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.