Journal of Critical Reviews

ISSN- 2394-5125 Vol 7, Issue 7, 2020

ACNE SCAR; A REVIEW OF CLASSIFICATION AND TREATMENT

Azadeh Goodarzi 1, Elham Behrangi 1, Mohammadreza Ghassemi 1,
Niloufar Najar Nobari 1, Afsaneh Sadeghzadeh-Bazargan 1, Masoumeh Roohaninasab 1*
1. Department of Dermatology, Rasoul Akram Hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran

*Corresponding author: Masoumeh Roohaninasab,

Department of Dermatology, Rasoul Akram Hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
Email: [email protected]

Received: 17.02.2020 Revised: 22.03.2020 Accepted: 06.04.2020

Abstract
Acne is a common disease that is more common in adolescents, with more than 80% of the cases and 5% of older people
experiencing it. Approximately 14% of the cases have psychological and social consequences for the individual. The main types of
acne scars, which include icepick, rolling, and boxcar are discussed in this article. This classification system for acne scar enables the
physician to identify precisely the subtypes of the wound. After defining the type of wound, appropriate and effective treatment
protocols can be developed. There are numerous treatments for acne scar, the most important of which are discussed in this article.

Keywords: Acne scars, icepick scars, rolling scars, boxcar scars, acne scar treatment.

© 2020 by Advance Scientific Research. This is an open-access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
DOI: http://dx.doi.org/10.31838/jcr.07.07.204

INTRODUCTION Many people that have inflammatory acne are disposed to

Acne vulgaris prevalence is about 90% among teenagers and broad scarring, which is challenging to treat. The information
in some case it remains to adulthood with a main psychosocial about acne scarring pathogenesis is little. Scarring is a result of
effect [1-3]. Scarring result of these acne usually appearance in abnormal wound healing or resolution after the injury that
face and body of patients that has negative effect on general happens in the sebaceous follicle through inflammation of
patient functional and social well-being[4]. Many acne. Immune responses of Cell-mediated related to the
inflammatory skin diseases eventually lead to scarring, the clearances of antigen and tissue damage. Studies showed that
most important of which are acne, wounds, and deep burns[5]. in timed inflamed wounds of identified period (6 hours, 24
Acne scars are categorized into hypertrophic, atrophic, or hours, 48 hours, 72 hours, and 6 to 7 days) the number of CD4
keloidal with atrophic is the most common. Atrophic scars are T cells present in wounds from scares was about half those
additionally divided into icepick, rolling scars, and boxcar[6]. originate in lesions of without scares. In wounds of 6 to 48
Ideal treatment can occur base on scar type[6]. hours, the amounts of blood vessels, macrophages, and
vascular bond molecules were great and comparable in both
Many methods utilize for acne scar treatment including laser, patients sets, while the numbers of Langerhans cells and the
cosmetic filler, microneedling, local tumescent, Subcision, level of cellular activation was low in lesions from scares,
chemical peels, onion extract. suggestive of an unsuccessful answer to the causal antigens.
The aim of this study is introducing of type of scar related to However, for scares treatment there was an response
acne and therapeutic method for each one. upregulation with more cellular activation, influx of
macrophages and skin homing memory/effector cells[13, 14].
Pathogenesis
The acne pathogenesis is associated with many agents, like Types of acne scar
enhanced sebum production, change of the quality of sebum Acne scars are divided into three main groups. icepick scars,
lipids, androgen motion, the proliferation of rolling scars, and boxcar scars[15] (Figure 1).
Propionibacterium acnes in the follicle, and follicular The reason for the placement of acne scars in these three main
hyperkeratinization[7]. Raised sebum excretion contributes to categories is that the scars have both natural biology as well as
the improvement of acne. Neutral and polar lipids produced by specific physical properties.
sebaceous glands serve a variety of functions in signal
transduction and are included in biological pathways[8, 9]. Depth, width, and 3D architecture are three crucial factors in
determining the type of acne scar.
In addition, fatty acids do as ligands of nuclear receptors like
PPARs. Sebaceous gland lipids exhibit direct pro-and anti-
inflammatory properties, while the induction of 5-
lipoxygenase and cyclooxygenase-2 pathways in sebocytes
leads to the creation of pro-inflammatory fats. Moreover,
hormones similar to androgens control sebaceous gland size
and sebum secretion. Androgens only promote sebocyte
proliferation in cell culture; whiles PPAR ligands are needed
for the induction of differentiation and lipogenic activity[10].
On the other hand, keratinocytes and sebocytes are stimulated
by P. acnes via TLR, CD14, and CD1 molecules[11].
Pilosebaceous follicles in acne lesions are environed by
macrophages expressing TLR2 on their surface. TLR2
activation leads to a triggering of the nuclear transcription
factor and thus the production of cytokines/chemokines,
phenomena observed in acne lesions. Furthermore, P. acnes Figure 1. A novel classification system: 3 basic scar
induces IL-8 and IL-12 release from TLR2 positive types—icepick, rolling, and boxcar
monocytes[8, 12].

