Last updated November 2021
- There are various types of acne scars, each treated with different methods
- Scar treatment needs to be matched to the patient’s types of scars, skin type, and recovery time permitted
- There are various types of scarring classified based on whether it is severe scarring and morphology
- Scar treatment on olive or darker skin types carries the risk of post-inflammatory hyperpigmentation. Non-laser resurfacing carries less risk of this than lasers
- Laser resurfacing includes carbon dioxide laser or erbium lasers, or fractional laser like the Fraxel or fractional CO2 lasers
- Non-laser treatments include the Infini radio-frequency needling, skin needling, TCA CROSS, and subcision
- Generally multiple sessions are required for the best results, and in most cases can be improved, but not completely resolved
What types of acne scars are there?
- Macular scarring – this type is characterised by flat areas of increased and decreased pigmentation as a result of acne. Although there are not any indentations in the skin or raised scars, this is considered a scar by many patients who have this problem
- Boxcar scars – these are superficial punched out scars that have sharp vertical edges on the cross section, and can be round or oval shaped when seen from above
- Rolling scars – these appear as undulations in the skin and are usually caused by tethering of the skin to underlying structures
- Deep divots – these are simply very deep scars that involve loss of subcutaneous tissue volume and result in a large divot
- Ice-pick scars (also called depressed scars) – deep but small holes in the skin, similar to the indentation left by an ice-pick
- Hypertrophic scarring and keloid scars – where there is a raised and often pigmented scar as a result of acne. They may be red/purple, and disproportionate to the size of the initial trauma caused by the acne
What are the different severities of acne scars?
Macular scarring or flat scarring that is characterised by flat areas of increased or decreased pigmentation visible from greater than 50cm.
Mild disease that is visible at distances of less than 50cm and can be covered by make-up. Examples include mild rolling acne scars.
Moderate disease that is visible at 50cm or greater and is not easily covered with make-up or the normal shadow of a shaved beard hair. Stretching the skin can flatten the scar. Examples include more significant rolling scars, shallow boxcar scars, and mild to moderate hypertrophic scars.
Severe disease as in grade 3 but scarring is not flattened by stretching the skin. Examples include severe boxcar scars, deep divots, ice pick scars (or depressed scar), and hypertrophic/keloid scarring (very raised/pigmented scars).
What skin care helps with scarring?
There are a number of skincare products that can be used to help reduce acne scars. These products can be added to your skincare routine to lighten the scars and benefit the general health of your skin.
Using a cleanser every morning and night is integral to keeping your skin as healthy as possible. A nourishing cleanser like the Aspect Dr Deep Clean Facial Cleanser can help remove congestion in oily skin, while the lactic acid also helps to break down acne marks. Consider adding an exfoliating cleanser in your skincare regime in order to clear your skin of any dead skin cells.
A glycolic serum such as the Aspect Exfol L can provide hydration and boost collagen and elastin production, which is perfect for those who suffer from acne or acne marks.
A retinoid in the form of a serum can also improve acne scarring, such as the Biopelle Retriderm Vitamin A Serum. This contains concentrated amounts of Vitamin A, which helps to regulate oil levels and reduce skin hyper-pigmentation. To learn more about retinoids in skincare.
Hyperpigmentation is a common side effect of acne, and is usually a result of inflammation or trauma to the skin. Medical grade skin care can assist in treating this problem. Retinoids, or analogues of vitamin A, can help skin turnover and keratinisation (which can block pores) and reduce acne. Using a non-comedogenic sunscreen like the SkinCeuticals Ultra Facial Defense SPF50 can reduce post-acne skin tone changes. Occasionally, a skin lightening agent like the Neoretin Discrom Pigment Lightening Peel Pads can also be used to treat hyperpigmentation caused by acne. For more information about how to treat hyperpigmentation.
It is important to treat the general quality of the skin in addition to treating the acne scarring. This helps to reduce the overall appearance of the scars.
What laser is best for acne scars?
