Your Easy Guide to Acne Scarring Treatments
Doctor’s Note
As dermatologists, we recognize the physical and emotional burden of acne scarring. Scars can range from deep pits to minor discolorations and both can impact an individual's self-esteem. Different types of scars require tailored treatments, which range from topical solutions to more advanced dermatological procedures.
What is Acne Scarring?
If you took our Skin 101 course, you are already a board-certified dermatologist and this will be review for you. If you did not take our course, let's review how/why a scar forms.
When acne-related inflammation penetrates deeply, it damages our collagen in the dermis. The body tries to rebuild our dermis ASAP, but does a sloppy job making new collagen.
Why does this matter? Because it affects our treatment options! The dermis is deep and difficult to reach with topicals. How do we get into the dermis to repair it? Procedures! Microneedling, lasers, chemical peels, filler, and poking a needle in there (called "subcision") are all meant to repair our collagen in the dermis.
Types of Acne Scars
Acne scars can be either atrophic (depressed) or hypertrophic (raised). Atrophic scars include boxcar, ice pick, and rolling scars. Knowing the type of scar helps in choosing the best treatment. Here are the most common acne scars:
Ice Pick Scars
Ice pick scars are deep and narrow.
They have a “pointed” appearance, resembling small holes or puncture marks on the skin.
They commonly occur on the cheeks and forehead.
Rolling Scars
Rolling scars are wavy. They create an uneven texture due to tethered bands under the skin's surface.
Rolling scars usually affect the lower cheeks and jaw.
Boxcar Scars
Boxcar scars are broad, rectangular depressions with defined edges.
They tend to be more noticeable on the lower cheeks and jawline.
I always think boxcar scars look like a missing puzzle piece!
Acne Scarring Treatment Overview
Dermatology offers many treatments tailored to various scar types and severities. From lasers to chemical peels to microneedling, there's so many treatments available! This detailed overview will explore the primary treatments, helping you navigate the path to smoother skin.
Chemical Peels
Best For: Boxcar + Rolling Scars
Process: Application of acid solutions build collagen
Examples: Glycolic, TCA, PCA, Vi peels
Punch Excision
Best For: Icepick + Boxcar
Process: Removes small, deep scars by cutting them out. The wound is then closed with stitches, allowing new, smoother skin to form in place of the scar.
TCA CROSS
Best For: Icepick + Boxcar
Process: High-concentration acid applied directly to scars to build collagen in that specific area
Lasers
Best For: All Scars
Process: Uses light to build collagen
Examples: Fraxel, CO2, Clear and Brilliant
Microneedling
Best For: All Scars
Process: Uses fine needles to build collagen
Examples: Can addition additional Platelet Rich Plasma (PRP)
Filler
Best For: Boxcar + Rolling
Process: Injected into depressed scars to raise the surface to the level of surrounding skin; offers immediate but temporary results.
Examples: Restylane, Juvederm
RF Microneedling
Best For: All Scars
Process: Uses microneedling with radiofrequency energy to heat the skin and build collagen
Examples: Morpheus8, Vivace, Genius, Infini
Subcision
Best For: Rolling
Process: Needle inserted under the scar to break up deep scar tissue;
TCA Image: Mitra D, Singh GK, Singh T, Mitra B. Use of 27-gauge Tuberculin Syringe for Trichloroacetic Acid Chemical Reconstruction of Skin Scars (TCA-CROSS). J Cutan Aesthet Surg. 2021 Jul-Sep;14(3):357-358. doi: 10.4103/JCAS.JCAS_147_20. PMID: 34908780; PMCID: PMC8611708.
Punch Excision Image: Hurkudli DS, Sarvajnamurthy S, Suryanarayan S, Chugh VS. Novel uses of skin biopsy punches in dermatosurgery. Indian J Dermatol. 2015 Mar-Apr;60(2):170-5. doi: 10.4103/0019-5154.152519. PMID: 25814706; PMCID: PMC4372910.
Lasers for Acne Scars
Laser treatments use focused light to target damaged skin, creating tiny injuries that encourage the body to produce more collagen. This process helps smooth out the skin and reduce the visibility of scars. Lasers can also even out skin tone and reduce dark spots caused by acne. There are two main types of lasers. Ablative lasers remove the top layer of skin. The CO2 and Erbium YAG lasers are the most popular. Ablative lasers are effective for really deep scars, but they have a longer recovery time of one to two weeks. Non-ablative lasers heat the underlying skin without removing the top layer. The Fraxel Dual and Clear and Brilliant are popular choices. Non-ablative lasers have minimal downtime, but they may require multiple sessions and are less effective for deep scars. Choosing between ablative and non-ablative lasers depends on scar severity, skin type, and preferences regarding downtime and side effects.
