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Boston Cosmetic


Scar Tissue Formation from Dr. Ishoo on Vimeo.

Although acne often is a chronic condition, even if it lasts only during adolescence, it can leave life-long scars. For this reason acne scars can be just as upsetting to the acne sufferer as the acne itself. But before you despair there are lots of treatment options available to get rid of both acne marks and scars. Additional information provided at

Scars are reminders of injury to tissue and the body’s attempt to repair that injury. Acne scars are the result of inflammation within the dermis brought on by infected comedone. The scar is created by the wound trying to heal itself resulting in over production or loss of collagen in one spot. There are two main types of acne scars: hypertrophic (raised) and atrophic (depressed). Both are formed in the same way – inflamed lesions destroy a portion of the dermis along with the collagen in that area and leave significant scarring and texture irregularities. Atrophic scars are caused when the damaged collagen only partially, or not at all, grows back. This leaves a depressed area in the skin. Hypertrophic scars on the other hand are caused by overproduction or abnormal production of collagen, leaving a raised, thick scar.

There is no way to predict who will scar, how deep the scars will be, and if they will improve over time. Generally scars result from severe inflammatory cystic, nodular acne, but even whiteheads can cause scars if not treated properly. Though by no means a perfect solution, one way to prevent scars or to ensure that they aren’t very severe is to have Dr. Ishoo and his staff of acne-certified professionals evaluate and treat your acne as early as possible and for as long as necessary. The more thoroughly the deep pore collections are extracted and the faster you respond to the inflammation in the skin the more likely we can prevent or minimize scars.

The acne related scarring can present in a variety of forms which dictate the treatment.

Depressed acne scars typically present in the following forms:

1. Icepick scars

Appearance: Icepick scars are typically deep, very narrow scars that extend into the dermis and usually occur on the cheeks.. There is an Orange peel appearance to the skin. The skin looks as if it has been pierced by an ice pick or sharp instrument. Ice pick scars seem to make a small, wedge depressions in the skin. Some may look like a large, open pore.

Development: Ice pick scars develop after an infection from a cyst or other deep inflamed blemish works its way to the surface. Skin tissue is destroyed, leaving a long column-like scar.

Treatments: Ice pick scars can be treated with punch excision or Fraxel dual 1550nm or Fraxel Re:pair CO2 LASER resurfacing.

2. Boxed or Boxcar

Appearance: Boxcar scars are rectangular or oval depressions with steep vertical sides similar to chicken pox scars. Wider than ice picks, boxcar scars give the skin a pitted appearance.

Development: The underlying inflammation destroys collagen leading to loss or tissue under the skin. The overlying skin becomes depressed due to lack of support. Boxcar scars may be superficial to severe, depending on the amount of tissue lost.

Common treatments: Treatments for boxcar scars include punch excision or elevation, dermal fillers and fat grafting, and laser resurfacing using the Fraxel Repair or Fraxel dual. Boxcar scars also respond well to TCA cross chemical peel treatments.

3. Rolling scars:

Appearance: This type of scarring results in deep rolling or “wave-like” changes or shallow smooth indentations across otherwise normal appearing skin.

Development: Rolling scars result from fibrous bands of tissue developing between the skin and the subcutaneous tissue below after a period of inflammation. These bands pull down the skin surface, binding it to deeper structures of the skin. It is this pulling of the epidermis from below that creates the rolling appearance of the skin.

Common treatments: Rolling scars are best treated with subcision with or without fillers and fat grafting. These scars can also improve with Fraxel dual or Fraxel Repair LASER resurfacing.

4. Enlarged Pore

Appearance: Appears as a tiny hole on the face. Also known as a superficial pit scar,

Development: this is a formerly clogged pore which was never healed. Enlarged pores can be found on the face, specifically on the central cheeks and around the mouth and nose.

Common treatments: Best treated by LASER resurfacing to stimulate collagen production and closing of the pores but also may respond well to the punch techniques.

As seen in the illustration above, scars are marks where the skin is depressed or pitted. The more pitted the scar is, the more difficult and aggressive the treatment must be to achieve meaningful improvement. Atrophic acne scars cannot really be completely eliminated but with both resurfacing treatment and fillers they can be improved about 80%. By seeing how a scar reacts to gentle stretching you can get a rough idea of what type of treatment would be best for you. Shallow or soft-sided scars will almost or totally disappear when the skin is pulled taut; these types of scars can be corrected with resurfacing and fillers. Scars that cannot be stretched out when you pull the skin generally require surgical excision to correct. Only a well-equipped medical office with well trained staff such as Boston Acne Center can offer effective acne scar treatment.

Raised acne scars typically present in the following forms:

5. Hypertrophic Scars

Appearance: A hypertrophic scar looks like a raised, firm mass of tissue but remain within the confines of the wound which is different from true keloid in which case the scar tissue grows well passed the shape and confines of the original wound. Hypertrophic scars caused by acne are the result of inflamed nodulocystic acne or acne conglobata and are most often found on the torso, especially in men.

Raised Papules are small hypertrophic bumps. These raised scars are most common on the nose and chin and are usually treated by techniques which flatten them. However, once removed, scarring may be left in their place. Typically these scars are 1 to 2 millimeters in diameter, but some may be much larger – 1 centimeter or more.

Development: Unlike ice pick or boxcar scars, hypertrophic scars are not caused by a loss of tissue. Rather, they develop because of an overproduction of collagen created when the skin responds to injury. The excess amount of collagen that forms gets piled up in fibrous masses thus resulting in protruding, firm, and smooth scars.

Common treatments: These scars may regress spontaneously to some extent over time. Steroid (cortisone) creams, silicone tapes, or injections of corticosteroids and flurouracil are used to help reduce and flatten the scar. Interferon injections are also used to soften scar tissue. These scars can also be treated with combination of excision and LASER resurfacing if particularly large and disfiguring.

6. Keloid Scars:

Appearance: A keloid scar is one in which there is raised overgrowth of dense scar tissue. It extends beyond the shape and borders of the original wound and it appears as smooth, red or purple grape-like outgrowths from the original wound. This contrasts with hypertrophic scars, which stay within the borders of the original wound. A keloid is a raised, smooth but lumpy. Keloids can be red or purplish in color and most significantly, keloids extend above the skin’s surface. This type of scar can hurt, be itchy, and even become infected.

The term ‘chéloïde‘ was coined by Alibert in 1806, from the Greek ‘chele‘, meaning crab’s claw – to describe the lateral growth of tissue into unaffected skin.

Development: This usually develops due to abnormal over production of collagen after any injury as in after the inflamed nodulocystic acne has healed. Keloid scars appear to be genetic and are more common in people with darker skins, especially African-American and Asian races. Unfortunately, once keloids develop they can grow both uncontrollably and unpredictably and even recur after treatment.

Common Treatments: It does not normally regress spontaneously and it will usually recur after excision. Streoid and flurouracil injection in to the scar and silicone tape are used to reduce the scar. Laser treatments can be combined with steroid treatment in order to reduce the recurrence of keloids. In cases of severe or disfiguring keloid scars, there may be a role for excision followed by intensive wound treatment with steroid creams, injections and silicone tape to minimize the abnormal collagen overproduction. Sadly keloids remain difficult to treat and, as already mentioned, may even return after treatment.