Finding out the “why” is the first step to avoid scarring in the first place.

Jan 21, 2022 | Blog

By Beth Shapouri

Medically approved by Jerry Tan, M.D. | Dec 13, 2021

As if dealing with acne wasn’t hard enough for the 50 million Americans who experience it, oftentimes those bumps leave behind an insidious calling card: acne scars. Those indentations, bumps, and discolored spots can hang around long after the offending pimple has healed. How common are they? “At least half of the patients I’ve seen struggling with acne are also affected by facial acne scarring,” says Jerry Tan, M.D., an adjunct professor of dermatology at the University of Western Ontario and an Acne Store advisory board member. Yes, you read that correctly—at least half. So if you’re dealing with acne scars on your face, you’re not alone.

Their emotional impact, too, can’t be understated—in fact one 2017 study showed the blow to your self-esteem can be major [1] so preventing and minimizing acne scars can be a huge boon to your psyche. The first step: Understanding how they develop. Here’s the breakdown.

What causes acne scars?

It all comes down to one major thing, according to Tan: Inflammation. It’s a key component to acne in general and when it’s combined with what Tan calls “inadequate matrix repair capacity” (translation: your skin’s inability to repair itself properly), it can cause permanent damage to the tissue that results in a scar. The inflammation can also trigger something else: “The release of pigment into the deeper layers of the skin and outside the skin cells themselves.” And that means you may also experience hyperpigmentation in the form of dark brown spots.

So how can you tell whether or not your pimple will result in a scar? There are three main predictors. The first is intensity. “The more severe the acne is and the longer it persists, the more likely that will leave scars behind.” Second is how hands-on a patient has been with their bumps. “Picking or squeezing pimples tends to induce more inflammation and irritation, and therefore a greater risk of scarring.” Last is a family history of acne scarring, which reflects an inherited tendency to more severe acne or the inability to adequately repair scars. Also: Be aware that some treatments or products that can contribute to irritation and inflammation in improperly used. These include retinol, salicylic acid, glycolic acid, and benzoyl peroxide. But wait, you’re thinking, aren’t those things supposed to help my acne? Yes, but overdoing it “can damage the skin barrier and lead to more irritation or inflammation,” Tan warns. Bottom line: You want to err on the side of caution when treating existing acne so you don’t make things worse and wind up with scars and hyperpigmentation.

What are the different types of acne scars?

There are a few major categories to get acquainted with: The most common are atrophic scars [2] that have lost volume, which research indicates is due to a loss of collagen. [3] These look like little indentations on the skin and can be square-shaped box scars, sharply indented ice pick scars, or wavy rolling scars. The next are scars with added volume like hypertrophic or keloid scars, which are raised. Annoyingly, you’re not bound to any one kind of acne scar—you may have some combination of all of them. There are some marks left by acne which are not scars as there is no change in skin volume but can still be bothersome. In doctor-speak, brown or darker marks are called post-inflammatory or macular hyperpigmentation while red marks are known as macular erythema.

“So how can you tell whether or not your pimple will result in a scar? There are three main predictors.”

Why do I get acne scars and some people don’t?

The truth is, we don’t know exactly why some people are more prone to acne scarring than others. But there are theories, says Tan. A family history of scarring, for example, is common in people who suffer from post-acne marks. It’s not a case-closed situation though. “That hasn’t been adequately studied to be certain,” Tan insists. But research into the genetic links are ongoing—in fact, a 2018 study identified 15 regions of the human genome that increase the susceptibility to acne, [4] so a solid answer may be in our future.

It’s a commonly held belief that those with darker skin are more likely to scar than their fairer counterparts, but it’s likely not as simple as that, says Tan, “Quite frankly, it may simply be that in patients with very light skin color, we’re just not able to visualize their acne scars quite as easily.”

And then there’s your skin’s individual ability to bounce back: “There are patients who just don’t seem to have a greater potential of skin repair,” Tan adds. That’s where plain ol’ luck may come into play. Individual behavior is at play too. If you’re a skin picker or put harsh ingredients on your skin that disrupt your protective skin barrier, you may be contributing to the problem. So keep your hands off—don’t squeeze or pick at your acne—and proceed with caution when treating acne lesions.

What can you do to decrease your chances of acne scarring?

First, don’t panic. Some of the acne scars you do get may lessen naturally over time as skin cells turn over and your skin tissue heals. For those that seem to be sticking around, take a trip to your dermatologist to inquire about retinol creams and in-office procedures like lasers, microdermabrasion, microneedling, fillers, chemical peels, or certain minor surgeries like subcision and punch-grafting. Your best-fit treatment will depend on the type and level of scarring you’re dealing with, so it’s always best to consult with a dermatologist who is an expert in scar repair to come up with a game plan.

