Most of us can relate: We picked at a pimple, and then picked at again, and then lo and behold, a scar was left behind, whether that be an “acne mark” like a dark spot, or a scar. And sometimes it occurs even without picking, which, of course, is incredibly frustrating. “Unfortunately, all skin types can be prone to acne scarring,” says Delray Beach, FL dermatologist Francesca Lewis, MD.
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However, acne scarring varies greatly, from alterations in skin pigmentation to changes in texture, which is what we think of when we think of traditional scars, like those from surgery. “An alteration in the skin’s surface is what we consider a ‘real scar’ and not color change,” adds Spokane, WA dermatologist Wm. Philip Werschler, MD. Here, we get all the details on acne scarring, straight from the pros.
Which skin types and colors are most prone to discoloration from acne scarring?
When dermatologists discuss skin types, they classify them using the 6 Fitzpatrick Skin Types (FST), with 1 being the most fair skin that always burns and never tans, and 6 being dark brown or black skin that never burns and always tans. “Interestingly, we see the most significant pigmentary alteration—hyperpigmentation ‘dark scars’— in the middle skin types, especially FST 3 and 4,” says Dr. Werschler. “There is a tendency to see post-inflammatory erythema—redness or ‘red scars’—in FST 1 and 2. Hyperpigmentation is more difficult to spot in FST 5 and 6. With excessive manipulation, any skin type can develop ‘white scars’ or areas of pigment drop out, which is referred to as post-inflammatory hypopigmentation. This is very hard to treat and also cover up.” Dr. Lewis agrees, saying it is common to see pink scars in fair-skinned patients and hyperpigmented scars in darker-skinned patients.
What about textured scars (versus discoloration)?
“We divide scars into three basic types: elevated or hypertrophic/keloid; depressed or pitted or atrophic; or flat with textural change,” Dr. Werschler explains. “The vast majority of textural and depressed acne scars results from picking, manipulation, poking, etc. Elevated or papular or hypertrophic scars—the first group—are frequently from a genetic predisposition to heal with an over-abundance of collagen. This can happen in all skin types, but is more common in FST 1, 5 and 6.”
Though genetics play a role, Dr. Werschler says redheads and darker skin types seem to be predisposed. “Historically, African Americans were considered to be more prone to keloid-type scarring, but this type of scar can occur in any skin type,” adds New York dermatologist Doris Day, MD. And though these types of raised scars can occur on all areas of the body, they’re more common on the chest, jawline, tops of shoulders and even earlobes.
Atrophic scars are described as flat, shallow depressions that heal below the top layer of skin. “This is another form of acne scarring, which includes different types like boxcar scars, ice pick scars and rolling scars,” says Dr. Lewis. Boxcar scars typically result from widespread acne on the lower face, and are usually box-like with defined edges. Ice pick scars are also common on the cheeks and lower face, and look like smaller, more narrow indentations that point downward into the skin, as if an icicle were to prick your cheek. Rolling scars appear wavy and vary in depth across the skin.
What are the best topical products to use for treating hyperpigmentation from acne scars?
Though hydroquinone is a hot button ingredient, Dr. Day still considers it the gold standard for lightening dark spots. “I typically use a 4-percent formulation, and often combine it with tranexamic acid, vitamin C and retinol. However, arbutin is a good and safe substitute for hydroquinone,” she says. “I love my Ultra Brightening Cream for hyperpigmentation from acne or from the sun. It contains arbutin, vitamin C ester and a gentle yet powerful retinol called HPR. I also like philosophy Miracle Worker.”
Dr. Lewis is also a fan of hydroquinone, but most often recommends a combination of prescription and medical-grade skin lighteners to help fade the scars. “A mainstay of treatment is prescription-grade hydroquinone, which will help effectively lighten the marks over a period of two to three months. We may also combine ingredients such as kojic acid, arbutin, tranexamic acid, and azelaic acid in prescription compounded topical creams or medical-grade skin care.”
Washington, D.C. dermatologist Tina Alster, MD prefers “a combination of A Method C Antioxidant Gel 20%—to brighten skin in the morning under sunscreen—and A Method Advanced TX Lightening Gel Elixir to fade pigmentation at night while sleeping. The TX stands for tranexamic acid, which lightens and corrects skin discoloration.”
Dr. Werschler considers himself “a bit old school” on treatments, but his protocol almost always involves an “old-formula combination of tretinoin, hydroquinone and triamcinolone. “This is referred to eponymously as the Kligman formula,” he says. “But there are many good OTC products out there as well.”
Regardless of skin type, all dermatologists stress the importance of using sunscreen to minimize redness and hyperpigmentation from acne, and to help it heal with minimal to no scarring. “I recommend applying a zinc-based SPF every single morning,” adds Dr. Day.
Which in-office treatments are best for correcting hyperpigmentation from acne scars?
Hyperpigmentation can be treated with a variety of interventions, from light microdermabrasion to superficial fractionated laser treatments. Although Dr. Alster recommends laser treatments for a wide variety of scars, including keloids and atrophic acne scars, she prefers a different method for treating hyperpigmented acne scars. “I use either chemical peels or microneedling because these treatments do not heat the skin, which often worsens hyperpigmentation,” she explains.
Dr. Lewis also utilizes chemical peels for pigmented scars, as well as “microneedling treatments or ResurFx laser for depressed scars, IPL—Intense Pulsed Light—or excel V for pink scars, and the Clear + Brilliant laser for overall skin tone and rejuvenation.”