Few skin conditions torpedo self-esteem the way acne does. As it turns out, a face full of painful lesions — not to mention unsolicited, tone-deaf advice from family and strangers alike — has a way of driving people into hiding. Throw in a whole internet's worth of unverified anecdotes about banishing acne for good and you've got a recipe for disaster.
Treating acne is maddening. Even if your breakouts are under control, you may be left with dark spots, red spots, dents, and/or bumps — the ghosts of hell-zits past. Today's super-saturated skincare market offers thousands of products that claim to fade acne scars, but frankly, very few of them work.
Before you drench your face in retinol and acids to fade your acne scars, you should figure out what caused them in the first place — and if they're even scars at all.
What The Heck Are Acne Scars, Anyway?
Scar tissue forms when an injury or illness damages your skin's ability to produce collagen, the protein that gives skin its structure. As Dr. Meghan Feely, a board-certified dermatologist practicing in New York and New Jersey, explained to me in an email, the same process causes acne scars.
Inflammation — redness, pain, and/or swelling — from deep-rooted zits can injure surrounding skin cells, altering the collagen they produce to repair injured skin. Depending on the amount of collagen the damaged cells produce, she explained, patients are left with either atrophic or hypertrophic scars.
Atrophic scars happen when acne-damaged skin cells don't produce enough collagen to refill the injured area, leaving indentations in the skin. Any dimpled, dented texture you notice after a breakout heals is caused by atrophic scarring.
Typically, these scars present in one of three patterns: ice-pick (deep and narrow, like pinholes), boxcar (wide and squared-off) and rolling (wide and rounded). The shape and size of atrophic scars depends on the extent of the tissue damage, as well as how your skin typically heals from injury.
When acne-damaged skin cells overproduce collagen, they leave hypertrophic scars, which are raised and often shiny. Hypertrophic scars occur more frequently in severe wounds that don't close early on in the healing process: a surgical incision is less likely to leave a raised scar than, say, a massive cyst that repeatedly gets its head scratched off.
However, whether or not you get hypertrophic scars mostly comes down to genetics. If your family members tend to develop raised, bumpy scars, you probably will, too.
Generally, only very severe acne leaves scars. Age and family history influence their development to some extent, but according to board-certified dermatologist Dr. Diane Madfes, the biggest scarring predictors are the acne's depth and duration.
The deeper the zits and the longer they go untreated, the more likely they are to cause permanent damage — which acne scars are, unfortunately.
If you're not sure what you're dealing with, gently run your fingers over the spots in question. If they're indented or raised, you have acne scars; if they're smooth, but discolored, you have something else.
If My Dark Spots Aren't Acne Scars, What Are They?
Not all breakouts leave scars. Mild lesions may not go deep enough to damage collagen-producing cells and some deep-rooted zits don't stick around long enough to cause permanent structural damage.
However, inflammation from a breakout can piss off cells closer to the surface of your skin, causing them to function abnormally for a while. This process is what causes some zits to leave dark or red spots when they heal.
The colour of a post-acne mark depends on which cells were damaged. Dark spots are caused by damaged melanocytes, which produce melanin, the pigment that gives our skin its colour. These spots are usually brown, but can be purplish or bluish depending on your skin tone. This type of discoloration is called hyperpigmentation.
Some breakouts leave red spots when they heal, which is a sign of damaged or irritated surface-level capillaries. Your body's first response to illness or injury is usually to increase blood flow to the affected area, causing temporary redness and swelling known as erythema.
Erythema usually dissipates once a wound has healed, but sometimes capillaries around the healing site are too damaged to immediately return to their normal, pre-injury state.
Both of these conditions are caused by inflammation and persist after it clears, so their full names are post-inflammatory hyperpigmentation or erythema — PIH or PIE for short. The superficial cell damage behind PIH and PIE is temporary, though the marks can take months or years to fade.
If your post-acne marks aren't clearly brown or red, you can figure out if they're PIE or PIH by pushing on them gently with a fingertip. PIE temporarily disappears when pressed because doing so cuts off blood flow to the affected capillaries. Unlike blood, melanin is static, so PIH marks will look the same regardless of how much you poke at them.
What Can I Do To Prevent Scarring And Pigmentation?