CO2 Laser Acne Scar Procedure
Laser procedures usually last ~30 minutes to an hour, and a topical anesthetic may be applied to minimize discomfort. Ablative lasers (CO2, Erbium) typically require 1 - 2 weeks of recovery. Non-ablative lasers (Fraxel, Clear and Brilliant) involve a few days of recovery.
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Lasers (especially CO2) are great for DEEP scars. You couldn’t get the Before + After results (seen below) without a CO2 laser.
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-Icepick Scars
-Boxcar Scars
-Rolling Scars -
CO₂ laser works better than TCA CROSS (Ahmed et al)
Laser + radiofrequency microneedling together works better than laser alone (Kim et al)
Laser and radiofrequency microneedling are equally good (Hendel et al).
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CO2 Laser Acne Scars Before and After
Majid I, Imran S. Fractional CO2 Laser Resurfacing as Monotherapy in the Treatment of Atrophic Facial Acne Scars. J Cutan Aesthet Surg. 2014 Apr;7(2):87-92. doi: 10.4103/0974-2077.138326. PMID: 25136208; PMCID: PMC4134658.
Microneedling for Acne Scars
Microneedling for acne scars involves using fine needles to create tiny punctures in the skin. This controlled micro-injury stimulates the body's healing process, increasing collagen to smooth out. Microneedling can also enhance the absorption of skincare products to help them do their job! There are a few main types of microneedling:
Microneedling + Platelet-Rich Plasma (PRP) uses tiny needles to create small skin injuries that boost collagen production. PRP, made from your own blood and full of growth factors, is applied to help skin heal and look younger. This combo is great for smoothing skin, reducing acne scars, and making skin look fresher naturally.
Microneedling + Exosomes uses tiny needles to create small skin channels for exosomes—tiny packets filled with growth factors and proteins. These help skin repair and regenerate faster, improving skin texture and reducing wrinkles. It’s a good choice for boosting collagen, reducing wrinkles, and making skin look more youthful.
Microneedling + Topicals uses tiny needles to help topical treatments like vitamin C serums or hyaluronic acid penetrate deeper into the skin. This makes them more effective for hydrating skin, boosting collagen, and keeping skin healthy. It’s a flexible option for treating everything from acne scars to signs of aging.
Microneedling Acne Scars: Procedure
Microneedling procedures typically last ~30 minutes to an hour, often with a topical numbing cream to reduce discomfort. Recovery typically involves a day or two of redness and mild swelling.
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I find sometimes patients are disappointed with microneedling, but you really need 4 - 6 sessions and wait ~6 months to see results. One treatment is not going to do much. Microneedling can help superficial scars, but it’s not enough for deep scars.
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- Microneedling + Platelet-Rich Plasma (PRP) works the same as Microneedling + Botox (Albalat et al)
- Microneedling + peel together works better than peel alone (Pakla-Misiur)
- Microneedling + Platelet-Rich Plasma (PRP) together works better than Microneedling alone (Nandini et al)
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Microneedling Acne Scars: Before and After
Before and After Image: Gupta M, Barman KD, Sarkar R. A Comparative Study of Microneedling Alone Versus Along with Platelet-Rich Plasma in Acne Scars. J Cutan Aesthet Surg. 2021 Jan-Mar;14(1):64-71. doi: 10.4103/JCAS.JCAS_190_20. PMID: 34084010; PMCID: PMC8149985.
Radiofrequency Microneedling for Acne Scars
RF microneedling combines regular microneedling with radiofrequency (RF) energy. This treatment uses fine needles deliver heat deep into the dermis. This stimulates 10x more collagen production than regular microneedling! RF microneedling also promotes skin tightening and overall rejuvenation, making it a versatile option for various types of acne scars, from shallow to deep.
Morpheus8 - FDA Approved in 2020. Called “Morpheus8” due to needles being up to 8mm long! This depth is more for body contouring. There is another handle with shorter needles meant for the face.
Infini - FDA Approved in 2013. Often found to be more painful than newer devices.
Genius RF - FDA approved in 2019. The “newer” version of the Infini. Less painful due to real-time feedback. Newer also means more expensive!
Secret RF - FDA approved in 2018. Has insulated needles and very precise heat energy. Best for patients with a darker skin tone.
The procedure is minimally invasive, with mild redness and swelling typically resolving within a few days, offering patients noticeable improvements in skin tone and texture over several sessions.
