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Types of Acne Scars, Boxcar, Rolling & Icepick scars

Acne and acne breakouts are one of the most common reasons that patients consult with dermatologists each year. Unfortunately, there are a great many acne lesions which lead to acne scarring. Acne and acne scarring affect both men and women from their teenage years, well into their 50’s. With 50 million individuals suffering from acne at some point in their lives, close to 40% of patients will develop acne scars at some point, according to the American Academy of Dermatology (AAD). Dr. Michele Green is a world expert in treating all types of acne scars, in every skin tone. From Fraxel, dermal fillers, to chemical peels, microneedling, to laser resurfacing, Dr. Green will create a unique treatment protocol for you to address your acne scars and help give you back beautiful, clear skin.

Types of acne scars

Anyone who develops acne lesions or breakouts can develop acne scars. With more severe acne lesions, the greater the risk of acne scarring. There are many different types of acne scars and they can develop regardless of how diligent you are in taking care of your skin. Since there are different types of acne and all acne scars are not the same, they each cannot be treated by the same methods. Acne scars generally fall under two main categories, atrophic scars and hypertrophic scars.

I -Atrophic Acne scars

Atrophic acne scars are caused by a loss of tissue.  Atrophic scars are the most common type of acne scar, and occurs mainly on the face.  Atrophic scars are depressed scars beneath the skin. These acne scars form due to the skin’s inability to produce enough collagen as the wound heals. This loss of collagen creates a depression in the skin which can vary in size from a small indentation to a larger defect in the skin.

Atrophic scars are often the result of acne pustules or cystic acne which form on the face. The infection and pus from the acne breakouts and pustules cause the destruction of skin and prevent it from healing properly. These types of atrophic scars are commonly seen in chicken pox scars, which develop from patients picking their skin and not allowing new collagen to form.  Based on these two main categories, acne scars can be further divided into four subcategories. These subgroups of acne scars are ice pick scars, boxcar scars, rolling scars, and keloid scars.

II – Hypertrophic scars

Hypertrophic scars are formed due to an increase in the amount of tissue formed by the skin, which makes the scars have a raised appearance on the skin.

The hypertrophic acne scars grow above the surface of the skin and  look like a raised firm skin growth. These acne scars are usually larger in size than the initial wound left from an acne flare up. Hypertrophic scars are not only caused by acne but can also be caused by any from of trauma to the skin. These types of scars, unlike other forms of acne scars, are not caused by a loss of tissue. Rather, they are caused by an overproduction of collagen at the site of the previous acne breakout.

The three different types of atrophic scars

Ice Pick Scars

Ice pick scars are deep, narrow scars which have the initial appearance of an enlarged pore. The term “ice pick” scar comes from the fact that the skin appears as if it has been pierced by a sharp tool, or ice pick. These scars extend deep into the dermis and develop due to skin infections and inflammation which find its way into the skin. Ice pick scars are caused by cystic or inflamed acne. The infection and inflammation from the acne breakouts cause a loss of skin tissue resulting in a perforation of the skin, which appears like a small thin column or a narrow deep hole.  

There are several treatment options for acne scars such as punch excision or laser treatment. Punch excision involves performing a small excision of the scar, utilizing a punch biopsy tool. After the scar is surgically removed, the would is sutured or glued together, and allowed to heal. Punch grafting is another procedure which can be done for ice pick scars. This type of procedure however is usually reserved for deeper and larger scars. A skin graft is taken from behind the ear and used to close the defect in the skin.

Boxcar Scars

Boxcar scars develop when inflammatory acne destroys the collagen fibers within the skin. This type of acne scar leaves a depression in the skin as a result of collagen loss. This loss of collagen can result in a sunken appearance in the skin due to a lack of tissue support. The lack of support results in a depression within the skin. The appearance of boxcar scars can be superficial to deep, depending on the amount of skin atrophy involved from the infection associated with the acne breakout. Boxcar scars are wider than ice pick scars, are round or oval in appearance, with deep vertical sides.

There are several types of treatments available for boxcar scars such as dermal fillers, punch excision, punch grafting, and laser treatment. With punch excision, the affected scar is removed, sutured, and improves the appearance of the scar.

