As if persistent breakouts weren’t bad enough, acne scars run far deeper for many of us than what is visible, physically and emotionally. If you have acne scars, you know what I am saying here. If you want to better understand those of us who do, the psychosocial impact of acne and acne scars is well documented in several studies

Why do acne scars form?

Most simplistically, if too much or too little collagen is produced when our bodies are trying to repair damaged tissue, scars form. Overproduction of collagen causes hypertrophic scars (keloids). When too little collagen is produced, depressed or atrophic scars result. Ice pick, rolling depressions, and boxcar are atrophic scar types.

Is there a treatment or laser that will remove acne scars?

Nope. There is no singular treatment to treat all scar types. Acne scar type determines treatment approach. Again, for those in the back, each scar type must be matched to the appropriate treatment method.

For example, a patient presents with acne scars of varying types. The treatment plan may include TCA CROSS for ice pick scars, subcision and dermal fillers for rolling scars, and surgical removal for a few of the deep, non-distensible boxcar scars.

Why are acne scars so difficult to treat?

Visible, depressed scars on the surface are bound to the dermal layer with scar tissue, or tissue is missing. In other instances, deep pigmentation, post-inflammatory hyperpigmentation (PIH) or post-inflammatory erythema (PIE), is persistent. None will fade or fill on their own or with over the counter products. Dermatological and surgical intervention is required to treat each scar type with the appropriate treatment method.

Besides matching scar types and treatment methods, the number of treatments vary. Skin type, general skin quality and how quickly skin responds to treatments are the determining factors. For instance, a fast responding patient may require only one TCA CROSS session for ice pick scars while a slow responding one may require 4-6 sessions.

Generally, scar treatments have two phases. The first phase is to reduce the depth and width of scars. The second phase is to clear pigment and finesse and smooth the skin surface.

Phase One: Common treatments for each scar type

Ice pick scars appear as deep, narrow pits in skin. 

To reduce the depth and width, a series of TCA CROSS (Chemical Reconstruction of Skin Scars) will oftentimes raise the base of the scar flush or close to flush to skin’s surface. 

After TCA CROSS, post-inflammatory hyperpigmentation (PIH) is common. The trade-off between a smoother physical surface and PIH is worth it for most patients. Clearing PIH can be accelerated with products, chemical peels, pigment targeting lasers or intense pulsed light treatments.

Ice pick scars also are commonly treated by Punch Excision. For punch excision, a tool with a round blade is used to cut around or punch out the scar. The wound is stitched closed, replacing the ice pick scar with a flat line scar.
To keep the line scar as fine and short as possible, Botox can be around the stitched wound to eliminate stretching or moving this area as it heals.

Boxcar scars appear as divots or wide pits with clearly defined borders.

Depending on the depth and width of boxcar scars, subcision with dermal fillers for the distensible scars (scars that flatten and flush to skin surface when stretched) or a series of TCA Paint (TCA CROSS for broad scars) are generally the best initial options. 

Subcision is a minor in-office surgical procedure used to untether the scar tissue connecting the scar with the dermal layer. Once released, the tethered area lifts. Dermal fillers may then be injected to keep the space open and separated to prevent reconnection and smooth skin surface.  Watch this animated video demonstrating subcision.

Other options may include surgical removal for the deep, broad, non-distensible ones. For shallow boxcar scars, chemical peels, Pixel Resurfacing, SkinPen with TCA or a series of Secret RF may be all that’s needed to smooth skin.

Rolling scars appear to be similar to boxcar cars, but they tend to be more shallow and have sloping edges that make the skin surface appear uneven and wavy. 

Because rolling scars tend to be distensible, they generally respond beautifully to subcision and dermal fillers as initial treatments.

As stated, Phase One treatments are to raise the base of scars as close to the surface of the skin as possible. 

Phase Two treatments target overall skin texture and clarity. 

Phase Two: Common treatments to smooth overall texture

For further correction, chemical peels, laser resurfacing, microneedling with topical acids and microneedling with radiofrequency (Secret RF)  smooth skin and stimulate collagen. 

For persistent PIH or PIE, Excel V, chemical peels and IPL clear pigment issues and redness.

Of course, the best scar is the one you never get. Treat acne as quickly as possible. Cut to the chase, and see a dermatologist. The journey may be slow, but stick with the plan. Acne can be controlled and cleared with patience and compliance of recommended treatments and products.

Read more about acne and acne treatments.

An excellent resource for those who suffer from dermatillomania (aka. skin picking):