Types of Acne Scars and Treatment

There are two main categories of acne scars. The first are atrophic scars caused by a loss of tissue, with three types known as ice pick, boxcar, and rolling. The second type, called hypertrophic or keloid scars, are caused by excess tissue.

Acne scars can be difficult to treat, and they always require professional help if you want to see real improvement. Over-the-counter products aren't powerful enough to improve the look and texture of acne scars.

This article explores the different types of acne scars and how they are treated. Your options depend on the type of scarring you have, and if you have more than one type, you may benefit from a customized combination of several acne scar treatments.

Ice Pick Scars

Ice pick scars are deep, very narrow scars that extend into the dermis. The skin looks as if it has been pierced by an ice pick or sharp instrument. Ice pick scars seem to make a small, thin, deep hole into the skin. Some may look like a large, open pore.

How They Develop

Ice pick scars can develop if an infection or inflammation from a cyst or blemish works its way to the surface. Skin tissue is destroyed, leaving a long, column-like scar.

Treating Ice Pick Scars

You have a few options for treating ice pick scars. Punch excision is a common ice pick scar treatment. During the procedure, your physician takes a small, cookie-cutter-like tool to cut out the scar. The skin is then glued back together to heal.

Punch grafting is done for larger, deeper ice pick scars. As with punch excision, the scarred tissue is removed from the skin. The hole is then filled with a graft of skin, usually taken from behind the ear.

These procedures can leave small scars, which are flat and level with the surrounding skin. This makes them much less noticeable.

TCA cross-hatching, which uses TCA chemical peel in tiny amounts into the small holes is another treatment that's used for ice pick scars.

Boxcar Scars

Boxcar scars are round or oval depressions with steep vertical sides. Wider than ice pick scars, boxcar scars give the skin an uneven, pitted appearance.

How They Develop

When an inflammatory breakout destroys collagen, the tissue is lost. The skin over this area is left without support, creating a depressed area. Boxcar scars can range from superficial to severe, depending on the amount of tissue lost.

Treating Boxcar Scars

The most common treatment for boxcar scars is a dermal filler. These are injected into the scar, helping to raise depressed areas of the skin and leaving it more even with the surrounding surface.

Dermal fillers are fast, simple procedures compared to other types of acne scar treatments. The results aren't completely permanent, but dermal fillers can last for 18 months to two years.

Laser resurfacing is another option. There are many different types of lasers, and they all work a bit differently. In general, lasers help to stimulate new skin tissue and collagen to form, improving the tone and texture of the skin. 

Boxcar scars can also be treated with punch excision or punch elevation. Punch elevation is very similar to punch grafting, but instead of using a graft, the skin at the base of the scar is raised up, helping to level off the surface.

Rolling Scars

This type of scarring causes rolling or wave-like depressions across otherwise normal-looking skin. Rolling scars differ from boxcar scars in that they aren't sharply defined. They make the skin look uneven and craggy.

How They Develop

Rolling scars arise when fibrous bands of tissue develop between the skin and the subcutaneous tissue below. These bands pull the epidermis, binding it to deeper structures of the skin. It is this pulling of the epidermis from within that creates the rolling appearance of the skin.

Treating Rolling Scars

Subcision is one effective method used to treat rolling scars. This is a simple surgical procedure, performed under local anesthesia on an outpatient basis. A dermatologist will insert a needle parallel to the skin, cutting the fibrous base of the scar that is pulling down on the skin from below. Once the bands have been cut, the skin looks smoother.

Hypertrophic and Keloid Scars

Hypertrophic scars are firm, raised scars that grow above the surface of the skin. Hypertrophic scars caused by acne are most often found on the torso, especially in men, but they can happen anywhere on the body. Hypertrophic scars are more common after a deep wound or trauma.

Keloids are a more severe type of raised scar. They differ from hypertrophic scars in that keloids grow larger than the original wound. They can send out raised, lateral shoots that expand much farther than the wound itself, and can continue to grow long after the original wound has healed. Some people are more prone to developing keloids.

How They Develop

Hypertrophic scars develop because of an overproduction of collagen. In the case of keloids, the skin continues to produce collagen even after there's no need for further skin repair.

Treating Hypertrophic Scars and Keloids

There are many different options for treating hypertrophic and keloid scars. The best treatment for you will depend on your personal situation, but can include:

• Steroid (cortisone) creams
• Silicone gels
• Cryotherapy (freezing the scars with liquid nitrogen)
• Tapes
• Pulsed dye laser treatments
• Injections to help shrink and flatten the scar

Care must be taken while treating these scars to avoid aggravating the skin, which can lead to a worsening of the keloid.

Post-Inflammatory Hyperpigmentation

Discoloration left on the skin after a pimple has healed is extremely common for people with acne, and it isn't considered a true acne scar.

This post-inflammatory hyperpigmentation is a flat area (neither raised nor pitted) that ranges in color from pink to red, purple, brown, or black, depending on your skin type.

How It Develops

Post-inflammatory hyperpigmentation develops when a wound, rash, pimple, or other trauma causes skin inflammation. As the skin heals, it produces too much melanin, the substance that gives skin its color. This leaves a darker area when compared with the surrounding skin.

Treating Post-Inflammatory Hyperpigmentation

In many cases, treatment isn't necessary because discoloration often fades away on its own over time. In cases where the discoloration isn't fading, or if you just want to help speed up fading, there are a few options for you.

Over-the-counter products that contain alpha-hydroxy acids can help fade minor to moderate discoloration. For more severe post-inflammatory hyperpigmentation, prescription strength topical retinoid or azelaic acid creams are good options, as are creams containing hydroquinone or vitamin C. And procedures that use chemical peels can be helpful as well.

A Word From Verywell

Even with the most careful and conscientious treatment, you may develop acne scars. If you have acne, you're likely to want to get breakouts under control as much as possible. It's very difficult to effectively treat acne scars if you're still actively breaking out.

If you need help treating acne, see a dermatologist. Your dermatologist can help you find an acne treatment that will help get breakouts under control. Once your skin is reasonably clear, the next step is treating acne scars. Your dermatologist can help with that too.