Dermal fillers make a significant cosmetic improvement for acne scars. Dr. Green uses several different types of dermal fillers, including Restylane, Sculptra, Juvederm, and Bellafill to treat these atrophic scars. These dermal fillers are injected into the scar, or the areas of depression and collagen loss in the skin.  The dermal fillers treat the dressed areas of the skin and fill in the atrophy, making the surface of the skin smooth. These dermal fillers make an immediate and long term cosmetic improvement in the appearance of the acne scars. The only drawback is that these dermal fillers are not a permanent solution to treating acne scars. Restylane and Juvederm may last 6 to 12 months, Sculptra for two years, and Bellafill up to five years.

The appearance of atrophic scars, such as boxcar scars, can also be improved with laser treatment to stimulate collagen production therefore improving the texture of the skin. Dr. Green utilizes a combination of the V-Beam laser, Fraxel laser, eMatrix radiofreqency laser, chemical peels, and mircroneedling, to help improve your skin. A treatment plan with the best combination of dermal fillers and lasers for your skin type will be customized by Dr. Green during your consultation.  

IMAGE47 25 34 year old woman treated with acne scars treatment MGwatermark

Rolling Scars

Rolling scars have this name since they have the appearance of rolling or wave-like depressions in the skin. Rolling scars differ from boxcar scars in that they do not have sharply defined borders. The skin itself looks wavy and rough from the surface.

Rolling scars are formed due to fibrous bands of tissue developing between the skin and the subcutaneous tissue underneath the skin. The fibrous bands pull the epidermis, binding it to the subcutaneous tissue deep within the skin. The impact of the epidermis being pulled down is what creates this rolling, wavy appearance to the skin.

Rolling scars are the most difficult type of acne scars to treat and need a combination of laser treatments and dermal fillers to improve the appearance of these scars.

Hypertophic scars

Keloid Scars

Keloids are a more severe type of raised scar which differs from hypertrophic scars in that keloids grow much larger than the original acne scar or wound. Keloids scars can be painful, sending raised collateral roots from the surface of the skin that expand much further than the original wound. Keloids often continue to grow long after the original wound has healed. Some people are more predisposed to developing keloids based on their skin type, with darker skin patients generally being more predisposed.

Unlike other forms of atrophic acne scars such as ice pick scars and boxcar scars, with keloid scars, the skin does not realize that the wound has already healed, and continues to produce new collagen as if it is trying to still repair it. The excess tissue from the overproduction of collagen is what causes the formation of these keloid scars. Hypertrophic and keloid scars should only be treated by a board certified dermatologist or plastic surgeon experienced in treating these types of scars. 

Caution is needed while treating these keloid scars to avoid further aggravation of the skin, which can lead to a worsening of the scar. The process to treat keloid scars is typically a lengthy one which includes the use of silicone gels, V-Beam laser treatments , and steroid injections.

Treating hyperpigmentation from acne

Acne related hyperpigmentation occurs when acne breakouts or blemishes heal and leave behind dark spots. Hyperpigmentation from acne breakouts can be very frustrating since the acne has finally healed and now there is a dark mark or scar from the acne.

Treating hyperpigmentation from acne is a speciality of Dr. Michele Green.  She has created special compounds in her MGSKINLABS, Inc line of products for patients to use especially for dark spots and skin discoloration.  Based on your skin type, Dr. Green will create a skincare treatment protocol designed for you.  Generally, Dr. Green will prescribe a hydroquinone based product, along with her Vitamin C serum, and retinol cream to exfoliate the skin and reduce your hyperpigmentation. There are also other treatment options such as chemical peels, hydrafacials and microneedling which Dr. Green will utilize to reduce the hyperpigmentation and contribute to the healing process.

Best Acne Scar Treatment Options 

Dermal Fillers

Dermal fillers can replace volume loss in depressed acne scars filling in the indentations caused by the scar.  Not all acne scars can be treated with dermal fillers.  Acne scars such as rolling scars and boxcar scars can be effectively treated with dermal fillers to create a smoother appearance.  Hyaluronic acid fillers such as Juvederm or Restylane are most commonly used to treat depressed acne scars.  The amount of dermal filler needed will vary and depends on both the severity of the scars and the number of scars being treated.

During the treatment the needle is inserted underneath the scar.  Once the needle is carefully positioned, the filler is then deposited into the depression and the process is repeated in each individual scar until all of the scars have been treated. The goal of dermal fillers is to reduce the appearance of these depressed acne scars.

