Pulling in: Scars caused by loss of tissue

Some acne scars appear as holes, pits, or craters in the skin. Called
atrophic scars or crateriform scars, these depressed, cavity-like,
inward-directed scars are associated with a lack of tissue that
occurs when the inflammation from healed acne causes destruction
to the skin (similar to scars that often result from chickenpox). The
scar tissue contracts and binds the skin down.
Terms and descriptions related to this type of scarring will be help-
ful when talking with your dermatologist and reviewing treatment
options, because some treatments work better than others for dif-
ferent scars. Here are some more descriptive names:
Ice-pick scars: These scars are the most common acne scars
that occur on the cheeks. They’re most often small, with a
somewhat jagged edge and steep sides — like wounds from an
ice pick. They can be shallow or deep. Ice-pick scars may
evolve into depressed fibrotic scars over time.
Depressed fibrotic scars: These scars are usually quite large,
with sharp edges and steep sides.
Boxcar scars: These scars are angular and usually occur on
the temple and cheeks, and can be either superficial or deep.
They are similar to chickenpox scars.
Rolling “hill and valley” scars: These scars give the skin a
wavelike appearance. They have gently sloping rolled edges
that merge with normal skin.

acne scars and a look at the treatment

Thinking about Therapy

Your dermatologist, internist, pediatrician, school nurse, school
counselor, or other healthcare provider may be able to steer you in
the right direction and find someone who can help you or your
child contend with some of these emotional issues while they work
on the physical ones.
The good news is that the vast majority of people suffering from
depression can be treated successfully. Speak to your doctor about
the way you feel and ask her to treat you or your child or to make a
referral to a psychologist or psychiatrist.
Ideally, you or your child’s primary care provider or psychothera-
pist should maintain a close relationship with your dermatologist
so that they can discuss treatment and any changes in medica-
tions, and so on.
There are many types of psychotherapy and psychotherapists. You
can choose from:
 Psychiatrists: They are medical doctors and are able to pre-
scribe prescription medications, if required.
 Clinical psychologists: They usually have a master’s or doc-
toral degree in psychology.
 Psychiatric social workers: To become qualified as a social
worker that provides psychotherapy, a person must have
earned a minimum of a master’s degree in clinical social work.
 Counselors: Generally, they may have only a bachelor’s
degree in education, psychology, or theology.
Some dermatologists, albeit few and far between, are capable of
handling both the physical and emotional consequences of acne.
Several of my colleagues have been trained as dermatologists as
well as psychologists and psychiatrists. If you’re fortunate to have
access to any of these specialists, go for it!
Avoid quick fixes promised by audio and videotapes or books. You
can’t find true “quickie cures” for acne or for its emotional compo-
nents. Both sets of symptoms require time and patience.

Recognizing acne as a feature of emotional disorders

When self-esteem and self-image become an overwhelming preoccupation in some
people, they may show signs and symptoms of types of acne that have severe
underlying emotional and psychiatric underpinnings.
 Acne excorieé. This is a self-inflicted skin condition in which the sufferer has a
compulsive, irresistible urge to manipulate their skin and to pick real, as well as
imagined, acne lesions. This results in a worsening of acne and sometimes scar-
ring of the face. Also known as acne excorieé des jeunes filles, this type of acne
is almost invariably seen in young females. Jeunes filles means “young girls” in
French, but this condition is also seen in adult women (and males aren’t immune).
Many of these females deny that they manipulate their skin, but it’s rather obvi-
ous when you can see scabs that are almost always present on their faces. It’s
assumed that they have an underlying obsessive-compulsive disorder, a type
of emotional problem characterized by persistent thoughts and ideas and repet-
itive behavior.
 Body Dysmorphic Disorder (BDD). This psychiatric condition is characterized
by a fixation and chronic complaining about a nonexistent or minimal cosmetic
defect or minor flaw in one’s physical appearance. The “flaw” can be wrinkles,
large pores, or just a few pimples. The person with BDD exhibits an unreason-
able amount of anguish about them. BDD occurs equally in males and females.
BDD often results in significant suffering and social difficulties. Individuals with
BDD have variable degrees of awareness concerning the psychiatric nature of
the illness. Many people continue to agonize about an imagined defect although
they’re aware that their concerns are excessive, while other folks have no insight
into their unusual preoccupation with their appearance. Some people with BDD
frequently develop major depressive episodes and are at risk for suicide.
Treating acne excoriée and BDD is a major challenge. Certain medications and
cognitive-behavior therapies can complement each other and be helpful for some
people. Cognitive-behavior therapy involves discovering, challenging, and changing
the underlying negative thoughts and beliefs that the people with these conditions
repetitively dwell upon.
In addition to these treatments, family education and counseling, to help family
members understand what’s going on and how to help the sufferer, and group ther-
apy may be of benefit. Unfortunately, individuals with acne excoriée and BDD often
refuse psychiatric referral because of their poor insight into the underlying psychi-
atric illness.

