Types of Acne Scars and How To Treat Them

How To Identify and Treat the Different Types of Acne Scars

Acne scars fall into two main categories: those caused by a loss of tissue (atrophic scars), and those caused by an excess of tissue (hypertrophic scars). Within these categories, there are four main types of acne scars: ice pick, boxcar, rolling, and keloid scars.

Acne scars can be difficult to treat, and always require professional help if you want to see real improvement. Unfortunately, over-the-counter products simply aren't powerful enough to improve anything besides discoloration.

There are procedures, though, that can improve the look and texture of your skin. Your options depend on the type of scarring you have. Most people have more than one type of scarring on their skin, so you might need a few different treatments to see the best results.

Here's a look at the different varieties of acne scars and their recommended treatments.

Ice Pick Scars

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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 develop after an infection from a cyst or other deep inflamed 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. Just like 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). It's a meticulous process, but makes an immediate improvement in the skin's texture.

Although both of these procedures themselves can leave small scars, the resulting scars are flat and level with the surrounding skin so they are much less noticeable.

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 be superficial to severe, depending on the amount of tissue lost.

Treating Boxcar Scars: Just like with ice pick scars, boxcar scars can be treated with punch excision. These types of scars can also be treated with punch elevation. It's very similar to punch grafting, but instead of using a graft, the skin at the base of the boxcar scar is raised up, helping to level off the surface of the skin.

The most common treatment for boxcar scars, though, are dermal fillers. These are injected into the scar, helping to raise depressed areas of the skin leaving it more even with the surrounding skin surface. Dermal fillers are fast, simple procedures compared to other types of acne scar treatments. The drawback is the results aren't completely permanent, but new dermal fillers can last for 18 months to 2 years.

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

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. The skin itself looks 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 Boxcar Scars: Rolling scars are best treated with subcision. This is a simple surgical procedure, done under local anesthesia as an out-patient. A scalpel is inserted 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 raised, firm 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 grown long after the original wound has healed. Some people are more prone to developing keloids.

How They Develop: Unlike ice pick and boxcar scars, hypertrophic scars are not caused by a loss of tissue. Rather, they develop because of an overproduction of collagen. In the case of keloids, it's like the skin doesn't know that the wound has healed, and continues to produce collagen.

Treating Hypertrophic Scars and Keloids: There are many different options for treating hypertropic 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, or 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 isn't a true acne scar, but rather post-inflammatory hyperpigmentation. It's incredibly common for people with acne. 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) leaving a darker area.

Treating Post-Inflammatory Hyperpigmentation: In many cases, you don't have to do anything; discoloration often fades away all 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 topical retinoid or azelaic acid are good options, as well as creams containing hydroquinone.

A Word from Verywell

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

First things first, 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 you with that too.

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