Acne scar treatments: what actually works for each scar type

Acne scars are not one thing. "Acne scarring" describes several distinct types of tissue damage, and what works for one type may not work for another. Understanding your scar type is the most important first step in building a treatment plan.

Scar types and what causes them

Atrophic scars (depressed — the most common)

Atrophic scars form when the skin loses collagen during healing. There are three main subtypes:

Ice pick: Deep, narrow channels (like a puncture). The hardest to treat because the scar extends into the deep dermis. Width: &lt;2 mm.

Boxcar: Wider, flat-bottomed depressions with sharp, defined edges. Easier to treat than ice pick. Width: 1.5–4 mm.

Rolling: Shallow, undulating depressions with sloped edges — caused by fibrous bands that tether the skin downward. Often the most responsive to treatment.

Hypertrophic and keloid scars (raised)

Hypertrophic scars are raised but stay within the original wound boundary. Keloids grow beyond the wound boundary. Both result from excessive collagen production during healing.

These are more common on the chest, back, and shoulders. They require different treatments than atrophic scars.

Post-inflammatory hyperpigmentation (PIH)

PIH is dark discoloration after acne heals — this is not technically scarring (it's a pigmentation change, not a structural change). It often fades on its own over months. Many patients confuse PIH with scars; they require different treatments.

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Treatments for atrophic scars

RF Microneedling (Morpheus8, Potenza, Genius RF)

RF microneedling is one of the most effective treatments for atrophic scars — particularly boxcar and rolling scars. The combination of physical collagen disruption (needles) and thermal energy (RF) stimulates significant collagen remodeling.

Best for: Boxcar and rolling scars. Less effective for ice pick.

Sessions: 3–4, spaced 4–6 weeks apart.

Results: Meaningful improvement (30–60% reduction in scar appearance in studies). Rolling scars respond most dramatically.

Cost: $800–$2,000 per session; $2,400–$8,000 for a full course.

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Traditional microneedling (no RF)

Standard microneedling (Collagen PIN, SkinPen) is effective for mild-moderate atrophic scarring, particularly rolling scars. Less powerful than RF microneedling, but also less expensive and has shorter downtime.

Best for: Shallow rolling scars; skin texture generally.

Cost: $200–$700 per session; 3–6 sessions typically.

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Laser resurfacing

Ablative (CO2, Erbium): The most powerful option for atrophic scars. Ablative lasers vaporize the outer skin layers, forcing complete resurfacing. CO2 laser can achieve dramatic improvement in a single session.

Downtime: 1–2 weeks of significant peeling, redness
Best for: Moderate-to-severe boxcar and rolling scars; overall texture
Not appropriate for darker skin tones (high PIH risk)
Cost: $2,000–$5,000 per treatment

Fractional non-ablative (Fraxel 1550/1927, MOXI): Treats columns of skin while leaving surrounding tissue intact — less downtime than ablative, requires more sessions.

Downtime: 3–5 days
Best for: Mild-moderate scarring
Safer for skin of color than ablative
Cost: $1,000–$2,500 per session; 3–5 sessions

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Subcision

Subcision is a minor surgical technique where a needle is inserted under a rolling scar and moved laterally to cut the fibrous bands tethering the scar to deeper tissue. It addresses the structural cause of rolling scars — the tethering — rather than trying to resurface from above.

Best for: Rolling scars specifically. Often combined with RF microneedling or filler for enhanced results.

Sessions: 1–3, spaced 4–6 weeks apart.

Cost: $300–$800 per session.

Note: Not all providers offer subcision. It requires hands-on skill and is often performed by dermatologists or experienced NPs/PAs rather than basic estheticians.

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TCA Cross (Chemical Reconstruction of Skin Scars)

TCA Cross involves applying high-concentration trichloroacetic acid (80–100% TCA) precisely to the base of individual ice pick scars using a toothpick-sized applicator. The controlled destruction triggers repair that fills in the scar from the bottom up.

Best for: Ice pick scars — this is one of the only treatments specifically effective for them.

Sessions: 1–4, spaced 4–6 weeks apart. Multiple treatments needed as ice picks fill progressively.

Cost: $150–$500 per session (often priced per number of scars treated).

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Dermal filler for scars

Hyaluronic acid filler (Juvederm, Restylane) or biostimulators (Sculptra, Radiesse) can be injected directly into deep rolling or boxcar scars to lift the depression.

Limitation: Filler is not permanent — HA fillers last 6–18 months. This is a maintenance approach, not a structural correction.

Best for: Patients who want immediate improvement while collagen-induction treatments take effect (combined approach).

Cost: Varies by filler type; often $400–$800 for a small volume targeted at scars.

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Treatments for hypertrophic and keloid scars

| Treatment | Mechanism | Best for |
|---|---|---|
| Corticosteroid injections | Reduce inflammation, flatten scar tissue | Hypertrophic scars, small keloids |
| 5-FU injections | Anti-proliferative; reduces excessive collagen | Keloids |
| Pulsed dye laser (PDL) | Targets vascularity in scar tissue | Red/inflamed raised scars |
| Silicone sheeting | Hydration and pressure | Prevention and mild flattening |
| Surgical excision + radiation | Physical removal + prevention of recurrence | Large keloids (high recurrence risk without radiation) |

Keloids are the hardest type of acne scar to treat and have significant recurrence rates after removal.

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Treating post-inflammatory hyperpigmentation (PIH)

PIH responds to:
Topical brighteners: Tranexamic acid, kojic acid, vitamin C, azelaic acid
Chemical peels: Glycolic acid, mandelic acid, lactic acid (avoid TCA/higher peels on active PIH without guidance)
Low-fluence IPL (skin of color: proceed carefully; test first)
Time: PIH fades without treatment in 6–24 months in most cases

PIH is NOT treated with subcision, filler, or ablative lasers — those are for structural scars.

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Building a treatment plan

A realistic plan for moderate atrophic scarring:
Assessment: Scar typing by a qualified provider (not every treatment is right for every scar)
Rolling scars: Subcision → RF microneedling series (3–4 sessions)
Ice pick scars: TCA Cross (1–3 sessions)
Boxcar scars: RF microneedling or fractional laser
PIH: Topicals throughout (vitamin C, tranexamic acid, daily SPF 50)
Maintenance: 1 annual RF microneedling or laser treatment

Most patients with moderate acne scarring need 6–12 months of treatment to achieve their best result. Expect visible improvement in 3–4 months; full results at 6–9 months.

Questions to ask your provider

What type of scars do I have, and which modalities do you recommend for each?
Do you perform subcision, or do you refer for that?
Are you comfortable treating my skin tone with this device?
What does a full treatment course look like for my specific scars, and what's the realistic cost?
When should I start seeing results, and how do we evaluate progress?

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