Accutane and depression: Is there a link?

For several years, there has been debate over whether Accutane
(isotretinoin), a drug prescribed for serious cases of acne, could be
causing depression that results in suicide in teenagers taking this
powerful medication. Turn to Chapter 13, where I take on this con-
troversial debate about this drug and its generic formulations.
Lots of kids with acne who have never taken Accutane are
depressed. Moreover, since Accutane was introduced in 1982, it’s
likely that depression during this time has decreased in those who
sorely needed the drug and were successfully treated with it.

Helping Your Child Deal with Acne

Acne affects adolescents at a time when they’re developing their
personalities and evolving into adulthood. During this time, peer
acceptance is very important to them and physical appearance
and attractiveness is highly associated with peer status. Besides
the physical scars that severe acne can produce, your teen may
also be suffering emotionally.
Acne can be a real drag on a kid’s daily life. Acne on the face can
bring out cruel taunts, teasing, and name calling from other kids.
Some kids become so preoccupied with how their skin looks, that
they may not want to go to school, lose self-confidence, pull away
from their friends, show a dramatic change in their thinking and
behavior, become withdrawn, and even may begin to feel depressed.
The following list goes over some of the various teenage behaviors
and coping mechanisms that they may develop to deal with acne:
 Grow their hair long to cover their face.
 Become so embarrassed that they avoid eye contact.
 “Cake on” heavy makeup to hide the pimples.
 Lose interest in sports such as swimming or basketball
because of the need to undress in locker rooms and expose
their back and chests.
 Become shy and even isolated and prefer to stay in their
bedrooms.
 Start to develop any of the symptoms of depression from the
list in the “Detecting depression in teens” section.Offering your help
Here are a few seemingly simple, yet effective, ways to communi-
cate your willingness to help:
 Let your children know how much you care: Give your child
adequate time to bring up the subjects of their acne and allow
them to address or respond to your questions about the
behavioral changes you’ve noticed.
 Listen patiently: They may want to communicate their feel-
ings but have difficulty doing so. Think back to your own teen
years. You may not have always felt like it was easy to be open
about your thoughts and feelings.
 Don’t be overly judgmental about your child’s appearance:
Approach the subject of acne in a gentle, caring manner and
try to give a little space when it comes to some of the rela-
tively harmless decisions they make about their clothing and
grooming habits.
 Keep the lines of communication open: Take the time to pay
undivided attention to your kid’s concerns. It’s important to
keep the lines of communication open, even if your child
seems to want to withdraw.
 Don’t lecture on the subject: Try to avoid telling your child
what to do. Instead, pay careful attention and you may dis-
cover more about the issues causing his problems.
Detecting depression in teens
It is common for adolescents — or anybody for that matter — to
occasionally feel unhappy. However, when the unhappiness lasts for
more than two weeks, and the teen experiences other symptoms,
then he may be suffering from depression. Determining if a teenager
is depressed can be a very tricky undertaking. Dramatic physical
and mental changes seem to take place almost overnight and it
sometimes seems hard to tell the “normal” from the “abnormal.”
Depression is a more commonly recognized condition in adoles-
cents than it had been in the past. Parents should look for common
signs of depression in adolescents and they should be dealt with in
a serious manner and not just passed off as “growing pains” or the
normal consequence of adolescence. If you observe some of the
signs or behaviors listed in the following bulleted list, they may be
indicators of depression. They’re not always diagnostic of teen
depression; however, they may indicate other psychological,
social, family, or school problems. Among these are:
 Sadness, anxiety, or a feeling of hopelessness
 A sudden drop in grades
 Loss of interest in food or compulsive overeating that results
in rapid weight loss or gain
 Staying awake at night and sleeping during the day
 Withdrawal from friends
 Unusual irritability, rebellious behavior, or cutting school
 Physical complaints, such as headaches, stomachaches, low
back pain, or excessive fatigue
 Use of alcohol or drugs
 Promiscuous sexual activity
 A preoccupation with death and dying
Don’t be afraid to talk to your child about feelings. If you sense a
change or that something is seriously troubling your child, you
may be right. You can even ask about suicidal thoughts. You won’t
increase the possibility of suicidal behavior by asking if someone
has thought about it. Asking such a question does not “put
thoughts into their heads” but rather is more likely to identify if
they may be at risk.
If you or your loved one is finding it extremely difficult or impossi-
ble to handle the emotional aspects of acne, get help. And, if you
don’t feel that you can communicate effectively with your adoles-
cent, get help. Talk to your pediatrician or primary care practi-
tioner or ask for a referral for counseling. Strong suicidal thoughts
are an emergency and call for immediate action. Don’t go it alone.

