Original Contributions

Postacne scarring – a quantitative global scarring grading system

Blackwell Publishing Inc

Greg J. Goodman1,2 & Jennifer A. Baron3

1
Skin and Cancer Foundation of Victoria
2
Monash University Department of Community Medicine, Victoria, Australia
3
Oregon Health & Science University, Portland, OR

Summary Background There is no global quantitative grading system for assessing the disease load
and global severity of disease in a patient with postacne scarring.
Aims The purpose of this article is to provide a quantitative grading system that would
allow more objective communication between practitioners of a patient’s global disease
severity and between investigators, educators, and proceduralists of the efficacy of grade-
specific operative interventions or therapies.
Patients/methods We describe a global scoring system that we have found clinically useful
to assess disease load and severity of acne scarring and illustrate the reproducibility
of this system in a small prospective study. Photographs of 21 patients were assessed
independently by four observers, two of whom were physicians and the other two nurses.
Results A quantitative global acne scarring grading system is presented. No substantial
difference among acne scarring scores was seen between observers, with inter-rater
agreement within four score points in 19 of the 21 patient-photos assessed.
Conclusions A global acne scarring grading system is presented that would allow inves-
tigators, educators, and proceduralists to compare their cases more accurately and to have
a more objective discussion of the efficacy of operative interventions or therapies. This scoring
system is shown to be reproducible among observers independent of medical back-
ground, suggesting that patients can be assigned scores equally by physicians and nurses.
Keywords: acne scarring, quantitative grading, scar

hypertrophic scars may need intralesional injections,

Introduction
Grading postacne scarring has been looked at as an
exercise in morphological assessment of individual
scars. This is required so that one can plan treatment
specifically for this scar. A rolling type scar may be filled
or resurfaced, a punched out scar grafted, elevated, or
excised, a deeply atrophic scar may need fat transfer,
Correspondence: Greg J Goodman, MD; Skin and Cancer Foundation of
Victoria and Monash University Department of Community Medicine, 8th
Floor, 443 Toorak Road, Toorak 3142, Victoria, Australia.
E-mail: greggoodman@greggoodman.com.au
Accepted for publication November 13, 2005
and other scenarios require similarly specific treatment.
Classification of individual scar morphology is becoming
honed with several attempts being proposed in the
literature. They all have ramifications for the management
of those individual scars but do not offer any global
overview of that patient’s level of disease. These morpho-
logical classifications of acne scars have been variably
based on pathophysiology and morphology1,2 or on
morphology as it relates to treatment options.3,4
What we lack in the literature on postacne scarring
is a global severity scale. We have such systems for
many dermatological disease states such as psoriasis,5
rosacea,6 photodamage, and wrinkles.7 Each provides a
construct for assessing a patient’s disease globally and,

48 © 2006 Blackwell Publishing • Journal of Cosmetic Dermatology, 5, 48–52

 Postacne scarring • G J Goodman & J A Baron

Table 1 Global acne scarring classification.

Number of lesions: Number of lesions: Number of lesions:

(Grade) Type 1 (1–10) 2 (11–20) 3 (> 20)

(A) Milder scarring (1 point each) 1 point 2 points 3 points

Macular erythematous or pigmented
Mildly atrophic dish-like
(B) Moderate scarring (2 points each) 2 points 4 points 6 points
Moderately atrophic dish-like
Punched out with shallow bases small scars (< 5 mm)
Shallow but broad atrophic areas
(C) Severe scarring (3 points each) 3 points 6 points 9 points
Punched out with deep but normal bases, small scars (< 5 mm)
Punched out with deep abnormal bases, small scars (< 5 mm)
Linear or troughed dermal scarring
Deep, broad atrophic areas
(D) Hyperplastic 2 points 4 points 6 points
Papular scars
(D) Hyperplastic Area < 5 cm2 Area 5–20 cm2 Area > 20 cm2
6 points 12 points 18 points
Keloidal/hypertrophic scars