With the most advanced technology available, both non-fractional and fractional lasers can treat acne scarring. This will depend on the types of scars, and can provide dramatic results.
Non fractional laser
Laser resurfacing (non-fractional) with a carbon dioxide laser or erbium laser is a method of treating severe acne scarring. These lasers remove the top layer of skin, resulting in the growth of smoother new skin that lessens the appearance of scarring. Also, removing the top layer of skin effectively works to create a more level skin surface, by matching up the level of the ‘normal’ skin with the level of the indented scarring. Laser resurfacing not only addresses the scarring, but can also significantly improve the appearance of sun damaged (pigmented/wrinkled) skin.
Although this is very effective, there is usually a two week recovery period associated with the procedure, and it often requires light sedation. It’s a more intensive procedure than Fraxel laser.
Carbon Dioxide Laser
The Carbon Dioxide (CO2) laser heats the skin to cause tissue contractions that even out skin texture, and is effective with multiple treatments; but often causes some undesirable side effects. These can include prolonged redness, a waxy appearance or loss of pigmentation.
The Erbium laser was introduced as an alternative to the CO2 laser that produces less thermal energy and requires less recovery time. The Erbium laser takes a thin layer off the top of the skin to resurface it, but doesn’t produce results as dramatic as the Carbon Dioxide laser. However, there is less risk of side effects associated with the Erbium laser.
Instead of treating the whole skin surface, small columns of laser energy are fired into the skin, and the skin in between these columns are spared. This leads to faster healing times, less risks and less complications. One of the other key advantages of fractional lasers is their ability to penetrate deeper into the skin than non-fractional lasers. By doing so, these lasers are able to effectively stimulate the production of new collagen. This raises indented or atrophic scars to the level of the normal skin, as opposed to non-fractional resurfacing which removes the layer of the normal skin down.
One of the first fractional lasers used was the Fraxel laser. This is classified as a non-ablative laser, it does not destroy any tissue, but instead heats columns of tissue with laser energy. It is this heat energy that stimulates new collagen production in the skin.
Carbon Dioxide Laser
Fractional carbon dioxide lasers have been a recent development that can provide superior results to Fraxel laser. Fractional carbon dioxide lasers are ablative lasers, they vaporise columns of skin as well as heat the skin. By ablating as well as heating the tissues, more collagen stimulation and new skin formation occurs and it is possible to achieve superior results to non-ablative lasers like the Fraxel. At the Victorian Cosmetic Institute we use the Lumenis Ultrapulse fractional carbon dioxide laser with the Deep Fx handpiece for acne scars. This handpiece fires very fine columns of laser energy deep into the skin with only a small percentage of the skin’s surface being affected. The recovery period from fractional carbon dioxide laser ranges from 3 to 10 days depending on the intensity. The results from fractional carbon dioxide lasers are particularly effective in treating fair skin types. For olive or darker skin types, there may be an increased risk of post-inflammatory hyperpigmentation (darkening of the skin post-treatment), and for these skin types, we recommend Infini radiofrequency needling treatments.
Our PiQo4 picosecond Nd:YAG laser, which is used also for tattoo removal and pigmentation removal, can also be used at settings to help promote collagen production and treat mild superficial acne scars to help raise small indentations in the skin. The advantage of this is that it has only a small amount of downtime in comparison to the above treatments, however multiple treatments need to be performed. Usually, several treatments are required. There have been clinical studies showing the effect of this laser on flattening the topography of scarred skin, and a general overall improvement in skin texture and smoothness. Generally, this laser is very mild, and not particularly effective in treating scarring.
Non-laser treatments for acne scarring
There are a number of treatments that don’t use laser or thermal energy. Skin needling is commonly used to stimulate collagen production and regenerate the skin to improve the appearance of acne scars. Other medical treatments include radio-frequency or chemical peels.
