Why do people scar?

Scarring tends to be genetically linked to an individual's unique inflammation response. Those people with a "secondary inflammatory response" to trauma tend to scar, while those with a "single inflammatory response" to trauma tend not to scar. This explains why some people will scar easily and others maintain a smooth complexion even through moderately severe battles with acne.

Prevention

When it comes to scarring, preventing any future scarring is the best first course of action. First, agressively treat acne, thus preventing further scarring. There are two ideal options when it comes to treating acne. The Regimen should clear up most cases of acne. In very severe cases, doctors will often prescribe Accutane to their patients. Also, it is vitally important that you do not pick at your skin. Many dermatologists contend that scars are really more from picking than from the acne itself. This is not to say that the occasional popping of a zit will lead to scarring. Occasional popping can often be performed quickly and safely. It is the picking afterward that often leads to the worst scarring. Try to leave your skin relatively untouched.

What to expect

Once acne is under control, surgical scar revision is an option. However, scarring is a permanent condition, so scar treatments may improve the condition, but rarely remove it. The aim should be improvement, not cure. Depending on the dermatologist or plastic surgeon and his or her level of expertise as well as the topography of a person's skin, surgical results vary widely. The scientific community agrees that topical treatments are largely ineffectual.

Acceptance

Another “treatment” for acne scarring is simply accepting oneself. None of us are perfect, and many people suffer with acne scarring and live normal and happy lives. Very often, acne scarring is seen as more severe by the person with the scarring than by others. Practicing self-acceptance goes a long way.

Ice pick Common

Ice pick scars are deep pits that are usually less than 2mm across. They extend into the skin, giving the skin an appearance of having been punctured by an ice pick.

Boxcar Common

Boxcar scars are angular scars with sharp vertical edges, and resemble the scars left by chicken pox. They may be shallow or deep, and are most often found on the cheeks and temples.

Rolling Common

Rolling scars are caused by damage under the surface of the skin. They give the skin a wave-like appearance. They tend to be wide and shallow.


Hypertropic Less common

Hypertrophic scars are raised and lumpy. They tend to appear on the back and chest, but can also appear on the neck and face. Often the result of severe acne (cysts or nodules), they generally stay within the boundary of the original wound, and may decrease in size over time.

Hyperpigmentation Not scars

Hyperpigmentation refers to the red or dark marks that are left behind after a pimple heals. These marks, also called macules, are not scars, but are often confused with scars because they can last for months or even years before they fade. For more information on hyperpigmentation and treatment options, click here.

Before you embark upon acne scar treatment:

  1. Be free of active acne. Skin must be free of active acne. If you have active acne, read here for a strict pre-procedure regimen that must be followed for at least three months prior to scar revision.
  2. Educate yourself. Arm yourself with information from this page before meeting with your chosen doctor.
  3. Find the right doctor. Find a doctor you trust.

About

Ablative laser resurfacing involves the use of a laser to remove skin so new skin can form in its place. Theoretically, laser resurfacing is promising because the penetration depth into the skin is more easily controlled with a laser than with other methods. The procedure involves passing the laser over the treatment area 1-3 times and can take just a few minutes for small areas or an hour or more for large areas. Local anesthesia is used.

Performing ablative resurfacing with the CO2 (carbon dioxide) laser is slightly more powerful than with the Er:YAG and thus tends to produce somewhat better results, but also comes with more severe side effects, and a longer recovery time.

Cost
  • $3000-$6000 per treatment
  • May be repeated after 6 months
Side effects
  • Crusting, oozing
  • Hyperpigmentation AKA darkening of skin
  • Hypopigmentation AKA lightening of skin (less common than hyperpigmentation)
  • Prolonged redness
  • Eczema
  • Milia
  • Acne
  • Cysts
  • Infection
  • Dilated blood vessels
  • Hypertrophic scarring
Recovery

Skin is covered with a dressing for 3 days

Healing takes 10-21 days

Skin will be pink for 1-3+ months

Read Reviews   
2.6/5 - 164 reviews
About

Ablative laser resurfacing involves the use of a laser to remove skin so new skin can form in its place. Theoretically, laser resurfacing is promising because the penetration depth into the skin is more easily controlled with a laser than with other methods. The procedure involves passing the laser over the treatment area 1-3 times and can take just a few minutes for small areas or an hour or more for large areas. Local anesthesia is used.

The Er:YAG laser or Erbium (YAG) as it is sometimes called was designed to have more mild side effects than the CO2 laser. More research is neeeded comparing the Er:YAG to the CO2 or the fractional laser.

