How to Get Rid of Acne Scars: Everything You Need to Know

Acne scars.

It's a cruel joke after enduring years and years of acne.

Trust me, I know how that feels.

I've struggled with acne for most of my life and still have scars to this day.

That's why I created this definitive guide on acne scars.

I'll show you how to get rid of acne scars using the latest medical research and clinical studies.

Let's beat acne scars together!

Are you ready to get started?

Table of Contents

What Are Acne Scars?

First, we need to learn more about acne scars.

In this chapter, I'll explain:

• What are acne scars?
• What causes acne scars?

What Are Acne Scars?

Acne scars are essentially damaged skin left behind by inflammatory acne.

They come in many shapes and sizes, from pitted to indented to raised scars.

What Causes Acne Scars?

In short, acne scars are caused by chronic inflammation.

What do I mean by this?

You might recall that acne is an inflammatory skin disease, characterized by:

• Blocked pores (excess sebum, keratin, and dead skin cells)
• Bacteria proliferation (Propionibacterium acnes), and
• Chronic inflammation

Every time you get a pimple, it means that P. acnes, a naturally occurring bacteria in your skin, has grown out-of-control.

The bacteria feeds on excess sebum in your hair follicle and multiplies in numbers.

This damages the surrounding skin and triggers an inflammatory response.

Normally, inflammation is a good thing.

It puts your immune system on high alert, induces blood clotting, and activates wound healing processes to repair injured skin. (1)

Unfortunately, inflammation only exacerbates the problem with acne. 

It weakens your hair follicle and allows P. acnes to spread to neighboring skin tissue.

This causes further cell damage and sets off a vicious cycle of injury-inflammation.

If left unchecked, inflammation will severely damage your skin.

That's why chronic inflammation is responsible for most acne scars.

You'll see how this works as we walk through the different stages of acne.

The Different Stages of Acne

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Stage 1: Microcomedone

The perfect storm of excess keratin and sebum (thanks to hormonal changes during puberty) causes dead skin cells to stick together.

This results in the dreaded "clogged pore".

Keratin is a tough protein found in skin cells that provides your skin's protective properties.

Sebum is an oily substance produced by the sebaceous gland. It has lubricating and hydrating properties that help maintain your skin's acid mantle.

Stage 2: Whitehead / Blackhead (Pimples)

Unable to leave, the mixture of keratin, sebum, and dead skin cells create a "bulge" in the hair follicle. This is called a whitehead (closed pore) or blackhead (open pore).

To make matters worse, P. acnes feeds on the excess sebum and grows out-of-control.

Stage 3: Papule / Pustule (Severe Acne)

As P. acnes continues to multiply, it triggers an inflammatory response.

Your immune system intervenes by dispatching white blood cells to the area.

Unfortunately, these white blood cells are unable to control P. acnes growth.

Instead, they get stuck in the sticky mixture of sebum, keratin, dead skin cells, and P. acnes (colloquially known as "pus").

This combination is highly inflammatory.

It weakens the walls of the hair follicle and spills into the adjacent skin tissue.

This causes further cell damage and continues a vicious cycle of injury-inflammation.

Stage 4: Cyst / Nodule (Very Severe Acne)

By this point, chronic inflammation and P. acnes expansion has completely destroyed the hair follicle and most of the surrounding skin tissue.

Important components of the skin such as collagen have also been compromised.

This type of deep cystic acne is what causes acne scars.

CHAPTER 2:

Types of Acne Scars

We're all different in our own ways.

You might like cats, while I prefer dogs.

The same is true of acne scars.

You might have lots of atrophic scars, while I tend to get hypertrophic scars and keloids.

It depends on how our body heals itself.

In this chapter, we'll look at the different types of acne scars and how to identify each one.

Acne Scars vs. Acne Marks

First, there tends to be a lot of confusion between acne scars and acne marks.

Many people who think they have acne scars actually have acne marks.

Acne Scars

Acne scars are changes in skin texture caused by the loss of collagen (atrophic scars) or excessive amount of collagen (raised scars).

Unfortunately, acne scars do not go away on their own.

Acne Marks

On the other hand, acne marks are changes in skin color caused by excess melanin (hyperpigmentation) or chronic inflammation (erythema).

Fortunately, acne marks often resolve themselves and are easier to treat than acne scars.

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Atrophic Scars

Atrophic scars are "pitted" depressions in the skin caused by the loss of collagen. (2)

You tend to get these scars where deep cystic acne has lingered for a long time.

• Ice Pick Scars: deep and narrow holes that resemble "ice pick" punctures
• Boxcar Scars: indentations with borders (like a fingernail was pushed into the skin)
• Rolling Scars: continuous depressions with no defined borders (like waves or ripples)

Chapter 3 covers general treatments for atrophic scars.

Chapter 4 covers treatments specific to ice pick scars.

Chapter 5 covers treatments specific to boxcar scars and rolling scars.

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You might also have tethered scars.

This means there are fibrous bands between the base of the scar and the underlying tissue.

These bands "pull" on the scar and create the appearance of depressions or indentations.

• Tethered Scars: fibrous bands pulling down on the scar

Hypertrophic Scars & Keloids

Raised scars are elevated bands of scar tissue caused by excessive collagen growth. (3)

They are thick, lumpy, and may appear shiny. These scars are usually red to pink.

• Hypertrophic Scars: thick, fibrous bands, may go away on its own
• Keloids: lumpy, shiny, may grow larger and does not regress by itself

Research also suggests there's a genetic component to raised scars, especially keloids.

Chapter 6 covers treatments for hypertrophic scars and keloids.

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Hyperpigmentation

We often get dark spots as well after acne.

Thankfully, this is not an acne scar and will usually go away by itself.

