Case Study
Case 36: 'Tiny Holes' Appearing in the Skin — Anetoderma and Focal Loss of Elastic Tissue
Quick Answer: Small, soft, depressed areas that look like tiny 'holes' in the skin — sometimes feeling loose or pouch-like on touch — may represent anetoderma, a benign condition involving focal loss of elastic tissue in the skin. It can occur spontaneously or follow acne, folliculitis, trauma, chickenpox, other inflammatory skin conditions, or occasionally connective tissue disorders. These are not open pores or infections. Limited treatment options for selected cases include retinoids, fractional lasers, microneedling, and collagen-stimulating procedures — and above all, patients must stop picking or traumatising the area. Case Snapshot: A user asked: "Small holes connect in my skin — how do I fix this?" Their images showed small, soft, depressed areas giving the appearance of tiny 'holes' — with the giveaway quality that they weren't pores or pits of scar tissue, but slack little depressions in otherwise normal-looking skin. What Is Anetoderma? Anetoderma is a condition of focal loss of elastic tissue — the skin's elastin fibres, which give it snap and recoil, disappear in small discrete patches. Where elastin is lost, the skin loses its internal scaffolding tension and sags inward or outward, producing lesions that appear as: Small pouch-like or depressed areas Localized skin thinning Lesions that feel loose or herniated on touch — the classic examination sign: a fingertip pressed on the spot sinks in, as if through a small buttonhole in the skin's elastic sheet It is usually benign — a structural quirk rather than a disease process that spreads or harms. Where It Comes From Anetoderma can be: Spontaneous (primary) — arising on previously normal skin with no identifiable trigger Secondary — following previous acne, folliculitis, trauma, chickenpox, or other inflammatory skin conditions: the inflammation quietly digests the local elastic fibres, and the deficit shows itself as the depression after everything visible has healed Occasionally associated with connective tissue disorders — one reason evaluation goes beyond the skin surface in atypical, numerous, or progressive cases Not Pores, Not Infection — and Why That Matters The user's framing — "holes in my skin" — captures how alarming these look, and the first therapeutic act is correct labelling: these lesions are not true 'open pores' and not infections. They will not respond to pore products, antibacterials, or cleansing routines, and they are not something spreading through the skin. They are focal elastic-tissue deficits — closer in nature to a localized loss of the skin's rubber-band layer. Dermatologic evaluation is still useful, because similar-appearing lesions can occasionally mimic other conditions — atrophic acne scars, other atrophic disorders — and because confirming anetoderma may prompt a look for associated conditions in selected patients. The Honest Treatment Conversation Elastic tissue, once lost, is difficult for the body to rebuild — so expectations must be set honestly: treatment options are limited and help selected cases rather than erasing lesions. The options with rationale: Retinoids — supporting dermal matrix remodelling over months Fractional lasers — controlled dermal injury to stimulate new collagen and elastic tissue Microneedling and collagen-stimulating procedures (including MNRF) — the same remodelling logic used for atrophic scars, applied here to firm the depressed patches Improvement is typically partial and gradual; combinations and multiple sessions are the norm, and a dermatologist will candidly triage which lesions are worth treating. The One Instruction That Protects You Most importantly, avoid repeatedly picking or traumatising the area — trauma and inflammation are exactly what destroys elastic tissue, so worrying at the lesions can worsen texture changes and mint new ones. For secondary anetoderma, treating the driver — active acne or folliculitis — closes the factory making future lesions. When to See a Dermatologist See a dermatologist for confirmation of the diagnosis, for a considered opinion on whether procedural treatment suits your lesions, and promptly if depressions are numerous, enlarging, or accompanied by other symptoms — the scenario where associated conditions get screened. Book an evaluation here. FAQs Q: Will the holes get bigger or spread? Individual lesions are usually stable. New lesions can appear if an underlying inflammatory trigger continues — which is why treating active acne or folliculitis matters. Q: Are these the same as acne scars? They're cousins: acne scars are collagen loss, anetoderma is elastic-tissue loss — both can follow acne, both are treated with remodelling procedures, and examination tells them apart. Q: Can creams fill the depressions? No cream restores lost elastin. Retinoids modestly support remodelling; meaningful change, where achievable, comes from procedural collagen stimulation. Q: Is anetoderma dangerous? The skin lesions themselves are benign. Atypical or extensive cases are evaluated for rare associations — a check, not a cause for alarm. 📌 Case Study Reference: Publicly shared patient images and query, r/DermatologyQuestions, Reddit — "Small holes connect in my skin — how do I fix this". Educational discussion only; not a final diagnosis. Clinical commentary by the Allodermis dermatology team.