Morpheus8 for Acne Scars
Radiofrequency microneedling procedures typically last ~30 minutes to an hour, often with a topical numbing cream to reduce discomfort. Recovery typically involves a day or two of redness and mild swelling.
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RF microneedling can work well, but it is HIGHLY dependent on the provider. It is easy to mess up!
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- Laser + radiofrequency microneedling together works better than laser alone (Kim et al)
- Laser and radiofrequency microneedling are equally good (Hendel et al)
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Morpheus8 Before and After
Chandrashekar BS, Sriram R, Mysore R, Bhaskar S, Shetty A. Evaluation of microneedling fractional radiofrequency device for treatment of acne scars. J Cutan Aesthet Surg. 2014 Apr;7(2):93-7. doi: 10.4103/0974-2077.138328. PMID: 25136209; PMCID: PMC4134659.
Chemical Peels for Acne Scars
Chemical peels stimulate collagen and elastin production, which helps smooth and firm the skin, making acne scars less noticeable. Peels come in different strengths, from mild to strong. Mild and medium peels may require multiple treatments (3 to 5 sessions every 2 to 4 weeks), while deeper peels are more effective but have a longer recovery time. Here are some popular peels:
VI Peel: A medium-depth peel that improves skin tone, texture, and clarity while reducing acne scars.
PCA Peel: Customizable for various skin types, effective for treating acne, hyperpigmentation, and fine lines.
Glycolic Acid Peel: Stronger peels (50-70%) work on medium to deep acne scars.
TCA Peel: Targets deeper skin layers, treating severe acne scars, wrinkles, and pigmentation issues.
Jessner's Peel: Combines salicylic acid, lactic acid, and resorcinol, effective for acne, hyperpigmentation, and sun damage.
Chemical Peel Acne Scars: Procedure
Chemical peels are quite quick, usually less than 10 minutes. For superficial peels, recovery is a few days. For deeper peels, it can be about a week.
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Chemical peels are good for superficial acne scars. I wouldn't use them for deep acne scars.
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- Microneedling works better than peels (Ishfaq et al)
- Microneedling + peel together works better than peel alone (Pakla-Misiur)
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Chemical Peel Before and After
Puri N. Efficacy of Modified Jessner's Peel and 20% TCA Versus 20% TCA Peel Alone for the Treatment of Acne Scars. J Cutan Aesthet Surg. 2015 Jan-Mar;8(1):42-5. doi: 10.4103/0974-2077.155082. PMID: 25949022; PMCID: PMC4411592.
TCA CROSS for Acne Scars
The TCA CROSS (Trichloroacetic Acid Chemical Reconstruction of Skin Scars) technique is a specialized treatment for acne scars that uses trichloroacetic acid (TCA). This acid is applied directly to the scars to help improve their appearance. It works by stimulating the skin to produce more collagen, which is like a natural filler that smooths out the scars over time.
This treatment is especially effective for scars that are deep or have a particular shape, like icepick or boxcar scars. To achieve the best results, multiple treatment sessions are usually needed, spaced several weeks apart. Each session builds on the progress of the last one, gradually reducing the visibility of scars. After each session, you might notice some temporary redness and flaking, but these side effects usually go away quickly.
Overall, TCA CROSS is a reliable option for people looking to make their acne scars less noticeable. It helps the skin heal and become smoother by encouraging collagen production, which is key to improving the texture and appearance of scars.
TCA CROSS: Before and After
Fabbrocini G, Annunziata MC, D'Arco V, De Vita V, Lodi G, Mauriello MC, Pastore F, Monfrecola G. Acne scars: pathogenesis, classification and treatment. Dermatol Res Pract. 2010;2010:893080. doi: 10.1155/2010/893080. Epub 2010 Oct 14. PMID: 20981308; PMCID: PMC2958495.
TCA CROSS: Procedure Details
The TCA CROSS procedure is a quick treatment, usually taking just a few minutes per session. Recovery time is typically around a week, during which you might experience redness and scabbing at the treated sites. Patients usually need ~ 3 - 6 treatments with spaced 2 - 8 weeks apart.
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We love TCA CROSS for icepick scars in particular! Relatively low downtime and it really does work well.
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Platelet rich plasma (PRP) works better than TCA CROSS (Mumtaz at al)
CO₂ laser works better than TCA CROSS (Ahmed et al)
For rolling scars, subcision works better than TCA CROSS (El-Rahman Ramadan)
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Filler for Acne Scars
Injectable fillers are used to treat acne scars by adding volume to the indented areas. This process involves injecting a substance, such as hyaluronic acid, beneath the scar to raise it to the level of the surrounding skin. The added volume smooths out the skin’s surface, making the scars less noticeable.