Also known as hyperpigmentation, these brown spots are caused by excess melanin.

Melanin is an important pigment in your skin. It determines your skin color and protects your skin from the sun's UV rays.

• Hyperpigmentation: dark spots caused by excess melanin

Chapter 7 discusses common treatments for hyperpigmentation.

CHAPTER 3:

Atrophic Scars

If your acne scars are pitted, indented, or "saucer-like", you probably have atrophic scars.

These are the most common types of acne scars, and include ice pick scars, boxcar scars, and rolling scars.

Atrophic scars are caused by inflammatory damage from chronic and/or severe acne.

Fortunately, these treatments may help:

• Chemical Peels
• Dermabrasion
• Microdermabrasion
• Dermal Fillers

For additional options, see chapters 4 and 5.

Chemical Peels

Chemical peels are a popular and affordable option for acne scar treatment.

The most common peels include alpha hydroxy acids (AHAs) like glycolic acid and lactic acid.

How It Works

Chemical peels cause a mild exfoliation of the epidermis to mid-dermis. It helps "unglue" the bonds between dead skin cells and allows them to naturally slough off. (4)

This helps smooth uneven skin texture and reduce the appearance of atrophic scars.

Chemical peels also trigger inflammation and stimulate collagen production. (4)

This can help "fill in" the pits and depressions left behind by severe acne.

Following a chemical peel, your skin should appear brighter and more even looking.

Don't forget to use sunscreen after a chemical peel!

RELATED:

• Best Chemical Peel for Hyperpigmentation

Types of Chemical Peels

There are many types of chemical peels:

• Glycolic Acid: the most popular type of superficial peel
• Lactic Acid: a superficial peel similar to glycolic acid
• Mandelic Acid: a gentle peel usually found in DIY products
• Salicylic Acid: a great option for oily skin and clearing up acne
• Trichloroacetic Acid (TCA): a popular and effective medium peel
• Jessner's Solution: a light to medium peel often combined with other peels
• Phenol: the strongest type of peel (with a long list of side effects)

Your dermatologist or esthetician will determine which peels are suitable for you based on your skin type, degree of scarring, and medical history.

About the Procedure

Chemical peels are quick and easy. They can be done by your dermatologist or at home.

Side effects include redness, itchiness, and for stronger peels, flaking and peeling.

Make sure to follow these general safety tips:

• Keep the solution away from your eyes, lips, and other sensitive areas
• Use a timer to record how long the peel is on your face
• End the peel with a neutralizing solution like baking soda and water

Cost of Chemical Peels

According to Healthline, prices range from $150 for light peels to over $3,000 for deep peels.

Verdict

Chemical peels are a tried-and-true option for acne scars and hyperpigmentation.

PROS

CONS

• Smoother skin
• Improves uneven skin tone
• Simple and affordable

• Mild stinging, redness, and itching
• Multiple sessions are required
• Increased sun sensitivity

Dermabrasion

Introduced in the 1950s, dermabrasion is one of the earliest acne scar treatments.

These days, it's used more for deep wrinkles, sun damage, and pigmentation disorders.

How It Works

Dermabrasion "buffs" away entire layers of skin with a rapidly rotating abrasive tip. (5)

The tip can be a serrated metal wheel, diamond tip, or wire brush.

This facial resurfacing technique triggers inflammation and wound healing signals that encourage collagen remodeling.

In particular, it may help plump up the appearance of boxcar scars.

Here's a demonstration of dermabrasion by Dr. Leif Rogers (before and after results here).

About the Procedure

Dermabrasion takes anywhere from a few minutes for smaller areas to 1-2 hours for larger areas to complete.

Your dermatologist will inject a local anesthetic to limit the pain.

Following the procedure, your skin may feel tender, swollen, and appear red or pink. New skin usually takes 7-10 days to form. Unfortunately, the pinkness can last for several weeks. (6)

Contraindications

Dermabrasion is not suitable for everyone, particularly those who:

• Have active acne (may worsen inflamed cysts and pimples)
• Are taking oral retinoids (Accutane)
• Have active cold sores, or
• Have a family history of keloids

Given the long recovery time, number of side effects, and high dependency on operator skill, dermabrasion has been largely replaced by laser treatments (covered in Chapter 5).

Cost of Dermabrasion

According to the American Society of Plastic Surgeons, the average cost of dermabrasion was $1,170 in 2017.

Verdict

Dermabrasion can be effective but has mostly been replaced by laser resurfacing.

PROS

CONS

• May improve scar texture
• Stimulates collagen growth

• Moderate pain, swelling, and tenderness for a few days
• Redness or pinkness can last weeks
• Expensive

Microdermabrasion

Microdermabrasion is a milder version of dermabrasion with fewer side effects.

This treatment is widely available at salons, spas, and dermatologist offices.

How It Works

Instead of an abrasive tip, microdermabrasion uses fine particles of aluminum oxide or sodium bicarbonate to achieve the same exfoliating effect.

These fine particles are blown onto your face, brushing away dead skin cells, and then immediately sucked back into the machine through a vacuum.

Here's a demonstration of microdermabrasion by Anahi Leal.

About the Procedure

Since the effects are less pronounced, multiple sessions are generally required.

What's nice though is the convenience and affordability of this treatment.

And if you're a frequent user, you can save a lot of money by investing in a personal microdermabrasion machine to use at home.

Verdict

Microdermabrasion is a convenient and affordable option for mild atrophic scars.

PROS

CONS

• Improves mild atrophic scars
• Convenient and affordable
• Can be done from home

• Effects are less pronounced
• Requires multiple sessions

Dermal Fillers

Filler injections are commonly used for wrinkles and fine lines.

