Treating hyperpigmentation and scarring caused by adult acne can be a tough task for therapists, especially with clients wanting immediate results. AMANDA PAULEY talks to the pros about how to treat the issue and manage client expectations

Despite new movements focused on making post-acne hyperpigmentation and scarring less “taboo”, such as Dermalogica’s #skinindividual campaign which aims to reduce the stigma around acne, the physical and mental marks left by the inflammatory skin condition are still a big concern for Brits. Research collated from sources including the Happiness Research Institute and the British Journal of Dermatology has shown the impact acne can have on an adult’s quality of life, with 44% of people with the condition now suffering with at least one mental health condition.

So, it’s easy to understand clients’ frustrations when they think they’ve reached the finish line of their skin health marathon, getting those pesky acne symptoms under control, to then be presented with the long-lasting after effects of the breakout – stubborn red marks, discolouration and scars.

“The number of clients I’ve seen who tell me they’ve been everywhere and tried everything, and that doctors and skin therapists have told them they might just have to live with it, is astonishing,” says Pamela Marshall, clinical aesthetician and co-founder of Mortar & Milk in Fulham, London. “[The industry] needs to be doing more.”

One of the biggest challenges for salons and spas is building trust with clients who may struggle to open up, having grown up in a social mediadominated world obsessed with “perfection”. The starting point is educating clients on the causes and differences between post-inflammatory hyperpigmentation and acne scars, and how these conditions can be managed with treatment approaches from a trusted professional.

What causes post-acne hyperpigmentation?

One of the biggest misconceptions you might face is clients thinking hyperpigmentation is the same as a scar. “Post-inflammatory hyperpigmentation (PIH) comes from inflammation in the skin,” says Marshall. “When the skin is wounded, with an acne spot for example, it inflames and triggers melanocyte production, which can lead to excessive melanin coming to the surface, causing those dark or red marks.”

Marshall explains that melanin can also spread to the surrounding area near the injury, meaning it doesn’t matter how small or inconsequential the spot is, it has the potential to leave behind a larger mark after the infection has cleared, which could linger for weeks, months or, in some cases, even years.

It’s also important to know that darker Fitzpatrick skin types have a higher propensity for increased melanin production when wounded, which means postacne hyperpigmentation is much more common in clients of colour.

“We all have a similar amount of melanin but in darker skin tones the melanocyte cells are bigger and more active, which is why these clients will hyperpigment more as a result,” says Dija Ayodele, founder of Black Skin Directory, an online resource connecting women of colour to expert skincare professionals in the UK.

“It’s about managing expectations. Don’t promise flawlessness, promise to improve the appearance of their condition”

How can it be treated?

The good news for clients is that post-acne hyperpigmentation can naturally fade over time, but how quickly varies person-to-person. A treatment and homecare routine that helps them achieve skin health will aid the process, using the right ingredients to boost cell turnover without causing excessive inflammation or damage to the skin’s barrier function.

“In clinic, we often start with a lower pH peel and give clients products to use at home to increase skin hydration and barrier function, then we move on to microneedling, which is excellent for forcing skin to remodel itself by building new collagen and elastin,” says Marshall. “I also tell clients not to use AHAs more than once or twice a week because used too often they can interfere with a healthy skin barrier function, causing inflammation.”

Niacinamide and certain mushroom extracts are also good at reducing pigment, while vitamin C is cited as another wonder ingredient, “as it’s a natural way to fade red and dark marks and rejuvenate skin’s clarity,” explains Dr Howard Murad, founder of the eponymous brand.

“Retinol can also help stimulate cell renewal and improve texture.” Using sunscreen daily is also crucial because UVA and UVB rays can make discolouration of hyperpigmentation much worse.

All the experts recommend taking photos of your client at every step of their treatment journey, which you can show them if they’re feeling disheartened with the speed of the results. “Clients look at themselves in the mirror every day so they don’t always take into account the changes that are occurring,” adds Ayodele.

“Having these photos in your arsenal means you can show them exactly how much they’ve progressed, while explaining that if the condition took X amount of time to form then it will take time to clear. It’s about managing expectations. Don’t promise flawlessness, promise to improve the appearance of their condition.”

What causes acne scarring?

Adult acne can also leave scars, which most commonly occur when the serious types of spots (nodules and cysts) burst and damage the nearby skin. “A scar refers to a dent or change in the skin structure due to loss or excess accumulation of the skin’s scaffolding proteins after severe inflammation from a healing breakout,” says Candice Gardener, digital education manager for skincare brand Dermalogica.

Acne scars also come in different types, with the most common being ice pick, which appear as small, deep holes that look like the skin has been punctured with a sharp object; boxcar, round or oval depressions or craters; and rolling, caused by bands of scar tissue that form under the skin, giving it an uneven, “rolling” appearance.

“People with bad acne scars can feel very self-conscious and often end up going to great lengths to hide them. The situation can be made worse if that person feels like they are being stared at,” says Esther Fieldgrass, founder of clinic chain EF Medispa. “Therefore, you need to communicate a realistic outcome to the client, which you always aim, but can never promise, to exceed.”

“People with bad acne scars can feel very self-conscious and often end up going to great lengths to hide them”

How can it be treated?

Fieldgrass recommends microneedling, derma stamp, laser and specialised peels as effective scar treatments to help to rebuild the dermal scaffolding and plump out the skin, but warns to be mindful of the client’s skin type and medical history, including contraindications like keloid scarring.

Marshall agrees a cautious approach is best. “For boxcar scarring, for example, I use microneedling infused with hyaluronic acid and then let it heal for at least six weeks, putting the long-term health of the skin above anything else,” she says. However, if the scar is a particularly deep, textural one then it may be worth referring the client to a specialist.

“It’s about getting the best outcome for your client. I sometimes do referrals to dermatologists who can inject in and around those scars with fillers to plump up the skin and give a smoother canvas, so to speak. I think knowing when to refer makes you a better therapist,” adds Ayodele.

Vitamin A taken orally, topically and in treatment can also help reduce scarring, explains Tracy Tamaris, director of education at the International Institute for Anti-Ageing (IIAA), which distributes skincare brand Environ.

“Skin that is vitamin A-deprived will become less active and damage to DNA will not be repaired, which means melanin distribution will be irregular and collagen and elastin production will decline with poor-quality production.” The success of the client’s skin journey will rely on their homecare and lifestyle choices as much as the in-salon treatments. “One way to deal with acne scars is to help prevent their appearance in the first place – clients need to know that picking at the skin leads to scars and that sun exposure can aggravate them,” says Murad.

When advertising your services, use a selection of before-and-after photos on different types of acne scarring so people can see “real” results. “It’s [about] not letting the condition affect the [client’s] confidence or self-worth,” explains Murad.