly appear on your lower cheeks and jawline. But have sloping edges, which makes the texture of your skin appear uneven.
The same treatments that treat boxcar scars can also be used to treat rolling scars. These include chemical peels, microneedling, dermabrasion, laser therapy, and filler injections.
Dr. Levy is a board certified dermatologist specializing in medical derm with expertise in acne, rosacea, skin cancer, psoriasis, and skin manifestations of rheumatologic disease. Her undergraduate education was completed at the University of Pennsylvania where she graduated summa cum laude and was inducted into the Phi Beta Kappa honors society. She graduated with a distinction in research from the Icahn School of Medicine at Mount Sinai and was inducted into the Alpha Omega Alpha Honor Medical Society. During medical school, she received a one year Doris Duke Clinical Research Fellowship Award. During that time, she investigated imaging techniques for early diagnosis of head and neck cancer. Her training continued with a medical internship at Memorial Sloane Kettering Cancer Center followed by dermatology residency in the Department of Dermatology at Yale University, one of the most prestigious dermatology departments in the country. Following her residency, she worked as a clinical Instructor at Yale School of Medicine. She currently sees patients in New York City and Westport Connecticut and is a Clinical Instructor in the Department of Dermatology at Mount Sinai School of Medicine. She is a Fellow of the American Academy of Dermatology.
Dr. Levy is well published in the field of dermatology having written articles on atopic dermatitis, psoriasis, acne, and skin manifestations of systemic disease. She is an avid lecturer and has been invited to lecture at state wide dermatology meetings. She is the editor of a board review Dermatology textbook.