More recently, however, dermatologists have started using fillers for acne scars. (7)

How It Works

Fillers are injected into the scar to encourage revolumization of skin tissue.

This raises the skin surface and reduces the appearance of pitted and indented scars.

Common fillers include:

• Hyaluronic Acid
• Poly L-Lactic Acid
• Calcium Hydroxylapatite
• Polymethylmethacrylate

Fillers are usually temporary and require periodic "top-ups" to maintain results.

Here's a quick video that explains how fillers work by Dr. Davin Lim.

Types of Dermal Fillers

There are many types and brands of dermal fillers. You'll want to consider:

• Duration: how long will it last?
• Results: how effective is it?
• Speed: how quickly will I see results?
• Price: how much is it?

Hyaluronic Acid (HA)

HA is a temporary filler that lasts up to 18 months.

Hyaluronic acid is one of the most abundant materials in the skin's extracellular matrix. It serves many functions including wound healing, skin regeneration, and hydration.

Studies on HA fillers show improvements in scar appearance with minimal side effects. (7)

Brand names include:

• Juvederm (Allergan)
• Restylane and Perlane (Galderma)
• Prevelle (Mentor)
• Belotero (also known as Esthelis-Merz)

Poly L-Lactic Acid (PLLA)

PLLA is a semi-permanent filler that lasts up to 2 years.

It's made of synthetic biodegradable polymer and can stimulate collagen growth within a few weeks of the injection.

Studies on PLLA and acne scarring have all shown positive results. (7)

A study in 2014 also examined PLLA injections following ablative CO2 laser treatment. The authors noted that 95% of scars showed improvement after 3 months. (8)

Brand names include Sculptra.

Calcium Hydroxylapatite (CA)

CA is a semi-permanent filler that lasts up to 18 months.

It's made from natural substances found in bones and teeth and can create significant volume in a short period of time.

There is only one study on CA and acne scars with a small sample size (10 participants). (9)

Brand names include Radiesse.

Polymethylmethacrylate (PMMA)

PMMA is a tongue-twister of a filler that is specifically FDA-approved for acne scars. (7)

It's a synthetic and biocompatible filler that can produce long-lasting results (>3 years).

Brand names include Bellafill (previously called Artefill).

About the Procedure

A filler injection is usually a quick visit with your dermatologist.

Side effects may include mild pain, discomfort, and redness.

Cost of Dermal Fillers

According to the American Society of Plastic Surgeons, the average price of fillers were:

• $600-$700 for hyaluronic acid and calcium hydroxylapatite
• Around $900 for PLLA and PMMA

Verdict

Dermal fillers are a relatively new technique for treating atrophic scars.

PROS

CONS

• Encourages tissue revolumization
• Quick and easy procedure

• Limited clinical studies
• Results are temporary
• Expensive

CHAPTER 4:

Ice Pick Scars

If your acne scars resemble small puncture marks, you likely have ice pick scars.

These are caused by deep cystic acne, such as a large cyst or nodule.

Use these effective treatments to get rid of ice pick scars for good:

• TCA CROSS
• Punch Excision
• Punch Grafting

TCA CROSS

TCA CROSS (“Chemical Reconstruction of Skin Scars”) is a simple and effective procedure for removing ice pick scars.

How It Works

It involves applying a high concentration of trichloroacetic acid (TCA), typically 70-100%, with a wooden toothpick to the base of the ice pick scar.

This burns away problematic scar tissue and triggers wound healing signals.

Collagen growth and tissue repair follows to help "fill in" the scar cavities.

The result is smoother skin and less noticeable acne scarring.

Here's an excellent video on TCA CROSS by Dr. Davin Lim.

Clinical Evidence

On average, studies have shown a 25% improvement in scar appearance after one session of TCA CROSS. Most people will need 3-6 sessions every 2 to 8 weeks. (5)

About the Procedure

During the treatment, it's perfectly normal to see a white frost appear. This will subside in a few hours and indicates the depth of TCA penetration.

Cost of TCA CROSS

According to Dr. Davin Lim, TCA CROSS costs between $1,000 to $1,400 per session.

Verdict

TCA CROSS is a simple and effective treatment for ice pick scars.

PROS

CONS

• Very effective for ice pick scars
• Noticeable results after 1-2 sessions
• Simple procedure

• Temporary discomfort and redness
• Relatively expensive

Punch Excision

If TCA CROSS was unsuccessful, you may want to consider surgical options such as punch excision. It's considered one of the best treatments for ice pick scars. (5)

How It Works

Your dermatologist or plastic surgeon will use a "punch tool" (the same one used for biopsies) to remove the ice pick scar.

Afterwards, they'll stitch up the wound with sutures or steri-strips.

Following surgery, collagen fibers form new skin tissue in place of the ice pick scar.

Keep in mind that this still leaves behind a small scar. For this reason, punch excision is often paired with laser therapy to remove residual scarring.

Here's a demonstration of punch excision by Dr. Jason Emer.

Cost of Punch Excision

According to RealSelf, punch excision may cost upwards of $1,000 per session.

Verdict

Punch excision is an effective surgical treatment for ice pick scars.

PROS

CONS

• Very effective for ice pick scars

• Surgery leaves behind a smaller scar
• Requires preparation and downtime
• Expensive

Punch Grafting

Punch grafting is an alternative technique for ice pick scars. (5)

How It Works

Similar to punch excision, a small tool is used to remove the scar. But instead of closing the wound, a skin graft (usually taken from behind the ear) is inserted.

The idea is for the skin graft to plug the hole and connect itself to the surrounding skin.

This makes the ice pick scar less noticeable.

Since grafts are taken from another part of your body, there's always a risk of texture and color mismatch with the original scar.

