Acne Scar Treatments: What Actually Works for Each Scar Type

No single treatment works for every acne scar. The type of scar decides the tool: narrow ice pick scars respond best to focused treatments such as TCA CROSS or punch techniques, boxcar scars to resurfacing (fractional lasers, peels, microneedling), rolling scars to subcision or fillers, and raised scars to steroid injections or lasers. Most people have a mix, so dermatologists usually combine treatments. And the honest headline from the research is that the evidence behind all of them is thinner than clinic marketing suggests.

What type of acne scar do you have?

The American Academy of Dermatology (AAD) splits acne scars into two big groups. Depressed (atrophic) scars are the most common and come in three shapes:

• Ice pick scars: small openings that go deep into the skin. DermNet describes them as narrow, V-shaped and deeper than they are wide, and says they make up about 60 to 70% of atrophic scars.
• Boxcar scars: round or oval dents with distinct, sharp edges, wider than ice pick scars.
• Rolling scars: wide, shallow dips with sloping edges that give skin a wavy look. DermNet notes they can be smoothed out if you stretch the skin, a useful clue.

Raised scars form when skin makes too much collagen. The AAD says hypertrophic scars tend to show up on the jawline or trunk 1 to 2 months after a breakout clears, while keloids grow larger than the original spot and can start 3 to 12 months after acne clears. Raised scars are more common in people with darker skin tones.

One important check first: flat brown, red or purple marks are usually not scars at all. They are colour changes that tend to fade on their own (see acne scars vs dark spots and post-inflammatory hyperpigmentation).

Which treatment matches which scar type?

This is the practical map, pulled from the AAD’s treatment pages and DermNet’s scar-matching summary. It shows which options are typically used, not a guarantee of results.

What does the evidence actually show?

The best overview is still a Cochrane review of acne scar interventions, which pooled 24 randomised trials with 789 participants. Its conclusion was blunt: the results “do not provide support for the first-line use of any intervention in the treatment of acne scars.” Evidence quality ranged from very low to moderate, mainly because trials were small and poorly blinded. A few findings stand out:

• Fractional lasers beat older non-fractional non-ablative lasers on participant-rated improvement.
• Chemical peeling performed similarly to fractional laser and to skin needling, but was not tolerable for 16% of participants in the trials that reported it.
• Injectable fillers improved scars more than placebo, the only comparison with moderate-quality evidence, but there was no long-term follow-up.

That review dates from 2016, and newer work has added data without fully fixing the quality problem. A 2026 meta-analysis of 17 studies (1,111 participants) found microneedling plus platelet-rich plasma (PRP) roughly tripled the chance of an excellent result compared with microneedling alone, yet the authors themselves flagged the overall low quality of the included studies. A 2023 network meta-analysis of six energy-based devices (11 studies, 405 patients) was limited by small samples and a lack of head-to-head trials.

Which options help depressed scars?

TCA CROSS for ice pick scars

CROSS (chemical reconstruction of skin scars) uses a tiny amount of high-strength trichloroacetic acid pressed into the base of each scar to trigger new collagen. DermNet says it uses 70 to 100% TCA, that most patients need 3 to 6 sessions spaced 2 to 8 weeks apart, and that a 1 to 2-grade improvement over about 6 months is a realistic expectation. Risks include lingering redness, pigment changes and, occasionally, disappointing results.

Microneedling

Fine needles create controlled micro-injuries that prompt collagen production. The AAD says acne scars typically need 3 to 5 sessions every 2 to 4 weeks and that it is safe for all skin tones. It is often combined with PRP, radiofrequency or peels. Full details are in microneedling for acne scars.

Chemical peels

Peels remove damaged outer layers and stimulate collagen. The AAD says mild and medium peels for scars usually take 3 to 5 treatments given every 2 to 4 weeks, with 2 to 4 weeks of at-home skin priming first. See chemical peels for acne.

Fractional lasers

According to StatPearls, CO2 lasers produce superior results for acne scars while erbium (Er:YAG) lasers are better tolerated with less downtime, shallow boxcar scars respond best, and ice pick scars usually need a second treatment on top. More in laser treatment for acne scars.

Subcision

A needle is slipped under a rolling scar to cut the fibrous bands tethering it down. The AAD describes this kind of minor surgery as lifting the scar from the tissue beneath, done under local anaesthetic. In one prospective study of 45 patients with skin types III to V, four monthly sessions of subcision plus microneedling improved scars by at least one grade in 95.6% of people, with redness, swelling and pain lasting 1 to 2 days. There was no control group, so treat that figure as encouraging rather than definitive.

Fillers

Fillers add volume under a depressed scar. The AAD says most last from 3 months to 2 years, with some permanent options, and need touch-ups. In the US, one polymethylmethacrylate-collagen filler has an FDA approval (2014) that specifically covers moderate to severe, atrophic, distensible facial acne scars on the cheek in patients over 21. “Distensible” means the scar flattens when you stretch the skin, which is typical of rolling scars.

How are raised and keloid scars treated?

For hypertrophic scars the AAD lists lasers, corticosteroid injections and prescription topicals. StatPearls reports 57 to 83% improvement in the appearance and texture of hypertrophic scars after 1 to 2 pulsed dye laser treatments.

Keloids are harder. The AAD’s keloid page says 50 to 80% of keloids shrink after a series of steroid injections, but many regrow within five years, and injections can leave lighter spots in darker skin. Freezing (cryotherapy) is not recommended for darkly pigmented skin because of the risk of permanent light spots. Cutting a keloid out on its own is a poor bet: the AAD says nearly 100% return, which is why surgery is followed by other treatments such as pressure garments or cryotherapy.

What if you have darker skin?

Skin of colour is more prone to both raised scars and to pigment problems after treatment, so the choice of procedure and settings matters more:

• Lower pigment risk: the AAD says microneedling, radiofrequency and radiofrequency microneedling are safe for all skin tones.
• Lasers need careful settings: StatPearls says non-fractional CO2 resurfacing is not recommended for skin types IV and above. In the 2023 network meta-analysis, fractional CO2 ranked highest for post-inflammatory hyperpigmentation risk among six devices. A review of non-ablative fractional lasers in skin of colour found hyperpigmentation risk rose with treatment density, and recommended gentler, more spaced-out sessions.
• Peels: the AAD warns that people with skin of colour can develop permanent pigment problems without an experienced provider, and a 2018 review advises avoiding deep peels in skin types IV to VI.

A useful question at consultation: “How many patients with my skin tone have you treated with this, and what settings do you use?”

What should you know before booking treatment?

• Get active acne under control first. The AAD stresses early acne treatment and not picking as the best way to prevent new scars (see should you pop pimples?).
• Expect several sessions and slow results. The AAD notes treatment is “rarely one and done” and recommends limiting sun exposure for 6 to 8 weeks afterwards.
• Isotretinoin timing is a clinician call. StatPearls notes traditional teaching was to wait 6 to 12 months after isotretinoin before resurfacing, while a 2018 review says newer evidence found insufficient reason to delay some procedures. See isotretinoin.
• Budget for it. The AAD says insurance typically does not cover scar treatment.

Frequently asked questions