Ultimate Guide to Scars from Pimples and Cystic Acne
Acne scars and dark spots can occur when pimples and blemishes heal incorrectly. Although some minor acne breakouts will disappear without leaving behind any marks, other mild, medium, or severe acne breakouts leave behind pitted, raised, or discolored scars. Fortunately, there are a variety of ways these blemishes can be treated, both invasive and non-invasive.
- Social Toll
- Emotional Stress
- Marks vs. Scars
- Why Spots Appear After Acne
- Types of Acne
- Types of Acne Scars
- Professional Treatments
- Darker Skin Tones and Acne
- Natural Treatments
- Reactionary Treatments
- Preventative Treatments
- Dangers of DIY Solutions
- Trends & Fads
- List of Sources
Acne scars, according to the American Society for Dermatologic Surgery, are sometimes left behind after inflamed skin erupts into pimples due to bacteria, excess oil, or dead skin cells clogging pores. The smaller and less consequential the breakouts, the fewer the chances are that the tiny zits will result in acne scars. Minor pimples tend to go away quickly and heal without any aftermarks on the skin.
However, the bigger the breaks in the pores and follicle walls, the more likely severe acne lesions may prompt telltale spots or crevices to appear as the body naturally creates new collagen fibers during the healing process. Prevalent scarring, especially on the face, can have an impact on how the sufferer is perceived by society and can even go as far as to negatively affect a person's social, financial, and relational areas of life.
How Common are Acne Scars?
Whereas dealing with mild to severe active acne is bad enough, many individuals are dismayed to realize that after their breakouts have finally gone away and healed, they are left with all manner of scars or marks in the facial region or other parts of the body that they must address. As reported by the National Center for Biotechnology Information and U.S. National Library of Medicine, approximately 650 million people around the globe are impacted by acne, making it the single most common skin disease. As a result, acne scars serve as a reminder of the bumps and pimples that were once in their place, with 40% of individuals who suffer from acne eventually producing acne-related scarring.
What are the Common Causes of Acne Scars?
It is often advised not to pop pimples since that could potentially leave marks on the skin. This statement isn’t necessarily 100% true. Instead, the surgeon noted that simply popping blackhead or whitehead pimples on the skin’s surface won’t leave scars. After all, when receiving a facial treatment, the method of extraction generally involves a sanitized way of draining minor pimples from the surface of the skin to improve it, not to cause scars.
However, picking at acne in an unsanitized manner and popping pimples with the fingernails or fingertips could indeed cause more inflammation and also drive bacteria deeper into the skin, prompting bigger problems and scars in the end.
It has been noted that while minor blackheads and whiteheads that show up on the surface of the skin aren’t the types of acne that typically leave scars, deep cystic acne that is filled with pus or painful hard nodules that reside deeper in the skin are more likely to create scars. While it is a good rule of thumb to keep fingers away from acne-ridden faces as much as possible, it is particularly important to get professional treatment for serious cystic acne or major nodules, before they form scars.
Additional factors that can determine the formation of acne scars include the following:
- If cystic acne continues to occur during back-to-back bouts of breakouts, the likelihood that some deep cysts will leave scars is increased
- Lengthy periods whereby the cysts remain deep within the skin can mean that fat stores and collagen production are hindered, causing visible scars to appear on the epidermis
- Developing inflammatory acne with deep or large cysts or nodules tends to create more scars
The Social Toll of Acne Scars
As with active acne, acne scars can cause distress in many aspects of a person’s life. Acne scar sufferers are more apt to be viewed as less attractive than their peers with clearer skin. Those afflicted with scars are also often viewed as being less confident, not as happy, nor as healthy and successful as people whose skin isn't marred by marks. Additionally, people without clear skin are thought to be shyer and more insecure due to their skin problems.
The survey went on to examine how unclear skin could negatively impact other areas of an individual's life who deals with damaged skin. Survey respondents thought people with acne scars would not have as high of a chance as clear-skinned people to gain a job or to become a good entrepreneur. Scar sufferers were even pegged as individuals who suffered from reduced speaking skills and viewed as people who lacked romantic aptitudes.
Troublesome acne scars show up more often in conspicuous locations like the face, instead of more so on the chest and back where the imperfections can be readily covered with clothing most times. The visible facial scars become difficult to constantly hide under makeup or behind a sweeping mane of hair. As such, the scars and attributes associated with people who have them become a constant source of anxiety and worry.