While highly effective, the procedure is also quite painstaking – up to 20 or more replacement grafts may be required in a single session (ouch!).

Cost of Punch Grafting

According to RealSelf, punch grafting may cost between $250 to $750 per scar.

Verdict

Punch grafting is an alternative surgical option for difficult ice pick scars.

PROS

CONS

• Very effective for ice pick scars, especially if they are unresponsive to traditional treatments

• Surgery leaves behind a smaller scar
• Risk of texture and color mismatch
• Expensive

CHAPTER 5:

Boxcar & Rolling Scars

Boxcar scars are indentations that look like a fingernail was pushed into your skin.

Rolling scars are continuous depressions that look like waves or ripples.

Both are caused when inflammatory acne has spread to the surrounding skin.

Try the following treatments to banish both types of acne scars!

• Microneedling
• Subcision
• Laser Resurfacing
• Radiotherapy
• Punch Elevation (boxcar scars only)

Microneedling

Microneedling is a simple and effective treatment for both boxcar and rolling scars.

This procedure is also known as skin needling or collagen induction therapy.

How It Works

Microneedling involves using a small handheld tool with ultra fine needles (derma roller or microneedling pen) to "punch" tiny holes into your skin.

This triggers inflammation and wound healing signals that stimulate collagen growth. Over time, new skin tissue "fills in" the old scar margins.

The result is smoother skin and an overall improvement in scar appearance.

Microneedling is particularly well-suited for darker skin tones due to the lower risk of hyperpigmentation compared to treatments like laser resurfacing. (10)

Clinical Evidence

Between 2011 and 2016, over 10 studies evaluated the effectiveness of microneedling. Most of these found microneedling was effective on its own or in combination with scar treatments like chemical peels and subcision. (10)

In particular, one study in 2014 of 30 patients noted that microneedling produced an average improvement of 50-75% on a scar assessment scale. (11)

About the Procedure

Before getting started, your dermatologist will apply a numbing cream or spray to help ease the pain and discomfort.

A recovery serum such as hyaluronic acid is also applied to lubricate the skin and encourage collagen formation after the treatment.

Microneedling is generally well-tolerated and requires no downtime. Redness and swelling should subside in 2-3 days.

Initial results are usually seen within 6 weeks with full results after 3 months. (5)

Skin texture may continue to improve over 12 months as new collagen is deposited.

Microneedling with PRP ("Vampire Facial")

Thanks to Kim Kardashian, the "vampire facial" has grown rapidly in popularity.

The actual procedure is called microneedling with platelet-rich plasma (PRP) and involves using your own blood as the recovery serum!

Before the treatment, a syringe of blood is taken from you and put through a centrifuge machine to separate the PRP from red blood cells.

But why put blood on your face?

As it turns out, PRP contains an abundance of growth factors essential for collagen formation.

By applying PRP directly, you can jump-start the recovery process and obtain better results from microneedling.

Maybe that's why vampires never age?

Here's a video demonstration of microneedling with PRP.

Cost of Microneedling

Standard microneedling costs anywhere from $200 to $700 per session. Keep in mind that most people will need 3-6 sessions for best results.

Microneedling with PRP will set you back around $750 per session.

Verdict

Microneedling is a simple and effective treatment for stimulating collagen growth.

PROS

CONS

• Very effective for atrophic scars
• Low risk of hyperpigmentation

• Mild pain, redness, and soreness
• Can be expensive

Subcision

Subcision is short for subcutaneous incisionless surgery.

It's considered the gold standard for removing tethered scars.

Boxcar scars and rolling scars are often held down by fibrous bands of scar tissue between the base of the scar and the underlying tissue.

These fibrotic "tethers" create the appearance of depressions and indentations.

How It Works

Subcision aims to eliminate atrophic scars by manually breaking the fibrous bands with a special needle (such as Nokor).

Following the procedure, new collagen growth raises the skin surface back to normal.

This can greatly diminish the appearance of boxcar scars and rolling scars.

Clinical Evidence

In a 2005 study of 40 patients, subcision resulted in approximately 50% improvement in scar appearance according to both patients and investigators. (12)

About the Procedure

Subcision is a simple and well-tolerated procedure.

First, a local anesthetic is injected to manage the pain and discomfort.

Your dermatologist then inserts a special needle under your skin to break the fibrous bands. The needle is passed in multiple directions to ensure no fibrotic tethers remain.

Some minor bleeding and soreness is expected after the operation.

Here's an excellent video of subcision by Dr. Davin Lim.

Contraindications

Subcision may not be suitable for those who:

• Have a history of keloid or hypertrophic scars
• Have bleeding or blood clotting disorders
• Are taking oral retinoids (Accutane)

Cost of Subcision

According to RealSelf, the average cost of subcision is around $1,450 per session.

Verdict

Subcision is the gold standard for removing tethered scars.

PROS

CONS

• Very effective for tethered scars (includes boxcar & rolling scars)

• Highly dependent on practitioner skill
• Expensive

Laser Resurfacing

Laser technology has been used for decades to treat all types of acne scars.

Today, fractional lasers provide excellent results with few side effects and very little downtime.

In addition, some such as the pulsed dye laser can reduce skin redness as well. (13)

How It Works

When laser energy penetrates your skin, it "vaporizes" the underlying cell tissue.

This causes targeted thermal damage in the dermis with minimal damage to the epidermis.

These wounds trigger inflammation and stimulate collagen production.

Over time, new collagen is deposited that improves the appearance of atrophic scars like boxcar scars and rolling scars.

I've included a brief overview of the different types of lasers below:

• Ablative Lasers
• Non-Ablative Lasers
• Fractional Lasers

If you prefer to watch a video, here's an excellent explanation of lasers for acne scars.

