Treatment approaches for acne scars

Physical treatment is a part of acne therapy and is essential to obtain maximum therapeutic results. Acne scar treatment forms an important part of physical treatment.

Types of scars

Physical treatment for scars depends on the type of scar determined by their shape, number, depth, localization and duration. It also depends on the patient’s skin and localization of the lesions.

Macules or “pseudoscars” are flat reddish spots in the final stage of the most inflamed lesions. The site is pigmented. It occurs more in darker skinned people.

Hypertrophic scars or keloids result from increased tissue formation and excessive collagen.

The more common are four types of scars caused by loss of tissue:

  • Ice pick scars occur on the cheek, look like someone has used a little ice pick. The lesions have jagged edges.
  • Box scars are large, U shaped depressed fibrotic scars with sharp edges and steep sides.
  • Rolling scars are deep and soft and have gently rolling edges which merge with the skin.
  • Atrophic scars are small, white and soft and barely raised above the surrounding skin.


At the outset the patient should be told about the risks and benefits involved, since the outcome varies. Complete erasure of the scar may not be possible and for best results multiple treatments may be required.

The patient’s medical history must be thoroughly examined. Treatment should not be done on patients who have recently undergone oral therapy, have a history of keloids, non acne or persistent facial acne.

Types of treatments

Collagen injections: Collagen is injected under the skin to fill deep soft scars. It is not suitable for ice pick scars and keloids. The cosmetic effect lasts for three to six months and may be extended with further injections.

Autologous fat transfer: Here depressed scars are raised by injecting fat under the skin surface - taking fat from another part of the body. Since the fat is absorbed in 6 to 18 months the procedure must be repeated.

Dermabrasion: Here under local anesthetic, a brush or a fraise removes the surface skin and changes the contours of the scars. Superficial scars can be completely removed and the depth of deep scars can be reduced. The treatment does not work on ice pick scars, making them more prominent, and on scars which are wider under the skin than on the surface. It often does not give the best results on U shaped scars. In dark skinned patients it causes coloration needing further treatment.

Microdermabrasion uses aluminium oxide crystals passing through a vacuum to remove surface cells, avoiding further wounds. Microdermabrasion can be used on small and faint scars but it is not powerful enough for other acne scars.

Chemical peels

The three types of chemical peels used are superficial, intermediate and deep peels.

Superficial peeling has the highest risk-benefit ratio. It can remove macular scars and the accompanying pigmentation. The skin gets a healthier complexion and the size of the skin pores is reduced. Ice pick and U shaped scars can also be given this treatment. The skin has to be prepared for 15 to 30 days before treatment with keratolytic products and depigmenting creams. The side effects include erythema folliculitis, flare of acne lesions and hypopigmentation or hyperpigmentation.

Intermediate and deep peeling have a lower risk-benefit ratio and the effect on atrophic scars is mild and for a shorter duration. They have no effect on keloids. The risks of scarring and pigmentation are increased.

Laser resurfacing

Varieties of laser treatment are possible depending on the intensity and wavelength of the lasers. Laser therapy is non-invasive, does not require anesthesia and is less painful.

Results from laser surfacing have been encouraging. However, erythema occurred in all patients and in 54% it lasted for longer than three months. Hyperpigmentation occurred in 29% but faded within 3 months. Other problems requiring medical intervention were present in 54% and lesion flare-ups occurred in 29%. Longer wave length lasers achieved quicker results.

The pulse-dye and intense pulse light laser can raise depressed scars and improve hypertrophic facial scars. High energy pulsed CO2 lasers have shown good results with atrophic and shallow U shaped scars, improving skin appearance by giving it a more homogenous look.

Skin surgery

There are several types of skin surgery. Punch excision can treat ice picks and deep scars simultaneously if they are at least 4 to 5mm. apart.

Punch elevation combines punch excision and grafting without causing skin color or texture mismatch. A necessary condition in this treatment is that the scars should have sharp edges and normal bases. Box car scars therefore cannot be treated with this method.

Skin grafting is especially needed to close the defect of unroofed sinus tracts.

Combination treatments

Each type of scar has an optimal treatment method. Sometimes, for example, punch excision and elevation needs to be combined with laser resurfacing to improve skin appearance.