Acne is complicated, to say the least. There's seemingly no limit to the different ways it can manifest, or the various hard-to-diagnose causes. There's also the aftermath of a breakout, which can result in hyperpigmentation and acne scars. The two are often confused, but dermatologists say that's nowhere near the truth. "Many of my patients come in and refer to their dark spots as acne scars when it's post-inflammatory hyperpigmentation," says dermatologist Corey L. Hartman, M.D. "The difference is in texture."
Dr. Hartman explains that acne scarring occurs when nodulocystic acne — the big, often painful kind — creates scar tissue that pulls down the skin. "We usually call these icepick scars," says Hartman. "You can tell the difference if there is a noticeable texture when you rub your skin. That is true scarring." Hyperpigmentation, on the other hand, is discolouration of the skin that generally remains smooth to the touch without raised texture.
The idea of rolling hundreds of tiny needles across your skin to treat acne scars may seem counterproductive, but Dr. Hartman says microneedling is excellent for diminishing the appearance of scars. "Microneedling is a good option because it delivers collagen stimulation through pressure, which allows the skin to remodel itself," he explains. Technically, creating tiny punctures (or injuries) in your face will allow it to heal and produce new collagen.
Dermatologist Candrice Heath, M.D., also recommends microneedling for patients with acne scars — provided it's done at the hands of a medical professional. "Microneedling is a great middle ground between topical treatments and aggressive lasers that are commonly used for scarring," she says. "However, you want to make sure it is being done in the hands of someone experienced with skin of colour. You do not have to be aggressive, because then you can cause irritation and hyperpigmentation."
Laser treatments, which are also used to treat hyperpigmentation in some cases, are safe for treating acne scars in dark skin, but Dr. Hartman advises to tread lightly. "Generally, CO2 lasers," like the popular Fraxel laser, "are off the table," he says. "Many professionals will agree that it isn't friendly for brown skin tones because it's an ablative laser which completely resurfaces the skin." Dr. Hartman explains that, depending on the depth and density of the CO2 laser, you can do serious damage to the skin's pigment, permanently removing it or even causing hyperpigmentation.
Instead, fractionated lasers, like Picosure, safely deliver pressure to targeted areas using heat. The laser was originally used for tattoo removal, but also effectively regenerates skin and improves collagen production. "Picosure breaks up pigment, and it's also great for refining texture," Dr. Hartman says. "It's a better option that will deliver safer results more slowly."
Though Dr. Heath and Dr. Hartman both recommend more intensive in-office treatments to treat acne scars, that doesn't necessarily rule out the use of topicals. According to Jenna Lester, M.D., head of the new Skin of Colour Clinic at University of California, San Francisco, chemical peels can work wonders for people struggling with acne scars. "Salicylic and glycolic acid are great for resurfacing dead skin and improving your complexion overall," she says. "These peels will also help prevent and treat hyperpigmentation that may occur as a result of your acne."
Additionally, Dr. Lester recommends asking your doctor about tretinoin if you're struggling with acne scars. "Tretinoin helps improve cell turnover, treat acne, and increase collagen disposition, therefore improving the appearance of acne scars and your complexion," she explains. Depending on the severity of your scars, your doctor may utilise steroids to smooth texture. "If you have thick, keloid-like scars, which people do get from acne, Kenalog injections help flatten that scar tissue," Dr. Lester adds.
The most important thing is that you talk to your doctor before taking treating your scars into your own hands. "You don't want to add insult to injury and encourage hyperpigmentation or worsening of your acne scars," says Dr. Lester. "An ounce of prevention is worth a pound of cure when treating conditions like acne scars in dark skin."