Acne Scars: What Causes Them and How to Get Smooth Skin Fast

If you’re feeling self-conscious because of acne scars left behind on your face, even after your acne has cleared, this article will help you understand the root causes of why these scars don’t heal on their own, and which treatments are truly effective, safe, and worthwhile.

Each type of acne scar involves different degrees of skin damage, so treatment requires precise, specialized techniques, whether it’s laser therapy, TCA CROSS, or newer technologies like RF Microneedling and subcision (cutting fibrous tissue under the skin).

I’ll cover the causes, treatment methods, precautions, costs, and how to choose a safe clinic at every step. By the end, you’ll have a deep yet easy-to-understand grasp of acne scars and be ready to make informed decisions.

What Are Acne Scars?

Acne scars are a common skin problem that often remain after severe acne inflammation has subsided. Many people might mistake them for “acne marks,” but in reality, an acne scar is a type of permanent indentation or pit in the skin, caused by irreversible damage to the skin tissue in that area, preventing it from regenerating as before.

How Do Acne Scars Differ from Regular Acne Marks?

Regular acne marks are usually just red or brown discoloration from inflammation, which can fade over time or be accelerated with topical treatments and appropriate skincare.

Acne scars, however, are actual indentations caused by the collapse of skin tissue, especially after severe inflammatory acne like cystic acne or large pustules. Aggressive picking or squeezing of acne can further damage deep skin tissue, leading to scar formation.

How Many Types of Acne Scars Are There?

Acne scars come in various forms, and each type responds differently to treatment. I’ll briefly explain them (in-depth details for each type will be in a later section):

• Ice Pick Scars – Deep, narrow, like tiny pinholes.
• Boxcar Scars – Defined edges, medium depth, square or angular.
• Rolling Scars – Undefined edges, wavy or undulating skin surface, appear deep but not sharply defined.

Acne scars are not just a cosmetic concern; they involve damaged skin structure. Effective treatment therefore requires technologies that penetrate deep into the skin layers, such as lasers, energy-based devices, or specialized procedures, which we will discuss in the next section.

What Causes Acne Scars?

Actually, acne scars aren’t solely caused by “acne” itself. They result from the skin’s self-healing process after severe acne inflammation, which sometimes doesn’t complete perfectly, leading to “deep indentations” or “pits” replacing the destroyed original tissue.

Reasons for Acne Scar Formation:

• Severe acne inflammation spreading deep into the dermis. Inflammatory acne, especially cystic acne or cysts, often destroys collagen and underlying skin tissue. When inflammation subsides, the skin tries to repair itself, but if it cannot produce enough tissue, an acne scar forms instead.
• Aggressive picking, scratching, or squeezing of acne. These actions exacerbate acne inflammation and cause deeper skin damage, resulting in more tissue loss that the body cannot fully repair.
• Bacterial infection in hair follicles. When sebum clogs hair follicles along with Propionibacterium acnes bacteria, it triggers deep inflammation that affects the skin’s structural layers.
• Genetics and individual skin factors. Some individuals, even with mild acne, are more prone to developing acne scars than others. This relates to their skin structure and collagen production mechanisms.

Why Are Some People More Prone to Acne Scars?

Based on my experience, individuals with thin skin, sensitive skin, or pre-existing collagen issues are more susceptible. Also, those who don’t treat acne early on, allowing inflammation to spread, or even those who use unsuitable products that worsen their acne, are all factors that make acne scar formation easier.

How Many Types of Acne Scars Are There?

Acne scars are not all alike. Each type has different depths, widths, and damaged skin structures, which directly affects the treatment method. In medicine, we divide acne scars into 3 main types:

1. Ice Pick Scars

• Appearance: Small, deep pits, similar to being pricked by a needle or tiny ice pick.
• Depth: Deep, penetrating into the dermis and potentially the subcutaneous fat layer.
• Problem: Most difficult to treat due to deep tissue damage.
• Common Treatments: TCA CROSS, Fractional Ablative Lasers, RF Microneedling (Sylfirm-X).

2. Boxcar Scars

• Appearance: Wide scars with well-defined edges, resembling a box or depression.
• Depth: Medium, not as deep as Ice Pick scars.
• Problem: Makes the skin look uneven and noticeable when light hits it.
• Common Treatments: CO2 Laser, Erbium YAG, RF Microneedling, Subcision.

3. Rolling Scars

• Appearance: Wavy, undulating skin surface, ill-defined edges.
• Depth: Often located in the deep subcutaneous tissue.
• Problem: Makes the face look uneven, especially noticeable with side lighting.
• Common Treatments: Subcision (cutting fibrous tissue under the skin), Fillers, RF Microneedling, certain types of lasers.