Ablative Lasers

Ablative lasers are more intense as they can remove entire layers of skin. Local anesthesia or sedation is often required to reduce discomfort and pain. (14)

Ablative lasers such as the carbon dioxide (CO2) and Erbium are much more effective for acne scar treatment. (15)

That's because these lasers go deeper and trigger collagen remodeling in the dermis.

Carbon Dioxide (CO2) Laser

The CO2 laser was considered the “gold standard” of laser treatment for wrinkles, fine lines, and acne scars during the late 1990s and early 2000s. (16)

However, there were many side effects, including pain, redness, and hyperpigmentation.

This caused many practitioners to switch to the Erbium laser.

Today, CO2 lasers have been largely replaced by fractional CO2 lasers, which provide similar results with fewer complications.

Erbium (Er:YAG) Laser

The erbium yttrium aluminum garnet (Er:YAG) is a milder type of ablative laser.

In practice, however, it was found to have similar side effects as CO2 lasers. (16)

Non-Ablative Lasers

Given the issues with ablative lasers, many surgeons switched to non-ablative lasers.

These work by heating up skin tissue without damaging the actual structure.

While non-ablative lasers have fewer side effects and shorter recovery times, they are less effective than their ablative cousins.

Neodymium (Nd:YAG) Laser

The neodymium yttrium aluminum garnet (Nd:YAG) laser is often used for patients with darker or more sensitive skin.

This procedure requires more frequent sessions (3-5 times per month) but can provide long-lasting improvements.

Fractional Lasers

Fractional lasers were a breakthrough in laser technology.

These types of lasers can achieve excellent results without the unwanted side effects.

Rather than a continuous beam, the fractional laser is split into thousands of microscopic treatment zones that are treated in pulses.

This allows more skin tissue to remain intact which significantly speeds up recovery times (24 hours compared to 2 weeks for ablative lasers) and limits adverse side effects.

Fractional lasers are available in both ablative and non-ablative versions. This comes as traditional lasers have adopted the fractional technique.

For instance, the fractional CO2 laser has replaced the traditional CO2 laser.

FRAXEL is a popular brand that offers fractional ablative and non-ablative lasers.

About the Procedure

People often describe laser resurfacing as "rubber bands snapping your skin".

A local anesthetic is used to dull the pain (sedation may be required for extensive treatments).

Your dermatologist then treats the acne scars with a laser wand.

Your skin will feel tender and swollen after the treatment (and appear red). Apply an ice pack and follow your doctor's instructions for at home care.

Depending on the laser, side effects may include hypopigmentation (loss of skin color), hyperpigmentation (darker skin color), and prolonged redness. (17)

Cost of Laser Resurfacing

Laser therapy tends to be an expensive procedure. According to the American Society of Plastic Surgeons, the average costs were:

• Over $2,100 for ablative laser treatment
• Over $1,100 for non-ablative laser treatment

Verdict

Fractional laser resurfacing can improve many types of acne scars.

PROS

CONS

• Effective for many types of acne scars
• May help with scar discoloration

• Mild pain, redness, and sensitivity
• Risk of hyperpigmentation (especially in darker skin tones)
• Expensive

Radiotherapy

Radiofrequency is a promising new treatment for atrophic scars.

Also known as microneedling fractional radiofrequency (MFR), it combines elements of microneedling, fractional laser techniques, and radiofrequency energy.

The main downside is the high cost and limited availability (the equipment can be prohibitively expensive for many dermatologists).

How It Works

A device similar to a microneedling pen is used to punch tiny holes into your skin. During each "punch", radiofrequency energy is emitted from the tips of the needles.

This causes targeted thermal damage in the dermis which triggers collagen remodeling.

The result is softer and smoother skin with less noticeable acne scarring.

Here's a demonstration of radiotherapy by Dr. Jason Emer.

Clinical Evidence

In one study, researchers evaluated the progress of 31 patients that underwent MFR for acne scar treatment. They found significant improvements after four sessions of radiofrequency spaced 6 weeks apart. (18)

About the Procedure

Your dermatologist will use a device (similar to a microneedling pen) to "stamp" areas across your face. This may require 2 full passes to cover the most surface area.

Side effects include mild pain, redness, and itchiness.

Cost of Radiofrequency

According to Fashionista, radiofrequency treatment can cost around $1,000-$2,500 per session. With multiple sessions, you could be looking at over $5,000 in costs.

It may be hard to find dermatologists that offer this treatment due to the high equipment cost.

Verdict

Radiotherapy is an expensive alternative for stubborn atrophic scars.

PROS

CONS

• Very effective for atrophic scars that are unresponsive to traditional treatments

• Limited clinical studies
• Limited availability
• Very expensive

Punch Elevation

Finally, punch elevation is a surgical technique that works well on boxcar scars.

This procedure is similar to punch excision (used for ice pick scars).

How It Works

Your doctor will use a small "punch tool" to remove the boxcar scar.

The skin tissue is then carefully pulled up to the level of the surrounding skin and held in place with sutures or skin glue.

Punch elevation is effective because it lifts the base of the boxcar scar to match the height of the surrounding skin.

The punched tissue is essentially a skin graft in the same location.

Since the skin graft is taken from the same site, there's no risk of texture or color mismatch (as with punch grafting). (5)

Similar to other punch techniques, this treatment will leave behind a smaller scar. So you'll need further treatments like laser resurfacing to get rid of residual scars. (19)

Cost of Punch Elevation

According to LakeView Dermatology, punch elevation may cost around $100 per scar.

Verdict

Punch elevation is an alternative surgical option for boxcar scars.

