Acne Scars: An Update on Management

Abdulhadi Jfri, MD, MSc, FRCPC, FAAD1-5; Ali Alajmi, MD, FRCPC, FAAD6;
Mohammad Alazemi, MD7; Malika A. Ladha, MD, FRCPC, FAAD1,8
Harvard Medical School, Harvard University, Boston, MA, USA
1

2
Department of Dermatology, Brigham and Women's Hospital, Boston, MA, USA
3
King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
4
King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
5
Division of Dermatology, Department of Medicine, Ministry of the National Guard-Health Affairs, Jeddah, Saudi Arabia
6
Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
7
Farwaniya Hospital, Kuwait City, Kuwait; 8Division of Dermatology, University of Toronto, Toronto, ON, Canada
Conflicts of interest: The authors have no conflicts to disclose.

ABSTRACT
Acne vulgaris is a troubling skin disease known to have both physiologic and psychological effects on patients. Acne scars, a frequent
complication, can further impact patients’ quality of life. Scars result from an impairment in the healing process. Acne scars can be
categorized as follows: atrophic scars (including ice pick, rolling, boxcar subtypes) and trophic (including hypertrophic and keloid
scars), the latter being less common. Though various treatment approaches have been suggested, there is a lack of high‐quality
evidence on effective, type-specific acne scar approaches. Herein, we aim to review the current evidence for treating various acne
scars.
Keywords: acne scars, atrophic, ice pick, rolling, boxcar, hypertrophic, keloid

Introduction Ice Pick Scars

Acne vulgaris is the most common skin disease affecting Ice pick scars extend vertically into the deep dermis or
adolescents and adults.1 Studies have demonstrated that about subcutaneous tissue. They are narrow (<2 mm) at the surface
99% of the population has had acne at some point in their lives, and taper as they extend into the deep dermis. Conventional skin
varying in degree of severity, duration, and age of onset.1 resurfacing treatment options may not be adequate due to their
depth. Punch excision can be used to treat ice pick scars. Though
The psychological impact of acne is well known. Acne can have
this method forms a new scar, it is generally less visible than
social and psychological consequences beyond the apparent
the original ice pick scar.5 The punch excision can be followed
visual deformity. This common condition has been linked to
by a resurfacing procedure after 4 to 6 weeks, which can further
stress, anxiety, depression, and suicidal ideation.2 Singam et al.
improve the scar’s appearance. Notably, laser skin resurfacing
reported that severe acne is associated with comorbid mental
can be safely and effectively performed on the same day that the
health disorders in 25% of acne patients, including anxiety,
punch scar is created.6
adjustment, personality, and substance use disorders.3 Acne has
also been associated with reduced academic achievement and Another treatment option for ice pick scars is chemical
social difficulties.1 reconstruction of skin scars (CROSS) using high concentrations
of trichloroacetic acid (TCA) to induce skin regeneration. TCA
Acne scars are a frequent complication that results from damage
is strictly applied to localized areas; the controlled application
to the skin during the healing process of lesions, with studies
results in a shorter recovery time compared to medium or deep
indicating that 50% of those suffering from acne may develop
scars.4 Increased risk of scarring is associated with severe disease,
time between acne onset and first effective treatment, relapsing
acne, and males.4 Herein, we discuss different types of acne scars
and present an updated review on type-specific management
approaches.
Discussion
Acne scars can be classified as atrophic, hypertrophic, or keloidal.
The morphology of these scars is summarized in Figure 1.
Atrophic acne scars are further subdivided into three subtypes:
ice pick, rolling, and boxcar.
The management approach for treating acne scars should be type-
specific given the differences in underlying pathophysiology.
Treatment options for each type of scar are summarized in
Table 1. Figure 1. Acne scar types. Courtesy of Abdulhadi Jfri MD.