Detecting Depression in Yourself and Your Family

It’s very normal for people with severe acne to feel down and
despondent; even mild acne can give you the blues. However, if
you or someone in your family is feeling unhappy more often and
doesn’t seem to enjoy anything anymore, you need to consider the
possibility that you or that person may be suffering from depres-
sion. Here are some of the signs of depression:
 Increased fatigue, low energy
 Feelings of pessimism
 Loss of enjoyment in things that previously gave pleasure
 Crying spells
 Sleep disturbances
 Hating to get out of bed
 Social isolation
 Loss of appetite or the opposite
 Lots of new physical complaints
 Decrease in sexual drive
 Irritability, anger, or aggressiveness
 Feelings of worthlessness and guilt
 Withdraw from family and friends
 Suicidal thoughts
If one or more of these descriptions rings a bell, talk to your doctor
about it. If you or your loved one is having suicidal thoughts, seek
immediate evaluation and treatment.

Facing Acne Can Be Tough — Bu You Can Do It

Our society places a great emphasis on physical appearance. In a
culture where looks are overly emphasized, feeling good about
yourself is easier said than done. We’re constantly bombarded with
advertising that displays models and movie stars, all of whom are
depicted as paragons of beauty and flawless perfection. They often
serve as the spokespeople for health and beauty aids that imply
that you can look like them if you “get with it” and do what they do
or buy the products they’re promoting.
When you see media portrayals of all those people with perfect
skin, just remember that almost all of those photos are touched-up
and airbrushed. Some of the models even have acne, just like you!
Even mild cases of acne can leave a person with a negative
self-image — sometimes well beyond the degree of the actual phys-
ical appearance. These negative feelings are particularly prevalent
when you have a concentration of lesions on your face, which is
your greeting card and introduction to the world. Unlike many
other skin conditions, acne lesions wind up on areas that often
aren’t concealed by clothing.
Acne is often a source of anxiety that can impact your self-image
and confidence. Some of the things you might be experiencing are:
 Feeling uncomfortable in social settings
 Having less self-confidence
 Becoming more preoccupied with your appearance
 Feeling like you’re trapped in a perpetual adolescence
 Being sad and sometimes getting depressed (see the following
sections)
These negative effects and feelings can put pressures on your
social, work, or school life.
Here are some suggestions that you can use to cope with some of
these negative feelings:
 Wash your face no more than two to three times a day (unless
you’re a coal miner!). Check out Chapter 2 for my face wash-
ing tips.
 Get a new haircut or hairstyle (bangs are great!). Spruce up your wardrobe.
 Educate yourself. Read about acne in this or other sources.
 Find the right dermatologist or healthcare provider to treat
your acne. (In Chapter 8, I tell you how to go about it.)
Here are some tips for if and when you start undergoing treatmen
 Stand at least two feet away from all mirrors for the next two
months.
 Measure progress monthly instead of daily; be a patient
patient!
 Take a picture of your acne when it’s at its very worst. Put th
picture in your bottom drawer and don’t look at it for two
months, because that’s how long it may take to see significan
improvement.
 Be sure you know the names of and exactly how to use your
acne medications. (I spell out all of this information in
Chapters 7 through 13).
 If you’re still feeling emotionally overwhelmed and possibly
depressed, see the next section.

Coping with the Psychological Scars

The psychological impact of acne can lead you to feelings of
diminished self-esteem and be a source of anxiety when it
comes to dealing with the world. If you’re a teen with acne, you
may have been told, “It’s no big deal, and anyway, you’ll grow out
of it. You’re just experiencing a normal part of life.” But to you,
having acne is a big deal; you feel insecure and lack self confi-
dence. Every day you have to deal with school and other kids who
seem perfect (even if they’re not). You don’t feel like you have time
to “grow out of it.”
The truth is that many folks don’t “just grow out of” acne and
others wind up growing into it. And if you’re an adult, you don’t
even get the benefit of having lots of other peers around in the
same boat. You have a whole different set of stressors (job inter-
views, presentations, black tie events, and carpools) associated
with your acne. And darn it, you thought you were past this stage
anyway.
The main thing to remember, whatever age you are, is that acne is
treatable. (Take a look at Chapters 7 through 15 to find just the
right way to treat your acne.) In this chapter, I talk about ways to
deal with the invisible scars that some people carry around with
them — the ones that are carried on the inside. Although most
other people see acne only on the surface, the burden goes much
deeper.

