Severe Acne Scars

Active acne breakouts cause much frustration while they’re at their peak, but perhaps the worst comes after they’ve disappeared.

Post-acne scarring is a real problem for many acne-sufferers, a problem which requires adequate and persistent treatment. While blemishes and pimple scars may go away with time, you can’t do anything immediate to remove old, stubborn and more severe forms of acne scars. At-home treatments may show limited results when it comes to getting rid of them. Looking on the bright side though, we are lucky to be living in an age of advanced medical technologies, with a range of acne scar removal methods available to us. Now let’s review the best scar treaments for acne scars.

Types of Severe acne scars

First things first – let’s review the different types of scars that usually follow severe acne breakouts. Scars appear in cases where the inflammatory lesions have deeply penetrated the skin. The deeper the inflammation reaches, the greater the risk of scars appearing. (Hence the importance of treating acne quickly, before the underlying tissue has been affected.) The degree of damage can vary, so scars differ in their depth and the exact shape they take. In order to estimate the severity of your scars and to be able to choose the best scar removal plan accordingly, you should understand the basic typology of acne scars. They definitely don’t respond to treatment in a universal manner.

Atrophic (depressed) scars

Atrophic scars are the most common type of all and are caused by loss of tissue. Atrophic means depressed, indented or ‘pitted’, so these scars take the form of – more or less – tiny hollows on the skin tissue. Loss of collagen during the inflammation phase of inflammatory or papulopustular acne is the main reason for the formation of atrophic scars. When an inflammatory breakout destroys collagen, new skin can’t easily reappear over the given area – it loses support and gives way to depressed marks. Depending on their perimeter width, atrophic scars are further classified to boxcar, ice pick and rolling scars.

Boxcar scars are pitted and wide, in the form of an oval depression on the skin’s surface, resembling the look of chickenpox scars. Boxcar scars can be compared to the look of a fingernail print on the skin, but they are sharp-edged: their steep and defined edges move straight down into the skin. Appearing most often on the lower cheek and temple area, where the skin is thicker, boxcar scars result from tissue loss. These scars are very deep and usually measure a few millimetres in breadth. When they are shallow, they respond well to skin resurfacing treatment. The shadows of the indented skin make it very difficult to hide boxcar scars with conventional makeup or concealers.

Ice pick scars are narrow, deep and V-shaped. They go deep into the skin, extending into the dermis, with a perimeter that doesn’t spread more than 2 mm. Resembling a broadened, empty pore, ice pick scars develop after an infection from cystic acne – the most serious and painful type of acne, which emerges when cysts bulge underneath the skin. The column-like perforations make the skin look as if pierced by an ice pick or a sharp instrument – hence the name. These tiny round or oval holes are most difficult when it comes to treatment as they go much deeper under the skin surface.

A type of more broadly spread, wavy indents are called rolling scars. These have curved edges and look a bit like tiny hills. They can be shallow too, but very severe cases are not uncommon, since they also appear due to varying degrees of inflammatory acne. These are much affected by the skin’s aging process – with time they can appear more pronounced.

Hypertrophic scars

Hypertrophic scars are raised above the skin’s surface. They are caused by excess collagen retained in the area after the acne inflammation has healed. This type is less common on the face, while it’s often seen on the back and shoulders.

Keloids are a type of raised scar and can be more severe and definitely not treatable with over-the-counter creams. Unlike other hypertrophic scars, keloids usually grow even larger than the original wound. They may take time to fully develop, even months after the acne has healed. Some people are more prone to keloid scars, including those with more pigmented skin, such as African-americans, Latinos, or people with a genetic predisposition to keloids inherited by their parents.

Treatment options

Severe acne scars can be difficult to treat with over-the-counter products. To put it simply, removing deeper atrophic scars calls for a doctor. Unfortunately, these types of scars generally do not respond well to topical creams only. You will likely need to collect expert advice on most suitable surgical methods. Moreover, a dermatologist can help you put current active breakouts under control, if you still have them. While your skin is still facing breakouts, it’s hard to treat acne scars using any method,. Here is a guide to the most promising dermatological procedures available out there.

Punch Excision

Punch excision is a medium-invasive technique, also found by the name of punch biopsy. It is used for treating extreme acne scarring and it’s the number one choice for deep ice pick scars. It combines well with other techniques, mainly lasers and peelings. What does it involve? Basically, punch excision is a surgical procedure where the dermatologist uses a small cutting tool to really punch out the problematic cyst or scar tissue.

The spot is then stitched back together and even if a new scar forms as a result of the removal of bad skin from the previous scar’, this one quickly disappears. It doesn’t mean that there will no longer be a visible scar after undergoing punch excision, but there is a big improvement. This a fairly affordable service. The price depends on the amount of scars that need to be treated. Yet, it is rarely used on its own, which means that the necessary post-surgical treatment methods, such as chemical peels for example, can drive the total price up.

Punch Elevation

This is a similar technique used for deep atrophic scars, where instead of removing the bad skin in a scar, as in excisions, this part of the scar is pushed upwards and lined up with the surrounding skin. It is often used for treating boxcar scars, as it’s best for scars with sharp edges, so that when the scar surface gets elevated, it can even out and appear much less visible. Punch elevation combines well with laser resurfacing, explained below.

Punch Grafting

This is a third variant of the surgical techniques involving the same type of tool. Instead of stitching back the wound as in excisions though, this method involves a skin graft. It means that a healthy piece of skin is collected from a different part of the body – usually from behind one of the ears – and is packed back into the hole of the punched out scar. The procedure boasts some very effective improvements in the skin surface, leaving a much less noticeable new scar.  