The Emotional Toll of Dealing with Acne Scars
Acne is known to cause depression, taking a toll on people who must deal with the day-to-day problems associated with trying to "put your best face forward" in a social media-focused selfie world that often expects perfect skin. Thoughts of suicide can accompany acne, along with stressful social interactions and psychological problems worse than those experienced by people who are afflicted with health-related conditions such as epilepsy, asthma, and arthritis.
Now that more data is arising about the impact of scars on a person's quality of life, a greater focus is being placed upon the prevention of acne scars to alleviate the feelings of sadness attributed to such suffering. It isn't simply a matter of vanity to seek the enhanced appearance, higher levels of self-esteem, and confidence boosts that can accompany clearer skin. Addressing the scars and marks left by acne vulgaris can also improve a person's skin health, especially as they move forward in learning how to prevent post-acne scarring in the future.
Acne Marks versus Acne Scars
When dealing with skin damage as a result of acne, it is important to distinguish between scarring and post-inflammatory hyperpigmentation, also called PIH. The dark spots that are PIH are often confused with acne scars and mislabeled as such. Pinkish, reddish, or even purple-colored spots are post-inflammatory erythema or PIE.
PIE and PIH are discoloration conditions, and not technically acne scarring, although they are often called scars. It is critical to learn the difference between hyperpigmentation and erythema issues versus scarring as a result of acne lesions since the conditions are accompanied by different treatment methods.
Why do Pink, Red, or Dark Spots Form After an Acne Breakout?
With erythema, acne sufferers who have light or pale skin tones may discover that their acne marks are red, purple, or pink. Those with darker skin tones may find that their acne marks turn brown or black, as in the case of post-inflammatory hyperpigmentation.
One test to determine if you are dealing with acne marks instead of acne scarring is to slightly stretch the surface of the skin. If you slightly stretch your skin and the spots disappear for the moment, you are dealing with acne spots that should fade over time and not scar the skin.
While they can be unsightly and frustrating, post-inflammatory hyperpigmentation or erythema marks can fade over time, using these tips and others covered in this guide:
- Use a high SPF broad spectrum sunscreen correctly and diligently, even when the weather is overcast and the sky is gray
- Avoid the sun's harmful ultraviolet rays whenever possible since they can darken already pigmented spots on the skin
- Utilize retinols and dark spot treatment options to speed up the healing process
- Be patient as some acne marks may take from 3 to 24 months to fade
- Stop picking at or popping new pimples, which might encourage scarring
Acne scars, on the other hand, are more permanent than acne marks. True scarring involves damage or indentations in the skin. View the aftermath of scarring from acne lesions as wounds that can happen just like any other injuries or scars to the skin. Deep acne scars affect the underlying collagen of the skin causing the skin to heal with fibrous tissue instead.
As the skin creates new collagen fibers in an attempt to repair the damage, scars can form and the repaired skin will not appear as soft or smooth as the skin once was. Similarly that a bad cut on your arm might heal but leave tougher skin that is raised, indented, or of a different hue than your normal skin color, scarring from acne can leave the same long-lasting marks.
There is hope for a treatment for such scars, though, so don't despair. Although acne scarring is permanent, there are proactive, surgically-invasive and less-invasive methods of treating acne scars to reverse the skin indentations or abnormalities that they cause.
As you will learn in this guide, collagen damage and acne scarring do not need to be a lifelong condition. Advances in scar treatments can help improve all manner of acne scarring, which can appear in a plethora of shapes and forms.
Terminology & Definitions
Comedones Acne lesions popularly known as whiteheads or blackheads are comedones - generally, pimples that are the color of the flesh or a follicle. Frequently, they show up on the chin or forehead, with the blackheads representing open comedones while whiteheads are considered closed comedones.
Hyperpigmentation (dark spots) Higher amounts of pigmentation or melanin occur to create darker spots, like freckles. The post-inflammatory hyperpigmentation marks are often confused with acne scarring but usually fade over some time.
Retinol Solutions used to treat dark spots include retinol or retinoids, which are derivatives of vitamin A. Whether over-the-counter or prescription-strength, retinoids help produce new skin cells and fade blemish scars
Salicylic Acid At times combined with benzoyl peroxide or retinol within over-the-counter acne medications, salicylic acid works to stop new acne by unclogging pores.