Considering emerging technologies

Many technologies that were initially developed as anti-aging wrin-
kle treatments are now becoming useful in treating the scars asso-
ciated with acne, including radio waves. This novel treatment,
referred to by the brand name Thermage, uses radiofrequency (RF)
emissions to deliver controlled amounts of energy (heat) into the
collagen layers of the skin. It has a cooled application tip to protect
the epidermis from heating up. It’s supposed to penetrate deeper
in the skin than other methods and cause thermal injury to seba-
ceous glands. Currently, it’s being used to tighten the skin as a non-
invasive face-lift. More research is needed to see if it works on acne
and acne scars. The procedure can cost between $2,000 and
$5,000. See Chapter 14.

Vacuuming your skin: Microdermabrasion

This technique is a surface form of dermabrasion. I call it “der-
mabrasion lite.” Rather than a high-speed brush, microdermabra-
sion uses aluminum oxide crystals passing through a vacuum tube
to remove surface skin. The crystals are literally blasted onto the
skin and then vacuumed away accompanied by surface skin cells.
Microdermabrasion can be performed by anybody — your Aunt
Gertrude, a physician, a nurse, or an aesthetician.
At most, microdermabrasion is effective in reducing fine lines,
“crow’s feet,” and age spots, but this treatment isn’t effective for
diminishing acne scars. That’s because only the very surface cells
of the skin are removed and a mild exfoliation takes place.
Microdermabrasion runs from $150 to $300 per treatment.
Dermabrasion may result in pigmentary streaking in people with
dark skin types. If you have dark skin, make sure your doctor has
extensive experience (and success) at treating others with your
skin type.

Trying out dermabrasion

Before there were lasers, superficial acne scars were smoothed out
with a procedure known as dermabrasion. Dermabrasion was used
to minimize small acne scars. As the name implies, dermabrasion
involves removing the top layers of skin.
Dermabrasion has been around for many decades. Initially, sandpa-
per was used to remove damaged skin and allow new skin to grow
in its place — yes, I’m serious. But now, electrical machines are
used to abrade the skin. These gadgets have quickly rotating
wheels that have a rough wire brush (fraise), or a burr containing
diamond particles. The wheel is attached to a motorized handle.
Dermabrasion may make ice-pick scars and depressed fibrotic
scars more noticeable if the scars are wider under the skin than at
the surface. Dermabrasion is used mainly for the “softer” scars. It’s
rarely used for hypertrophic scars. Over the past decade, this pro-
cedure has fallen out of favor with the availability of newer, easier-
to-use techniques such as lasers. I no longer recommend it.
A qualified dermatologic or plastic surgeon performs dermabra-
sion on a single visit as an office procedure. First she anesthetizes
your skin with a numbing spray, such a Freon. You may also be
given a sedative to make you drowsy before she sheers away your
scar tissue. A full-face dermabrasion can be as costly as a laser
resurfacing procedure. It can cost $2,500 to $4,500.
In darker-skinned people, dermabrasion may cause dramatic
changes in pigmentation and worsen hypertrophic or keloidal scars.

Contouring the defects: Fill ’er up!

Another option for improving the appearance of certain acne scars
is known as soft tissue augmentation. These procedures have a very
limited use, and at most, they can help with some of the shallow
“hill and valley” soft scars with gentle sloping edges. They don’t
work well for ice-pick, deep boxcar, or depressed fibrotic scars.
Materials, including your own fat, can be injected into the depressed
area of the scar to elevate it to the level of the normal surrounding
skin. The material is injected under the skin to stretch and fill out
superficial and deep “soft” scars. Many substances are available and
many new ones continue to be introduced. Most doctors have a vari-
ety of fillers to choose from, including the following:
 Collagen: Collagen injections are intended to replenish your
natural collagen and minimize surface unevenness by lifting
and filling depressed lines and scars. The original bovine col-
lagens Zyplast and Zyderm can’t be used in people with
autoimmune diseases. Skin testing to look for possible allergic
reactions is necessary before they’re injected.
The newer human-derived collagen products such as
Cosmoderm and Cosmoplast offer alternatives to those who
are allergic to the bovine derived collagen. No skin testing is
required with these agents.
Collagen injections are temporary, and last about six months
(give or take a few months), so ongoing touch-ups are
necessary.
 Fat: To correct deeper defects caused by scarring from nodu-
lar acne, fat transplantation utilizes your own fat. The fat is
taken from another site on your own body and injectedbeneath the surface of the skin to elevate depressed scars.
Because the fat is reabsorbed into the skin over a period of 6
to 18 months, the procedure usually must be repeated.
 Newer fillers: There has been an increase in the number and
quality of filler substances used to help plump up acne scars.
Restylane and Hylaform are now available and there are many
more to come. Longer-lasting results are expected from these
materials.
Unless the borders of atrophic scars are soft, there is little place
for fillers in the treatment of acne scars. They’re probably best
used as a complementary procedure with other surgical treat-
ments described in this chapter. Depending on the type and
amount of filler used, treatment can cost between $400 and $750
and $1,000 and $1,200.

