How to Treat the Different Types of Acne Scars

HomeBlogHow to Treat the Different Types of Acne Scars

Subcision & Excision of Acne Scars – Results & © Brian S. Biesman, M.D.

Acne scarring is a tough condition to treat. There are several different types of acne scars and each requires a unique type of treatment. For that reason, there is no single treatment that is “best”, because every patient’s scarring is different.

When we treat acne scars, our goal is to achieve the best improvement in scarring by removing or reducing irregularities in the skin surface.

Treating acne scars always starts with a conversation about expectations

Before starting treatment, I always discuss expectations with my patients.

Without exception, my patients who have acne scarring think it’s the first (and only) thing people notice, even if their scars are barely visible to someone else. During the consultation, we spend a great deal of time discussing expectations for final outcomes. 

I tell them that the goal of treatment is to improve the appearance of the skin surface as much as possible. However, their skin will never be perfect or look as if they never had acne scarring. I advise patients that if their goal is to have scars fully eliminated, they should not undergo treatment as they are unlikely to be satisfied with their results. The last thing I want is patients to have a vision for an outcome that is not realistic. 

I prepare all of my acne scar patients with the expectation that treatment is a journey. It will likely require a series of treatments spaced out every one to two months and for at least a year in order to get best outcomes, although I do expect to see improvement with each treatment.

I also caution my patients to be careful when looking at before and after photos, because acne scars are very hard to photograph accurately. For example, if you illuminate a depressed scar directly, it may not be visible. If you illuminate it from the side, a fairly shallow indentation may look much deeper.

With all these caveats about treatment, is it worth it?

According to my patients, yes.

I always ask patients what improvement they achieved after treatment, and the majority of patients tell me they see a 30-70% improvement in the appearance of their skin surface. Some are in the 90-95% range, and some patients say 10%. Even if they only see a 10% improvement, the majority of these patients are happy they sought out treatment.

The different types of acne scars

There are three main categories of acne scars: rolling, boxcar, and icepick. 

The most common types of scars, rolling scars, are depressed. Rolling scars create wave-like depressions that aren’t sharply defined and shadowing in most lighting scenarios.

Boxcar scars are round or oval scars with steep vertical sides. They are wider than icepick scars and are typically more noticeable than rolling scars.

Ice pick scars appear as deep, narrow pits. They look like a scar made from a tiny ice pick or sharp instrument. Ice pick scars are very small but can be very challenging to treat.

How we treat acne scars

Sometimes, patients come to us for help with scarring when their acne is not under control. For some patients, their skin will never be without some type of breakout. In either scenario, it is important that active acne breakouts are controlled as well as possible before starting treatment of acne scarring. In these cases, we may coordinate care with a dermatologist.

To treat different types of acne scars, we first consider the three main characteristics of the scars:

  1. Contour – Are they depressed or elevated? If depressed, how deep are they?
  2. Skin Texture – What is the skin quality? Is it smooth and shiny or relatively normal?
  3. Color – Are the scars discolored? Acne scars can be the same color as the surrounding skin, or they may be pink, red, or even white.

We then create a treatment plan customized to each patient’s scars. We always identify a starting set of procedures. Subsequent procedure plans may be made depending on the response to the initial treatments. In this manner, we will come up with the best recommendations for them. 

Surgery can treat depressed scars

The most common concern that we hear from patients is depression of the scars. This occurs mostly with rolling or boxcar scars. If a scar is depressed, it means the skin is bound down to the underlying tissue, causing shadowing or even a crater-like appearance. By releasing the scar tissue that is pulling down on the center part of the scar, the scar will no longer be depressed as much. Releasing a scar is accomplished through a technique known as subcision.

Subcision is highly effective

Subcision is a widely used term that can refer to a number of different procedures. Many subcision techniques are not particularly effective. Over the past 25-30 years I have worked to develop and refine a subcision technique that is highly effective in the treatment of depressed acne scars.

When we do subcision, we start by identifying the area to be treated. We like to make sure that we are seeing the same areas that will benefit from subcision as our patient. This ensures we treat all affected areas that are most important to them. 

We then administer anesthesia. This involves a series of injections, which are not terribly comfortable. However, the anesthesia is extremely effective and once the treatment area is numb, the rest of the procedure is a breeze! 

We use a special device to aggressively release the scars in the entire affected area, whether it’s the cheek, temple, forehead, area around the mouth, and/or chin. We can usually do this with a single-entry point on each side; no sutures are required.   

