Acne scars are more complex than many people think.

 

At first glance, they may all look like similar “depressed scars,” but in reality, the treatment direction can change completely depending on whether the concern is a red mark, a narrow and deep ice pick-like scar, a rounded depression, or a box-shaped scar with clear borders.

 

That is why the most important step in acne scar treatment is first identifying what type of scar it is.

 

Acne scars are broadly classified into ice pick scars, rolling scars, and boxcar scars.

 

In other words, although we use the single term “acne scars,” several different scar types are often mixed together on the actual skin.

If you look at the image above, you can see that acne scars differ in shape from the beginning.

 

Some scars are narrow and deep, as if pierced by a sharp pick. Some are rounded and depressed. Others have a square-like shape with clearly defined edges.

 

Red marks are also often present together.

 

If someone had a habit of squeezing acne by hand from a young age, or if the inflammation was deep and lasted a long time, these red marks and depressions may remain into adulthood.

 

The problem begins when we try to treat all of these scars with one laser in the same way.

 

Red marks require attention to vascular response.

 

Deep holes require narrow and deep stimulation. Rounded depressions may require release of fibrous tissue pulling the skin from underneath. Box-shaped scars require softening of the sharp borders.

 

Simply put, acne scar treatment is not about “resurfacing everything at once.” It is closer to identifying each scar shape and combining the right methods for each type.

Let’s first look at red marks.

 

After acne becomes red and swollen, the redness can remain for a long time. This is often not simply brown pigmentation, but redness caused by a lingering vascular response in the area where inflammation occurred.

 

During wound healing, new blood vessels can form. When this vascular response remains for a long time, it can appear as a red acne mark.

 

In this case, rather than aggressively treating depressed scars first, we need to separately consider treatment for reducing redness.

 

This is where vascular lasers may be needed.

 

In other words, red marks should be approached not as “shaving down the scar,” but as reducing the remaining vascular response.

The second type is the ice pick scar.

 

As the name suggests, it looks like a scar made by a sharp pick. From the surface, it may look like a very small pore, but in many cases, it is actually a narrow scar that extends deeply into the skin.

 

These scars may not respond well to light surface stimulation alone.

 

Because each opening is narrow and deep, a method that accurately stimulates the inside of the scar is needed.

 

That is why treatments such as TCA CROSS, a chemical reconstruction technique, or dense needle-based treatments such as MTS or Dermapen may be considered.

 

Review papers also describe the CROSS technique as being used for ice pick scars and narrow boxcar scars.

However, the important point here is that stronger is not always better.

 

If the stimulation is too strong, redness, pigmentation, or worsening of the scar can occur. Therefore, the intensity must be adjusted according to skin thickness and scar depth.

The third type is the rolling scar.

 

This type looks like a rounded depression, and the skin surface may appear uneven or wavy.

 

Rolling scars are often not just a surface problem. In many cases, fibrous tissue underneath the skin pulls the skin downward.

 

To put it simply, it is as if a tough cord is attached under the skin and pulling the surface down.

 

That is why simply resurfacing the surface with a laser may not be enough for rolling scars.

 

This is where subcision becomes important, because it releases the fibrous tissue pulling from underneath.

 

Subcision is a method that uses a needle or cannula to cut the tethered fibrous tissue beneath the skin.

 

In the literature, subcision is also described as a suitable treatment for rolling acne scars.

 

After releasing the fibrous tissue, collagen boosters or fillers may sometimes be used together to prevent the space from collapsing again.

 

So for rolling scars, what matters more than “resurfacing the surface” is releasing the structure pulling from underneath and, when needed, helping the area fill in more naturally.

Source: https://pmc.ncbi.nlm.nih.gov/articles/PMC5749614/

The fourth type is the boxcar scar.

 

This type looks like a square-shaped depression or a scar with relatively clear borders.

 

When the scar is broad and depressed with angular edges, light can create shadows, making the scar appear more noticeable.

 

In the past, fractional laser treatments were commonly used for these scars.

 

Fractional lasers can still be meaningful today, but depending on the sharp borders and depth of the scar, treatments such as RF microneedling like Potenza, MTS, CO2 laser border softening, and collagen regeneration treatments are often considered together.

 

For boxcar scars, the “angular shadow” is just as important as the “depth.”

 

If you look at the image above, the depressed base of the scar is one issue, but when the edges are sharp, light bends around the border and creates a darker shadow.

 

By softening the sharp edges with a CO2 laser, the scar may not disappear completely, but the skin surface can look smoother because light is less likely to catch on the edges.

The important point here is that most patients do not have only one type of scar.

 

On one person’s face, red marks, ice pick scars, rolling scars, and boxcar scars are often mixed together.

 

That is why acne scar treatment is difficult.

 

Red marks may require vascular lasers. Ice pick scars may require CROSS or dense needling.

 

Rolling scars may require subcision. Boxcar scars may require border softening and collagen-regeneration treatment.

 

In the end, acne scar treatment cannot be explained simply as “a few sessions of fractional laser.”

 

We need to classify the scar types, assess the depth, distinguish redness from pigmentation, and plan the order while considering skin thickness and recovery ability.

 

There is also something patients should understand.

 

Scar treatment creates new stimulation in the skin and induces collagen remodeling during the healing process.

 

Because of that, some pain, redness, crusting, dryness, and temporary pigmentation can occur.

 

It is closer to a treatment that “creates a controlled injury again so the skin can regenerate in a better direction.”

 

For that reason, it is important to allow enough recovery time rather than repeating treatments too frequently at overly short intervals.

Source: https://pmc.ncbi.nlm.nih.gov/articles/PMC5749614/

To summarize, the most important part of acne scar treatment is classifying the scars by type.

 

Red marks require assessment of vascular response. Ice pick scars require separate stimulation of narrow and deep openings.

 

Rolling scars require release of fibrous tissue underneath. Boxcar scars require treatment of both the angular borders and the depressed base.

 

Rather than trying to solve every scar with one device, the key is to first identify which scar types are mixed on your face and combine treatments accordingly.

 

Acne scar treatment is not a quick one-session solution. It is closer to reading the structure of the scars and gradually redesigning the skin step by step.

 

That is why, in scar treatment, a more realistic approach is to allow enough time and usually plan treatment over at least two to three sessions while observing the progress.

 

In the end, the difference in scar treatment does not come from “how strong the treatment is,” but from “which method is used for which type of scar” :)

 

This was Director Won Dae-han.

 

Thank you for reading.

 

※ This article is intended to provide general medical information. Actual suitability for acne scar treatment, treatment methods, number of sessions, and treatment intervals may vary depending on scar type, skin thickness, presence of pigmentation, redness, and previous treatment history. An accurate diagnosis and treatment plan should be determined through consultation.