Considering other surgical treatment options

Atrophic scars, such as ice-pick scars, boxcar scars, and small
depressed fibrotic scars, may be removed or improved by a punch
excision of each individual scar.
Excising scars: When zits are literally the pits
In this procedure, each scar is cut down to the layer of subcuta-
neous fat; the resulting hole in the skin may be repaired with
sutures or with a small skin graft. Alternatively, the punch may
simply be elevated. There are three techniques:
 Punch excision: Your doctor removes the pitted scar with a
cookie-cutter-like tool that punches out small portions of skin.
The surrounding healthy skin is joined together by suturing.
 Punch replacement: As with the punch excision, the scar is
removed and then replaced with a skin graft of unscarred
skin, usually harvested from behind the ear. This method is
usually the most successful for treating deep scars.
 Punch elevation: Here the scar is punched out, but not dis-
carded. It is allowed to float up to the level of surrounding
skin.
Your dermatologic or plastic surgeon may allow the scar from
punch techniques to fade on its own. Or she may perform the pro-
cedure before a more generalized resurfacing technique such as
laser resurfacing is performed. Less commonly, dermabrasion,
microdermabrasion, and chemical peels are sometimes used in
conjunction with punch techniques.
The prices of these procedures vary and depend upon the number
of grafts or punches that are done. Punch grafting can run $50 to
$150 per graft or $1,000 to $2,500 per session.
Subscising scars
Subcision helps to restructure and remodel scar tissue by breaking
fibrous bands that are creating tension between the epidermis and
deeper structures. It also helps induce new collagen formation. This
method is useful for indented, rolling scars that result from scar
tissue holding the skin down. This is a very specialized procedure
that is performed by a qualified dermatologic or plastic surgeon.
To perform this technique, a sharp instrument such as a tiny
scalpel or needle is used to undercut and lift the scar tissue awayfrom unscarred skin, elevating the skin to make it even. The sub-
scising procedure breaks down adhesions (old bands of scar
tissue), which helps to reorganize the formation of new collagen
and elastic tissue for a smoother skin surface. The overlying skin
isn’t cut, so sutures aren’t needed.
This breaking down of scar tissue helps to level the playing field.
After the wounds heal, an injection with a filler material under the
scar can help to replace any remaining defects and bring them to
surface level. The filler can be made of one’s own fat or a collagen
or other synthetic substance that I describe in the section
“Contouring the defects: Fill ’er up!”
The procedure can cost between $200 and $1,000 depending on the
number of lesions treated.

Shooting scars

Non-ablative lasers include:
 InfraRed Lasers produce invisible light. They’re most commonly used for ther-
mally induced dermal remodeling and use water as their targets. They are min-
imally absorbed by melanin, the epidermal skin pigment, which makes them
suitable for all skin types. These lasers use aggressive skin cooling to limit the
heating effect, creating a controlled injury to the dermal collagen, with subse-
quent remodeling and tightening.
 N-Lite Laser is another non-ablative laser. It is now being used to trigger colla-
gen formation.
 Sprinkling laser beams: A kinder, gentler laser is now available. This latest laser
is called the Fraxel laser. Unlike older lasers, which shoot a single solid beam
of light, the Fraxel laser shoots out tiny clusters of beams that burn the skin in
patterns of dots. It burns away old skin cells and spurs the growth of new cells
and stimulates the production of collagen that, in time, tends to “fill the dots”
and smooth out the skin.
The theory behind this is that such “fractional” treatment allows the skin to heal
much faster than if the entire area were treated at once, using the body’s nat-
ural healing process to create new, healthy tissue to replace skin imperfections.
There is less injury to the skin with this method and less downtime compared
with the older lasers, and there’s minimal discomfort as compared to the abla-
tive lasers.