PROS

CONS

• Very effective for boxcar scars
• Raises the scar surface to match the surrounding skin

• Surgery leaves behind a smaller scar
• Requires preparation and downtime
• Expensive

CHAPTER 6:

Hypertrophic Scars & Keloids

If your acne scars are thick, hard, and elevated, you likely have a hypertrophic scar or keloid.

Also known as raised scars, these "knots" of skin tissue are caused by excess collagen.

Fortunately, there are many effective options for removing raised scars, including:

• Silicone Gels & Sheets
• Onion Extract Gel (Mederma)
• Corticosteroid Injections
• 5-Fluorouracil Injections
• Laser Resurfacing
• Surgical Excision

Hypertrophic Scar vs. Keloid

You may have heard the terms "hypertrophic scar" and "keloid" used interchangeably before.

However, they are not the same!

Keloids and hypertrophic scars are so similar that even doctors often can't tell the difference.

Both have a lumpy texture, appear discolored (red to pink), and may feel itchy or painful.

The key difference is that keloids tend to grow beyond the original wound.

Keloids also do not regress on their own. Hypertrophic scars, on the other hand, may disappear by itself within 1-2 years of the initial injury.

In addition, some individuals are genetically predisposed to developing keloids. Extra caution should be taken in these cases due to the higher risk of keloid recurrence.

Here's a summary of hypertrophic scars vs. keloids (20):

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Hypertrophic Scar Treatment

In 2014, the international advisory panel on scar management provided updated clinical recommendations on hypertrophic scar treatment. (21)

First-Line Treatments

The first-line treatment for hypertrophic scars is silicone gels or sheets. These are applied directly onto the scar for 2 months.

If there are no results, the panel then recommends intralesional corticosteroid injections (repeated monthly). This is a simple in-office procedure done by your dermatologist.

Second-Line Treatments

If there's still no progress, you may wish to consider laser treatments such as pulsed dye lasers and fractional CO2 lasers. These help remove scar tissue and encourage new collagen growth.

As a last resort, you may consider surgical removal. According to the panel, surgical intervention can relieve tension in the scar, a major factor in its development. (19)

Keloid Treatment

The international advisory panel also provided updated guidelines on keloid treatment.

First-Line Treatments

The first-line treatment for keloids is silicone gels or sheets plus corticosteroid injections (repeated monthly).

If there's no improvement after 8-12 weeks, the panel then recommends 5-fluorouracil in combination with corticosteroid injections.

Second-Line Treatments

If there's still no progress, laser therapy and surgical excision can be considered.

You should be aware that there's a high risk of keloid recurrence following surgery.

Silicone Gels & Sheets

Silicone gels and sheets have been a mainstay of scar management since the 1980s. (3)

They are used to treat mild cases of raised scars and often paired with corticosteroid injections or surgical excision.

How It Works

Researchers believe silicone products work by hydrating and protecting the scar tissue. This helps prevent skin dehydration which can trigger excess collagen production. (22)

Clinical Evidence

In a 2017 review of 20 clinical trials, researchers noted that silicone gels and sheets were effective at preventing scars and reducing scar thickness. (23)

Silicone Gels

Silicone gels are convenient, dry quickly, and better suited for scars on the face.

You should apply silicone gels twice a day for at least 2 months.

RELATED:

• Best Scar Gel
• Strataderm Review

Silicone Sheets

Silicone sheets are pre-shaped strips that work well for body scars.

You should wear silicone sheets for at least 12 hours a day for 2 months. (3)

After each use, the sheet must be rinsed and left out to dry (a bit inconvenient).

Verdict

Overall, silicone gels and sheets are highly recommended for all types of raised scars.

PROS

CONS

• Very effective for raised scars
• Very affordable

• Results take months
• Sheets require washing & drying

Onion Extract Gel (Mederma)

Mederma is a popular scar gel that uses onion extract (allium cepa).

How It Works

Studies show that onion extract can reduce fibroblast activity (cells that produce collagen). (24)

Onion extract also contains quercetin, a plant flavonoid that may inhibit collagen growth. (25)

By reducing collagen levels, onion extract helps prevent new scars and flatten existing ones. It can also reduce scar discoloration.

Clinical Evidence

The clinical evidence, however, is mixed:

• One study reported no difference between onion extract and Vaseline (26)
• Other studies reported positive results with onion extract (27, 28, 29)
• Most studies tested multiple actives instead of onion extract on its own
• One of the studies was funded by Merz (manufacturer of Mederma) (29)

Verdict

Overall, Mederma is an affordable option for preventing and treating raised scars.

PROS

CONS

• Softens raised scars
• May reduce discoloration
• Very affordable

• Mixed clinical studies
• May cause itchiness and irritation

Corticosteroid Injections

Intralesional corticosteroid injections (also called cortisone shots or steroid injections) have been used for acne scar treatment since the 1960s. (3)

Today, it remains one of the most effective options for raised scars.

Personally, I've had great success with it for my hypertrophic scars and keloids.

One advantage of corticosteroids is that it's injected directly into the scar tissue. This makes it much more potent at reducing scar height and discoloration.

How It Works

Researchers believe corticosteroids have anti-inflammatory properties that help "turn off" overactive wound healing signals which trigger collagen growth. (3)

This may explain why it can flatten hypertrophic scars and prevent keloid recurrence.

Studies on corticosteroid injections indicate a variable success rate of 50-100%. (3)

About the Procedure

Steroid injections are a quick in-office procedure done by your dermatologist.

Results typically require 2-3 injections (repeated monthly) but may take up to 6 months or more for larger scars.

Side effects include temporary pain and discomfort. Atrophy is a concern but can be mitigated through lower dose injections over multiple sessions.

