Acne-Scar Assessment

Distinguishing active acne, colour change and true scarring

• Active acne — current inflamed lesions. Scar treatment is generally deferred until this is controlled, because new lesions create new scars.
• Post-inflammatory erythema — pink or red flat marks where a lesion has settled; frequently fades over months.
• Post-inflammatory hyperpigmentation — brown flat marks, more common in deeper skin tones, and worsened by sun exposure.
• Atrophic scars — indented scars, often described as ice-pick, boxcar or rolling, reflecting loss of tissue.
• Hypertrophic and keloid scars — raised, firm scars more often seen on the chest, shoulders and jawline.

Flat colour change is not a scar in the structural sense, and treating it as though it were leads to unnecessary procedures.

Why scar type affects planning

Different scar types respond to different approaches, and most faces have a mixture. Deep narrow scars behave differently from broad shallow ones, and raised scars need an entirely different approach from indented ones. Planning is therefore about the mix, the depth, the number and the skin type, not a single technique applied to everyone.

Skin tone matters as well, because some approaches carry a higher risk of pigmentation change in deeper skin tones, and that risk is weighed before anything is recommended.

What happens during the consultation

Examination is done in good light and, where useful, with the skin stretched, because that reveals the true depth and edges of indented scars. Your acne history, current treatment, tendency to pigment or to form raised scars, and previous scar procedures are reviewed.

Photographs may be taken with your consent, as change in scarring is gradual and difficult to judge from memory.

Treatment and management planning

Where treatment is appropriate, it is usually staged: control active acne first, address pigmentation and sun protection, then consider textural work over a series of sessions with recovery time in between. Approaches are chosen for the scar type rather than being applied uniformly, and the sequence and likely number of sessions are discussed in advance.

Scar treatment is a slow process measured in months, and results are gradual.

Suitability, limitations and referral

Complete removal of acne scarring is not achievable. A realistic aim is improvement in depth, shadowing and texture, with the skin looking smoother rather than unmarked. Some scars improve considerably, others only modestly, and a small number do not respond.

Risks include temporary redness and swelling, pigmentation change, infection and, uncommonly, worsening of scarring. Where scarring is extensive, where keloid formation is a feature, or where surgical scar revision is likely to be required, referral is discussed.

Preparing for your appointment

• Attend without makeup so scars can be assessed accurately
• Bring photographs from when your acne was most active, if you have them
• List previous scar treatments, including any laser, needling or peels, with approximate dates
• Note any tendency to develop raised scars or pigmentation after injury