6 • Editor: Dr. Richard Thomas • Volume 27, Number 6 • November-December 2022

chemical peels. The degree of clinical improvement is dependent Conversely, Peterson et al. found that 15 patients diagnosed
on the total number of treatments.7 with rolling and boxcar scars responded better to 5 sessions of
TCA CROSS can also be used in darker skin types. In a study a combination of RF and FRF than patients with ice pick scars.11
evaluating the efficacy and safety of CROSS technique, Another mode of therapy for ice pick scars is resurfacing lasers.
researchers used 100% TCA to treat ice pick scars in patients This treatment modality has yielded only mild-to-moderate
with Fitzpatrick phototypes IV and V. Nearly 75% of participants efficacy for ice pick scars, compared to other subtypes. Sardana
experienced excellent improvement in the appearance of their et al. reported that treatment with a 1,540 nm fractional non-
scars after 4 sessions at 2-week intervals.8 ablative laser improved scar appearance for only 25.9% of
Radiofrequency (RF) is another option for treating ice pick patients with ice pick scars, compared with 52.9% and 43.1%
scars. RF devices use electromagnetic radiation to produce an improvement in boxcar and rolling scars, respectively.12
electric current that delivers heat to the dermis, which in turn Combining ablative fractional carbon dioxide (CO2) laser with
causes neocollagenesis and skin contraction. This technique is platelet-rich plasma (PRP) injections represents an innovative
considered both safe and efficacious, offering minimal downtime approach. PRP involves preparing and administering the
and adverse events.9 Additionally, RF is a safe procedure in skin patient’s own concentrated platelets in plasma containing
of color (SOC) as it does not directly target pigment. variable growth factors and cytokines that promote wound
Several studies have demonstrated the effectiveness of RF healing. A recent meta-analysis investigated the efficacy and
in the management of ice pick scars. Ramesh et al. reported safety of combining fractional CO2 laser with PRP for managing
that fractional bipolar RF (FRF) achieved good results in 73% atrophic acne scars. It was concluded that the dual approach led
patients after 4 sessions. Patients with ice pick scars exhibited to enhanced outcomes compared to using ablative fractional
a better response than those with rolling and boxcar scars.10 CO2 laser alone. Specifically, the combination resulted in clinical

Scar Type Presentation Treatment Options

Ice pick • Narrow (<2 mm) at the surface and tapers as they • Punch excision
extend to deep dermis • Chemical reconstruction of skin scars (CROSS)
• Extend vertically into the deep dermis or subcutaneous using trichloroacetic acid (TCA)
tissue • Laser resurfacing
• Radiofrequency
• Platelet-rich plasma
Rolling • Dermal tethering of abnormal fibrous bands which • Subcision
produces a dell in the skin. • Injectable fillers
• Scars are 4-5 mm wide that are sloped with shallow • Non-ablative laser
borders • Microdermabrasion
• Microneedling
• Platelet-rich plasma
Boxcar • Broad, round-to-oval or rectangular depressions, • Resurfacing laser
usually box-like depressions with sharply defined edges • Punch excision
• Punch elevation
• Microdermabrasion
• Chemical peeling
• Injectable fillers
• Non-ablative lasers
• Platelet-rich plasma
Hypertrophic • Pink raised lesions that persist within the borders of the • Intralesional corticosteroid injections
original site of injury • Vascular laser (e.g., pulsed dye)
• Intralesional 5-fluorouracil (5-FU)
• Laser resurfacing
• Cryotherapy
• Imiquimod cream
Keloids • Reddish-purple scars that frequently extend beyond the • Intralesional corticosteroid injections
borders of the original site of injury • Intralesional 5-FU
• Intralesional interferon
• Intralesional bleomycin
• Imiquimod cream
• Laser resurfacing
Table 1. Clinical presentation and treatment options of acne scars