The likelihood of developing scars, PIH and/or PIE is mostly down to genetics, but as Dr. Madfes explains, inflicting additional trauma on already inflamed skin makes things worse:
"Some people tend to pick at the acne scar, or the acne bump, because they feel a raised surface. [...] Light trauma should not cause marks, but if someone's going to pick, try and get out the pus, or manipulate the area, [they're] going to increase the incidence of scarring and hyperpigmentation".
Anything you can do to encourage proper healing, on the other hand, is good. Besides resisting the urge to squeeze, Dr. Madfes recommends keeping open lesions "moist and covered" until they heal — she specifically says Vaseline is a great wound protectant — and using a moisturiser with ceramides. However, she emphasises that the best way to prevent picking — and by extension, PIH/PIE or scars — is to resolve the acne that causes it in the first place.
How Do I Get Rid of Them?
Mild PIH and PIE — with no accompanying active acne — will resolve with on their own within a year. If that's too long to wait, sunscreen is the surest way to speed up the fading process.
When your skin darkens from sun exposure, your PIH does too; wearing a broad-spectrum, high-SPF formula every day protects your skin from further damage and helps it heal properly.
However, most people who seek treatment for PIH/PIE and scarring also have active acne — and every specialist I spoke to for this story agrees that resolving chronic acne is the first step to treating post-inflammatory marks. Mild acne can be effectively treated with over-the-counter products; Dr. Madfes recommends starting with a product containing micronised benzoyl peroxide. Non-micronised particles are too big to penetrate pores and their irregular size and shape makes them prone to clumping together — which renders the medication less effective and more irritating.
Whichever treatment you choose, be patient: topical medications take at least three months to show results.
Moderate to severe acne benefits from professional intervention and the earlier, the better. If your insurance covers it, see a dermatologist as soon as possible. When you request an appointment, specifically ask to see an acne specialist. If there's a long wait, put your name on the cancellation list and check in every few weeks.
At your appointment, give the dermatologist a detailed history of your acne — including medications you've tried in the past, any you take now and your tendency to develop PIH, PIE, or scars — so they can decide how best to treat you.
Dermatologists aim to resolve acne before treating pigmentation or scarring, but many medications and procedures do both at once. Topical retinoids (tretinoin, tazarotene and adapalene) are proven multitaskers and dermatologists frequently prescribe them to treat acne and hyperpigmentation.
For patients with active acne and pigmentation to address, some favour chemical peels. Acne specialist Mary Freihofner told me that she uses glycolic, mandelic and salicylic acid peels for her acne clients with hyperpigmentation — but once the lesions have healed, she thinks microdermabrasion works faster.
Erythema may not respond to hyperpigmentation treatments and in those cases, Freihofner finds vitamin C peels to be quite effective.
If Acne Scars Are Permanent, What Can I Do About the Ones I Have?
There are effective ways to treat acne scars, but they don't come cheap. Since scarring is caused by damaged tissue in the dermis — the middle layer of skin — treating it requires some level of penetration. Many dermatologists, including Dr. Feely and Dr. Madfes, treat acne scarring by way of dermal resurfacing techniques, most of which involve lasers.
Certain types of lasers can penetrate the epidermis — the outermost layer of skin — to stimulate collagen-producing cells in the dermis, reducing the appearance of scars over time. Lasers are less invasive than traditional surgical techniques, but all dermal penetration has risks: you don't want to damage any nerves or blood vessels while you're poking around down there. This is why laser resurfacing is performed only by specially trained, licensed professionals.
You don't necessarily have to see a dermatologist for laser therapy, though; many skincare clinics offer the same services. Raelle Levicke, a laser technician at About Face Skincare in Philadelphia, swears by fractionated lasers and intense pulsed light (IPL) treatments.
She explained that surface-level treatments — chemical peels, microneedling and microdermabrasion — are somewhat effective at fading hyperpigmentation, but they literally don't go deep enough to treat scar tissue.
Fractionated lasers are her weapon of choice for acne scars and severe hyperpigmentation, but she prefers IPL treatments for treating erythema. Depending on the case, her patients see results after two to four sessions.
I know from experience how horrible it is to feel like you're doomed to cycle between painful breakouts and scars forever, so if there's one point I want to really hammer home, it's this: find a licensed professional who specialises in acne treatment. A dermatologist who's normally up to their eyeballs in melanomas will probably treat you differently than someone with years of experience treating acne.
There's someone out there who can help you — don't give up until you find them.