Types of Acne
Various kinds of acne can produce different types of acne scars. An inflamed acne lesion at times bursts open through the follicle wall, damaging the skin and underlying collagen fibers. Other lesions remain contained within the skin but cause problems just the same.
Cystic Acne and Nodules Cystic acne and nodules have certain similarities, according to the American Academy of Dermatology. Both forms of often painful acne are the result of pores that get blocked by dirt, oil, or other irritations. The difference is that cystic lesions contain pus, and are therefore softer than nodules, which are harder and don't break open.
Whereas cysts from cystic acne contain pus that can often erupt and spill onto the skin, nodules remain firm and contained deeper beneath the surface of the skin. Each form of acne can damage layers of collagen as well as the fat stores in the skin's support system and cause scars.
Papules and Pustules Similar to cysts and nodules, the raised pimples are known as pustules and papules also vary due to their contents. However, nodules are bigger than papules and pustules - plus, nodules appear in deeper skin levels.
Pustules look like blisters because they contain a yellow type of pus. Papules, on the other hand, are hard and firm to the touch. Follicles that continue to become more irritated can transform smaller pustules and papules into larger cysts and nodules. Groups of papules near one another can make the skin feel rough, similar to sandpaper.
Types of Acne Scars
In general, there are four major categories of scars: rolling scars, boxcar scars, ice pick scars, and hypertrophic scars.
The main difference between them is the shape and projection level of such scars, with bad breakouts sometimes causing so much damage to the person's underlying fat cells or collagen that a depressed space is left in the skin. Those holes can take on a variety of shapes and patterns.
Atrophic and Depressed Scars At the root of the term "atrophic scars" is the related word "atrophy," which refers to a tissue that has degenerated to the point of wasting away. As such, "atrophic acne scars" refer to areas of skin that have sunken due to the destruction of the collagen underneath. Such scars can form after a person heals from bad inflammatory acne that leaves the skin with pitted scars.
The term "depressed scars" is a catchall phrase for several types of acne scars that have caused an individual's skin to sink beneath the layers of surrounding healthy skin. The loss of fat and tissue after a breakout can cause boxcar scars, ice pick pits, or rolling scars to develop, which can be described as both atrophic and depressed.
Boxcar Scars When most people hear the word "boxcar," the immediate image of a railroad train car springs to mind. As such, boxcar scars are reminiscent of sharp-edged train cars, near one another along a line. Instead of having the round edges that other types of scars may possess, boxcar scars have straighter edges but are birthed out of similar inflammatory acne conditions that cause other indented scars.
Boxcar scars may appear to cast small shadows on the skin when they are left untreated. Unlike raised keloids and hypertrophic scars, the boxcar versions are shallow, with defined edges and flat bottoms, which make them similar in appearance to chickenpox scars. Boxcar scars may be just as pitted and uneven as other angular scars, but they aren't usually as deep as ice pick scars.
Hypertrophic or Keloid Acne Scars Whereas depressed scars form a crater or valley in the skin, other scars are "hypertrophic," meaning that additional scar tissue causes the fibers to raise instead of sink into the skin. Such scars are known as keloids or keloid bumps. The scars occur when the body produces too many dermal cells or connective tissue cells known as fibroblasts in response to the trauma that cystic acne creates. Therefore, the resulting keloid scars are often raised and of a different color than the skin but can be treated with cortisone injections to flatten the projected skin and retinol or laser treatments to address the issues with uneven skin tone.
Ice Pick Scars Ice pick scars are deep and pitted, appearing as huge pores dotting the skin. However, the indented scars with well-defined and sharp borders happen when collagen collapses and the skin sinks into pits of depressions or what appear to be holes as if the person has been poked or stabbed with an ice pick - hence the name.
The scar tissue that forms in the wake of an active acne breakout can sometimes bind and pull the skin farther down to the fibers beneath it, creating the ice pick look or other forms of depressed scars.
Rolling Scars or "Rolling Hill" Scars The terms "rolling acne scars" or "rolling hill scars" point to the aftermath of acne that makes the skin appear as if it has the topography of small hills and mounds. The rolling scars show up as waves of mountainous skin, due to how resulting bands of tissue are created deeper beneath the surface of the skin.
Acne Scar Treatments, Home Remedies, and Removal
Acne scar removal, according to Johns Hopkins Medicine Health Library, is dependent upon the severity of the scars in question, along with the overall health of the patient. However, as you'll read in the following sections, there are many ways of improving the damage left by acne, either via DIY home methods or by using a medical professional to address the problem.