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 ACNE SCAR; A REVIEW OF CLASSIFICATION AND TREATMENT

Rolling Acne Scars

The rolling acne scars on the skin resemble strips from the The difference between the three main types of scars is
dermis to the subcutaneous tissue. illustrated in Figure 6.
They are usually 4 to 5 mm wide. Anchoring the abnormal
fibrous layer of the dermal layer to the subcutaneous layer
results in the shading of the healthy skin surface[15](Figure
2).
Correcting and treating the subcutaneous layer makes it
successful in treating this type of scar.

Figure 6. The difference between the three main types of

scar.

Other less common scars

Figure 2. Rolling scars along the cheek. In addition to these three main types of scars, there are other
scars, including sinus tracts, hypertrophic scars, and keloidal
Boxcar Scars scars[15, 17]. These types of scars are less common and may
Boxer scars are divided into two shallow boxer scars and deep develop after acne treatment, which is discussed below.
boxer scars according to their depth. Boxcar scars are round to
rectangular depressions with sharply demarcated vertical Hypertrophic and Keloid Scars
edges, similar to varicella scars. These scars are wider at the Hypertrophic and keloidal scars are associated with excess
surface than icepick scars. They are not tapered to a point at collagen deposition and decreased collagenase activity[16].
the deep layer[15].
Hypertrophic scars are pink, raised, reddish, pruritic lesions
These types of scars are either shallow (0.1 to 0.5 mm) or deep caused by an overgrowth of fibrous connective tissue but
(greater than 0.5 mm) and are usually 1.5- to 4- mm in unlike keloids, they do not extend beyond the margins of the
diameter (Figure 4). acne. They are more commonly seen than keloids and may be
These scars may need to be removed if they are more than 3 smaller in size than them (Figure 7). These scars are usually
mm in diameter (deeper boxcar scars). However, if these scars caused by thermal injuries and injuries involving the deep
are not sincere, they can be treated with fractionated laser dermis layers of the skin and are prevalent in all races. These
therapy[4, 6]. scars remain in the borders of the main wound[8].
Keloids are raised, reddish-purple lesions produced by
overgrowth of fibrous connective tissue and develop after
healing of a skin injury. After an injury has occurred, the skin
cells and fibroblasts begin multiplying at the site of the wound
to repair the damage. In the case of keloid formation, these
cells do not stop after the wound has been filled. These scars
proliferate beyond the borders of the main injury[8]. In people
with dark skin, hypertrophic and colloid scars are more
common[15].

Figure 4. Boxcar scars on the cheek.

Icepick Scars
Icepick scars are <2 mm (deep narrow) cylindrical
depressions that occur at the infundibulum. And extends
vertically to the deep dermis layer or subcutaneous layer[15].
These types of scars are not always, but are usually recognized
with a wider surface opening than the deep layer (Figure 5).
Their depth is below that arrived with regular skin-resurfacing
alternatives.
Figure 7. (a) Hypertrophic and (b) Keloid Scars
Due to the Icepick scars depth, punch excisions and AFL are
rather useful[4, 6, 16]. Treatment of acne scar
Several methods have been used for acne scarring
treatment[18, 19]. Each method can select for scar treatment
base on scar typing. Table 1 shows methods that utilized for
each scar type.

Figure 5. Icepick scars on the cheeks.