Patients should expect to have some swelling and/or bruising, so I advise them to set aside five to seven days for recovery before they look their best. 

Many of our patients have undergone numerous other acne scar treatments before seeking help from us. A large percentage of these experienced patient find that our subcision technique produces more improvement in their scars than any of their previous treatments combined.

Some patients also elect to undergo more than one subcision treatment. The timing of additional subcision depends on outcomes from the first treatment. 

Punch excision is best for deep scars

Many deep pitted scars sometimes require punch excisions. With this procedure, we remove the scar and close it up with a stitch. We often will perform laser treatment of the scars at the same time in an effort to achieve best outcomes. The sutures are removed a week later. 

Laser treatments often follow surgery

Subcision and punch excision improve skin contour, but they don’t treat skin texture. Therefore, surgery to treat different types of acne scars is often followed by laser treatments. We have a wide variety of treatment options available.

As I mentioned above, it can be difficult to predict which treatment will provide the best response to some acne scars. We may treat a patient with a particular device and upon follow-up feel that better results may be achievable with a different approach. In this situation, will recommend making a switch for the next treatment session. I always start with the treatment combination I believe will have the best likelihood of success.

We often recommend treatment with a laser, such as UltraClear Laser or Fraxel, or another energy-based device like Morpheus 8 radiofrequency microneedling. This can be done at the same time as subcision to improve skin texture and quality. A series of additional laser or Morpheus 8 treatments are typically required at one-month intervals.

UltraClear laser resurfacing is one of my favorite treatments to use in the management of acne scarring. UltraClear is the world’s first cold fiber laser solution that offers patients fast treatment sessions (between 10 to 15 minutes for a full face), the lowest pain and discomfort level, and the shortest recovery time. It can treat a wide range of skin types, and it is the only safe and effective laser of its class for Asian and darker skin.

Fraxel laser resurfacing in combination with platelet-rich plasma (PRP) treatment may be an excellent option for some patients. The resurfacing power of the Fraxel laser used in conjunction with the healing power of the patient’s blood (PRP) provides unparalleled rejuvenation of the skin. Fraxel laser can be used safely on a full range of skin color.

Laser treatment is always customized

 There is a group of patients who require only laser or energy-based device treatments. In this case, our experienced team will make a personalized treatment plan to help the patient achieve the best outcome as quickly as possible.

Nearly all our patients require a series of treatments to improve acne scar appearance.  Treatments are typically performed every one to two months. For most patients, it is important to avoid sun exposure immediately before and after any laser or energy-based device treatment.

Follow-up after treatment typically occurs at about one month. For our long-distance patients, we can do a virtual follow-up via a video call. Plans for the next treatment are typically made at this time. 

Fillers can be the icing on the cake

I use injectable fillers as the final “icing on the cake” to maximize scar improvement after we’ve already done treatments that will produce lasting improvement, such as subcision, punch excisions, and/or laser treatments. Some fillers may be administered at the time of subcision or laser treatment, while others are given once all other treatments have been completed.

The fillers I typically use to treat acne scars include Restylane, (a hyaluronic-based, temporary filler), Bellafill (a permanent filler), and Sculptra (a semipermanent filler). 

I was part of a clinical trial that validated the effectiveness and safety of Bellafill for acne scars. Many patients see a dramatic improvement when it is used to treat depressed scars. Because it is a permanent filler, I first use a hyaluronic acid filler like Restylane to make sure the scars respond the way we want them to.

I often use Sculptra in conjunction with UltraClear resurfacing to help improve the appearance of atrophic scars. (Atrophic scars refer to skin texture that is thin and wrinkly.)

Treatment ends when scar appearance improves

I tell patients that there are two potential end points to acne scar treatment:

  1. The appearance and texture of your skin has improved to the point that you are happy when you look in the mirror.
  2. I feel the likelihood of additional improvement is low.

It is extremely important to me that my patients have realistic expectations going into any treatment. If I feel there is a reasonable chance of making additional progress, I am happy to perform more treatments. If I feel that the relative likelihood for improvement is not great, I communicate that clearly and make a plan with that patient. 

If you have acne scars, we can help

Treatment of acne scarring is a marathon, not a sprint. If you can give us a year and can be patient, we can typically treat different types of acne scars with excellent success. My staff and I are here to provide guidance, set expectations, and create a custom treatment program to help you feel comfortable with your appearance.

If you value a practice that wants to give you the best possible experience and ensure you get the best possible results, call us at (615) 329-1110 to schedule an appointment today.

Contact Us