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Very severe acne is often the cause of deeper cysts and pustules, which must be treated on time, otherwise there is a serious risk of scars that remain on the face.

Acne scars


Acne scars and spots may mark the face of a person for ever. This is the reason why acne should be treated dermatologically in a timely and reliable manner, so that to avoid the formation of acne scars. In case of scars’ appearance, they must be treated using the best possible way.

Acne scars are caused by the growth or loss of skin tissue.

Acne is an inflammatory disease of the sebaceous glands of the skin and when its progression is allowed without effective treatment, its topical destructive process blocks the smooth healing of the specific area. This is due to the fact that the basic unit on the skin for the healing process is the hair sebaceous follicle, which cannot act properly under conditions of inflammation.

Following inflammation, the healing process is either inadequate or excessive and results in the growth or loss of skin tissue.

In cases of mild inflammation, the remaining lesions may just be erythemas or pigmentations, while in other cases they may be more severe. Therefore, the remaining lesions may be mild to very severe scars and probably localized on the face, neck, shoulders, chest and back.

How is it possible to prevent the development of acne scars?

People with acne that want to avoid the development of acne scars should pay particular attention both to timely treatment of acne using the most advanced dermatological methods, which do not necessarily include the administration of drugs per os, as well as to avoid touching the areas with acne lesions, i.e. not to push with their fingers at the areas with skin lesions.

Timely and individualised treatment of acne reduces or eliminates the chance of scarring. If the person avoids touching acne lesions with the fingers, then their spread on other areas can be prevented as well as the swelling of already existing lesions.


Most acne scars are atrophic and, depending on their morphology, they can be classified in 3 types:

  • Ice pick scars (narrow deep pits)
  • Boxcar scars (wide deep pits)
  • Rolling scars (wave-like)

Ice pick scars (narrow deep pits) look as if they have been caused by the hit of a sharp tool’s head, like the sharp pit caused on the ice by the icebreaker. This is why they have are called ice-pick.

These scars are narrow but deep, extending into the deep dermis.

These specific scars are the most difficult ones to be treated.

Boxcar scars (wide deep pits), which can be narrow or deep, as opposed to ice pick scars, are more rounded, like cavities, but they may also have vertically organized sides, and they may be successive, just like wagons -“boxcar”.

Rolling scars (wave-like) create wave-like appearance and texture on the skin’s surface and they are usually caused by dermal tissue atrophy.

Treatment methods for acne scars

The above three types of acne scars may co-exist on a person’s face or back.

Depending on their type, they can be treated using a specific method or a combination of methods, which are chosen after the personalized clinical evaluation of each case.

The methods applied are the following: peeling with phenol, dermabrasion, Diamond Microdermabrasion, dermasanding, subcision, microsurgical removal, punch excision or elevation, filling using implants, lipo-filling, LASERs and, now, Fractional Microneedling RF, which is a system of fractional radiofrequencies with insulated micro-needles.

What is the target of acne scars’ treatment methods and how do they work

The target of the above mentioned treatment method is twofold. One of their uses focuses on the breakup of fibre bundles, which force the skin to create folds, forming acne scars. On the other hand, they trigger the production of those skin’s proteins which contribute to its regeneration, such as collagen and elastin.

Collagen, which is the most abundant component of dermal connective tissue, can be distinguished into seven different types. However, it is just types Ι and ΙΙ that constitute the main components of papillary and reticular skin layers, onto which we want to focus in order to improve acne scars.

This means that through the stimulation of increased production of these types of collagen, we ensure immediate and visible effect in relation to scars’ improvement.

All the above mentioned methods target the triggering of biological process, through which the production of collagen and elastin is increased. This means that they trigger fibroblasts, causing new collagen formation.

Nevertheless, they differ among them as far as the mode of action and the degree of effectiveness achieved through each method’s application are concerned.

LASER application for the improvement of acne scars

Ablative Exfoliative LASER

The advanced fractional LASER CO2 and Er:YAG scan the skin, they induce sublimation and exfoliation in specified microscopic zones of the skin, leaving the intermediate zones intact.

This procedure offers the advantage of a much more powerful healing process of the skin, since the intermediate zones that remain intact serve as reservoirs for intact follicles, from which healing starts and is supported.

The time needed for healing, as well as the risk of side effects are minimized in comparison to traditional CO2 and Er:YAG LASER. They are applied gradually and using low intensity in repeated sessions until the desirable result is achieved.

Nevertheless, their use is limited depending on the time of the year and sun protection.

Non exfoliative LASER systems

A variety of non exfoliative LASERs are used for the treatment of mild atrophic acne scars.

The systems that have been used for this reason are 1.320 nm Νd:YAG and 1.450 nm Diode LASER .

These specific LASERs do not exfoliate the skin, as they target the water-containing tissues of the skin.

Non exfoliative LASER systems do not cause skin peeling, but they are less effective, achieving partial improvement, and they can only be applied for the treatment of mild atrophic scars.

It must be noted that the degree of clinical improvement is significantly smaller than that achieved by the other methods.


LASER for the residual red and hyperpigmented acne lesions.

These advanced LASERs remove selectively their chromophore target. Pulsed Dye Laser is used for red residual acne lesions and Q-Switched Laser is used for hyperpigmented acne lesions.

Subcision application for the improvement of acne scars

Subcision is a minimally intervening procedure, which is performed using a needle after topical anaesthesia, in order to break the connective tissue fibres that, in certain cases, “pull” the scars downwards.