There are some acne scars which benefit from subcision being performed at the same time as the dermal fillers are injected.  Since many scars are so tightly bound down below the skin, subcision is needed to physically release this scar tissue. Sculptra, Juvederm Voluma, Bellafill, and Restylane Lyft, can also be used to treat larger areas of dermal loss, from deeper acne scars and defects in the skin.

Fractional Laser Treatment

The Fraxel laser is a highly effective treatment for anyone with acne scars who wants to improve their skin texture. Through non ablative laser resurfacing technology, the Fraxel laser is able to use microscopic “cuts” in the skin and produce new, healthier, skin. In addition, this laser therapy has a dual setting for acne scars which are atrophic, such as rolling scars and boxcar scars.  The Fraxel laser will stimulate new elastin and collagen production, producing new skin, and providing visible improvement in your acne scars.  After a series of 3 to 5 laser treatments, there will be a noticeable difference in your skin and its healing process regarding your acne scars.  Dr. Green calls the Fraxel laser the “magic eraser” since it is such an effective treatment for hyperpigmentation and brown spots as well.

The Fraxel laser treatment has minimal downtime with only a few days of redness and some minimal exfoliation.

eMatrix Laser Treatment

eMatrix is an FDA approved laser resurfacing treatment to minimize visible acne scars, superficial wrinkles and stretch marks for all skin types. In addition, eMatrix laser therapy minimizes fine lines and wrinkles along with treating acne scars by stimulating cellular renewal and new collagen production. This treatment is unique as it offers the same results as ablative laser treatments by gently resurfacing the skin over 4 to 6 treatments. 

The eMatrix laser uses radiofrequency energy to deliver heat to the epidermis without disrupting the skin’s surface. After the treatment you may experience some mild roughness and redness for approximately 48 hours. Results are cumulative, over the course of 3 to 6 months, as the skin continues to rebuild new collagen.

V-Beam Pulsed Dye Laser Treatment

The V-Beam pulsed dye laser therapy targets the redness from acne inflammation. The light from the laser is selectively absorbed by red blood vessels in the skin. Following the laser pulse, the laser energy is transmitted to the blood vessel wall, which leads to a narrowing of the wall and a shrinking of the size of the blood vessel. This in turn leads to a reduction in facial redness.  The V-Beam pulsed dye laser is used for red acne scars, rosacea, stretch marks, and angiomas.

YJL ematrix acne scars 2wk ba ANGLEL MGwatermark

Subcision

Subcision is a procedure which uses a needle to break apart the scar tissue which adheres the upper layer of the skin to its underlying layers. This technique involves using a needle in sweeping motions to precisely break up the scar tissue adhering to the upper skin.

Dr. Green often injects dermal fillers at the same time that she performs the subcision. The injected filler works to stimulate the body’s collagen production while temporarily filling in the depressed scars.

Chemical Peels

Chemical peels are designed to enhance the skin’s texture and promote cellular turnover. Peels remove dead skin cells or damaged skin cells from the surface of the skin, stimulating the growth of new collagen, to reveal healthy looking skin. Chemical peels can also improve the appearance of fine lines, acne scarring, sun damage, and other skin blemishes. 

There are different types of chemical peels, formulated with different types of acids and various strengths, to create mild, medium and deep chemical peels. The strength of the chemical peel used depends on the condition being treated. A series of chemical peels, combined with Retin-A, retinols, and hydroquinones, can increase the cosmetic results of the chemical peel.

These chemical peels can be used for acne scars or areas of hyperpigmentation and discoloration not only on the face. Many patients have acne papules, cystic acne and acne scars on their chest, back, and buttocks.  Chemical peels are an effective treatment on these other areas of the body.

Glycolic acid peels, which are composed of alpha-hydroxy acids (AHA), are used for mild chemical peels, which are able to exfoliate and unclog blackheads, decrease pustules, treating blemishes, and help in producing new healthy skin.

Trichloroacetic acid (TCA) peel is a type of chemical peel which only dermatologists, like Dr. Michele Green, are able to perform in a medical setting. There are different strengths of TCA used, from 10% to 100% for treating acne scars. Dr. Green does several different strength acid peels for acne scars and areas of hyperpigmentation and discoloration.

TCA cross is a unique method of treating deep acne scars.  A very high concentration of TCA is placed directly into medium depth acne scars. The TCA will produce a “frost” or whitening of the area immediately, which then peels off over several days. TCA cross technique is often used in patients with ice pick scars. Careful use of sunscreen and sun avoidance is essential after chemical peels to avoid hyperpigmentation of the treated area. TCA cross is preferred for patients with lighter skin tones to avoid the side effect of hyperpigmentation.