Laser skin resurfacing

There are many types of lasers and there are a number of new pro-
cedures now available that complement or even surpass previous
scar revision techniques such as those that I describe later in the
chapter. Treatment with some of these devices can be used to help
improve and treat acne itself (see Chapter 14 where I discuss other
types of lasers that treat acne in more detail), and as a simultane-
ous benefit, they can stimulate collagen remodeling and result in
the improvement of the appearance of acne scars.
Laser resurfacing can result in uneven skin tones in people with
darker skin.
Treatment with laser resurfacing takes place in an office setting.
Typically three sessions are performed. For a “full-face” resurfac-
ing, the cost can be $3,000 to $8,000 and up!
Sometimes, laser resurfacing and other surgical treatments
(described in the “Considering other surgical treatment options”
section) for acne scars are combined. The surgical treatment is
usually completed 6 to 12 weeks before the laser is called into
action. This waiting period gives your skin time to heal and
remodel itself.
The two major categories of lasers that are used in acne scar ther-
apy are the resurfacing (ablative) lasers and the non-ablative lasers.
Ablative lasers
The powerful ablative lasers literally remove the outer layers of
the skin by using high-energy light to burn away scar tissue, and
stimulate the dermal collagen to tighten, reducing the amount of
scar visibility.
This procedure is used for deeper scars and carries the risk of fur-
ther scarring. Because the skin is injured and unprotected tissue is
exposed, great effort must be put into post-operative wound care
and infection prevention. The skin may remain reddened for sev-
eral months or a year afterwards.
Non-ablative lasers
At first, ablative lasers were used to recontour or vaporize the skin’s
surface. Now, techniques involving non-ablative lasers have taken
over because of their ability to promote collagen growth beneath an
acne scar without creating an external injury. The non-ablative
lasers produce a controlled injury to certain target structures in the
dermis, while completely sparing the epidermis from damage.The laser beams can penetrate into the dermis without injuring the
epidermis. By heating dermal collagen, they help to “tighten” the
dermis and result in less visible scarring. The theory is that the ther-
mal injury caused by the laser triggers a wound repair response,
including fibroblast activation and new collagen formation.
Non-ablative laser resurfacing can be effective for treating shallow
boxcar scars, as well as for smoothing and tightening scars that
have been treated previously. It is not very effective for deep,
depressed, craterlike scars.
A topical anesthetic is applied by a doctor or his medical assistant
about an hour before performing these procedures to make the pain
tolerable. The surface of the skin is cooled to prevent the laser from
damaging the epidermis. A patient will feel both the cold spray as
well as some amount of stinging and heat during the session.

Treating Your Scars

Don’t start any treatment for scarring until your acne is completely
gone and unlikely to come back. If you go to all the trouble and
expense to undergo a procedure (or multiple procedures) and then
get more acne, and thus more scarring, you have to go through it
all again. Just imagine how expensive that would be!
Skin resurfacing techniques (like dermabrasion), surgical excision,
and fillers have been used to diminish acne scarring for years with
mixed results. Currently, laser therapy has assumed a more impor-
tant role in the treatment of acne scars, and other newer surgical
methods featuring light and radio waves are an option to treat
your acne.
Most scar treatment focuses on facial scars. Generally, scars on
the chest and back don’t respond as well to the treatments men-
tioned hereafter. Because these scars are so hard to treat, the best
approach is to try to prevent them in the first place. If the preven-
tion route fails, the intralesional cortisone (steroid) injections that
I describe in the “Growing out: Collagen running amok” section,
earlier in the chapter, may help to shrink them.
One remnant of the recent past in treating acne scars is the chemi-
cal acid peel. Peels are sometimes used in the treatment of acne
and dark spots (see Chapter 13), and you may still hear about
them in conjunction with treating shallow acne scars. But, for the
most part, the results of chemical peels in treating scars are disap-
pointing, and the method has been replaced by others, notably
lasers, that I discuss.

Finding a physician

When you turn your attention to the treatment of acne scars, it’s
especially important that you find a doctor who is trained and
experienced in the procedures that I describe in this chapter, for a
number of reasons:
 Many of the treatments have sometimes been offered by inad-
equately trained practitioners, sometimes with devastating,
disfiguring results.
 Some of the treatments may result in more scarring if you
have a propensity to develop hypertrophic scars or keloids.
You need a reputable, experienced physician to help you
weigh the pros and cons with this type of scarring.
With the exception of microdermabrasion and most chemical
peels, which can be performed by a physician, nurse, or licensed
aesthetician, the procedures described in this chapter are per-
formed by a dermatologist or plastic surgeon in her office.If your doctor or dermatologist doesn’t treat acne scars, check out
Chapter 8 where I tell you how to find a dermatologist who does.
You can also go to the Web sites of The American Academy of
Dermatology (www.aad.org) and The American Society for
Dermatologic Surgeons (www.asds-net.org). These sites can
help you locate a dermatologist who has specialized training in
cosmetic and other types of skin surgery.
To find a plastic surgeon who performs these procedures, visit the
online referral service of the American Society of Plastic Surgeons
(ASPS) at www.plasticsurgery.org. This is the largest plastic
surgery organization in the world and the foremost authority on
cosmetic and reconstructive plastic surgery. (Check out Chapter
21 for more online resources.)