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 ACNE SCAR; A REVIEW OF CLASSIFICATION AND TREATMENT

Table 1. Methods for acne scar treatment bas on scar type in various studies
Type of scar Treatment procedure
Rolling acne scar 1. IPL[20]
2. PDL[21]
3. Picosure laser[6]
4. Local tumescent anesthesia[6]
5. Trichloride acid peel[6]
6. Ablative fractional co2 laser[22]
7. Hyaluronic acid gel injection[23]
8. Subcision[24]
9. Fractional non-ablative erbium[25]
10. Microneedling[26, 27]
11. Er:YAG laser[28]
12. 1450-nm Midinfrared Laser and 30% Trichloroacetic
Acid Peels[29]
13. Subcision and 1320‐nm Nd:YAG Nonablative
Laser[30, 31]
14. 70% TCA [32]
15. combined subcision and dermaroller[33]
16. Microneedling combined with PRP[34]
Boxcar scar 1. Excision[15]
2. NAFL or AFL laser[6]
3. TCA peel[6]
4. AFL LP Erbium[6]
5. 1,540‐nm fractional laser[25, 35]
6. Er:YAG laser[28]
7. 1450-nm Midinfrared Laser and 30% Trichloroacetic
Acid Peels[29]
8. Subcision and 1320‐nm Nd:YAG Nonablative
Laser[30]
9. 70% TCA [32]
10. Combined subcision and dermaroller[33]
11. Microneedling combined with PRP[34]
12. Fractional bipolar RF [36]
Hypertrophic and Keloidal scar 1. NAFL[6]
2. TCA peel[6]
3. PDL[37]
4. Triamcinolone Acetonide[38]
5. Corticosteroid injections[39]
6. Silicone gel sheeting[40]
7. Fluorouracil[41]
8. Onion extract[42]
9. fractional CO2 laser[43, 44]
10. 70% TCA [32]
11. combined subcision and dermaroller[33]
12. cryosurgery[45]
13. oral isotretinoin[46]
14. Focused Radiofrequency[47]
15. combined intralesional triamcinolone and verapamil
therapy[48]
16. pressure garment therapy (PGT)[49]
17. intense pulsed light (IPL)[50]
18. fractional carbon dioxide laser with low,medium or
high-dose isotretinoin[51, 52]
19. Microneedling and Platelet-Rich Plasma[53]

Icepick scar 1. Excision [6]

2. Fractional ablative erbium laser[6]
3. Fractional ablative co2 laser[6]
4. RF[6, 54]
5. Microneedling[6]
6. TCA peel[6]
7. 70% TCA [32]
8. combined subcision and dermaroller[33]
9. Platelet-rich plasma[55-58]

Silicone-based therapies oxygen permeability is increased. Thus decreasing hypoxia-

One of the main option for hypertrophic scars treatment is induced angiogenesis and tissue growth[61, 62].
silicone-based [59]. Numerous silicone products are presented
for prevention and treatment of acne scar[60]. Silicone gel Corticosteroid injections
sheeting (SGS) has ability in increasing of stratum corneum Intraregional steroid injections have been used for treatment
hydration and decreasing of water evaporation from the skin, of hypertrophic and keloids scars[39]. However studies
proposing occlusion and hydration is the mechanism of support corticosteroid injections using is second-line therapy
silicone-based products action[40]. Because of hydration the to treatments with silicone-based product. Triamcinolone is a

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 ACNE SCAR; A REVIEW OF CLASSIFICATION AND TREATMENT

commonly intralesional steroid therapy that improve scars of scarring compared to ablative lasers[87-89].
through fibroblast proliferation inhibition, collagen synthesis
decreasing and collagenase inhibitors inhibition[63]. Dermabrasion
Dermabrasion contains of manual dermasanding for removing
Laser therapy epidermis and upper dermis used hydrogen peroxide and
There are several types of lasers on the market that are used sandpaper for hemostasis, or using of rotating motorized hand
to treat skin problems. Clinical applications of skin laser piece attached to a serrated wheel, diamond-embedded
devices are determined by the wavelength, laser light, and fraises, and wire brush. Superficial skin layers removing cause
amount of laser absorption in the skin. Two general categories smoother wound healing process and new collagen
are defined for skin laser devices including ablative and non- forming[90-92].
ablative laser(NAR). The Ablative Laser such as co 2, Erbium
Yttrium-Aluminum-Garnet (Er:YAG), contains strong Subcision method
wavelength light that often destroys the outer layer of the skin. Subcision is a simple, safe, up-to-date method, with a different
Non-ablative lasers can penetrate the inner skin layer and mechanism underlying the treatment of atrophic scars such as
enhance collagen formation in this area, thereby helping to pimples - suture and chickenpox. Subgenus and RF fractional
improve skin regeneration[5, 64-66] . together are the best treatment for atrophic (depressed) scars.
The subcutaneous procedure uses a method of releasing
Scar treatment with laser is an adjunct treatment after silicone connective tissue or fibrotic tissue to treat and remove the
and intralesional corticosteroids according to the UICRSM pimple. The subsection is performed with a standard device
algorithm .PDLs lasers with 585-nm is used for treatment of with special needles called the needlepoint. The subcutaneous
hypertrophic scars and keloids[67]. In a meta-analysis study procedure is used to treat acne or so-called deep acne
an average 72% rate improvement of hypertrophic scars and scarring[24, 93].
keloids by PDL laser was demonstrated[37]. A systematic
analysis exhibits the PDLs laser have better effect on scar Cosmetic filler
treatment compared to fractional nonablative laser 1540nm, Recently, the injection of fillers have been advanced in scar
neodymiumdoped yttrium aluminium garnet laser 532 nm, treatment, these fillers contain temporary fillers such as
CO2 laser 10 600 nm and erbium:YAG laser 2940nm[68]. Some semi-permanent and permanent fillers[94]. Several cosmetic
studies shows good effect of ablative fractional laser compared fillers have been developed for treatment of acne scars by
to PDLs in scar treatment[69, 70]. swelling of tissue in these scars and stimulating of collagen
production [95]. Many of acne scars respond successfully to
Fluorouracil cosmetic fillers, in some case these fillers combined with other
Scar treatment with 5-FU was first suggested by Fitzpatrick in component to increase their function[96]
1999[71]. The more effective of 5-FU tattooing has been
confirmed than intralesional corticosteroids[72]. However Mesotherapy
The 5-FU injections in combined with intralesional Mesotherapy is one of the rejuvenation techniques that inject
corticosteroids and PDL treatments showed most effective in hormones, vitamins and plant extracts into the skin to help
scar treatment[73-75]. regenerate and tighten the skin as well as remove fat[97].

