Acne or scars: which is treated first?

First the inflammation, then the marks

People coming in for acne are most bothered by the red inflammation at first. Once that reduces, the red marks and the pitting that had not been noticeable come into view.

So one method does not finish it. The starting point depends on which is the bigger problem right now.

Not every lesion should be extracted

Comedones that can be extracted are better cleared. Lesions that are red and firm may have inflammation progressing inside the skin.

Pressing those forces the inflammation deeper and leaves red marks and pitting. So before treatment, lesions that need extraction are separated from lesions where the inflammation has to settle first.

Extraction where extraction is appropriate; an intralesional injection where inflammation needs calming; then watching how the skin responds.

Extraction alone does not prevent recurrence

Sebum keeps being produced and keratin keeps accumulating at the pore opening. Repeating extraction alone does not stop new lesions forming.

Where sebum output is high or lesions recur in the same place, a topical or an oral medication may be used alongside. The prescription differs depending on whether comedones dominate, inflammation dominates, and how much sebum is produced.

Acne leaves three kinds of trace

Even out the colour on the surface and the contour remains if the structure underneath is unchanged. Marks and pitting are different problems and take different approaches.

Why atrophic scars are treated in stages

Atrophic scars need treatment that stimulates regeneration in the dermis. Microneedles deliver energy into the scarred dermis and collagen production is induced during recovery.

Tip, depth and energy vary with the depth and shape of the scar and the skin thickness of the area. Dividing the stimulus across sessions within what the skin can recover from gives a better result than one strong session.

Care that supports recovery is needed after the stimulus, so the skin does not become over-sensitised.

So what comes first

• If comedones and red, painful lesions still recur, treating the inflammation comes first
• If there are almost no new lesions and pitting and uneven texture bother you more, the scarring side
• If both, stabilising the active inflammation first is the usual order

It is hard to decide on appearance alone. Whether the current lesion is an extractable comedone or inflammation progressing inside, and whether the remaining trace is pigment or actual pitting, has to be established first.

Frequently asked questions