Five Common Types of Acne Scars #Acne Scars don’t stand a chance against our newest multi-modality treatment regimen.

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Acne Scars don’t stand a chance against our newest multi-modality treatment regimen.


Ice Pick Scars   

Ice pick scars are the result of infected sebaceous glands in the skin. Ice pick scars are very deep holes that look like the skin has been punctured. When the body does not produce enough collagen in response to an injury, scars such as ice picks can form. Ice pick scars are usually 1-2 mm in diameter. They are so named as they form very narrow incisions into the upper level of the skin. The scar then dives below the surface, extending into the dermis. Ice pick scars develop from a deep infection in the skin. The infection makes its way to the skin surface, creating a cyst and thus the resultant scar.


We use multiple modalities for acne scar treatment including 1) multiple types of lasers, 2) medication for both the acne and the scars that form after the acne has cleared and 3) surgical approaches as needed. First, Cutera’s Xeo laser is excellent for building collagen. This treatment helps build and improve collagen from the inside out which helps to fill the scars from within.  Several treatments are usually needed. The procedures are done using local anesthesia, and it’s effective on all skin types. In one study, published in a 2015 issue of the Journal of Cosmetics, Dermatological Sciences and Applications, Dr. Hellman found that approximately four treatments with a radiofrequency device produced significant improvement in the depth of the scars.

We can add TCA treatment to the deepest of the scars. TCA or trichloracetic acid is a non-toxic chemical which has been used to perform skin peels for multiple decades. When TCA is applied to the skin, it causes the top layers of cells to dry up and peel off. This is a relatively inexpensive and easy treatment for deep and otherwise difficult to treat scars. The TCA CROSS procedure involves depositing small amounts of TCA at high concentration (70–100%) onto the surface of the atrophic scar. This causes a local inflammatory reaction leading to the formation of new collagen fibers. The aim is to improve the appearance of the scar by increasing collagen growth in the lower aspect of the scar and by reducing shadows cast over scar depressions. Complete resolution is unlikely to be achieved with this treatment method alone.

Lastly, we can add minor surgical procedures to the treatment plan. If needed we can then proceed with microneedling and subcision. These treatments take multiple months for effective results but are very well tolerated.

See this article for more information.

Boxcar scars


Boxcar scars are also depressed, but they tend to be broader and boxier than ice picks. Boxcar scars appear like chicken pox scars. They cause deep depressions on the skin and give the dermis a matted appearance. They are angular scars with sharp vertical edges. These scars are created when there is tissue loss in the skin because of an acne breakout. The skin is left without support and therefore collapses with no structure. A depression is left in place and this is what causes the wide pits. The depth of the depression may differ depending on the severity of the acne infection. Usually, the more severe the acne, the more the skin loss and the bigger the boxcar scars.

Treatment: Lasers work by creating new collagen beneath the surface of the skin. A series of treatments is likely needed based on the extent of scarring. Chemical peels can also help but to a lesser extent.

There is also a role for fillers for some depressed scars. Fillers have been gaining more widespread approval by the U.S. Food and Drug Administration recently. Dermal fillers work twofold by adding volume, and encouraging collagen formation beneath the surface by creating a supportive scaffold network. Fillers are best used after subsicion.


Rolling scars 

Rolling scars are also atrophic and have smooth edges that look like hills and valleys. These are also considered depressed scars. Rolling scars cause abnormal wave-like undulations on the dermis. They are caused by acne damage under the surface of the skin. They are wide and shallow scars. These give the skin a bumpy appearance. Fibrous tissue develops in the subcutaneous areas of the skin in an irregular manner.

Treatment:  The treatment of these scars like the previous discussion involves multiple modes of treatment.  Microneedling with or without PRP along with laser facial resurfacing is the key to excellent and long-lasting results. Microneedling creates tiny holes or pinpricks in the skin. The body’s natural healing process then kicks in to boost internal collagen production. Microneedling also opens channels in the skin that give PRP a chance to affect the lower dermis. PRP or platelet rich plasma contains healing factors in your own blood. Microneeding leads to channels that give access to deeper layers of the skin where platelet factors are needed most. PRP is created by taking some of your blood, isolating the platelet-rich plasma, which contains proteins and other growth factors. The process then involves injecting the PRP back into the scar. Multiple treatments are needed just as we discussed above.

Keloid scars

Keloids are raised scars that can be red or dark in color. Keloid scars tend to appear when the acne clears up. They are raised lesions which tend to get larger with time. They might itch or be painful in certain cases. They are often the result of more severe acne lesions. Keloid Scars are a type of hypertrophic scarring that can scar beyond the original wound site. There is an elevation in the production of collagen with these types of scars.

Treatment: Injections of steroids can flatten keloid scars. The goal is to make the inflammation go away. Also, laser treatments can improve any discoloration by targeting blood vessels. Cryosurgery freezes the scar tissue, causing it to slough off, but this can cause pigmentation problems of its own among people with darker skin, who are already at higher risk for keloids. Pigmented areas are treated with a different laser i.e our Cutera Enlighten III system. This laser is excellent for removing pigment and force the body into building new collagen at the same time. Again multiple treatments are needed to aid in acne scared skin total rejuvenation.


Hyperpigmentation occurs as dark spots or discoloration caused by acne-related inflammation. When skin becomes irritated, melanocytes become stimulated to produce melanin. This leads to the coloring of the skin which can range from purple, red, brown or black. Once a pimple starts, melanin starts being produced. Any further injury stimulates the melanocytes even more causing further hyperpigmentation which then makes the coloring harder to treat and fade.

Treatment: Once again the Cutera Enlighten III laser is an excellent choice. This is a picosecond non-ablative laser. This laser system uses  a newer technology, and as such it has much less downtime than older lasers. Older ablative lasers blast off the skin’s top layers, which requires significant downtime, but these newer non-ablative lasers pass through the skin’s upper layers to harmlessly heat the deeper tissues, stimulating collagen and smoothing the scar’s appearance.

Finally, we can add ZO products to the protocol as an adjunct to the treatment plan. Obagi has a lineup of products to help treat pigment including medical grade hydroquinone and fading creams that can be added to the laser treatment protocol. Other potential treatments include retinoids to increase skin cell turnover. These are used in addition to and during many of the other treatments mentioned above to improve the results of treatment and help sustain excellent skin quality.

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