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About Face

Chapter Four Acne Scarring Types of Scars Scar Treatments Dermabrasion Injections Dermal Punch Grafting Excision Face-lift

Types of Scars

The kind of scars caused by acne usually are “nonlinear”, meaning they do not have length. People who have been in a car accident, or suffered wounding from a knife, for example, would have long linear scars to deal with. Instead, a typical nonlinear scar caused by acne looks like a small pit in the surface of the skin. A more dramatic kind of scar caused by acne is the “ice pick” scar. This is a tiny, but very deep, pit in the surface of the skin - it looks like someone has taken an ice pick to the skin and punched a hole.

The body repairs itself by forming scars. After the infection and the inflammation caused by P. Acnes has subsided, the body repairs the damage done by creating a scar. It’s a process that might be repeated again and again over several years. The extent of the nature of scarring will depend on the depth and intensity of damage, and the length of time an area suffered inflammation. The result is an “underground”, or subcutaneous, network of scars: individual pits that show on the surface and tunnels that connect some of them below. Tunneling happens when two or more follicular canals rupture at the same time and join together as they heal.

To describe the condition to my patients, I sometimes use the layout of a bungalow for illustration. Think of the hallway in the bungalow as the tunneling. The hallway leads into various rooms, some of which have exits to the outdoors, some of which don’t. The rooms with exits are like fistulas in the skin that show on the surface with pits. The rooms without exits are cysts: pockets created under the skin attached to one another with tunnels, but with on exit to the surface. The scarring that you see on the surface might not reveal the full extent of scarring beneath the skin, just as a bungalow with a front and a back door doesn’t reveal all its rooms. And so, inflammation caused by acne creates tunnels, fistulas and cysts. The entire microscopic network is rigidly cast with scarring.

The first think I’ll do when a patient comes to me with acne scarring is examine the scars under an overhead light. Most acne scars are pits less than five millimeters in diameter with sharp “shoulders” perpendicular to the skin. They aren’t much wider than this because the hair follicle itself is only one or two millimeters in diameter, so the subsequent scar created in the follicular canal is not significantly bigger. Acne scars vary in size and shape from being relatively shallow to being narrow and very deep - the ice pick scars. As most public places are lit from above, it’s important to see how light is catching the scars. The rough edges of the pits actually cast tiny dark shadows.

Underneath the surface of the skin, subcutaneous scarring can cause a second visual effect by altering the contours of the face. Scarring causes a certain loss of tissue under the dermis layer of skin, and if the scarring extends over a wide-enough area, it’ll create a noticeable depression, a kind of shallow crater like you see on the surface of the moon. We call these “flat ovoid depressions”; they can be as wide as two centimeters in diameter.

Another kind of subcutaneous scarring results in “undulations”, or a washboard effect, especially in the cheek area. When scars mature, they contract, and if the scarring beneath the skin is extensive enough, the skin will pull up like an accordion under the surface.

Most acne patients have a combination of the various effects of scarring, though one kind of scarring often dominates. And the combination might vary from one area of the face to another. The center of a cheek might show mostly ice pick scars; toward the outside edges of the cheek, the scarring might be wider and shallower. The chin sometimes produces its own sort of scarring, called nodular scarring, which shows up as a patch of tiny bumps. The bumps are permanent scars that have thickened with age.

The thing about any kind of scarring, acne scarring included, is that a facial cosmetic surgeon can rarely take it away, or get rid of it. What we can do, as noted earlier, is play tricks with the eye so that the scarring is camouflaged. It’s a kind of trompe-l’oil where we alter the scarring so that light reflects on it differently or so that it fits the contours of the face in a subtler way.

Before anything can be done for a patient with acne scarring, the acne itself has to be permanently quiescent, meaning no longer active or continuing to produce eruptions. For most people, the worst of it is over by their mid-twenties, and we can start to treat them, but there is a relatively new drug on the market that helps to quiet the acne more quickly. It is 13-cis-retinoic acid - called Accutane.

Accutane was developed by the Roche drug company about six or seven years ago. It is available by prescription through dermatologists. What it does is slow down the maturation process of the epidermis, when, as I explained earlier, the cells migrate up from the basal layer to the surface to create new skin. Accutane “normalizes” the process in teens who are producing too much sebum and too much keratin. They stop having the problems of inflammation caused by plugged follicular canals.

Accutane is a very powerful drug, and the Compendium of Pharmaceuticals and Specialties lists many possible side effects. For example, Accutane is considered very dangerous to a fetus - no pregnant woman should consider taking it. Patients usually take it in cycles of only three or four months at a time, sometimes extended over a couple of years. It was originally prescribed by dermatologists for extremely bad cases of cystic acne. Now, with careful supervision and monitoring, including monthly liver tests, they’ll use if on less active forms of acne vulgaris.

I can’t do much for patients with acne scarring until the acne is quiescent and/or they’ve been off Accutane for at least six months.

This is because some of the effects of the drug are still at work on the epidermis, slowing down the creation of new skin. But the procedures we use to treat acne scarring require plenty of healing, and healing is partly a function of generating new skin.

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