Cost
  • $3000-$6000 per treatment
  • May be repeated after 6 months
Side effects

Er:YAG laser resurfacing was developed to have more mild side effects than CO2 lase resurfacing; it has similar side effects but they are less severe.

  • Oozing
  • Swelling
  • Redness
  • Hyperpigmentation AKA skin darkening 3-4 weeks after procedure (resolves itself in a few months)
  • May be less likely to cause hypopigmentation AKA skin lightening than CO2 laser
Recovery

After treatment you will experience redness and swelling. An ointment is normally applied to the skin during healing. Your doctor may or may not apply a bandage to your skin. If a bandage is applied, it will probably stay on for a week or so, and be changed periodically.

Redness from laser resurfacing can last several weeks. Your skin may maintain a pinkish coloration for months afterward.

Read Reviews   
2.6/5 - 164 reviews
About

In use since the late 1990s, fractional lasers are sometimes called “the laser equivalent to skin needling.” These lasers treat only a “fraction” of the skin in localized tiny spots.

Milder than CO2 and Er:YAG lasers; results are less impressive but side effects are less severe.

Cost
  • About $1000 per procedure
  • Generally 4-5 treatments are needed
Side effects
  • Scaling and crusting
  • Swelling
  • Post-inflammatory hyperpigmentation AKA temporary darkening of skin
  • Can cause keloid (raised) scarring on neck. Avoid neck completely.
Recovery

2-5 days of swelling and pinkness

Bronzed appearance and flakiness for 3-14 days

Read Reviews  
2.6/5 - 164 reviews
About

High-speed (30,000 to 60,000 rpm) diamond or wire wheel brush or sandpaper removes skin surface, providing removal of superficial scars and reduction of deeper scars.

Operator dependent!: be certain to find an experienced, qualified professional.

Often used 6-8 weeks after surgical scar removal procedures to smooth out the surface texture.

Cost
  • $1500 per treatment
  • Repeated treatment sometimes necessary
Side effects
  • Permanent or prolonged hyperpigmentation AKA darkening of skin or hypopigmentation AKA lightening of skin, especially in darker skinned individuals
  • Treatment demarcation lines apparent on skin
  • Infection
  • Raised or keloids scarring
  • Sun sensitivity
  • Dilated blood vessels
  • Eczema
  • Milia
  • Pain
Recovery

Vaseline and dressing applied for 2-4 days

A crust forms on the skin which flakes off within 10-14 days after treatment

Some redness and “windburnt” appearance can last up to 6-9 months

Read Reviews   
2/5 - 42 reviews
About

A needle is used to inject filler material into the atrophic scar. There is a wide range of materials used, including bovine collagen, fat, silicone, hyaluronic acid, poly-l-lactic acid, among others; most are not permanent. Researchers are still searching for the ideal material.

When fat is used, it is taken from elsewhere on the body (thighs, abs, buttocks). 50% of fat will be reabsorbed after 1 year. Some practitioners are also starting to use autologous fibroblasts (cultured connective tissue cells) with some success.

Silicone and Gore-Tex® are permanent. However, silicone has significant potential side effects, and Gore-Tex is not FDA approved.

Cost
  • $500-$1500
Side effects
  • Pain
  • Pigment changes
  • Bruising
  • Infection
  • Allergy
  • Hypertrophic scarring or keloids
  • Migration of product
  • Technical error

In addition, silicone filler may cause:

  • Hypersensitivity
  • Granuloma formation
  • Ulceration
  • Bumpiness
Recovery

Patient asked to limit facial motion for 24 hours

Read Reviews   
0/5 - reviews
About

The scar is cut away and unbound from the tissue below, allowing blood to fill underneath and clot. This blood clot can help form connective tissue under the scar, thus leveling it with the surface.

Suction may be performed in the days and weeks afterward to reintroduce clotting and to acheive better results.

Subcision is often combined with resurfacing (dermabrasion or laser).

Cost
  • $50-$750
  • Varies greatly depending on how the doctor charges, whether it be per scar or per session including multiple scars
  • Multiple attempts (1-3) are often required
Side effects
  • Bruising
  • Hypertrophic (raised) scarring
  • Scar recurrence
  • Discoloration
Recovery

Bruising and swelling are usually present for up to two weeks

Read Reviews  
3.5/5 - 24 reviews
About

Punch Excision: surgical removal of scar followed by suture.

Punch Elevation: center of scar (usually boxcar) is cut loose from the bottom, but is not discarded. It is allowed to float up to the level of the surrounding skin.

Punch Grafting: scar is removed and skin from elsewhere on the body, often from behind the ear, is attached in its place. This tends to work best for deep scars.