Skin needling is a very effective method of treating superficial acne scars. It is performed by puncturing the skin with multiple fine 3mm (long) needles attached to a small rolling pin. This stimulates collagen production and helps to lift up any ‘indented’ or atrophic scars. The advantage of this is that it can be used on all skin types including olive and dark skin types. People of Asian, African, and European background are able to have this treatment with less risk pigmentation changes in comparison to laser treatments post-needling. Also, it penetrates very deeply so that collagen can be stimulated on deeper scars. Usually it takes 3 to 7 days to recover, depending on the degree of the treatment.
Micro-needling is another form of needling that utilises fine needles attached to a stamping device that oscillates up and down to create thousands of micro-injuries to the skin. It generally is a lot less invasive than surgical skin needling. It has less downtime and generally requires more treatments to achieve similar results.
Infini combines both micro-needling with radiofrequency. It is effective for treating acne scars and skin tightening. It is particularly suited to olive or darker skin types. It has a lower risk of post-inflammatory hyperpigmentation than laser treatments, and the recovery time is significantly less than surgical skin needling.
Subcision is a method of undermining acne scars using a special needle or cannula. This breaks the skin free from the scar tissue that holds it down. It is a simple mechanical technique, but very effective. Subcision is another technique that is suitable for treating depressed scars. The size of the scar usually needs to be fairly large or deep. It involves putting a special needle under the depressed scar. Often acne scars are depressed because the skin is tethered to the underlying tissue.
TCA CROSS is a simple yet effective method of improving scarring. It is most commonly used for small indented acne scars. It involves careful placement of high concentrations of trichloroacetic acid into the scar with a toothpick. This stimulates the production of new collagen and remodelling of existing collagen to fill in the acne scar. The advantage of TCA Cross is that it’s localised to the problem only and not the unaffected skin.
Chemical peels are another method of treating more superficial scarring. Generally, medium to deep peels are required to achieve a significant result. However, a series of more superficial peels could help achieve some improvement in milder acne scarring without significant downtime.
Microdermabrasion is a technique that can also help, but only extremely slightly, with mild acne scarring. It uses a gentle vacuum to bring your skin in contact with a diamond-coated head that gently abrades the top layer of dead skin. This stimulates collagen production and helps with scarring. Generally, microdermabrasion requires more than a single treatment. Typically 10 treatments are required and the results are usually slight, and less dramatic than the other treatments. There is virtually no downtime with microdermabrasion, although there may be some redness that persists for a few hours.
Volume replacement for acne scarring
In many cases, volume loss occurs under the skin as a result of acne, particularly with cystic acne. Replacing volume with dermal fillers can aid in treating scarring.
Dermal fillers are a quick and effective means of replacing volume loss to improve scarring. By injecting these dermal fillers underneath scarring, they help to replace lost volume, and lift the skin towards its normal level.
Alternately, fat can be transferred from the abdomen, hips or thighs, and be injected underneath the areas of scarring. As well as providing additional volume to the area, fat contains stem cells which help in the skin regeneration process. Fat transfer can be combined with skin needling or laser resurfacing in the same session to synergise the treatments.
Comparison of treatments for acne scarring
TABLE: Comparison of various treatments for acne scarring
|Name of treatment||Effectiveness||Recovery period||Number of treatments required||Cost||Risk||Comments|
|Dermal fillers||+++||+||ongoing||+++||+||Temporary only|
|Dermabrasion||+++||+++++||+||+++++||+++++||Antiquated. Very risky and prolonged recovery|
|Fully ablative laser resurfacing with carbon dioxide laser and/or erbium laser||+++++||+++++||+||+++++||+++++||Can result in loss of pigmentation (hypopigmentation). Also effective for general improvements in skin and sun damage.|
|Infini Radiofrequency needling||+++++||++||++||+++||++||Particularly suited to olive or darker skin types.|
|Fraxel 1550nm||+||+++||++++||+++1/2||++||Not as effective as fractional carbon dioxide with similar recovery periods|
|Fractional carbon dioxide laser||+++++||+++||++||+++||+++||A good balance between recovery period and results|
|Portrait plasma skin regeneration||++||++++||++||+++++||+++||Prolonged downtime relative to results achieved.|
|Surgical skin needling*||++++||++++||++||++++||+++||Excellent results, but prolonged recovery times in comparison to fractional carbon dioxide or Infini RF needling.|
|TCA CROSS||++++||+++||+++||+||+++||Effective and cheap|
|Subcision||+++||+++||+++||+||++||For deeper scars|
|PiQo4 (picosecond Nd:YAG) laser||+||+||+++++||++||+||Minimal or no downtime. Multiple sessions essential|
|Superficial Chemical peels||+||+||+++++||+||+||Minimal downtime. May only make a slight improvement|
|Microdermabrasion||+||1/2||+++++||++||+||A light treatment. Likely to result in no improvements|
|Medium to deep chemical peels||++||++++||++||+++||+++ or more for deeper peels||Similar to Portrait plasma, but cheaper|
*This service is no longer provided by VCI, please refer to the micro-needling page for more information.