Treatment options from professionals and plastic surgeons include some of the following, which can help acne scars improve by using updated procedures or surgical techniques to customize solutions for patients:
Autologous Fat Transfer into Scars Fat transfers extract fat from the patient's own body to inject it into regions with depressed scars and raise them. The solution is not a permanent treatment since the transferred fat will eventually be reabsorbed by the body and cause the acne contours to become more visible again over several months.
Subcision Subcision is a surgical process whereby a small needle is used to break up any fibers tethered to the underlying skin structure. The doctor can also break up scar tissue during the subcision procedure, which is often combined with other scar treatment therapies, such as laser treatments. Once the fibrous tethers have been released, the once depressed skin is raised and appears smoother. Other forms of acne scar surgery involve excising the entire scar, leaving a new, but not as visible, scar as the removed lesion.
Dermal Fillers Dermal filler injections are very popular for adding volume to lips and smiles lines - but they are also a good alternative for filling atrophic scars caused by acne. Fillers like Restylane® and Juvederm® can help serve as a substitute for the lost collagen, however, the dermal fillers require upkeep and must be re-injected into depressed acne scars every 6 to 18 months.
Dermabrasion Not to be confused with microdermabrasion, dermabrasion involves the surgical removal of the skin's outer layer, using instruments that ablade or scrape away the epidermis, which can lighten acne scars. The process helps replace older skin with smoother, fresher skin - but it is more invasive than microdermabrasion.
Laser Resurfacing Another method of scar treatment is via laser resurfacing with either an ablative or non-ablative laser. The high-energy light of the laser helps to burn off portions of skin damaged by acne. Similar treatment options are available, such as intense pulsed light IPL therapy.
Chemical Peels Chemical peels are a method of chemically removing layers of skin that have been damaged by acne. There are different levels of such peels to address varying degrees of scarring. Superficial peels are better suited for minor pigmentation issues whereas medium or deep chemical peels can provide dramatic results for patients with severely pitted skin. The layer of skin that has been chemically removed is often replaced with a softer and clearer layer of skin, although those results may take several months to realize.
Microneedling Microneedling helps improve acne scarring by creating micro-wounds to encourage new collagen production. The controlled micro-wounds trigger the body to begin the healing process that ramps up collagen production to help new skin replace damaged skin.
Punch Grafts Deep acne scars can also be treated with a punch graft procedure, whereby the skin is punched circularly to remove each acne scar. The treated area is next replaced with non-scarred skin, which is often excised from the rear of the earlobe or another part of the patient's body.
Steroid Acne Scar Treatments Steroid injections can be used to treat those suffering from hypertrophic acne scars. Also called intralesional injections, these treatments will not help to make the texture of the skin better, but they can flatten thicker acne scars and lessen their appearance over several sessions.
Darker Skin and Acne
People who have darker skin types have different concerns when it comes to seeking acne scar treatments and the clearance of dark spots. It is important to note that darker skin tones may not benefit from all scar treatments such as deep chemical peels and harsh laser treatments, and may worsen the skin condition. Wearing oil-free sunscreen and practicing plenty of patience can help dark spots clear naturally, with enough improvement potentially happening within 12 months to not necessarily need professional treatment. Speak to a licensed dermatologist or plastic surgeon to evaluate your individual needs.
Natural Alternatives & At-Home Remedies
The expense of certain professional acne scar treatments or the cost of procedures to treat dark marks may drive some people to search for ways to improve their conditions from home. Others prefer natural ways to achieve similar results.
Whereas some DIY "natural" solutions touted on social media may seem like effective ways of treating skin damage from acne, they could be harmful. For example, hydrogen peroxide may worsen acne, and sulfur could leave the skin dry. Whereas the best method of treating acne scarring and marks is by preventing them, the following methods could help you treat them from home on a do-it-yourself basis.
Aloe Vera Aloe vera is a green plant with serrated leaves that contains a clear gel inside. That gel is often used to soothe burns and irritated skin and is also used to treat acne due to the excellent antibacterial qualities that the plant naturally provides.
Creams Over-the-counter creams designed to lighten marks darker than a person's normal skin tone include those with a 2 percent hydroquinone solution, along with other ingredients to soothe and heal the skin, like vitamin E. The controversial hydroquinone can also be prescribed in higher concentrations by a dermatologist, who may also recommend face washes containing salicylic acid or mandelic acid to increase skin cell turnover. Other favorite skincare creams found at beauty retailers include those containing crystals, lactic acid, and oils that purport to help improve the skin complexion.
