The Complete guide to Treatment of Acne Scars

Part III. Types of Acne scars, and 6 other factors that decide how much the scars will fade by.

Ideally this post should have preceded the earlier one, on how subcision works.

As scar revision outcomes have a lot to do with scar types — the other influences on treatment outcomes would be the skin type, location of the scars, duration of the scars — we will look at the types of scars in detail.

Acne scars can be broadly divided into depressed and elevated scars. The depressed scars are far more common than the elevated ones.

There are a few types of depressed acne scars — the rolling, boxcar (yes, like in the railways) and the ice pick scars. Each of these types can be again, superficial or deep. Let us look at each more closely.

Rolling scars

This is by far the best kind of scar to treat. It has relatively smooth margins, is not very tightly bound to deeper tissue(see boxcar scar below), and is not too pigmented either. This kind of scar gets lifted quite well, with just about any modality you choose to treat it with — lasers, microneedling, radiofrequency microneedling , subcision and so on. In fact, even repeated microdermabrasion (which is otherwise considered ineffective for acne scars) can give some results when it comes to rolling scars.

As mentioned earlier, the rolling acne scars can either be superficial or deep, as in the image below.

Boxcar scars

These again, can be superficial or deep. The ‘boxcar’ description comes from how the scars possibly look in a schematic cross section. Compared to the rolling scars, boxcar scars have a higher difficulty level — they have really well defined and sharp margins, which makes these scars very noticeable even from a distance. And the margins, more than the depth itself, tend to resist getting obliterated with treatments — be it lasers or surgical options.

Superficial and Deep Boxcar scars -schematic cross sectional description

Here, the deeper boxcar scars are hardly regular as in this image. Often, they are irregularly tethered to the surrounding structures at multiple depths. This is also the case with some deep rolling scars. So they would need combination treatments to address them at a 3 dimensional level.

The superficial boxcars, may only be slightly depressed from the surface, but because of their margins — the results may be much lesser compared to the rolling scars, superficial or deep.

Ice Pick scars

As the name suggests, these are scars that look like they have been picked out with an ice pick.

Very narrow, and sometimes very deep, the treatments for these scars has evolved as a special subset within the scope of acne scar treatments. For example, the CROSS (Chemical Reconstruction of Skin Scars), which we will be looking at next, was specifically developed to look at ice pick scars. Radiofrequency microneedling which delivers energy at specified depths into the skin, is also especially useful as the needles can target the icepick scars, much better than laser beams.

The other group, namely the hypertrophic scars — are usually divided into hypertrophic, papular and keloidal scars. We will be looking at this group and their treatment, in a separate article.

There are a few other factors that influence the response to scar removal treatment.

1. Age of the scars — the older the scar, the lesser the response, and more, the number of treatments required.
2. Activity of the disease — if the acne is not adequately controlled, either simultaneously or sequentially, then the overall outcome may not be as great. Maintenance therapy must never be overlooked.
3. Tendency to pigmentation — this is a relative issue. If there is a tendency to increased pigmentation, it is possible to overcome that with adequate precaution and planning.
4. Sun exposure — this can seriously interfere with new collagen formation. All that is required to manage this, is a good combination of oral and topical sunscreens, and the discipline to follow a good skin care regimen.
5. Smoking — this can suppress new collagen formation, and can also cause collagen breakdown. Smoking also causes premature skin ageing — which is not a great thing when we are trying to even out the scars.
6. Sleep — stress and lack of sleep are factors that can cause oxidation damage. Though antioxidants can help to some extent, it is always advisable to sleep better.

We will continue this series with discussions on the other aspects of acne scar removal treatment. Do check out the other articles in this complete guide series, and if you liked the information here, do be sure to clap for the article and to share it with people who may find it useful.