A Simple Guide to The Types of Acne Scars
Updated: Dec 22, 2021
If you've landed here, you’re probably wondering what you can do to get rid of your acne scarring. You’ve also probably discovered tons and tons of information, and found that it's not as easy as just putting on a cream and calling it a day either. Some dermatologists even suggest not using home products as they can be dangerous to your skin.
Essentially, acne scarring is a byproduct of healing, naturally or otherwise, and for many people it’s completely unavoidable. Almost everyone deals with acne scars at some point in their lives, and the types of scarring you can expect depends on the type of acne and how you treat it.
Unlike atrophic scars, keloid and hypertrophic scars form as raised lumps of scar tissue where the acne once was. This happens during the healing process of acne spots whereby scar tissue builds up causing different types of scarring to occur.
In general, moderate acne involves red bumps and pus-filled pimples, whereas severe acne, like cystic acne, leaves pus-filled bumps, or cysts, beneath the skin.
When these cysts heal, bright red or brown marks are left on the skin, which will usually fade away over time. However, in severe cases, permanent scarring usually develops as the skin heals, especially if the acne was picked on or squeezed instead of being treated.
Infographic: The Different Types of Acne Scarring
Atrophic Acne Scars
What is Atrophic Scarring?
Atrophic scarring usually occurs during the cystic acne healing process, brought on by the destruction or loss of collagen. These scars are best described by flat, shallow depressions or ‘craters’ that heal below the skin.
What Do Atrophic Acne Scars Look Like?
Atrophic scars are the most common type of scarring and they come in many different shapes and sizes. The three types of atrophic acne scars are: rolling scars, boxcar scars and keloid scars.
Rolling Acne Scars
What Are Rolling Acne Scars?
Rolling scars are the most common type of scars that form when long-term inflammatory acne is healing.
Rolling scars are best described as oval, uneven scars of varying size that form on the cheeks and chin. However, they can technically form anywhere on the body.
What Causes Rolling Acne Scars?
Rolling scars form when the proteins that provide structure to the skin are destroyed. While there are open wounds on the skin, the body does its best to heal and close these wounds. This can cause uneven skin due to a lack or build up of collagen.
How to Treat Rolling Acne Scars?
There is no one definitive way to treat rolling scars, but most treatment plans can be classified into stages. In the first stage, effort will be made to ensure there is no skin discoloration. This is usually accomplished with creams or medication.
Icepick Acne Scars
What are Icepick Acne Scars?
Icepick scars are deep and narrow scars that develop from more severe types of acne. These scars are also more difficult to treat than most other types of acne scars, which is why most people seek professional help.
Even though professional help may not completely cure these scars, it will at least reduce the severity of the scarring and make them less obvious.
What Causes Icepick Acne Scars?
Icepick scars are created when more severe types of acne, such as cystic acne, are healing. This is because cysts and other papulae tend to develop much deeper in the skin than normal acne, causing a scar that extends much further into the skin.
How to get rid of icepick scars?
Unfortunately icepick scars are the most difficult types of acne scar to treat effectively. The treatment for icepick scars is complicated because of how deep the scar runs in the skin.
Boxcar Acne Scars
What are Boxcar Acne Scars?
Boxcar acne scars are the last type of atrophic acne scars. These are scars that occur in between rolling and icepick scars, but they are not as wide as rolling scars and not as deep as Icepick scars. They usually have a flat bottom, and look as if a ‘box’ has been pressed into the skin.
However, this can be slightly misleading as the well defined edges of the scar do not have to be straight.
What Causes Boxcar Acne Scars?
Boxcar scars are caused by widespread acne, chickenpox, or varicella, a virus causing a red, itchy rash with blisters.
They are more common than icepick scars, but less common than rolling scars. Overall 20-30% of acne scars are boxcar scars.
How to Get Rid of Boxcar Acne Scars?
Like rolling scars, the treatment method depends mainly on the severity and depth of the scarring. All of the treatments for rolling scars can also be used to treat boxcar scars as they are very similar in nature.
What is The Best Procedure to Remove Atrophic Acne Scars?
The best treatment for acne scar removal depends on the type of scarring that has occurred.
The first step to treating acne scars is to ensure that the scar depth and/or height is more or less equal to the surrounding skin. The go-to treatment options to combat acne scarring are as follows:
In rolling scars, scars are dragged down by residual fibers left in the skin. During a subcision procedure a medical professional will use specialized tools to separate the layers of the skin to even out the overall skin tone and texture.