This patient had 3 Infini radiofrequency treatments to the acne scarring on her cheeks. This was combined with subcision and dermal filler.
How do you make acne scars go away?
Scarring can be treated through a variety of different methods, with varying recovery times. Skin needling, micro needling and laser resurfacing are some of the most common methods, but you should consult a doctor or skincare specialist to decide which treatment is right for your skin type and level of scarring.
Can acne scars be removed permanently?
The permanence of your scars may depend on the severity, but it is certainly possible to make scarring less noticeable.
What is the best treatment for acne scars?
There is no one size fits all solution when it comes to scarring, and the treatment that works for you will depend on your skin. Before committing to a treatment, you can try home skin care methods like using sunscreen everyday to reduce the chance of getting hyperpigmentation and scarring. Others include laser resurfacing, skin needling and radio-frequency.
How do I know which acne scar treatment is right for me?
You may not know until you have a consultation with one of our clinicians, who will ask you about your skin concerns and the goals you hope to achieve. We will assess the severity of your scarring and recommend a treatment plan based on your skin type and the time you have available for recovery.
How long does it take for acne scar treatment to work?
The length of time required to see results will depend on the treatment you’ve chosen, and it is usually best to stick with one treatment until the results are clear. For both laser treatment and skin needling, you should start to see some results after 4-6 weeks, but you may not see the final results until after about 3 months.
How many treatments do you need for acne scars?
Although there have been many advances in how to treat scars, it remains a difficult skin concern to correct. In most cases, an improvement is achieved, but due to the nature of the problem, it is not possible to completely remove scars in most cases.
Most of the treatments described require multiple sessions to achieve the best result. Each treatment stimulates remodelling of the skin’s collagen, and to get the best results. As a general rule, we allow 2 months as a minimum period between treatments. This time interval in-between is a balance between the time required for new collagen to form and the patient’s desire to achieve results quickly. New collagen formation can occur for up to 1 year post treatment, but patients are usually reluctant to wait a full year prior to deciding to retreat.
What should I expect after my acne scar treatment?
Afterwards, your skin will be red and slightly inflamed for one to two days. Some are more invasive than others and will require more specific aftercare. For example, fractional laser resurfacing is often seen as a ‘lunchtime’ procedure, while non-fractional laser resurfacing will require a 2 week recovery period in which you may have to limit physical activity and makeup use.
Why choose Victorian Cosmetic Institute for acne scar treatment?
There are many factors when deciding on the best scar treatment options. Our doctors, nurses and skin therapists are highly experienced in treating light to deep acne scars, and will be able to help you decide which effective treatment suits you and your skin condition/type best.
A consultation will help assist you in your decision about which procedure will best suit your goals and lifestyle. As a rule of thumb, the more invasive the treatment, the greater the downtime, and the greater the improvement.
The first step is simply contacting us for your initial skin consultation, where we will discuss with you what is a realistic and achievable outcome, and what to expect from your treatment.
Fill out our online form to book now or contact us on 1300 863 824 to start your skincare journey today.