Intense Pulsed Light (IPL) Carboxy therapy

Recently intense pulsed light (IPL) is found as an effective Carboxy therapy is a medical method in which carbon dioxide
agent in scar treatment. IPL mechanism is not fully detected. is used for therapeutic purposes. During treatment with
But it possibly targets vascular proliferation that is essential medical sterile carbon dioxide gas applied to the skin or
for collagen overgrowth and it has effect on pigmentation that adipose tissue, a sign of oxygen deficiency is sent and the
made during scar development [76-79]. organism replaces carbon dioxide with oxygen within
minutes[98].
Micro needling
Micro needling is a method that involves using thin needles to Combinational method
create hundreds of very thin holes on the skin. The small holes Many studies have investigated the efficacy of combination
created by the micropen machine allow the skin to begin to therapeutic method to treat acne scars. In meta-analysis study
regenerate by producing collagen and elastin. This process the PRP combined with ablative fractional CO2 laser was
improves wrinkles, fine lines, pimples, wounds and pores [26]. investigated for acne scars treatment by investigative clinical
A main concern related microneedling is clinical results trial results and patient improvement rates were significantly
dependent on subjective evaluation by physicians and/or increased after combination laser and PRP than laser
volunteers. Meanwhile after Micro needling treatment the alone[99]. In another systematic review study the efficacy of
histopathological response are few[2, 80-82]. PRP adding to the microneedling was investigated for acne
scars treatment and they showed the PRP addition to
Chemical peeling microneedling improves acne scar and furthermore improves
Chemical peeling is the most common cosmetic trials in scar subjective patient satisfaction[53].in numerous other studies
treatment and has been utilized for years. This procedure is the combination of dot peeling with Subcision and fractional
used chemical agents in which epidermis and dermis laser irradiation[93], Subcision‐suction method[100], carbon
destruction controlled .Chemicals peels are categorized based dioxide (CO2) laser with subcision[100], fractional carbon
on penetration depth including superficial (epidermis– dioxide (CO2) laser resurfacing with punch elevation[101],
papillary dermis), medium (papillary to upper reticular Fractional Erbium-YAG Laser and Platelet-Rich Plasma[102],
dermis), and deep peels (mid-reticular dermis)[83]. These Microneedle Fractional Radiofrequency and Topical Poly-
chemical agent including resorcinol, tretinoin, glycolic acid, Lactic Acid[103], Autologous Cell Regeneration Techniques
lactic acid, salicylic acid, and trichloroacetic acid for superficial with Dermabrasion[104] and promising results were
peels, phenol, TCA 35% to 50%, and Jessner solution recorded.
(resorcinol, lactic acid, and salicylic acid in ethanol) Medium-
depth peeling agents and Baker-Gordon or Litton phenol CONCLUSION
formulas for deep peeling agents[84-86]. There are no comprehensive guidelines available to optimize
acne scar treatment. There are various multiple management
Radiofrequency options, both medical and surgical, and laser devices are useful
Radiofrequency (RF) is used initially for skin regeneration. In in obtaining significant improvement. Further primary
this procedure the electromagnetic radiation produce an research, such as randomized controlled trials are needed to
electric current that heats dermis and cause skin contraction quantify the benefits and to establish the duration of the
and neocollagenesis. RF has reduced infection and risk effects, the cost-effective ratio of different treatments, and the

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