When you hear the term “acne scar”, you probably think of the dark spots commonly left behind after a troubling breakout. However, many acne scars refer to a very specific set of post-blemish marks that are even tougher to tackle than hyperpigmentation. “Atrophic [or pitted] acne scars occur when there is a loss of collagen in the skin and a depression forms at the side of the scar,” says board-certified dermatologist Dr. Elyse Love. When acne causes very severe inflammation, it can bypass the typical response of overproduced melanin and cause structural damage to collagen, fat, and elastin. Remember — collagen is the protein responsible for keeping your hair, skin and nails strong, and its natural loss over time contributes to the visible signs of aging, while acute loss results in acne scarring.
Unfortunately, treating pitted acne scars is neither easy nor quick. “[Acne scars] are difficult to treat because you have such a prominent loss of collagen in that area and it generally goes fairly deep within the skin. So it's not just surface-level that can fade quickly,” says licensed esthetician Scout Garbaczewski. “Professional treatments are going to be the most effective, but there are at-home options you can use in conjunction.”
Rebuilding collagen calls for a combination of active treatments that may be restrictive depending on your skin tone, but rest assured — it is possible. To sort through all of the available options, TZR tapped top skin professionals to better understand how to comprehensively address pitted acne scarring.
How to Identify Your Type(s) Of Pitted Acne Scar
“There are three types of atrophic, or pitted, acne scars: ice pick, boxcar, and rolling,” says Dr. Mark McKenna, chief medical officer and founder of OVME Aesthetics. You can suffer from all three scar types simultaneously with varying degrees of severity and treatment difficulty. “At a very high level, each type of pitted acne scar is variable in depth and definition of the edges,” he adds.
Ice Pick Scars
Ice pick scars are deep indentations that resemble enlarged pores or puncture wounds. These are considered the most difficult to treat due to their depth.
Boxcar scars are shallow and wide with sharp, defined edges making them another challenging case. “Boxcar scars are anecdotally referred to as pockmarks,” says Dr. McKenna.
Finally, rolling scars vary the most in depth and diameter and can create a wavy look to the skin. They have softer edges and are often considered the easiest type of pitted scar to address.
Not all breakouts result in scarring, but if you have a more severe classification of acne, increased sun exposure, and/or a tendency to pick at blemishes, your risk is increased. Consequently, it’s crucial to get acne under control before you can effectively treat scarring.
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How To Heal Acne & Minimize Scarring
Most acne treatments will involve a multi-pronged approach depending on the amount and severity of your breakouts, as well as the subsequent scarring. While all of these suggested treatments are great ways to address your scars, it always helps to speak with a board-certified dermatologist to clarify what methods will be best for you and your skin.
Chemical exfoliation, using actives like glycolic and salicylic acid, can increase cell turnover and break down acne-causing oil and bacteria. For stubborn and very inflamed acne that’s been resistant to other treatments, a dermatologist might prescribe topical or oral medications like Spironolactone or Isotretinoin. These methods can help reduce the severity of acne scars left behind.
Be careful not to over exfoliate and damage your skin barrier, which can lead to additional breakouts. Approximately three times per week is recommended to successfully tackle acne without irritation.
Canada-based licensed esthetician Anika Bodden stresses how anti-inflammatory and hydrating ingredients like sulfur and hyaluronic acid are crucial yet often forgotten parts of calming angry acne. “We’ve been told you have to dry out your face, but with hydrated skin, I can heal a pimple in two or three days.” These ingredients can and should be used with your active exfoliants for best results.
Avoid Pimple Popping
Picking, popping, and self-extracting your acne can not only cause hyperpigmentation but also induce the damage that creates acne scarring. Both Bodden and Garbaczewski advise against giving into the temptation to touch your face and, instead, reaching for pimple patches to heal skin quicker and further reduce your risk of developing scars.
Of course, it’s also important to protect all the work you’ve started with proper, daily sunscreen use. “Everyone should be wearing sunscreen,” says Dr. McKenna. “For people with acne it’s a no-brainer.”
How To Get Rid Of Pitted Acne Scars
The best topical product for both acne and improving the look of acne scars are retinoids. “Retinoids increase collagen production and increase your average skin cycle, so it gets [healing] moving along more quickly and helps clear up breakouts that can cause scars,” says Garbaczewski. Although topical retinoids aren’t likely to solve the problem altogether, particularly for older and deeper scars, they are an accessible starting point.
Prescription-strength retinoids, like tretinoin, are highly concentrated and will therefore work more quickly and efficiently. This strength level is the ideal choice for topically treating all acne scars and highly inflamed acne but may be irritating to those with sensitive skin. Over-the-counter retinols are less active but better tolerated, and will also help move the needle on texture, scarring, and milder breakouts.
First-timers should reach for gentler concentrations at 0.25% or 0.5% and apply a few times a week to build tolerance gradually. Give your skin the equivalent of one full cycle, approximately 28 days, to measure progress on scarring. Mild, shallow rolling scars are the most likely to improve from a retinoid alone.
Professional chemical peels stimulate collagen production using a clinical concentration of exfoliating acids, but your standard peels are best suited for mild scarring or those who don’t mind a longer treatment time. “If they want to continue with low and slow, I do find chemical peels absolutely help,” says Bodden. “But it’s not going to be as quick as laser or microneedling.”