How to Initially Identify Each Type of Acne Scar:

• If it looks like tiny, deep holes = Ice Pick
• If it has distinct, wide, square shapes = Boxcar
• If, when viewed from the side, the skin looks wavy and uneven = Rolling

How to Effectively Treat Acne Scars?

Effective acne scar treatment must primarily be based on the “type of scar” and the “depth of the problem.” This is because each type of acne scar responds differently to treatment.

Currently, the most effective acne scar treatments are typically medical procedures using specialized technology that can deeply penetrate damaged skin structures and directly stimulate new collagen production.

Medical Treatment Approaches:

• Acne Scar Lasers (Laser Resurfacing): Use lasers to stimulate skin cell turnover and collagen production.
  • Fractional CO2 Laser: Effective for Boxcar and Rolling scars.
  • Erbium YAG: For thin skin, reduces post-treatment redness.
  • Pico Laser (PicoSure, PicoWay): Less painful and also helps with marks.
• RF Microneedling (e.g., Sylfirm X Plus, Secret RF): Uses radiofrequency energy combined with tiny needles to stimulate deep collagen and break down fibrous tissue under acne scars. Highly suitable for Rolling and Boxcar Scars. Advantages include less pain than lasers, faster recovery, and safety for all skin tones.
• TCA CROSS: Direct application of TCA acid into Ice Pick scars to stimulate new tissue formation specifically at that site. Ideal for deep Ice Pick scars that lasers can’t address. Must be performed by a doctor, as application to surrounding skin can cause burns.
• Subcision (Cutting Fibrous Tissue Under Acne Scars): Uses a blunt-tipped needle inserted under the skin to release fibrous bands that pull the skin down. Suitable for Rolling Scars and scars with tethering. Combining with fillers or RF Microneedling can yield faster results.
• Fillers: Used to fill deep and fibrous acne scars, such as Rolling or Boxcar. Doctors may use temporary fillers to assess results before considering more permanent treatments.

Can Acne Scars Be Treated Naturally?

Generally, natural methods like vitamin C serums or fruit acids (AHA/BHA) might help with mild skin exfoliation and slightly reduce shallow marks. However, they cannot repair deeply damaged skin tissue like medical treatments can.

Choosing the Right Treatment for Each Type of Acne Scar:

Even with various technologies, choosing a method unsuitable for the scar type may lead to unclear results or unnecessary wasted time.

1. Ice Pick Scars (Deep, Pinhole Scars)

• Appearance: Small and deep holes, like being pricked by a needle.
• Effective Treatment Recommended by Doctor:
  • TCA CROSS ➜ Most effective as it targets the small hole directly.
  • Ablative Lasers (CO2, Er:YAG) ➜ Helps for scars that are not too deep.
  • Punch Excision ➜ For very deep scars that don’t respond to other treatments.
• Note: Ice Pick scars are the most challenging to treat and require consistency and specialized techniques.

2. Boxcar Scars (Scars with Defined Edges, Medium Width and Depth)

• Appearance: Square scars with defined edges, making the skin look uneven.
• Effective Treatment Recommended by Doctor:
  • Fractional CO2 or Er:YAG Laser ➜ To smooth the scar edges.
  • RF Microneedling (e.g., Sylfirm X) ➜ To stimulate deep collagen production.
  • Subcision + Filler ➜ To fill and release fibrous bands for smoother skin.
• Note: For thin/sensitive skin ➜ Use lower energy or non-ablative lasers like Pico or Non-Ablative Laser.

3. Rolling Scars (Wavy Acne Scars, Undefined Edges)

• Appearance: Wavy skin, appearing uneven when light hits it.
• Effective Treatment Recommended by Doctor:
  • Subcision ➜ To release fibrous bands under the scar, allowing the skin to lift.
  • RF Microneedling (Secret RF, Sylfirm X Plus) ➜ To stimulate deep collagen.
  • Filler ➜ Used after subcision for faster results.
• Note: Subcision combined with fillers yields better results than laser treatment alone for Rolling Scars.

Additional Recommendations:

• Darker skin / Sensitive skin ➜ Should avoid ablative (peeling) lasers and focus on RF Microneedling or non-ablative lasers instead.
• Mixed types of scars ➜ Use a combination of multiple techniques, such as Subcision + RF Microneedling + Fillers.

Which Acne Scar Treatment is Right for Whom?

Acne scar treatment isn’t always suitable for everyone or at all times. I’ll help you determine who is suitable and when to temporarily avoid treatment.

Appropriate Age for Acne Scar Treatment:

Generally, acne scar treatment can be done from late adolescence to adulthood. I usually recommend starting treatment when acne inflammation has stopped for at least 3-6 months, the skin condition is stable and not easily inflamed, and overall rest, skincare, and health are good.

