Hi guys! Dr Rakesh here taking over the blog (and giving Sam the day off!) to answer your questions on everything Acne Scarring.
1. Could you walk us through the different types of acne scars and how to identify them? Which scars are the hardest to eradicate?
After having a spot, you can be left with a mark. Most people will be left with discolouration of the skin. This can be either red (most common if you have fair skin) or brown (more common in darker skin) and fades over several weeks. It is common for the brown not to fade completely and leave a lasting mark. This is often described by patients as a scar and is called post inflammatory pigmentation medically.
Most doctors refer to scars when there is a change to the shape and texture of the skin caused by skin damage. This means that the mark will either be raised up from the surrounding skin or more commonly dipped and lower than the surrounding skin. The texture will also be firmer because it consists of dense collagen.
There are 3 types of dipped scars which are referred to by their shape. 1) Rolling scars are shallow scars with a curved base. 2) Box scars have vertical edges and a flat base and look similar to chicken pox scars. 3) Ice pick scars are the deepest scars and have an inverted V shape.
A small proportion of patients will develop raised scars called papular keloids. These tend to be seen on the shoulders and upper body, rather than the face.
Both post inflammatory pigmentation and acne scars are challenging to eliminate and require different treatment approaches. Treatments works best when tailored and individualised to each patient. The papular keloid scars can be particular challenging to improve and I would recommend seeing a specialist to treat these.
2. What are the best ingredients and products (or type of products) to get rid of the different types of acne scars? Which step in your skincare routine should you never skip?
It is very important that your acne is well controlled before focusing on acne scarring treatments as many scarring treatments can worsen active acne.
Generally, products that you apply to the skin surface are best for treating post inflammatory pigmentation marks. A regular SPF will help prevent worsening of the pigmentation, especially if you live in a hot climate or are going abroad.
Ingredients that can help improve the pigmentation more quickly include :
- Hydroquinone
- Retinoids
- Kojic acid
- AHAs
- Azelaic acid
If you have recurrent acne then I would say a retinoid is essential in your skin care routine. It helps prevent acne recurrence, remove pigmentation and also helps remodel acne scars.
There is not a one size fits all treatment for acne scarring. Often a number of treatments are needed to make scars look their best. The most common treatments used are micro-needling, laser resurfacing, chemical peels and surgery (the scar is physically removed and the skin stitched back together). Dermal Fillers can also be used to temporarily improve their appearance.
Patients can be disappointed with their scarring treatment when they are not given realistic expectations of what to expect. Most scars can be improved in appearance but it is usually not possible to remove a scar completely.
3. Say a spot/acne happens, what’s the first course of action to take to reduce the risk of scarring?
Acne scarring doesn’t just result from inflammatory acne. It can develop because spots are traumatised i.e. squeezed, picked, scratched, use of facial scrubs. Therefore it is important not to pick your spots, especially early spots.
An acne flare should be treated with an ingredient that will resolve the spot as quickly as possible to reduce the scarring risk. The will be either an anti-inflammatory, anti-biotic, antiseptic, retinoid cream or a combination of these. For more extensive acne flares your doctor may suggest a course of tablet antibiotics or even discuss using a drug called Isotretinoin.
4. If you already have vitamin C, retinol and acids in your routine, how should you alternate them to get the best results on scars? Are there ingredients that should never be used together?
A vitamin C (antioxidant) and retinol can be good as part of a daily skin care routine for most people. However acne scarring treatment requires a more targeted approach with either the products or the more invasive treatment listed in Q2 as part of a treatment programme.
It is common to experience excessive skin irritation, redness and peeling if too many abrasive or irritant skin care products are used. Often less is more and better results come from rationalising the products you use.
5. If nothing works topically, what treatment works best for scarring?
Patience is the key. The cream treatments and peels that help with pigmentation can take many months to have their full effect. Retinoid treatment to help with certain types of acne scarring can take years to have an effect!
The more invasive treatments vary in cost depending on where you go and the expertise of the person that you see. Chemical peels and micro-needling are often the most widely available and most competitively priced. Laser resurfacing and surgical treatments can be considerably more expensive, can have significantly better results but are less widely available as fewer people have the necessary expertise.
6. Do acne scars worsen as you age? How does ageing affect acne scarring?
The good news is that time improve all scars to some extent to pigmentation and most types of scarring. Notably not ice pick scars or papular keloids.
7. Is it possible to completely get rid of old acne scars? Are some scars completely permanent?
Although pigmentation can often fully resolve with or without treatment, it is a myth that acne scars can be cured. Things are not all bad though. Despite not being able to remove the scars entirely, today’s treatment can significantly improve their appearance for almost everyone.
8. If you’re concerned about wrinkles, fine lines and scarring, how should you go about treating your skin?
The treatment of wrinkles and fine lines and scarring can overlap. For example retinoids are used to address all 3 issues. However, the best treatment for your scars will depend on the scars, their location and your skin and may not necessarily improve wrinkle and fine lines. A specialist that knows how to treat all of these conditions can create a programme over time to address them all.
9. At what point should you go and speak to a dermatologist or GP about scarring?
If you have scarring, the time to speak to someone is if their appearance affects you. This can range from occasionally affecting your self-confidence to full clinical depression. The first person people go to is usually their GP. Although GPs can help with the psychological effects of acne scarring, they do not often have the expertise to have a detailed discussion about acne scaring treatments. I would recommend seeking a specialist if this is your main concern.
10. What mistakes can worsen acne scars? Are there any ingredients/ tools/treatments to avoid?
The biggest mistakes that people make that cause scarring is to traumatise their spots when they still have active acne. This is by either 1) picking their spots or 2) using a facial scrub (with particles) to make their skin smooth. Both traumatise your skin and make permanent scarring from spots more likely.
11. What are your thoughts on at-home micro-needling and/or LED light gadgets? Do they work and will they make things worse or better?
LED light treatment is interesting. I do not think that it is useful for the treatment of acne scarring BUT it is useful for active acne.
A number of companies have devices that used low level light (blue, red or both. There is good scientific evidence showing it can be effective at treating mild and moderate grade acne. The advantage of this treatment is that it can be used alongside more conventional treatments and rarely causes unwanted effects.
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