Topical treatments like retinol can enhance skin repair, collagen regeneration, and improve skin tone and texture to improve the appearance of scars and pigmentation.

[1]: How Acne Bumps Cause the Blues: The Influence of Acne Vulgaris on Self-Esteem
[2]: Acne Scars: Pathogenesis, Classification and Treatment
[3]: Acne Scarring—Pathogenesis, Evaluation, and Treatment Options
[4]: Genome-wide meta-analysis implicates mediators of hair follicle development and morphogenesis in risk for severe acne

Everything you need to know about mask-wearing for the acne-prone.

By Beth Shapouri

Just when we thought we’d seen it all when it comes to pimple triggers, the COVID-19 pandemic came along and introduced us all to a new word: Maskne. This condition, which refers to acne spurred on by mask wearing now has an official definition, according to a recently released study that narrowed it down to acne with an onset or change in severity within weeks of regular face mask-wearing over the lower face. [1] Researchers refer to this area as the “O-zone.” If you’re grappling with it, know you’re not alone. Dermatologists like Jerry Tan, M.D., adjunct professor of dermatology at the University of Western Ontario and an Acne Store advisory board member, have been flooded with pleas from patients for help in tackling the condition. What kind of mask should I pick to avoid acne? Can wearing makeup make things worse? How do I stop maskne once it starts? Dr. Tan has the answers.

Q: Articles about maskne are all over the Internet— is it a real thing?

A: It definitely seems that way. A lot of people are experiencing breakouts after wearing face coverings, but in some cases it’s not actually acne. For some, masks are triggering inflammation of the hair follicles, known as folliculitis, which might require an antibacterial or an anti-yeast medication to treat. Or it could even be rosacea—a skin condition characterized by redness of the cheeks that patients often mistake for acne.

You might be able to tell what you’re really dealing by taking a closer look: Acne is characterized by the presence of little blocked pores called comedones. White ones are called closed comedones; the ones that have a central gray opening are called open comedones or blackheads. If there’s no presence of comedones, the lesions themselves are likely not acne. Also, acne is ongoing, so different clusters of breakouts will come and go. Conditions like folliculitis tend to hit all at once while rosacea will also have the tell-tale feature of redness of the central face.

Q: What causes maskne?

Number one, wearing a mask increases the heat and temperature on the skin in that area, which cases irritation. Number two, it increases humidity. You also have to consider the ongoing circulation of bacteria and yeast from your nose and your mouth inside the mask. And then there’s the pressure and friction caused by mask. It’s really a perfect storm for clogging pores.

Q: Any tips for picking a good mask that doesn’t cause maskne?

The most important thing is to choose masks that have a very soft fabric; cotton if possible, since that’s the most breathable. If you prefer a surgical mask, that should work too since it likely has multiple plies of fabric that are softer and smooth on the inside. You also want it to fit well: It shouldn’t dig in or rub too aggressively against the skin but you want it snug enough to be effective in protecting you from airborne particles. I also suggest giving yourself periodic breaks when you’re properly distanced from others. Just take it down for a few minutes to give your skin a rest.

Q: How often should you switch out your mask?

Ideally, daily. I would hope you have a whole volleyball team of masks you can rotate on and off your face. Each player has 24 hours to perform and then goes off to the wash—then another mask goes up to play. Making sure your mask is fresh and clean is a surefire way to stop maskne caused by built up bacteria and sweat.

“A lot of people are experiencing breakouts after wearing face coverings, but in some cases it’s not actually acne.”

Q: Give it to us straight: Should you wear makeup when wearing a mask?

Having it on your skin under the mask is probably not going to help the situation. My suggestion is to skip foundation and stick to eye makeup, like eyeshadow and eyeliner. And do continue to wear sun protection—just avoid tinted sunscreens as they discolor the mask and can make them appear dirty.

Q: How do I prevent maskne?

As soon as you come home, remove your mask and cleanse your face. The primary focus is trying to be as gentle as possible, because your skin is already going to be under assault by the mask as well as what’s happening underneath it. Avoid soaps, which break down the skin barrier, and instead use a very gentle pH balanced cleanser or bar with synthetic ingredients—meaning not lye, the ingredient in a true soap. Then apply a good moisturizer to help repair and restore your skin’s protective barrier. To do that, I would look for products that contain ceramides, hyaluronic acid, glycerin, or dimethicone. Many products fit this description, so choose one that you like, make sure it doesn’t cause any problems with your skin, and use it daily.

Another change to make: If your acne care products are a little drying or irritating, use them at night only. This prevents more irritation during the day when you’re wearing your mask. And, finally, for daytime, putting on sunblock is absolutely fine. Just make sure that you use one you’ve had good results with in the past. You don’t want to risk trying a new formula now and wind up having a bad reaction.

[1]: Diagnostic and management considerations for “maskne” in the era of COVID-19

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