Acne Scarring

Acne scars form when inflammation from acne damages the deeper layers of the skin. When a pore becomes clogged with oil, dead skin cells, and bacteria, the follicle can swell and rupture. If the rupture extends into the surrounding tissue, the body initiates a repair process. In some cases, that repair leads to permanent changes in collagen, the structural protein that gives skin its strength and smoothness.

Scarring is more likely to occur with deeper, inflamed lesions such as nodules and cysts, but even moderate inflammatory acne can leave marks. The risk increases when acne is untreated, when lesions are picked or squeezed, or when breakouts persist for months or years. Genetics also play a role in how the skin heals.

It is important to distinguish true acne scars from post-inflammatory erythema or hyperpigmentation. Dark or red marks that follow acne are common and may fade over time. True scars, however, involve a change in skin texture, either a depression or a raised area, and do not resolve without treatment.

Acne scars fall into two broad categories: atrophic scars and hypertrophic scars. The distinction depends on whether there is a loss or excess of collagen.

Atrophic scars

Atrophic scars are the most common type and appear as depressions in the skin. They form when the body does not produce enough collagen during healing. There are three main subtypes.

• Ice pick scars are narrow, deep pits that extend into the dermis. They resemble tiny holes made by a sharp object and can be difficult to treat because of their depth.
• Boxcar scars are wider depressions with defined edges. They may be shallow or deep and often appear on the cheeks and temples. The borders are typically sharp, giving the skin a pitted appearance.
• Rolling scars create a wavy or uneven texture. These scars have sloping edges and are caused by fibrous bands that pull the skin downward. They are often more noticeable in certain lighting.

hypertrophic scars

Hypertrophic and keloid scars are raised rather than depressed. They develop when the body produces too much collagen during healing. Hypertrophic scars remain within the boundaries of the original acne lesion, while keloids can extend beyond it. Raised scars are more common on the chest, shoulders, and jawline and may occur more frequently in individuals with darker skin tones.

Many patients have a combination of scar types, which is why a comprehensive evaluation is essential before starting treatment.

A detailed skin examination is the foundation of effective treatment. During a consultation, Dr. Richey assesses the type, depth, and distribution of scars. She also evaluates overall skin health, ongoing acne activity, pigmentation changes, and skin tone.

Lighting plays a critical role in identifying rolling scars and subtle depressions. Photographs may be taken to document baseline appearance and monitor progress over time. The patient’s medical history, previous acne treatments, history of scarring, and expectations are carefully reviewed.

Skin type influences treatment decisions. Certain procedures carry a higher risk of pigment changes in darker skin tones, so customization is essential. Active acne must be controlled before addressing scarring, as new lesions can create additional scars.