Tea Tree Oil Tea tree oil is an essential oil that has long been favored for its cleansing properties. Used directly on pimples, the oil can help to penetrate the epidermis and clear out blockages in the sebaceous glands. As a preventative measure, tea tree oil can help to disinfect the pores, which could lessen the level of breakouts experienced and reduce resulting scars.
Preventative treatment is the best course of action to reduce acne scarring. Acne that has been drained and begun to heal with a scab should not be scratched, picked, or ripped away. Doing so could cause more scarring than what might have occurred, and also lengthen the time it takes for the injury to heal. Creating additional trauma to the skin can exacerbate the already deep trauma that certain acne lesions cause. Other preventative treatments include:
Vitamin C Serums and Supplements for Acne Scars Vitamin C is often mentioned when speaking of natural skincare options, due to its positive effects upon elastin and collagen production, which are vital proteins needed for new skin to generate. Getting enough vitamin C in the diet or via oral supplements and within topical treatments can assist in creating stronger and more supple skin that is less susceptible to acne.
Silicone Gel for Scars Silicone gel products containing Polymerized Siloxanes and vitamin E are also on the market as a non-invasive way that individuals can help to both prevent and treat scars at the same time, including those caused by acne.
It is a logical conclusion, but people who never seek treatment for their acne conditions are those who will frequently suffer more scars. It has been discovered that treating acne early by visiting a knowledgeable dermatologist or medical professional can help address and prevent future breakouts, which can lessen the chance of developing more scars.
Dangers of DIY Solutions
While it may be tempting to adopt some of the scar treatment solutions that medical professionals use in their offices and attempt to perform them at home, those actions can be dangerous. For example, do-it-yourself dermarolling and microneedling kits can be easily purchased online but also require sterile instruments, safety knowledge, and a steady hand. Home remedies, when done incorrectly, can cause the opposite desired effect, either worsening the condition of the skin or simply not achieving any noticeable results. It is always advised to seek a professional before starting any treatment plan, as they will be able to tell you the best course of treatment whether it be with an office solution or at-home therapies.
Trends and Fads
In spite of the many treatments that seek to improve the look of acne scars and dark marks, there is a movement on social media that is attempting to view acne sufferers in a new and more positive light. Channels dedicated to severe acne problems use labels such as "skin positivity" and "free the pimple" and "acne problems" to show off their scars, sans filters.
Some acne scar sufferers are showing off their raw and real skin conditions, and vlogging about their experiences in an honest way. The goal is to get people to love themselves, even during acne flare-ups and while healing from the scars that follow.
Silver Acne Skincare Products Meanwhile, as some folks are embracing their breakouts and scars, others are turning to new skin-care products that are infused with silver. The colloidal silver metal is being credited with containing properties that benefit acne - which is rational since hospitals have utilized the antibacterial agent to heal wounds for decades. Now, ground up silver particles are making their way into skin-care products as a possible anti-acne treatment.
Conclusion: Focus on Preventing More Acne Scars After Clear Skin
In the end, patients with acne scars may do well to visit a dermatologist or plastic surgeon to determine the specific type of scarring that they possess - or learn whether their problem is related to marks that can fade away.
When all other solutions have been attempted - such as getting good sleep to reduce breakouts, decreasing stress in your life and eating well - a medical professional might be the missing piece in the puzzle to finally get on the right path to ridding yourself of acne scars for good.
List of Sources
- Laser resurfacing - Mayo Clinic
- Acne Scar Subcision - NCBI - NIH
- 10 tips for clearing acne in skin of color | American Academy of Dermatology Association
- American Society for Dermatologic Surgery
- Facial Allergic Granulomatous Reaction and Systemic Hypersensitivity Associated With Microneedle Therapy for Skin Rejuvenation
- Acne Scar Removal | Johns Hopkins Medicine Health Library
- How People with Facial Acne Scars are Perceived in Society
- Different kinds of pimples | American Academy of Dermatology
- Acne Scarring - Jefferson University Hospitals
- The Use of Silicone Adhesives for Scar Reduction - NCBI - NIH
- US National Library of Medicine National Institutes of Health article, “Easy as PIE (Postinflammatory Erythema)”