Dermabrasion

Dermabrasion is a skin resurfacing procedure used in dermatology and plastic surgery to treat acne scars. A rapidly rotating device is used to sand the outer layers of skin. Primarily used to treat atrophic scars, such as boxcars, dermabrasion exfoliates the top layer of the skin and improves the appearance of acne scars.

Dermabrasion can take several weeks to recover from the procedure with most patients are red and sensitive for several weeks after the treatment. Dermabrasion is best utilized in individuals with fair skin. People with darker skin tones should avoid dermabrasion as it may result in further hyperpigmentation and skin discoloration. Strict sun avoidance and sunscreen is very important after dermabrasion as well.

Intralesional cortisone injections

Intralesional cortisone injections are administered directly into acne, acne cysts, keloids, or hypertrophic scars, and is a highly effective treatment to shrink up these raised scars.  Generally, a series of intralesional steroid injections of high concentration kenalog, are needed to flatten these scars.  If these scars are red or inflamed, the V-Beam pulsed dye laser is highly effective and used in combination with these injections to reduce the appearance of these hypertrophic scars.

Microneedling

Microneedling is also an effective treatment for acne scars with minimal side effects. The procedure entails using fine needles to puncture the skin to create a controlled skin injury. Microneedling stimulates the skin to generate new elastin and collagen as it heals. Platelet rich plasma (PRP) with microneedling has become an extremely popular way to treat acne scars since the growth factors introduced via PRP have the added benefit of rejuvenating the skin and increase wound healing.

Home acne scar treatments  

In addition to office laser treatments, chemical peels, and dermal fillers, there are several over the counter skin care products which can be used to treat acne and improve the appearance of your acne scars at home. Before you start any home skin care regime, it is important to consult with Dr. Green to make sure that these products or procedures are best for your skin type.  Dr. Green may recommend prescription retinoids, retinols, hydroquinones, or other lightening agents to help exfoliate your skin and improve the appearance of your acne scars.

Retinoids

Retinoids are a form of acne treatment with scar-smoothing benefits due to its ability to regenerate skin cells and improve skin texture. Retinoids are a derivative of Vitamin A. There are several alternatives such as retinyl palmitate, retinyl aldehyde, adapalene, isotretinoin, tretinoin and tazarotene, Hydroxypinacolone Retinoate and Bakuchiol. Each of these retinoids alternatives work differently. However, they all share the benefit of stimulating collagen production, therefore improving skin texture,  decreasing the amount of pimples and treating skin hyperpigmentation.

Tretinoin, Retin-A, Isotretinoin (Accutane) are prescription forms of Vitamin A with active retinoic acid which needs no conversion within the skin. The prescription forms are more potent and usually cause more skin irritation than the over the counter alternatives. Retinols are an over the counter form of Retin-A, do not require a prescription, and come in varying strengths. The strength and efficacy is dependent upon the form of the Vitamin A derivative and how the skin converts it to Retinoic acid.  

Salicylic acid

Dr. Green may also recommend at home peels or acne pads to exfoliate your skin and improve both your acne and acne scars. Her MGSkinLabs, Inc Retexturizing Pads and Pore Minimizer Cleanser both are ideally designed with salicylic acid to help exfoliate and unclog your pores, decrease acne papules and pustules, and remove blackheads.

FS pore minimizing cleanser

Salicylic acid is one of the best skin care ingredients to use for acne treatments. Not only does salicylic acid unclog your pores, but it also reduces inflammation. Added to your daily skin care routine, salicylic acid exfoliates the skin to reveal healthier skin cells and improve the appearance of acne scars. 

Cosmetic Treatment Options for Various Types of Acne Scars

Acne and Acne scarring can cause severe emotional distress for those who suffer from this skin condition. Many patients area self-conscious and are embarrassed by their acne or acne scars. Some patents feel depressed, or have anxiety or poor self esteem from stubborn acne and acne scars. If you suffer from acne and acne scars, you don’t need to suffer.

There are many new cosmetic treatments being done by Dr. Michele Green, in her NYC office, to help treat acne and acne scars. To find out what acne scar treatment will work best for you, please contact us online today or call 212-535-3088.

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