Acne Scarring: Diagnosis & Treatment


Acne scarring involves several aspects that need to be identified and discussed, as each aspect may benefit from different treatment options.
Our clinic has recognized expertise in acne treatment and acne scar reduction and are happy to discuss a treatment plan that’s right for you.
Acne scarring of the skin can result in changes in the surface, volume and movement of the skin.

1. Surface treatment in acne scars involves altering the color of the scar (e.g. lasers, broad band or intense pulse light) and inducing or reducing collagen in the underlying tissue.
2. Volume requires filling of atrophic (depressed) areas or sometimes decreasing the volume with thick or hypertrophic or keloid scars.
3. Movement problems in acne scars can benefit from neurotoxins such as botulinum toxin (BOTOX).
4. Surgical options for acne scars include punch techniques, excisions, and subcision.

Grade 1 Acne Scarring:

This involves mainly surface and color issues, with areas of scarring showing up as flat, pink areas, and in some cases brown (especially in darker skin types) or too white. Treatment options in this case include: skin products to use at home (e.g. containing vitamin C, retinol, tretinoin, hydroquinone, azelaic acid, glycolic acid), chemical peels, microdermabrasion, laser and broad band or intense pulse light.

Grade 2 Acne Scarring:

Again mainly surface marks, but also mild depressed or slightly thickened skin that can be covered with makeup and may not be that obvious from a distance. This form of scarring is a result of altered collagen reflectance, loss of skin glow, and shadows cast by scars. These scars require skin surface improvement and mild volume changes. Treatment options include skin products at home as mentioned in Grade 1 scarring, & also chemical reconstruction of skin scars (CROSS) and subcision. As well, microneedling (e.g. Dermaroller, Dermastamp), chemical peels, microdermabrasion, and resurfacing lasers (e.g. ProFractional laser) can gradually improve the quality of the underlying collagen.

Grade 3 Acne Scarring: “Moderate Scarring”

With this type of acne scarring, there is moderate atrophic (depressed scars), or hypertrophic (thickened) scars. This type of scarring is visible at conversational distance, & can be flattened through stretching out of the skin, but not easily covered with makeup. This form of scarring often benefits from “multi-modality” treatment, meaning improving volume with fillers, using laser resurfacing techniques (e.g. ProFractional laser), sometimes use of neurotoxins (e.g. Botox) to reduce movement in the area, and surgical options such as subcision or punch excisions.

Subcision is particularly useful for freeing up scars that are dish-like in quality and tend to be tethered down to underlying structures. The freeing up of the scar is performed with a hypodermic or other needle, often with concurrent saline injection (“chemical subcision”). Our clinic has extensive experience treating acne scars with all treatment modalities including subcision.

Grade 4 Acne Scarring: “Severe Scarring”

This type of acne scarring is non-distensable and represents severe atrophic (depressed) or hypertrophic (thick) scarring that is obvious at a conversational distance and unable to be flattened by stretching of the skin. The type of scarring observed here includes: deep box scarring, ice pick scarring, deep divots, and hypertrophic (thick) scarring. When treating severe acne scarring, we again want to improve the skin surface with the CROSS technique or laser resurfacing (e.g. ProFractional laser), improve volume (e.g. use fillers in depressed areas), use neurotoxins like Botox to reduce movement in some areas, and surgical options such as punch excisions or ellipse excisions of severely scarred areas.

Article by
Toronto Dermatologic Surgeon