Laser Resurfacing

The term refers to a specific laser treatment method effective in diminishing raised acne scars, since it has shown to reduce moderate-to-severe hypertrophic scars by 50-80%.

The method makes use of high-frequency laser  beam concentrated in the scar area and can be ablative or nonablative. The latter is a group of less invasive laser tools whose effectiveness, as with several other techniques, rests on stimulating collagen production. The ablative laser treatments involve scar tissue removal.  There is the more traditional CO2 laser resurfacing method, which is effective in boxcar scars. Unfortunately, laser resurfacing treatments have been shown to carry the risk of several moderate side effects, including the appearance of new acne. Your dermatologist can inform you in-depth and help you weigh out the side effect risks, since they’re the person that knows your individual skin condition best. You should also know that this method usually requires several sessions.


Yet another minimally invasive intervention, subcision is safe and simple. It involves the use of a tiny scalpel which is inserted horizontally, below the scar’s surface. On the one hand, it breaks the fibre within the scar tissue thus relieving the pull down and providing for an immediate improvement in smoothness. At the same time, the procedure stimulates the formation of new collagen within the scar. This in turn leads to an increased cell turnover (the process of natural replacement of old cells with new) and, eventually, to long-term scar reduction.


Dermal fillers are a minimally invasive method and the most popular option for correcting boxcar scars. Filler treatments are more affordable and involve a much faster and less complicated procedure. As the name suggests, the scar is “filled” with gel predominantly made of collagen, which masks the indentation and brings the area in line with the surrounding skin. However, most fillers are temporary and last no longer than 2 years, thus repeat treatments are mandatory. Since recently, a new cutting-edge permanent filler called Bellafil has been making waves on the acne scar reduction services market.  


The abbreviation stands for Chemical Reconstruction of Skin Scars and is another often chosen method for atrophic acne scars. It involves the use of tri-chloro-acetic acid (TCA), which is focally applied to the scar in high concentrations (70-100%), usually with a wooden toothpick or a similar instrument. The acid causes inflammation, which prompts the skin to form new collagen. This a very successful technique in minimizing and – in moderate cases – even fully improving the look of a scarred skin region.

Pulsed dye laser

PDL treatments and steroid injections are good for flattening keloids. The two methods have been used in combination and have shown good results.

Intuitively, it seems it would be easier to manage hypertrophic – raised – scars than to lift back atrophic – indented – ones. In reality, keloids are complex skin structures that need to be approached with a great deal of care. The pulsed dye laser works by concentrating a beam of light onto the blood vessels in the skin where the scar is. The light is absorbed by the skin and gets converted into heat, damaging the blood vessels in the keloid, but not affecting the surrounding tissue. The damaged cells then get absorbed into the blood system and are taken away, allowing flow to concentrate on healthy blood vessels.

Tips to keep in mind

Do not Rush

Bad acne often impact one’s body image negatively, and they can even cause more serious psychological challenges.

If you are one of these people, you are likely skimming this article now for hope and a promising reassurance that restoring smooth skin on your face or body has become easy with the advance of medicine.

This is partly true.

As you’re reading – new dermatological procedures have already helped thousands of patients. You need to understand though – grand claims of quick and full removal in cases of severe acne scars should be taken with a maximum dose of caution. No matter how anxious you are to restore healthy skin – please bear in mind that acne scar healing is a gradual process. Even with surgical methods, you need patience and endurance. Sometimes you might need to go back regularly for repeat treatments. In other cases you may end up with undesired side effects to treat after the scar healing process. Do not rush into a decision for a treatment and try to consult more than one doctor before you decide to spend money and hopes on a certain method.

Your Skin is a Living Organ

If you’ve carried yourself around with acne scars over the years, you’ve likely adopted a different perspective on your scars – you probably feel them like a weight.  But you’ll have to learn to approach your scars holistically, and sooner rather than later.

Acne is one of the most complex skin conditions and, while for some people pimples may go away after a certain period in life, for many of us they’re a lifelong reality. Scars can be dealt with more effectively if we see them as an integral part of our bodies and health. Therefore, caring for your overall health must become your priority. Eat a balanced and healthy diet, exercise, get good and regular night sleep, quit smoking. It all affects your skin’s ability to heal existing scars. This may not be a perspective likely to be learnt from just any dermatologist out there. Read and research constantly. Learn to accept your problematic skin and work with it – not against it.

Skincare is a Fulltime Job

You cannot neglect your skin. You cannot leave it on its own in this time of busy lives and abundant environmental stress factors and expect it to shine and blossom. You need to choose your skincare routine and stick to it consistently. Explore natural options and avoid too harsh dermatological products for your everyday use.


Serious inflammatory acne breakouts can cause severe, deep scars that do not disappear with time and can even get worse as the skin ages. The several different types of severe acne scars, particularly on the face, pose a psychological and aesthetic concern for many people. A range of dermatological techniques for reducing or removing acne scars are now readily available and some can be relatively affordable. You should understand your scars and consult a doctor to get advice on the most adequate treatment options for your specific case. Measure the pros and cons of undergoing a surgical procedure and opt for one only if you are absolutely comfortable.

Remember – your scars are not nearly as visible to anyone else as they are to you. Scars can be a distinctive feature of your individuality, but if you associate them with trauma and psychological pressure, you can now reap the advantages of living in a technological era and get some expert help in smoothing back your skin.

We would highly recommend you also read the following articles:
How to Get Rid of Pimple Scars
How to Lighten Scars: 12 Most Effective Scar Lightening Methods to Restore Your Skin