For challenging acne scars like ice pick and boxcar, potent trichloracetic acid (TCA) peels work in fewer treatments. Depending on the severity of scarring, significant improvement may occur after three to four peels whereas standard peels typically require a minimum of six. “TCA cross is a special technique that delivers a very high concentration of trichloroacetic acid (70-100%) directly into the base of an ice-pick scar to stimulate collagen and elastin production,” explains Dr. Love. “This procedure is different than full-face TCA peels, which typically range from 10% to 30% TCA.” Due to their strength, TCA peels are usually performed by medical professionals and are not typically the best option for darker skin because the acid concentrations required to achieve drastic change are high-risk for inducing abnormal pigmentation.
However, most peels can still be applied to darker skin that’s been properly conditioned and prepared for active ingredients. “With darker skin, I always take a more cautious approach,” says Garbaczewski. “Making sure the skin is strong and prepping the skin with [ingredients that prevent the overproduction of melanin].”
Microneedling is a highly effective and minimally invasive treatment for both mild and more serious acne scarring. It’s considered the best treatment option for acne-scarring in darker skin tones because it delivers quicker results compared to chemical peels and doesn’t use heat or active acids that come with the highest risk of hyperpigmentation and unintentional tissue damage. “Microneedling involves controlled microtrauma to the skin that stimulates collagen synthesis,” says Dr. McKenna. “It is particularly effective when it’s coupled with radiofrequency which essentially tightens the skin.”
Microneedling for acne scars is typically administered at a needle depth of 1.5 to 2mm in a series of three treatments, one per month, for best results. The procedure can be somewhat painful however, and numbing cream is often applied to reduce discomfort. Downtime may be up to three days of redness and sensitivity. “Many clients don’t require [numbing cream],” says Dr. McKenna. “You don’t want to work out or do anything crazy on the same day [as the treatment], but the next morning our clients are good to go.”
You can expect to see results six to eight weeks after your appointment as the skin continues to produce new collagen for several months after microneedling.
A potentially surprising scar treatment on the table is dermal fillers. Similar to how fillers increase volume in a variety of areas on the face, they can lift the skin to fill depressed space and create superficial smoothness.
BELLAFILL is currently the only FDA-approved filler for treating acne scars. This filler type is more durable, lasting up to five years compared to one or two years for standard filler, and has the potential to also stimulate natural collagen production. Several injections may be required depending on the acne scar. “Some instances it does work, but it doesn’t work very well for ice pick or box car lesions,” says Dr. McKenna. “Superficial [rolling scars] can respond well to dermal filler.” Your dermatologist will determine if your scar types are good candidates for treatment with dermal fillers.
Lasers treat hollowed scars by using heat to stimulate skin’s wound-healing response and produce new collagen. Where, how, and with what intensity laser energy is delivered largely affects who can receive the procedure and what it’s best for. “Ablative procedures [that remove skin’s top layer] are the most powerful and will show the best results with fewest treatments,” advises Dr. Love.
Traditionally, laser technology was limited to lighter skin tones. These lasers delivered fixed, intense amounts of heat to target areas that triggered negative responses in darker skin tones. Additionally, they were not technologically advanced enough to differentiate between melanin in the skin and targeted melanin in unwanted hair or abnormal pigment, causing unintentional damage.
Now, more sophisticated devices with adjustable settings have expanded treatment opportunities for patients with darker skin. “[The Halo] laser is a hybrid meaning it uses two different wavelengths. A superficial wavelength to target things like acne scarring and wrinkling and a deeper wavelength that can target things like pigment,” explains Dr. McKenna. “We can treat [almost all skin tones] which allows us a lot of flexibility.”
For all lasers, expect longer and more involved healing times where redness, sensitivity, flaking, and peeling will likely occur. Ablative lasers require two to four weeks of limited activity for a full recovery. Non-ablative options have shorter downtimes, around one week.
Excision & Subcision
In the most significant cases, removing scar tissue first is necessary to get rid of the scarring. “Subcision is helpful for scars that are bound down to the underlying skin surface,” says Dr. Love. This technique is best for rolling scars and uses a needle to break apart scarred, fibrous tissue which ultimately separates healthy skin lying underneath from scarred skin and helps to flatten the surface.
Although running the risk of worsened scarring, ice pick or deep boxcar scars are sometimes completely removed, or excised. A punch biposy tool that matches the size of the lesion is used to remove the scarred tissue, then the skin is stitched closed with a fine needle. This technique is often used in combination with laser resurfacing. “To put it in simplest terms, you’d be [treating] fresh skin as opposed to skin that [is deeply scarred with] a lot of fibrous, tough skin,” explains Dr. McKenna.
Treating Acne Scars Is A Multi-Prong Ordeal
Successfully treating acne scars requires a combination of at-home and professional treatments as well as patience. “[How long it takes to treat scarring] will depend on the depth of each individual acne scar, the amount of the face affected, the age of the acne scars, and the treatment used,” says Dr. Love. “In general, the greater the downtime, the less treatments needed. So, you may need three microneedling with radiofrequency sessions for every ablative laser treatment [because of how aggressive the latter is].” Many of these treatments are budget-dependent, but in any case, regular exfoliation, sun protection, and acne management will be the first steps for you on the road to fading acne scars.