It is a safe method that can ensure significant improvement of the wave-like scars in the long term most of the times.

It is used in combination with the other methods.

Punch elevation

It is applied on circular deep scars, using a circular instrument, with an edge of equal diameter with that of the scar, which excises circularly the scar, it takes it out and it elevates the surface of the scar up to the level of the surrounding skin. Stabilization is achieved using a strip on the surface. Following this, LASER is used for the abrasion.

Use of implants

An absorbable, non-autologous material, such as hyaluronic acid, hydroxyapatite, polylactic acid, or autologous fat- lipofilling – is implanted in the tissue located below the scar, so that to fill the gap.

Another purpose of the material’s infusion is to trigger collagen production.

This particular method is indicated for the treatment of soft and deep acne scars only, while the use of non-absorbable materials, such as silicone, is avoided, as it can cause side effects.


New method for the treatment of scars

System of Fractional Radiofrequencies using insulated microneedles RF

Medical technology is taking huge steps forward and the data are changing continuously through the development of methods aimed at minimal intrusiveness with the least possible pain, the shortest recovery period, and the best possible result, for all skin types.

This is the purpose of the new method’s application for the regeneration of the skin, which is called Fractional Microneedling RF, i.e. System of Fractional Radiofrequencies using insulated microneedles RF.

Today, the system of fractional radiofrequencies RF represents a cutting edge technology in invasive dermatology for skin regeneration and acne scars’ treatment.

It is an RF system with a head consisting of 49 insulated microneedles or micropins, which penetrate in a lower skin layer (0,5-2,0 mm) producing energy through the emission of radiofrequencies.

The system of fractional radiofrequencies RF, through its action below the skin’s surface, delivers the energy in a conical shape, with radiofrequencies that produce greater thermal stimulation.

The system of fractional radiofrequencies RF has the following advantages:

It does not exfoliate the skin and, therefore, it can be applied throughout the year, even during summertime;

It is indicated for all skin types;

No special treatment is needed after treatment;

It does not prevent make-up use after treatment.

Recovery is brief and there is no risk of hyperpigmentation.

Usually two or three sessions are required, at least 4-6 weeks apart.

The use of an individual detachable head per patient ensures hygiene.

The system of fractional radiofrequencies RF acts in depth, without affecting the skin’s surface and it triggers the required components that regenerate the skin, while it minimizes significantly the treatment and recovery duration.

It can be applied irrespectively of the time of the year or the morphology of the atrophic acne scars in only a few sessions.

For this reason it is the most modern and less painful method of invasive dermatology for the treatment of atrophic acne scars, irrespectively of their type.

Why should the microneedles be insulated?

Impedance (Z) represents a measure of the variable resistance of a material, when sinusoidal alternating current is applied across its two surfaces. The closer the current is applied to the surface of the skin and the upper dermis, the smaller the impedance. The deeper the current is flowing, the greater the impedance created due to the greater resistance of the tissues.

According to Ohm’s law, the voltage difference is equal to current * impedance.

Electrodes’ flow within the tissues undergoing voltage difference via a radiofrequencies system causes molecular oscillation, which results in the production of heat and local increase of temperature. The released heat equals to power * application time.

The smaller the impedance (Z) is, the greater the power (P).

Therefore, it can be concluded that power is greater on the surface layers of the skin and the upper dermis due to the smaller impedance and, as a result, the released heat is greater, too. For this reason it is important to use insulated needles, so that to prevent the release and flow of current on the skin and upper dermis, since the great release of heat due to the large impedance is avoided.

Consequently, with the insulated microneedles, which allow the current’s flow on their tip only, both the safe increase of power, allowing the required and optimal increased release of heat in depth within the dermis leading to the desired therapeutic result, and the protection of the upper layers of the skin and dermis from current flow, heat release and their adverse events, are achieved.

Other categories of scars include the following:

  • Keloid scars
  • Hypertrophic scars
  • Burn scars
  • Traumatic scars
  • Chickenpox Scars
  • Post-procedural scars

Scars usually appear following acne, some diseases, trauma or surgical procedures. They can be categorised according to three general types:

  • Hypertrophic erythematous scars, with almost the same appearance as keloids
  • Atrophic scars, such as the ones that develop after acne or chickenpox
  • Scars due to burns, which may have the characteristics of both the above types or present like diverse lesions of skin texture.

About the author:

Christofer Tzermias

Specialised in the UK (Oxford & London) and in North America (New York & San Diego) in the field of LASER Dermatology, Dr Tzermias, has been providing dermatological state-of-the-art treatments using cutting-edge LASER and Energy based Devices for over 20 years. He has been Director of Interventional and LASER Dermatology Department at the Athens Medical Center for over 18 years and for the last 9 years is the Scientific Director of IQ - Intensive Quality Dermatology & Cosmetic Surgery Clinics, which at the 2017 Healthcare Awards won the ‘Innovation Award for Innovative Services’ for their pioneering contributions. Since 2018, IQ Dermatology & Cosmetic Surgery Clinics has also been operating in London, UK and in Muscat, Oman. Dr Tzermias is a Fellow of the world-renowned American Society for LASER Medicine and Surgery (ASLMS), a Founder Member of the European Society LASER Dermatology (ESLD), the Vice President of the ‘Open Health Alliance’ and he is also on the Board of Directors of Elitour - Greek Medical Tourism Council.

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