Taking Initial Treatment Steps

The oral and topical treatments used to treat acne don’t do very
much to improve the appearance of acne scars. However, derma-
tologists and plastic surgeons do offer a number of treatment
options if you have scars. The type of treatment you decide upon
should be the one that is best for you in terms of your type of skin,
the cost of the treatment, and what you want it to accomplish.
Deciding whether you want
to do anything about it
A decision to seek treatment for acne scars, and the specific treat-
ments that you may choose, depend on a number of factors that
you and your doctor can discuss and weigh:
 How do you feel about your scars? You may have scars and
could care less about them or they may be psychologically
distressing to you. Do the scars emotionally affect your life?
Are you willing to live with your scars and wait for them to
fade over time?
 What’s your age, overall health, and medical history? If
you’re a teenager or healthy adult, you’d probably want to
wait until your acne is no longer active. If you’re an adult or
senior who has medical problems and are taking several med-
ications, consult with your primary care provider before
embarking on any surgical procedure.
 How bad are your scars? Are they disfiguring? The severity
of the scars can affect whether you’re willing to go through
treatment.
 What kind of scars do you have? Some scars respond more
readily to treatment, and others, like keloids, indicate that
treatment could actually cause more scarring. What’s your doctor’s opinion? An expert opinion as to
whether scar treatment is justified in your particular case may
help you decide upon the most effective treatment for you.
 What do you want to accomplish? Maybe you just want to
diminish the appearance of deep scars or maybe you’re trying
out for a part in a feature film.
 How will you pay for treatment? Get a handle on your
finances and insurance coverage before you make any deci-
sions. You need to determine the costs that you’ll have to pay
out of pocket and whether you can afford to do so. A signifi-
cant investment of time and money is often needed.
Most of these procedures aren’t covered by health insurance
plans because they’re generally considered to be cosmetic in
nature. It may go without saying, but I’ll say it anyway:
They’re all pretty expensive. Just to give you an idea, a laser
skin resurfacing can cost from $4,000 to $5,000 or more!
Also be aware that acne scars are particularly difficult to treat and
they can’t always be effectively corrected by one single treatment
method. In fact, using more than one method may yield better
results. Before committing to treatment of acne scars, you should
have a discussion with your doctor.

Pulling in: Scars caused by loss of tissue

Some acne scars appear as holes, pits, or craters in the skin. Called
atrophic scars or crateriform scars, these depressed, cavity-like,
inward-directed scars are associated with a lack of tissue that
occurs when the inflammation from healed acne causes destruction
to the skin (similar to scars that often result from chickenpox). The
scar tissue contracts and binds the skin down.
Terms and descriptions related to this type of scarring will be help-
ful when talking with your dermatologist and reviewing treatmentoptions, because some treatments work better than others for dif-
ferent scars. Here are some more descriptive names:
 Ice-pick scars: These scars are the most common acne scars
that occur on the cheeks. They’re most often small, with a
somewhat jagged edge and steep sides — like wounds from an
ice pick. They can be shallow or deep. Ice-pick scars may
evolve into depressed fibrotic scars over time.
 Depressed fibrotic scars: These scars are usually quite large,
with sharp edges and steep sides.
 Boxcar scars: These scars are angular and usually occur on
the temple and cheeks, and can be either superficial or deep.
They are similar to chickenpox scars.
 Rolling “hill and valley” scars: These scars give the skin a
wavelike appearance. They have gently sloping rolled edges
that merge with normal skin.Growing out: Collagen running amok
Scars that bulge out and look like lumps are associated with an
exaggerated formation of scar tissue due to excessive amounts of
collagen production. These are the two most common of this type:
 Hypertrophic scars: These scars bulge outward like lumps.
 Keloids: A keloid is a scar whose size goes far beyond what
would be expected from what seems to be a minor injury. It’s
kind of an “over-scarring.”
You can see examples of both of these scars in the color section
of this book. Both hypertrophic scars and keloids occur more
commonly in dark-skinned individuals. They also tend to run in
families — that is, growth of scar tissue is more likely to occur in
people whose relatives have similar types of scars.
These scars persist for years, but may diminish in size over time.
They’re notoriously difficult to treat and impossible to completely
eradicate. A single, optimal treatment technique for hypertrophic
scars and keloids hasn’t been developed, and the recurrence rate
of these scars after treatment is high.
Surgical management is reserved for cases that are unresponsive to
a conservative treatment, such as injecting cortisone into the scars
themselves. The cortisone injections often help to shrink thickened,
raised scar tissue. This procedure is similar to the procedure that is
used to treat acne nodules that I explain in Chapter 10. Surgical
treatment is a last resort because any person whose skin has a
tendency to form these types of scars from acne damage may also
form larger scars in response to any type of aggressive skin surgery.
In some cases, the best treatment for keloids in a person who is
highly likely to develop them is no treatment at all.
Certain lasers as well as intense pulsed light (IPL) devices that I
describe in Chapter 14 may prove to be effective for these stub-
born scars, but long-term studies are necessary to see how effec-
tive they will prove to be.