• Editor: Dr. Richard Thomas • Volume 27, Number 6 • November-December 2022 7

improvement, increased patient satisfaction, and accelerated their effectiveness for improving acne scarring.7 For punch
recovery after laser damage. However, further research is needed elevation, the punch biopsy tool is used to fragment the deeper
to evaluate the efficacy of PRP for acne scars.13 PRP can also be aspect of the scar without removing any epidermis or dermis.
combined with microneedling to treat any atrophic acne scars. Dermabrasion can be an effective option for managing boxcar
Rolling Scars scars, but it is a painful procedure that requires local or general
Rolling scars result from dermal tethering of abnormal fibrous anesthesia and the healing time may extend to several weeks,
bands that produce skin indentation. The scars are 4-5 mm wide with significant postoperative discomfort.21 Microneedling RF
and are sloped, with shallow borders. is another useful technique that can be employed to manage
Rolling scars can be best managed surgically with subcision, atrophic boxcar scars.11 RF does not directly target melanin and
which involves the use of a tri-beveled hypodermic needle to free can thus be safely used in SOC.
the tethering subdermal fibrous bands. Al-Dhalimi et. al showed Subcision is moderately effective for managing boxcar scars, but
that subcision downgraded the severity of rolling acne scars it can be combined with other resurfacing procedures such as
from moderate-to-severe grade to mild grade in 53% of patients, cosmetic fillers and non-ablative lasers to achieve better results.20
with minimal side effects.14 The subcision was done once and Chemical peeling with TCA can be used to manage hard-to-treat
repeated every 6 weeks, as required. boxcar scars.22 Finally, laser skin resurfacing can deliver excellent
Subcision has been combined with the application of soft tissue results for managing acne scars. One study demonstrated that use
fillers and non-ablative laser to improve the appearance of of a high-energy pulsed CO2 laser provided 75% improvement
rolling scars. Hyaluronic acid fillers can expand the volume of in atrophic facial scars, including boxcar scars.23 Ablative lasers,
tissue in these scars and encourage collagen production. Sapra such as CO2 and erbium-doped yttrium aluminum garnet
et al. assessed the management of rolling scars with poly-L- (Er:YAG), should be used with caution when treating atrophic
lactic acid (PLLA) in 22 patients and demonstrated that after 3 scars in SOC. The risk of postinflammatory hyperpigmentation
to 4 treatments at 4-week intervals with PLLA, 54.4% of patients (PIH) appears to be decreased with Er:YAG. Post ablative laser
exhibited excellent results.15 A controlled and blinded study was PIH may last for 5 weeks and can be treated with a topical
performed on 147 patients with rolling acne scars to evaluate the depigmenting agent such as hydroquinone 4% or combination
effectiveness of 1 injection of polymethylmethacrylate (PMMA) topicals (retinoid, hydroquinone and corticosteroid).24,25
filler. Neary 65% of patients demonstrated good improvement, Hypertrophic Scars and Keloids
compared to 33% of control subjects.16 Hypertrophic scars and keloids are more severe types of acne
Microdermabrasion and dermabrasion are physical ablating scars. They are less common compared to atrophic acne scars,
modalities used to manage rolling scars. Microdermabrasion but can be difficult to treat. Typically, hypertrophic scars appear
is more superficial whereas dermabrasion reaches the deeper as pink, raised lesions that persist within the borders of the
papillary dermis layer. The procedures promote a wound healing original site of injury.26 Keloids present as reddish-purple scars
response and new collagen formation. Eventually, dermabrasion that frequently extend beyond the borders of the original site of
treatment results in smoother and uniform appearance of the injury.27 From a pathophysiological perspective, hypertrophic
scar.17 Microdermabrasion received at weekly intervals appears and keloidal scars demonstrate excessive expression of collagen
to be safe in SOC.18 with reduced collagenase activity.28
Microneedling is another beneficial option for managing rolling Intralesional corticosteroid injections represent the mainstay
scars. Microneedling involves creating small wounds in the of treatment for hypertrophic and keloid scars. However,
dermis to activate a cascade of growth factors and eventually multiple treatment approaches can be used simultaneously
stimulate collagen production.19 Microneedling can be effective to maximize the potential for success and minimize adverse
in managing rolling scars for darker-skinned patients due to effects.29 For example, intralesional corticosteroid injections can
the low risk of hyperpigmentation compared to fractional non- be accompanied by 5-fluorouracil (5-FU) to reduce the risk for
ablative laser therapy.7 hypopigmentation, skin atrophy, telangiectasias, rebound scars,
ineffectiveness, and injection site pain.28
RF can also be used safely and effectively to manage rolling acne
scars with minimum adverse effects and limited downtime.7 Laser resurfacing can be considered for managing hypertrophic
and keloid acne scars. Specifically, pulsed dye laser is an
Non-ablative lasers can also be used to manage rolling scars. excellent option to consider.30 Thick keloid or hypertrophic
Their mechanism of action involves targeting tissues in the scars can benefit from using a combination of pulsed dye laser
dermis for selective photothermolysis to encourage collagen and and intralesional corticosteroid injections along with 5-FU.31 In
dermal remodeling, thereby improving the appearance of scars.20 fact, this combination seems to be the most promising, currently
Boxcar Scars available therapy for keloids.32
Boxcar scars are broad, round-to-oval or rectangular box-like Another effective non-surgical method for managing small
depressions with sharply defined edges. Punch excision and hypertrophic acne scars is cryotherapy, which can also be
punch elevation are two excellent techniques for the treatment combined with intralesional triamcinolone to maximize
of boxcar scars, but there is still a paucity in literature evaluating effectiveness.33

8 • Editor: Dr. Richard Thomas • Volume 27, Number 6 • November-December 2022

Surgical excision can be used in combination with other 14. Al-Dhalimi MA, Arnoos AA. Subcision for treatment of rolling acne scars in
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• Editor: Dr. Richard Thomas • Volume 27, Number 6 • November-December 2022 9