Cost
  • $250-$300 per scar
Side effects
  • Bruising
  • Scabbing
  • Keloid formation is possible
  • Punch Excision specific side effects: can leave new but smaller/less noticeable scar, which may require skin resurfacing
  • Punch Elevation specific side effects: sometimes the area that has been elevated may end up higher than surrounding skin
  • Grafting specific side effects: sometimes the area that has been grafted may end up higher than surrounding skin, the graft may not “take," and/or the grafted skin may not match surround skin perfectly
Recovery

Sutures removed after 1 week

6-8 weeks for complete healing

Read Reviews   
2.7/5 - 9 reviews
About

A solution containing alpha hydroxy acid (AHA) or beta hydroxy acid (BHA) is applied with gauze or cotton balls, then neutralized or washed off. The solution exfoliates the skin, removing the surface layer.

Light chemical peels aim to soften the appearance of minor surface imperfections, and are not adequate for most forms of acne scarring.

Cost
  • $50-$150 per session
  • Multiple sessions required
Side effects
  • Redness
  • Itching
  • Peeling
  • Increased sensitivity
  • Flaking
  • A frost will appear on skin that has been treated (temporary)
  • Hyperpigmentation AKA darkening of the skin (rare)
Recovery

Skin is extremely sensitive to sunlight after a peel. Sunblock must be used. Some peeling may occur for a few days, after which the skin may be slightly pink for a few days.

Read Reviews  
3.2/5 - 160 reviews
About

1-2 coats of 10%-40% TCA (tricolor acetic acid) is applied to skin and left on 30 seconds to 10 minutes, removing the top layers of skin. 60%-100% TCA is sometimes applied directly to scars.

Jessner's solution (glycol acid, salicylic acid) is another type of medium peel.

Medium depth chemical peels are for slight imperfections and are unlikely to noticeably improve acne scarring.

Because of the strength of the acids used, medium peels must be performed by a qualified professional such as a dermatologist or esthetician.

Cost
  • $150-$500 per treatment
  • Multiple sessions required
Side effects
  • Redness
  • Irritation
  • Photosensitivity AKA increased susceptibility to sunburn
  • Tight feeling
  • Flaking and peeling (1-10 days after)
  • Hyperpigmentation AKA darkening of skin sometimes occurs in people with darker skin tones; hydroquinone, a skin lightening agent, and avoiding sunlight can help
Recovery

For about 7 days the skin will be pink, then dark, and then peel

Must avoid sunlight for several months after

Use sunscreen

Read Reviews  
3.2/5 - 160 reviews
About

A plastic surgeon or dermatologist applies an extremely acidic solution (phenol or TCA) to the skin, thus removing surface layers as well as deeper layers of skin, allowing the skin to grow anew. Deep peels are serious medical procedures, requiring full cardiopulmonary monitoring and intravenous hydration; phenol in particular can be toxic to the kidneys.

Some doctors use general anesthesia or heavy sedation due to the severe pain these peels can inflict.

Cost
  • $2500-$6000 for full face
  • Only one procedure required
Side effects
  • Skin can permanently lose its ability to tan
  • Hypopigmentation AKA lightening of the skin can occur and can be permanent especially in darker skinned people. Deep chemical peels are not a good option for most darker skinned people.
  • Acne, milia, inflammation, pigment alteration, infection, skin atrophy, scarring, swelling
Recovery

A crust forms several days after the procedure. Within two weeks the crust will flake off and patients can normally leave the house. For several months the skin will appear pink. Sunlight must be avoided after the procedure, and sunblock should be worn long term.

Read Reviews  
3.2/5 - 160 reviews
About

A 30-gauge needle, tattoo gun with no pigment, or needle-studded roller is used to puncture the skin at a controlled depth, inducing trauma which heals with collagen remodeling.

Cost
  • $150-$500 per session
  • Results seen with 1-2 sessions. However, results may take 8-12 months to fully appear, since the skin’s collagen remodeling process happens slowly.
Side effects
  • Brief bleeding and oozing immediately after treatment
  • Redness
  • Swelling
  • Fluid retention under the skin (temporary)
Recovery

Redness and swelling for 2-3 days

No damage is done to the epidermis, so the recovery period is brief and mild

Read Reviews  
3.3/5 - 14 reviews
About

Steroids are injected into the raised scar. The steroids help interrupt the inflammatory response and the scar is reduced. Results are best when administered early.