The results of injectable fillers for acne scars can vary depending on the type of filler used. Typically, hyaluronic acid fillers like Juvederm or Restylane last between 6 to 12 months. Other fillers, such as Radiesse (calcium hydroxylapatite) or Sculptra (poly-L-lactic acid), can last up to 18 months or more. The duration also depends on factors like the treated area, the amount of filler used, and your metabolism.
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Filler is a good but temporary option. For longer lasting results, try TCA CROSS.
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Juvederm for Acne Scars: Procedure
Using fillers for acne scars is a relatively quick procedure, usually taking about 30 minutes. Recovery time is minimal, with potential minor swelling or bruising that typically subsides within a few days. Results can last from several months to over a year, depending on the type of filler used.
Juvederm for Acne Scars: Before and After
Bhatt M, Jamale V, Kale M, Hussain AA, Nikam BP. Monotherapy of Biofiller for Atrophic Acne Scars: A Prospective Nonrandomized Study. J Cutan Aesthet Surg. 2022 Jul-Sep;15(3):260-266. doi: 10.4103/JCAS.JCAS_58_22. PMID: 36561404; PMCID: PMC9764951.
Subcision for Acne Scars
Subcision is a minimally invasive procedure designed to treat acne scars by breaking up the fibrous bands of tissue that tether the skin down.
During the procedure, a small needle is inserted under the skin to sever these bands, which frees the skin from the underlying scar tissue. This action not only helps to lift and smooth out the skin's surface but also stimulates collagen production in the treated area. As the collagen forms, it further supports the skin's natural healing process, leading to a noticeable reduction in the appearance of scars over time.
The treatment typically results in minimal downtime, with patients often experiencing some swelling and bruising that resolves within a few days. Multiple sessions may be required to achieve the best results, depending on the severity of the scars.
Subcision for Acne Scars: Procedure Details
Subcision for acne scars typically takes about 30-60 minutes. You will be numbed with a local anesthetic. Recovery time is minimal, with possible minor swelling or bruising that usually subsides within a week. Results can be long-lasting, especially when combined with other treatments like fillers or laser therapy.
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We LOVE subcision! It works wonders especially on difficult rolling scars.
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- For rolling scars, subcision works better than TCA CROSS (El-Rahman Ramadan)
- Subcision combined with either CO2 laser or filler works better than subcision alone (Abdelwahab et al)
Subcision for Acne Scars: Before and After
Gupta A, Kaur M, Patra S, Khunger N, Gupta S. Evidence-based Surgical Management of Post-acne Scarring in Skin of Color. J Cutan Aesthet Surg. 2020 Apr-Jun;13(2):124-141. doi: 10.4103/JCAS.JCAS_154_19. PMID: 32792773; PMCID: PMC7394107.
Punch Excision for Acne Scars
Punch excisions are a precise surgical technique used to treat small, deep acne scars by physically removing them. During the procedure, a dermatologist uses a specialized circular tool to excise the scar, cutting it out completely. Once the scar tissue is removed, the edges of the wound are brought together and stitched closed, allowing the skin to heal more smoothly and evenly.
This method is particularly effective for ice pick scars, which are often too deep to be successfully treated with surface-level treatments. As the area heals, new, smoother skin forms in place of the removed scar, leading to an improved appearance.
The procedure typically involves local anesthesia to minimize discomfort, and the stitches are usually removed within a week or so.
While some minor scarring from the excision itself may occur, these are generally less noticeable than the original acne scars and can be further treated if necessary.
Multiple punch excisions may be performed in a single session, targeting various scars across the skin.
Demonstation Image Above: Hurkudli DS, Sarvajnamurthy S, Suryanarayan S, Chugh VS. Novel uses of skin biopsy punches in dermatosurgery. Indian J Dermatol. 2015 Mar-Apr;60(2):170-5. doi: 10.4103/0019-5154.152519. PMID: 25814706; PMCID: PMC4372910.
Punch Excision for Acne Scars: Procedure
During the procedure, the dermatologist first numbs the treatment area with a local anesthesia injection. You won’t feel anything after this! The entire procedure takes just a few minutes per scar. Recovery is just a few days. The stitches are usually removed after about a week.
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We LOVE punch excisions! It’s a relatively fast way to improve deep scars. You might get similar results with a CO2 laser, but the downtime for punch excision is much shorter.