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Case 18: Large Open Pores, Acne Scars and Early Forehead Lines Together — Building a First Skincare Routine That Works
Quick Answer: Enlarged pores with old acne scars suggest oily skin with past acne-related collagen damage, while resting forehead lines point to early skin ageing from sun damage and repeated expressions. The evidence-based starter routine: salicylic acid face wash, night tretinoin started low (0.025% for one hour, slowly titrated up), moisturiser, and broad-spectrum morning sunscreen. Deep ice-pick and rolling scars additionally need procedures such as TCA CROSS, microneedling, subcision, or lasers. Case Snapshot: A patient wrote: "I have large open pores, acne scars, and visible forehead lines even when my face is relaxed. I've never really used skincare before — just a face wash sometimes. Can you suggest a simple routine?" Their images showed all three concerns coexisting — a very common combination in oily Indian skin entering the late 20s and 30s. Reading the Three Concerns Together Enlarged pores + old scars tell one story: historically oily, acne-prone skin whose past inflammation damaged collagen around follicles — enlarging pore openings and leaving pitted scars. Forehead lines at rest tell another: early ageing, driven by cumulative sun damage degrading collagen and repeated facial expressions etching lines in — accelerated when no sunscreen has ever been used. The elegant part: the same core routine addresses all three, because retinoids and sunscreen act on collagen, the common thread. The Starter Routine — Simple by Design ✔️ Salicylic acid face wash — controls oil and keeps pores clear ✔️ Night tretinoin, started low: 0.025%, applied for one hour then washed off, a few nights weekly — then slowly titrated to higher concentrations and longer/overnight contact as tolerance builds. Tretinoin improves pores, texture, and fine lines simultaneously. ✔️ Moisturiser — protects the barrier so tretinoin stays tolerable ✔️ Broad-spectrum sunscreen every morning — prevents worsening of lines, pores, and scar pigmentation; for a lifelong non-user, this is the single highest-impact new habit Four products. No twelve-step routine required — consistency with these outperforms complexity. What the Routine Can and Cannot Fix Topicals will refine pores, smooth texture, soften early lines, and prevent progression. But deep ice-pick and rolling scars involve structural collagen loss and usually need procedures for visible improvement: TCA CROSS for ice-pick scars Subcision for tethered rolling scars Microneedling / MNRF for overall remodelling Fractional lasers for finishing texture Explore the complete options on our acne scar treatment and open pores pages. For the forehead lines specifically, once topicals plateau, targeted options exist within our anti-ageing treatments — from collagen-stimulating procedures to Botox for expression lines, chosen case-by-case. Sequencing the Journey Months 0–3: establish the four-step routine; build tretinoin tolerance Months 3–6: skin visibly refines; reassess which scars still bother you Months 6+: targeted procedures for residual deep scars and lines, on calm, retinised, sun-protected skin — which responds better and pigments less after procedures When to See a Dermatologist Starting tretinoin is best done with guidance — strength, titration speed, and irritation management are individual. And scar procedures always begin with an in-person scar-mapping assessment. Book a consultation to have the full plan sequenced for your skin. FAQs Q: Why start tretinoin for only one hour? Short-contact application lets never-treated skin adapt with minimal irritation; contact time and strength are then increased stepwise — same destination, gentler road. Q: Can forehead lines at my age really be reversed? Early lines soften considerably with tretinoin plus sunscreen; established resting lines may additionally need in-clinic treatment. Prevention from today is fully in your control. Q: How long before pores look smaller? Expect visible refinement at 8–12 weeks of consistent retinoid use, continuing to improve over months. Q: Can I use tretinoin and salicylic acid on the same day? Yes — the salicylic wash in the morning or as a rinse-off, tretinoin at night. Avoid layering leave-on acids directly with tretinoin in the early months to keep irritation manageable. Making Tretinoin Succeed on Never-Treated Skin Since this patient has essentially virgin skin, a few practicals decide whether tretinoin becomes a lifelong ally or a two-week failure. Apply to bone-dry skin — wait 15–20 minutes after washing, as damp skin absorbs more and stings more. Use a pea-sized amount for the whole face; dabbing extra on scars doesn't speed results, it just inflames. Buffer early: moisturiser before and after the tretinoin hour softens the landing. Expect the adjustment phase — mild flaking and a possible brief purge in weeks 2–6 are the skin adapting, not failing (see our retinoid dermatitis case for the full map). Protect the investment: every skipped sunscreen morning hands back a slice of the collagen tretinoin is building. Titration milestones — moving from one-hour contact to overnight, then from 0.025% upward — should be crossed only when the current step feels boring and uneventful, which is precisely the sign of readiness. 📌 Case Study Reference: Publicly shared patient images and query, r/IndianSkincareAddicts, Reddit — "Help me — I've large open pores and acne scars". Educational discussion only; not a final diagnosis. Clinical commentary by the Allodermis dermatology team.
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