with variable effort, awarding that patient with a score,
classification, or grading of overall involvement or
severity.
Global scoring for acne scarring would develop an
index of severity that would allow investigators, educa-
tors, and proceduralists to compare their cases more
accurately and to more objectively discuss and under-
stand the efficacy of operative interventions or therapies.
A quantitative method that we have used for some
years will be presented. Many articles discuss the
effects of a treatment modality8,9 or effects on the patient
psyche without reference to any such global severity
index.
Materials and methods
A scale of global severity has been developed with a
theoretical upper limit of 84 and lower limit of 0. This
relies on a scar count by type and a tallying up of the
number and severity according to an organized grading
system. Macular and mild atrophic scars score less
heavily than moderately atrophic scars and less again
than severe atrophic scarring (Table 1). Hypertrophic
and keloidal postacne scars are scored according to the
area of skin involvement (Table 1).
Milder scarring scores a maximum of 6 points. Three
of these points may be earned for over 20 of either
macular scars (hypopigmented, hyperpigmented, or
erythematous) or mildly atrophic scars. Less scar
numbers earn a lower score with 11–20 scars scoring
2, whereas 1–10 earn a single point.
Moderate scarring is scored more heavily with 18
points being possible. Six of these points are able to be
attained by over 20 scars of either moderately atrophic
small scars, small punched out scars with shallow bases
(shallow box scar scars3), or broad areas of moderate
atrophy. Again, fewer points are earned for fewer scars,
4 for 11–20 and 2 for 1–10.
Similarly, the severe forms of atrophic scars may score
a maximum of 36 points. A maximum 9 points are
scored when over 20 scars of any of the following types:
small, deep punched-out scars of 5 mm or less (deep
“box car” scars3), with normal bases, similar scars with
abnormal bases, linear or troughed scars, and deep,
broad atrophic scars. Six points are scored for 11–20
scars and 3 points for 1–10 scars.
With hyperplastic scarring, papular scars are dealt
with by number as for atrophic scars with 1–10
receiving a 2 point score, 11–20 a 4 point score and > 20
earning 6 points. However, keloidal and hypertrophic
scars are determined by area with a maximum of 24 points
awardable. If the area of involvement is less than 5 cm2
then 6 points are scored, between 5 and 20 cm2 then 12
points are scored and greater than 20 cm2 scores 18 points.
In a simple study of this classification system, photo-
graphs of 21 patients were assessed by four observers
independently. These observers comprised two doctors
and two nurses.

© 2006 Blackwell Publishing • Journal of Cosmetic Dermatology, 5, 48– 52 49

Postacne scarring • G J Goodman & J A Baron

Table 2 Example of scoring process for patient in Fig. 1 with severe atrophic scarring.

Number of lesions: Number of lesions: Number of lesions:

(Grade) type 1 (1–10) 2 (11–20) 3 (> 20)

(A) Milder scarring (1 point each) 1 point 2 points 3 points

Macular erythematous or pigmented – – –
Mildly atrophic dish-like – 2 –
(B) Moderate scarring (2 points each) 2 points 4 points 6 points
Moderately atrophic dish-like – – 6
Punched out with shallow bases small scars (< 5 mm) – – 6
Shallow but broad atrophic areas – 4 –
(C) Severe scarring (3 points each) 3 points 6 points 9 points
Punched out with deep but normal bases small scars (< 5 mm) 3 – –
Punched out with deep abnormal bases small scars (< 5 mm) – – –
Linear or troughed dermal scarring – 6 –
Deep broad atrophic areas 3 – –
(D) Hyperplastic 2 points 4 points 6 points
Papular scars – – –
(D) Hyperplastic Area < 5 cm2 Area 5–20 cm2 Area > 20 cm2
6 points 12 points 18 points
Keloidal/hypertrophic scars – – –
Total = 30 6 points 12 points 18 points

to have no real examples of macular scars but had many

Results
All acne scarring severity scores in this small study
fell between 4 and 30 and no substantial difference was
seen between the observers with inter-rater agreement
being within 4 points in 19 of 21 patients. This
concordance between observers suggests that patients
can be equally assessed by physicians and nursing staff.
An example will best illustrate this method (Fig. 1 and
Table 2). This male patient’s form will be filled out
sequentially starting with his mild scars. He was considered
examples of mild scars, specifically between 10 and 20 of
these, rendering a score of 2. Next, in the moderate
category, he had more than 20 moderate atrophic dish-
like and more than 20 punched-out small scars (less than
5 mm in diameter) with shallow bases, and between 10
and 20 scars showing shallow but broad atrophic areas.
This gave a score of 16 from the moderate scars. Lastly,
severe atrophy in this case was shown by less than 10
punched-out small scars with deep abnormal bases (“ice
pick” type scars), between 10 and 20 significant scars
with linear or troughed appearance (“corrugated iron
roof ” appearance) and less than 10 areas of deep broad
atrophy that usually represent subdermal (fat) atrophy.
He had no hypertrophic scar disease. Thus adding his
score he has contributions of 2 (mild disease scars) +16
(moderate disease scars) and 12 (severe disease scars)
totaling 30 (Table 2). Similar efforts rendered scores for
other patients with varying levels of disease severity
(Figs 2–6).

Figure 1 A patient exhibiting postacne scarring with a numerical
grade of approximately 30.
Discussion
Although somewhat cumbersome, as are all quantification
procedures based on individual lesion estimations, this
technique seems reasonably accurate, reproducible
between practitioners and able to assign a meaningful
severity score to individual patients. This may be useful

50 © 2006 Blackwell Publishing • Journal of Cosmetic Dermatology, 5, 48–52

 Postacne scarring • G J Goodman & J A Baron

Figure 2 A patient exhibiting postacne scarring with numerical Figure 5 A patient exhibiting postacne scarring with numerical
grade of approximately 5. grade of approximately 20.

Figure 3 A patient exhibiting postacne scarring with numerical Figure 6 A patient exhibiting postacne scarring with numerical
grade of approximately 7. grade of approximately 25.

where patients need to be followed-up to assess efficacy of

a given therapy or between investigators as two-
dimensional photography may not tell the complete,
three-dimensional story.

References
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© 2006 Blackwell Publishing • Journal of Cosmetic Dermatology, 5, 48–52