The bad news is that acne can have lingering long-term effects —
it can scar! The good news is that there are lots of ways to stop
acne from scarring, and many of them are presented in this book.
But if you already have scars, I have more good news — something
can be done about them. In this chapter, I delve even more deeply
into the dermatology tool chest in search of some heavy-duty and
“light” tools that may help you with your acne scars.
The treatments described in this chapter are considered to be
“surgical” in nature because they often involve cutting, abrading
moving, building up, and destroying tissue (skin).

Examining Acne Scars

Acne scars are caused by the body’s response — and sometimes,
overresponse — to injury caused by inflammatory acne lesions.
Most often, scarring results from severe nodular acne that occurs
deep in the skin. But, scarring also may arise from more superficial
inflamed lesions.
The term scarring technically refers to a process in which new
collagen is laid down to heal an injury. Collagen is a protein that
gives the skin its rigidity and strength and is produced by skin
cells called fibroblasts. In Chapter 3, I talk about how scars are
formed by collagen.Scars can take on a number of different appearances: They may be
flat; or sometimes, fibroblasts may work overtime and produce too
much collagen that results in scars that bulge out like lumps. They
can also form indentations (or pits) when there’s a loss of skin that
is replaced by collagen. Scars can be skin colored, whitish, purple,
red, or even darker than a person’s normal skin color.
There are times when “scars” aren’t really scars. After an acne lesion
has healed or even while healing, it can leave a pink, red, purple, or
a darkly pigmented mark on your skin. These marks are actually
macules, spots that indicate a temporary color change of the skin.
These areas of remaining inflammation or post-inflammatory change
aren’t scars because no permanent change has occurred.
Sometimes, especially in darker-skinned people, the spots tend to
be darker than the normal skin color and they tend to hang around
longer. This is known as postinflammatory hyperpigmentation (PIP),
an after-effect from a healing acne lesion itself. These lesions also
tend to fade in time, unless the pigment winds up deep in the
dermis (dermal melanosis). Dermal melanosis is a type of PIP that
is much harder to treat and may never fade away completely. I
cover PIP and options for stepping up the speed at which these
lesions fade in Chapter 12.
Some people endure their acne scars all their lives with little
change in them. Other people are luckier — their skin improves
and the scars undergo some degree of improvement over time, and
they sometimes transform (remodel) themselves and decrease in
size. I guess time does heal some, if not all, wounds.
I characterize the different types of scars next. Keep in mind that
some people have a combination of different types of scars so that
one treatment may not work on them all.

Dealing with Scars and Associated Conditions

In this part . . .
I give you tips on how to treat acne scars based on the
kinds of scars you have and the kind of skin you have.
Because acne can be so emotionally devastating, I also
delve into the emotional hurdles that you or your friends
and family have to contend with and how to help avoid,
manage, and prevent them. I then complete the picture
with skin conditions that look like acne — the acne imper-
sonators such as rosacea and razor bumps. I also tell you
what symptoms may suggest an associated hormonal dis-
order.

“Special Instructions for Reducing and Removing Facial Acne Scars”

One of the unpleasant ramifications of acne is the resulting scarring that can occur. This
is particularly the case where you have cystic acne as I did.

Once the acne is cleared, it often leaves behind pockmarks, red broken veins, and even
deep thickened skin in the form of impressions. These small indentations cause an
uneven reflection of light and so the marks look darker and worse than they really are.

Make-up is of little use because the skin is still uneven and impressions under the make-
up are still visible.

After my acne was cleared I became determined to get the scars removed. This is an
expensive undertaking if you go the medical routes of laser surgery, dermabraision
treatments, or the oxalate crystals treatments.
IN THE NEXT POST I WILL TALK MORE ABOUT RESISTANT ACNE METHODS

None of these alternatives are guaranteed and can cause even more skin damage. My
choice was to look at the acid peels and they too were quite pricey and could have
complications.

However, I did find a company that carries an extremely effective product called “ Skin
Peel 4000.” It was reasonable in price and they had 4 levels of peels, depending on how
deep you needed to have your skin peeled.

No harsh chemicals and no complications. I was very impressed with their level of
service as well. I did the peel and my scarring was dramatically reduced by at least 90%.

I get compliments on my skin – something I could only dream about in the past. I tried
the peels and to my amazement they worked extremely well.