Punch excision is the process whereby the scar is literally cut from the skin, and stitched back together. This forms a new scar, usually smaller and more even than the previous one.
Microneedling works by using micro-needles to create tiny punctures within the scar. These injuries usually heal within two days and new collagen is formed inside of the scar.
A microdermabrasion treatment involves smoothing out the skin. However it is much less effective at removing deeper scarring because it involves removing the top layers of skin, much like sanding paper.
Ablative laser treatments use high energy laser energy to remove the outer layers of skin whilst encouraging new collagen production in the lower layers of skin.
Non-ablative laser therapy uses heat to encourage new collagen production in the inner layers of skin without damaging the outer layer. Of all the listed treatment options laser therapy has the highest risk of side effects.
Acne Maintenance/Follow Up Treatments
The next stage in the treatment of acne scars involves making sure that there is no skin discoloration, and to further even out the skin. These are generally less invasive or even non-invasive procedures, and actually might just be continued versions of the treatments listed above.
Are Acne Scars permanent?
Almost all acne scars can be treated, but with varying levels of effectiveness. Like with many things the best cure is prevention. The hardest type of acne scar to treat are ice pick scars due to their raised nature.
Hypertrophic Scars vs. Keloid Scars
Hypertrophic and keloid scars are a different type of scarring than atrophic scars all together. If atrophic scars form beneath the skin, then hypertrophic scars form above the skin. Moreover, these scars tend to form from any minor injury, such as a small pimple or a big gash.
They form because of overactive responses to the wound, where extra collagen and granulation tissue is formed. In general, hypertrophic scars do not have edges that spill over, but do raise upwards. Keloids tend to be larger scars than the wound edges themselves and usually ‘spill over.’
Hypertrophic Acne Scars
What is a Hypertrophic Acne Scar?
When collagen is overproduced in the healing process of a wound, a hypertrophic scar may form. These scars can develop in any part of the body, and usually have a red/pink color and are slightly raised.
What Causes Hypertrophic Acne Scars?
Hypertrophic scars tend to develop in places where a wound is placed under constant tension or duress, such as when a wound is open for a long time, infected, or in an area that moves a lot such as the knee. However, mild injuries such as acne, small cuts, or even piercings can cause hypertrophic scars too.
How to Get Rid of Hypertrophic Acne Scars?
Although these scars are benign in nature, they are not very pretty sometimes. To alleviate the scarring, and in some cases remove it completely, many treatments can be performed. All of the treatments listed above are very effective for treating hypertrophic scars.
Moreover, lymphatic massages and corticosteroid injections can also be used to break up the collagen buildups in locations other than the face.
Corticosteroid injections into hypertrophic scars is a treatment highly recommended by many dermatologists. These agents break up collagen bonds and reduce inflammation-- the two main symptoms of hypertrophic scars.
Massages also work well for hypertrophic scars, and they are performed in many treatment centers for burns and wound recovery. By stretching the skin out, collagen can be broken up and scars can be released.
Keloid Acne Scars
What is a Keloid Acne Scar
Keloids are oftentimes confused with hypertrophic scars. However keloids are generally much bigger than the original acne that caused them. This gives the scar the appearance of ‘slipping over’.
Keloids are more likely to develop on the ears, shoulders, neck, chest, and back-- and are usually pink and/or purple in color. Unlike hypertrophic scars, keloid scars can grow and become worse over time.
What Causes Keloid Acne Scarring
Unfortunately the reason why someone develops keloids is not yet fully understood. However, in cases where keloids form instead of hypertrophic scars, Keloids tend to form instead of hypertrophic scar in people who have higher concentrations of melanin, or dark skin.
Moreover, people with a family history of keloid scarring have a higher risk of getting keloids. This leads us to believe individuals have a genetic predisposition to keloid scarring. The best treatment is preventing keloids from developing.
How to Treat Keloid Acne Scars
Keloid scars benefit from the multiple treatments listed above, as well as corticosteroid injections, massages, and cryotherapy, where liquid nitrogen is used to freeze the scar and force the collagen to break into smaller portions.
However, there is no one blanket treatment for all keloid scarring. Instead, patients should have a discussion with a licensed skin care provider, where all treatment options can be organized and discussed in a professional setting.