Here's a demonstration of a corticosteroid injection by Dr. Ho Rui Ming.

Cost of Corticosteroid Injections

Prices range from $50 to $100 per session.

Verdict

Corticosteroid injections are an effective and affordable option for raised scars.

PROS

CONS

• Very effective for raised scars
• Reduces scar height and color
• Relatively affordable

• Temporary pain and discomfort
• Requires multiple sessions
• Risk of atrophy (rare)

5-Fluorouracil (FU) Injections

5-FU is a medication traditionally used to treat cancer. Recently, however, it's been successfully used for recurring hypertrophic scars and keloids.

According to the international advisory panel, 5-FU injections may be considered when scars are unresponsive to traditional therapies. (19)

How It Works

Researchers have found that chemotherapeutic drugs like 5-FU can disrupt fibroblast activity, which reduces collagen production. (27)

This may explain why 5-FU injections can stop keloids from growing larger.

In cases of recurrent keloids, the panel recommends 5-FU injections in combination with corticosteroid injections.

Verdict

5-FU injections are a promising alternative for treating recurring keloids.

PROS

CONS

• Can stop recurrent keloids
• Reduces scar height and color

• Limited practitioner experience
• Unknown long-term side effects

Laser Resurfacing

Lasers can also be used to remove scar tissue and encourage new collagen growth.

How It Works

Lasers used heat energy to destroy scarred collagen and stimulate cell repair.

Most lasers today are fractional lasers, where the laser beam is split into thousands of microscopic treatment zones.

The advantage of this design is that it leaves the surrounding skin intact. This results in fewer side effects and faster recovery times.

About the Procedure

Fractional CO2 lasers and pulsed dye lasers are both recommended for raised scars.

Several sessions are generally required and side effects are usually minimal.

Verdict

Laser treatments are an effective but expensive option for raised scars.

PROS

CONS

• Directly destroys scarred collagen
• May help with skin discoloration

• Limited clinical studies
• Expensive

Surgical Excision

As a last resort, hypertrophic scars and keloids may be removed through surgery.

According to the panel, surgical intervention can relieve tension, a major factor in scar development. (19)

It's really important to note that keloids have a high chance of returning after surgical removal.

To prevent keloid recurrence, the panel recommends adjunctive therapies, such as:

• Silicone gel or sheets
• Corticosteroid injections
• 5-fluorouracil injections
• Radiotherapy
• Chemotherapeutic agents

Speak with your dermatologist to determine if surgery is suitable for you.

Verdict

Surgical excision should be considered as a last resort due to potential keloid recurrence.

PROS

CONS

• May relieve scar tension
• May work well in conjunction with other treatments

• High risk of keloid recurrence
• Requires preparation and downtime
• Expensive

Additional Treatments

Supplemental treatments for raised scars include:

• Pressure Therapy: constricts blood flow to limit collagen growth
• Cryotherapy: freezes scar tissue
• Superficial Radiation Therapy: uses low dose radiation to stop keloid growth (28)
• Chemotherapeutic Agents: may limit scar growth

CHAPTER 7:

Hyperpigmentation

Hyperpigmentation (a.k.a. dark spots) is very common when a pimple leaves town.

Fortunately, these are not acne scars.

Post-acne marks like dark spots usually go away on their own. If you want to speed up the process, you can try:

• Vitamin C
• Retinol (Vitamin A)
• Skin Lightening Creams

What Causes Hyperpigmentation?

Dark spots are caused by excess melanin, a pigment in your skin that determines your skin color and shields you from harmful UV rays.

Melanin is produced by cells called melanocytes.

When your body is under attack by free radicals from UV rays, pollution, and other sources, melanocytes respond by creating more melanin.

That's because melanin has antioxidant properties that allow it to neutralize free radicals.

This is also why you get "tanned" from spending time in the sun.

Now, back to acne.

When your skin is irritated and inflamed from fighting acne, it may cause your melanocytes to create extra melanin as well.

This results in the dark spots and brown marks commonly seen after acne.

Vitamin C

Vitamin C does amazing things for your skin.

It can help reduce the appearance of hyperpigmentation and uneven skin tone.

How It Works

Remember how hyperpigmentation is caused by excess melanin?

Well, vitamin C is clinically proven to slow down melanin production. (29)

It does this by inhibiting an enzyme called tyrosinase (involved in producing melanin). This helps reverse dark spots and brighten your overall skin tone.

But that's not all.

Vitamin C also promotes collagen formation. (29)

It influences gene expression and provides essential inputs to collagen production. This can help improve the texture of atrophic scars like boxcar and rolling scars.

Finally, vitamin C protects our skin from sun damage.

It has antioxidant properties that prevent UV rays from damaging our skin cells. (29)

UV rays are known to cause sunburn, dark spots, and skin cancer. (30)

Look For:

• L-Ascorbic Acid
• Sodium Ascorbyl Phosphate
• Magnesium Ascorbyl Phosphate
• Ascorbyl Glucoside

RELATED:

• Best Vitamin C Serum for Hyperpigmentation

PROS

CONS

• Brightens overall skin tone
• Promotes collagen production
• Protects skin from UV rays

• Stability issues with L-ascorbic acid
• Vitamin C serums can be expensive

Retinol (Vitamin A)

Retinol is another excellent ingredient for hyperpigmentation.

It's the strongest type of retinoid (class of vitamin A derivatives) available in OTC products.

How It Works

Similar to vitamin C, retinol reduces melanin production by inhibiting tyrosinase. This helps fade post-acne marks and troublesome dark spots. (31)

Retinol also increases cell turnover. This means dead skin cells naturally fall off faster to reveal smoother and brighter skin. (31)

PROS

CONS

• Smoother and brighter skin
• Increases cell turnover

• Potential skin irritation
• Increased sun sensitivity

Skin Lightening Creams

There are many skin brightening creams with active ingredients that target hyperpigmentation.

