6 The treatment of acne scars must be customized to meet the needs of the patient (age, skin type, extent, type, and nature of scars), the patient’s goals, and the patient’s lifestyle (downtime). In one method, acne scars may be graded on a four-point scale with grade 1 describing macular (flat) scars (erythematous hyper- or hypopigmented marks) and 4 being severe disease including scarring that is not flattened when the skin is manually stretched. There are several ways to classify acne scars. Other characteristics that can help define acne scars include textural irregularities, depression, aberrant pigmentation, erythema, vascular dilatation, unclear or irregular borders, and papules. Some acne scars are elevated above the surface of the surrounding skin and may be hypertrophic, but not quite keloidal. Clinicians may also encounter scars with more than one physical characteristic, such as pigmentation or erythema, in addition to being atrophic or hypertrophic. 5 There may be an inflammatory component to some acne scars. 4 Atrophic acne scars are the most common and are likely caused by inflammatory processes leading to the enzymatic degradation of the collagen fibers and subcutaneous fat. For our purposes, it is useful to recognize three main categories of depressed acne scars-icepick scars (deeper than wide), boxcar scars (wider than deep with distinct edges), and rolling atrophic scars (these can be smoothed out if stretched). The nomenclature for categorizing types of acne scars has not been entirely settled in the literature. Some patients with acne scarring may become despondent, and the emotional impact can last a lifetime.
3Įven relatively minor scarring can have a profoundly adverse psychological impact on the patient.
These scars may be aesthetically unappealing, and if hypertrophic, they may be painful as well. The incidence of acne scarring may be increased above the background injury with manipulation or “picking” by the patient. Scar formation is the normal and natural response of tissue to wound healing following an injury that is significant enough to elicit this host tissue response. As acne scars often worsen over time, many of these patients are beyond the “acne age” of late teens into the early twenties and are middle-aged. General dermatologists are frequently presented with acne scarring and asked to counsel patients with regard to their treatment options. 2 Moreover, the clinical severity of acne scars is not necessarily an accurate measure of the patient’s distress (i.e., mild scarring may result in significant distress), just as the clinical severity of the acne vulgaris may not be correlated to the incidence or severity of scarring. 2 Severely inflamed lesions may leave permanent scars, which can be associated with psychological pain, low self-esteem, and reduced quality of life. Acne scarring, which occurs in 95 percent of all people with acne vulgaris, 1 can be challenging to treat.
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