Cost
  • $50-$75 per injection
  • Repeated injections (one or more months apart) are often needed
Side effects
  • Atrophy: The area can become temporarily depressed
  • Bruising
  • Dilated blood vessels
  • Tissue death
  • Allergy
  • Hypopigmentation AKA lightening of skin (especially in darker skin)
  • Hyperpigmentation AKA darkening of skin
Recovery

No recovery period necessary

Any change is apparent by 6 weeks after that injection

Read Reviews  
5/5 - 1 reviews
About

Fluorouracil (a cancer drug) or bleomycin (an antibiotic) are injected into the raised or keloid scar, in the hopes of improving the scar's appearance.

These medications are often injected in conjunction with low-strength steroids to improve results.

Cost
  • Around $100-$150 per scar
  • 3-5 injections may be required
Side effects
  • Pain
  • Hyperpigmentation AKA darkening of skin
Recovery

None

Read Reviews  
0/5 - 0 reviews
About

Very cold liquid nitrogen is applied to the scar with a cotton ball or sprayer. Time of application can range from 10 seconds to 2 minutes. Sometimes this is combined with steroid injections for better results.

The goal of cryosurgery is to freeze the scar, which damages the scar/skin tissue. The tissue dies and is sloughed off, flattening the formerly raised area.

Cost
  • $75-$150 per scar, depending on how many are treated
  • 2-10 sessions are usually needed
Side effects
  • Hypopigmentation AKA lightening of the skin (can be permanent); freezing, especially for longer periods of time, can destroy melanocytes (pigment cells)
  • Some pain
  • Blistering: Can take several weeks to heal
  • Skin atrophy
  • Swelling
  • Hyperpigmentation AKA skin darkening
  • Rarely, bleeding or fainting
Recovery

Blistering takes about 3 weeks to heal

Read Reviews  
0/5 - 0 reviews
About

Microdermabrasion is often confused with Dermabrasion, but is very different. Microdermabrasion is a superficial treatment, often at a spa or esthetician's office, which produces no results for acne scarring. It is only aimed at improving skin "texture" and "glow."

During the procedure, a handheld vacuum pump propels very finely ground crystals at the skin at very high speed and then collects them. The friction detaches some of the very outermost skin cells. Microdermabrasion only affects as much skin as a light chemical peel.

Cost
  • $50-$250
  • 5-15 treatments
Side effects
  • Redness
  • Raised, uneven skin patches
  • Stinging/burning
  • Increased skin sensitivity to sunlight
Recovery

Some pinkness for 1-2 days

Read Reviews  
3.5/5 - 86 reviews
About

Topical scar treatments are largely ineffective, and usually achieve little noticeable change even in shallow scars. They include:

Prescription retinoic acid (Retin-A®): patient applies cream, gel, or liquid to scar twice daily. This can provide some minor improvement.

Over-the-counter onion extract (Mederma®): User applies 3 times daily.

Over-the-counter Scarguard®: This is a combination of silicone and cortisone. Buyer brushes liquid onto scars twice a day.

Over-the-counter silicone dressing: Buyer applies silicone gel sheets to scar. Sometimes pressure is also applied.

Cost
  • $15-$60 per product
Side effects
  • Retinoic acid (Retin-A): redness, peeling, stinging
  • Onion extract (Mederma): itching - sometimes severe, drying
  • Silicone/cortisone dressings: itching, redness, or infection
Recovery

N/A

Read Reviews  
3.6/5 - 1477 reviews

Note

Multiple treatments are very often combined for optimal results, especially in cases of more severe scarring.

Only a select few plastic surgeons and dermatologists specialize in acne scar revision surgery. There is a wide discrepancy in the classification and treatment of scarring. Be certain to find a provider who specializes in acne scar repair and who is passionate and experienced in this area.

Be sure to

  • Look at before and after photos, the more the better, especially patients with similar scarring to your own.
  • Be realistic about results. Look for improvement, not a cure.
  • Do your homework. Read about the procedures above and go to your meeting armed with knowledge.

Questions to ask a potential scar revision specialist

  • Are you board certified? Be certain that they are board certified.
  • How long have you been performing these procedures? Normally, the more experience the better, however, some younger surgeons may be more on top of the latest procedures.
  • Can I speak to some of your other patients? Ask for references for several patients who had similar scarring and speak to them about the process and their satisfaction with results.

Red flags

  • Their story changes: As you discuss different treatment options, if they tend to change their mind easily, or agree with whatever you say, consider this a huge red flag. A confident, experienced surgeon will possess strong, unwavering opinions.
  • Your gut tells you no: Trust your gut. If you just don't feel that the doctor is the right fit, trust that and move on. On the other hand, if you feel they are the perfect specialist for you, trust that feeling.
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