Look for some of these clinically-proven ingredients:

• Vitamin C: inhibits melanin, promotes collagen formation
• Retinol: inhibits melanin, increases cell turnover
• Niacinamide: prevents skin cells from receiving melanin
• AHAs: chemical exfoliation, increases cell turnover
• Kojic Acid: derived from fungi, powerful tyrosinase inhibitor
• Azelaic Acid: corrects uneven skin tone and dark marks
• Arbutin: powerful natural brightening agent found in bearberry
• Mulberry: helps with hyperpigmentation and used in traditional Chinese medicine
• Licorice Root: anti-inflammatory, helps with uneven skin tone

RELATED:

• Best Skin Lightening Cream for Hyperpigmentation
• Meladerm Review

PROS

CONS

• Creams are very affordable
• Bonus: skin hydration!

• Results may take months

CHAPTER 8:

How to Prevent Acne Scars

No matter how good the treatment, you can never completely eliminate an acne scar.

Scars will always be slightly different in texture or color from the original skin.

So the best strategy is to prevent acne scars in the first place!

Here are some tips on doing just that.

Here are some of my top tips on preventing acne scars.

Aggressively Treat Cystic Acne

One of my regrets as a teenager is not proactively treating my cystic acne sooner.

Had I done so, I'd have avoided most of the acne scars that I have today.

So make sure to aggressively treat cystic acne early on and you'll save yourself lots of pain and headaches in the future!

Here are my go-to products for treating pimples and cysts:

• 2% Salicylic Acid (I use this one by The Ordinary)
• Sulfur (I use this one by Kate Somerville)

If you find that topical treatments are not enough, speak to your dermatologist about additional options for severe acne (such as Accutane). You may also wish to visit an esthetician or clinic that has specialized in acne treatment (such as this one).

Sun Protection

Try to make it a habit of applying sunscreen before heading outside.

Even on cloudy days, there can still be significant UV rays that penetrate the atmosphere.

Avoid Picking Pimples

Unless you know what you're doing, don't pick at inflamed pimples and cysts!

You're more likely to aggravate the problem and increase the chance of acne scarring.

Drink LOTS of Water!

Hydration is often overlooked when it comes to acne scars.

Water is absolutely essential for healthy skin and normal wound healing.

So drink lots of water and also keep your skin hydrated with lotions and moisturizers!

CHAPTER 9:

Frequently Asked Questions

In this final chapter, we address some of the most common questions on acne scars.

What are acne scars?

Acne scars are damaged skin tissue caused by inflammatory acne.

They can be pitted, indented, or depressed, as with atrophic scars like ice pick scars, boxcar scars, and rolling scars.

Or they can be hard, lumpy, and elevated, as with raised scars like hypertrophic scars and keloids.

For more information, see Chapter 1.

How to get rid of acne scars fast?

Unfortunately, there's no overnight "quick-fix" for acne scars. That's just the truth.

The best thing you can do is learn more about acne scars and the available treatment options.

Then visit your dermatologist or other medical professional to decide on a treatment plan.

You can start right here with this definitive guide to acne scar treatment!

What causes acne scars?

Acne scars are caused by chronic inflammation that destroys healthy skin tissue.

This is usually associated with severe and prolonged cystic acne.

For more information, see Chapter 1.

How to get rid of acne scars naturally?

There's a lot of interest in using natural remedies for acne scars.

This include products like aloe vera, coconut oil, shea butter, and more.

In general, there isn't much clinical evidence yet to support or refute using natural remedies for acne scars.

If you want to see a science-based review of these natural remedies, let me know!

How to prevent acne scars?

If you want to prevent acne scars, it's important to aggressively treat cystic acne with topical treatments like salicylic acid, benzoyl peroxide, and sulfur.

If your acne is unresponsive to traditional treatments, speak to your dermatologist about additional options (including Accutane).

For more tips, see Chapter 8.

How to cover acne scars?

There are many products that claim to conceal acne scars, for those days when you want to look your best and not have to worry about them.

Acne scar concealers don't do anything to help the scar itself as it merely tries to camouflage the appearance of the scar.

Dermaflage is a well-known brand of acne scar concealers.

How to get rid of chest acne scars?

I know about this one all too well.

Acne scars on the chest are often keloids that appear spontaneously. This is due to the high tension in the upper chest (presternum) area.

Corticosteroid injections plus silicone gels are very effective for flattening keloids on the chest.

For more information, see Chapter 6.

How long does it take for acne scars to go away?

The answer is it depends.

Mild cases of atrophic and hypertrophic scars may go away on their own in 6 months to a year as your skin repairs itself and new collagen is deposited.

On the other hand, severe cases of acne scars like deep ice pick scars, widespread boxcar or rolling scars, and keloids are more difficult to treat.

These will not subside on their own and can benefit from professional treatment under a qualified medical professional.

References

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27. Ho WS, et al. “Use of onion extract, heparin, allantoin gel in prevention of scarring in chinese patients having laser removal of tattoos: a prospective randomized controlled trial.” Dermatological Surgery vol. 32,7 (2006): 891-6. https://www.ncbi.nlm.nih.gov/pubmed/16875470
28. Beuth J, et al. “Safety and efficacy of local administration of contractubex to hypertrophic scars in comparison to corticosteroid treatment. Results of a multicenter, comparative epidemiological cohort study in Germany.” In Vivo vol. 20,2 (2006): 277-83. https://www.ncbi.nlm.nih.gov/pubmed/16634531
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