Are you familiar with the internet phenomenon of haunting? It’s not ghosting—it’s that thing where, after finally extricating yourself from a relationship, the other person kind of…never really goes away. They’re still there, watching your Instagram stories, popping up in your Facebook feed, and constantly reminding you (annoyingly) of what used to be. Acne scars are like that. You’ve successfully resolved the cause of stress and put it behind you, yet every time you look in a mirror, there it is. Or at least, a memory of it you could do without.
So, how to deal with the persistent ghosts of breakouts past? “There are so many safe options,” says Dr. Ellen Marmur, who’s included in New York magazine’s list of top doctors and knows about all of them. Think of this handy guide as your own personal Ghostbusters—feel free to call upon it whenever you’d like.
Do I even have acne scars?
The best way to approach treating anything is to make sure you know what you’re treating. First things first, let’s rule out what’s not an acne scar. The flat, dark patches left behind by a breakout are not actually acne scars! Instead, they’re signs of post-inflammatory hyperpigmentation (PIH). While commonly confused for acne scars, PIH is your body’s natural response to any sort of skin trauma, from scratching a bug bite to picking a zit. These marks will fade on their own (eventually), or you can help the process along.
True acne scars are texture irregularities, not just pigmentation. The most common type of acne scars look like small indentations in the skin, while raised, bumpy scars are also normal. If this sounds like what you’re dealing with, congratulations! You are a sound diagnostician. It’s likely you know from experience, then, that acne scars particularly difficult to treat.
Whose fault is this?
Acne scars usually result from serious under the skin breakouts—cysts are more likely to leave scars than whiteheads and blackheads are. That’s because, unlike comedogenic whiteheads and blackheads, no amount of squeezing or picking will make a cyst pop. According to dermatologist Dr. Marmur, “50 percent of scars come from picking your face (or 'self-surgery').” The other 50 percent of the equation, then, is dependent on the type of skin you have. For example, people with slightly darker or olive skin tones are more likely to experience pigmentation and scarring after a breakout than their fairer counterparts. This has to do with the melanin already present in darker skin tones, but also with cells called fibroblasts which produce collagen and other fibers. In darker skin, fibroblasts are more active, causing the skin to over-heal and produce excess tissue, which then becomes a scar. And the other 50 percent is the depth of the pimple—the deeper the cyst is, the more likely it is to scar.
Doesn’t that add up to more than 100 percent?
You’re correct, thanks for paying attention. What are you going to do about it?
Well, can I prevent it?
To prevent scars is to prevent cystic acne—and you have to deal with any active acne you may have before you can get to the scars. To help, your derm can prescribe a topical antibacterial like Aczone, or you can try an over the counter alternative like Renée Rouleau’s Anti Cyst Treatment. The goal here is to calm the inflammation and reduce the lifespan of the cyst. If you’re dealing with a particularly red and painful cyst that you think will scar, your dermatologist can hook you up with a cortisone shot, which will calm inflammation from the inside out. However, this should be the exception, not the rule. For intense and frequent cystic breakouts, it may be helpful to speak to your dermatologist about starting an oral retinoid, like Accutane. “That would be a good preventative measure for scarring,” says Dr. Marmur, “but the right patient is one who can be really compliant, as it’s hard on the liver.” If you’re willing to make the commitment, a round of Accutane may ultimately be easier and more productive than treating acne scars. Plus, as Kate Moss says, nothing tastes as good as a glass of rosé consumed after a six-month course of oral retinoids feels, or something. Oh, and you should be wearing sunscreen.
Too late—now what?
Though they won’t get rid of scars, exfoliating products such as AHAs and salicylic acid will fade redness and discoloration left after breakouts. But if you have no active acne, you’re actually better off being kind to your skin than trying to scrub it out with abrasive ingredients. Look for products with hyaluronic acid, which draws moisture to the skin. Plump, glowy skin = minimized appearance of depressed scars.
Can't you give me anything stronger?
You can see your dermatologist for a series of laser treatments, depending again on your skin type and the kind of scar you’re dealing with. A fractional laser will probably be best. “Fractional lasers pierce tiny holes in scar tissue,” explains Dr. Marmur. “If you imagine the scar tissue is a rock that’s pulling the skin down, this breaks it up and releases it so the skin is nice and fluffy again.” As the skin heals, collagen production is increased, supporting the skin to the point where the depression is lifted. Fractional lasers treat the skin in a grid of dots, rather than one big sheet—this means that the skin will heal faster, but more treatments are necessary to ensure it hits everything. “Stop the use of topical actives before you do a laser,” says Dr. Marmur, because it “could be surprisingly strong if your skin is already sensitive.” That means no acids or retinoids for at least one week before and after your treatment.
This sounds a lot like microneedling.
Well, you’re not wrong. The philosophy of microneedling is to create lots of tiny injuries in the skin to promote a healing reaction and collagen production. However, as Dr. Marmur notes, “Microneedling is the poor man’s laser.” While your aesthetician can perform microneedling, and devices are available for at-home use, the good doc recommends against it for this purpose because “lasers are so much more controlled and consistent. An esthetician in a spa has certain things they’re allowed to do, but when you go to a board-certified dermatologist you have more choices.”
You sold me. Which laser should I use?
Lasers like Clear + Brilliant are pretty gentle—one treatment will leave skin feeling refreshed, while 5 treatments will neutralize about 40 percent of deep acne scarring. In terms of severity, it’s a bit stronger than microdermabrasion but less than lasers like Fraxel and Sciton Joule, which cause bleeding and come with longer recovery times. While your dermatologist can help choose the best laser for you, in general, Dr. Marmur says to “choose the gentler one first—ironically, sometimes a gentle one actually does better for you than the big strong ones.” An exception is made for raised scars, which are best treated with strong lasers that can dissolve the extra tissue on the surface.
Anything else I should know?
Of course there is. For a particularly deep scar (called an ice pick scar), your dermatologist can perform a punch excision in-office. Using a tool that looks like a pen, the scar is cut out and sewn up with a little stitch, making it “usually 90 percent better.”
Or, you can fill the scar with hyaluronic injectables. “I love using either Juvederm, Restalyne, or Radiesse to fill a scar. A misnomer is that people think they can push the filler to other parts of the skin—the skin isn’t like a waterbed. It’s long-lasting but not permanent, and won’t move with weight fluctuations or pressure.”
Or, you can start with a little filler and proceed with your laser treatment at the same time. “I often will do laser and filler on the same day,” says Dr. Marmur. “Lasers are delayed gratification, but filler is immediate. You can still do laser without affecting it.” While you wait between laser sessions, try to name a more iconic duo.
Or, you can try a more temporary filler like Dermaflage. Originally created for Hollywood use (because, Stars! They’re Just Like Us), this is a tinted silicone that can topically fill indented scars. Smooth a pea sized amount over the scar, press on the little Texture Pad it comes with, wait for the mixture to dry, et voila! Smooth skin, no lasers required. How’s that for a quick fix?
Photo via ITG.
Research by Ali Oshinsky.