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- For rolling scars, subcision works better than TCA CROSS (El-Rahman Ramadan)
- Subcision combined with either CO2 laser or filler works better than subcision alone (Abdelwahab et al)
Punch Excision Before and After
Faghihi G, Nouraei S, Asilian A, Keyvan S, Abtahi-Naeini B, Rakhshanpour M, Nilforoushzadeh MA, Hosseini SM. Efficacy of Punch Elevation Combined with Fractional Carbon Dioxide Laser Resurfacing in Facial Atrophic Acne Scarring: A Randomized Split-face Clinical Study. Indian J Dermatol. 2015 Sep-Oct;60(5):473-8. doi: 10.4103/0019-5154.159616. PMID: 26538695; PMCID: PMC4601415.
Acne Scarring FAQs
Acne Marks vs Acne Scars?
Acne Marks are temporary dark spots caused by inflammation, which fade over time with treatments like retinoids and sun protection. Acne Scars are permanent skin indentations or raised areas due to severe acne damage, requiring treatments like laser therapy or microneedling for improvement.
Does Accutane Get Rid of Acne Scars?
Accutane (isotretinoin) effectively treats severe acne by reducing oil production and inflammation, preventing new acne lesions. However, it does not get rid of existing acne scars. Treatments like laser therapy, microneedling, chemical peels, or dermal fillers are needed for improving acne scars.
Does Hydrafacial Help with Acne Scars?
Yes, a HydraFacial can help make acne scars look better, especially mild ones. It cleans and hydrates the skin, making it smoother. But for deeper acne scars, treatments like lasers or microneedling might work better.
Microneedling vs Laser for Acne Scars?
Lasers can be stronger than microneedling (particularly CO2 laser). If you have deep acne scars, laser is the better option.
The Ordinary Products for Acne Scars?
To reduce acne scars, it is necessary to use ingredients that build collagen. A great product is the Glycolic Acid 7% Toning Solution. It is a gentle exfoliating toner that helps to improve skin texture, reduce the appearance of scars, and enhance skin radiance. Also, Retinol 0.2% in Squalane encourages skin cell turnover, improves skin texture, and helps to fade acne scars over time.
What About Butt Acne Scars?
We can use any of the above treatments (microneedling, laser, peels, etc) on your tushy as well! And please do not be embarrassed!! We as dermatologists look at skin all day. There is nothing to be embarrassed about!
Can I Use Castor Oil for Acne Scars?
Yes! Castor oil is believed to aid in improving the appearance of acne scars due to its moisturizing properties and anti-inflammatory benefits. It may help reduce redness and promote skin healing over time.
Does Vitamin C Help with Acne Scarring?
Vitamin C can help improve acne scarring by brightening skin tone, promoting collagen production for smoother texture, and providing antioxidant protection against skin damage. Its anti-inflammatory properties also aid in healing and reducing redness associated with acne scars. Consistent use of a stable form of vitamin C in your skincare routine can contribute to visible improvements in the appearance of acne scars over time.
Is Niacinamide Good for Acne Scars?
Yes! Niacinamide is great for acne scars because it can fade dark spots and even out skin tone. It also calms redness and strengthens the skin's barrier, which helps in healing scars. By controlling oil production, niacinamide can prevent new breakouts that could lead to more scars. Using niacinamide regularly in your skincare routine can visibly improve the appearance of acne scars over time.
How to remove acne scars naturally in a week?
A: It's hard to remove acne scars naturally in a week, but you can try natural remedies to reduce their appearance. Some options include applying aloe vera, honey, or lemon juice. Remember, these methods may not work quickly, and it's always best to be patient and consistent.
Does niacinamide help with acne scars?
Yes, niacinamide can help with acne scars. It helps improve skin texture and reduce the appearance of dark spots, making scars less noticeable over time.
What’s the difference between acne marks and acne scars?
Acne marks are usually dark spots that fade over time, while acne scars are deeper indentations or raised areas on the skin that are more permanent. Marks are easier to treat than scars.
Does Accutane get rid of acne scars?
Accutane is primarily used to treat severe acne, not scars. While it can help prevent future scarring by reducing acne, it doesn't typically get rid of existing scars.
Does Accutane help scarring?
Accutane helps reduce severe acne, which can prevent future scarring. However, it doesn't directly treat existing scars. For existing scars, other treatments like laser therapy or chemical peels may be needed.
Does Arazlo lotion help with acne scars?
Arazlo is a prescription lotion that contains tazarotene, a type of retinoid, which helps treat acne by clearing up pimples and preventing new ones from forming. Arazlo is mainly used to treat active acne. While it can help improve the appearance of your skin over time by promoting skin turnover and collagen production, it’s not specifically designed to get rid of acne scars.