Acne vulgaris affects almost 80% of the population at some point in life and leads to scarring in up to 95% of patients with acne.1,2 Many patients suffer long-term psychological and social effects from the complications of acne.3 The prevalence of acne scarring in the general population has been estimated to be 1% but is much higher in the dermatology clinic population.4 Even though the treatment of acne scarring has greatly improved in the last decade with respect to safety and efficacy, many patients are unaware of their options regarding potential therapies. The proliferation of devices and techniques for improving acne scarring present a challenge for the clinician who must often apply several treatments for an individual patient with multiple types of acne scars.
Most patients with acne report that prevention of acne scarring is one of the main reasons for seeking professional dermatologic care, especially in severe cases. However, many patients specifically seek out the dermatologist or dermatologic surgeon to address acne scarring long after the active lesions have subsided. Only in the last few decades has improvement of acne scarring become a significant practice area for dermatologists with the development of new modalities such as lasers, surgical devices, chemical peels, and fillers.
Most patients with acne scarring have limited areas of involvement on the temples or cheeks. Some have more widespread involvement on the face, chest, and back. There is no correlation between the Fitzpatrick skin type and gender with acne scar severity.5 Although most acne scarring is atrophic, there are several subtypes and clinical variations. In addition, while the underlying pathophysiology of various types of acne scars may be similar, the treatment options vary for each type, so it is worth classifying acne scarring from a clinical perspective.
CLASSIFICATION: TYPE AND SEVERITY
Acne scars are either depressed (atrophic) or elevated (hypertrophic). There are three clinical subtypes of atrophic acne scars: icepick, boxcar, and rolling (Fig. 47-1). The elevated type acne scars can be hypertrophic or keloidal. Macular acne scars may also have associated vascular and pigment changes even if the skin texture is unchanged. Finally, it is important to note severity and distribution in selecting the appropriate treatment modality (Table 47-1).
Three types of atrophic acne scars. Appropriate therapy selection depends on the type of scars present.
TABLE 47-1Clinical Classification of Acne Scarring and Associated Skin Changes