Can You Treat Acne Scars if You Still Have Active Acne?

It’s not recommended to treat acne scars while you still have active acne, as some laser or procedural treatments can stimulate inflammation or disturb skin that is not fully healed.

What Are the Results of Acne Scar Treatment Like?

Acne scar treatment can yield truly good results, especially when appropriate technology is used for your skin type and treatment is continued according to the doctor’s plan.

However, what I want to emphasize is that “acne scars can improve significantly, but it doesn’t mean everyone will achieve 100% smooth skin.” Results depend on many factors, such as scar depth, previous treatments, and individual body response.

How Much Can Skin Smoothness Improve?

From a 2023 study in the Journal of Dermatologic Surgery, it was found that:

• Fractional CO2 Laser yielded an average of 50-70% skin smoothing after 3–5 sessions.
• RF Microneedling (e.g., Sylfirm X Plus, Secret RF) produced results comparable to lasers with less risk of irritation.
• Subcision combined with fillers can give faster and clearer results, especially for Rolling Scars.

Note: Noticeable results usually begin after the 2nd-3rd session, not after just one.

How Many Sessions Are Needed to See Results?

Can Acne Scars Be Completely Cured?

Acne scars cannot be 100% cured in all cases, but they can “significantly improve” to the point where makeup doesn’t settle into the indentations, or scars are not visible in photos. I have many patients whose skin has improved so much that they no longer need to cover up with makeup or feel self-conscious.

Doctor-Led Acne Scar Treatment Steps:

Acne scar treatment isn’t just about one laser session and done. It’s a process that requires planning, cooperation, and long-term follow-up. Here are the steps:

1. Skin Assessment and Treatment Planning:

• The doctor will thoroughly examine the scar characteristics: type, depth, and presence of fibrous bands.
• Light or magnifying cameras may be used to examine skin structure.
• “Before” photos will be taken for result comparison.
• “Personalized” treatment plan will be created:
  • Combining multiple techniques (Laser + Subcision + Filler).
  • Determining the number of sessions and interval between each.
  • For example, someone with both Ice Pick and Rolling scars might have a treatment plan combining TCA CROSS + Subcision + RF Microneedling.

2. Preparation Before Treatment:

• Stop using Retinol, AHA, BHA at least 3–7 days before the procedure.
• If you have a history of herpes, the doctor may prescribe preventive medication.
• Avoid waxing, facial scrubs, or irritating facial treatments.
• It’s recommended to get enough rest and drink plenty of water.

3. During the Procedure:

Depends on the chosen method:

• Laser: Topical anesthetic applied. Laser treatment takes 20–45 minutes.
• RF Microneedling: Anesthetic applied. Puncture with energy delivery deep into the skin layer.
• TCA CROSS: TCA acid dropped point-by-point into the scar.
• Subcision: Blunt-tipped needle inserted under the skin to release fibrous bands.
• Filler: Injected under the scar after subcision for immediate results.

4. After Treatment:

• Skin may be red, swollen, or feel slightly tight for 1–3 days.
• Avoid sunlight and refrain from makeup for approximately 1–3 days (depending on the procedure).
• Use gentle skincare products that aid skin repair, such as those with B5, Cica, Ceramide.
• The doctor may also prescribe topical or oral anti-inflammatory medication.
• The doctor will schedule follow-up appointments every 3–4 weeks to adjust the plan if necessary.

Post-Acne Scar Treatment Skincare:

After receiving acne scar treatment, whether it’s laser, RF, or other procedures, your skin will be delicate and require gentle rejuvenation. Here are the recommended proper care steps:

Precautions After Laser or Procedures:

• Avoid makeup for the first 1–3 days, especially after laser or RF, as pores are still open and skin is delicate.
• Strictly avoid sun exposure for 1–2 weeks. Recommend wearing wide-brimmed hats, masks, and applying physical sunscreen (e.g., Zinc oxide, Titanium dioxide).
• Avoid activities that cause sweating or excessive heat like saunas, running in direct sun, or strenuous exercise for the first 48 hours.
• Avoid irritating skincare products such as AHA, BHA, Retinol, high-concentration Vitamin C.

Recommended Skincare After Treatment:

• Skin Barrier Repair Gels or Creams: Such as those containing Panthenol (B5), Madecassoside (Cica), Ceramide. They help the skin heal faster and reduce peeling and tightness.
• Gentle Sunscreen with SPF50+ PA+++ and no alcohol or harsh preservatives. If your skin is very sensitive, a cream-based sunscreen (not gel) might feel more comfortable.
• Thermal Water Spray / Soothing Spray: Use throughout the day to cool and reduce irritation.

Habits That Aid Faster Skin Recovery:

• Drink at least 2 liters of water daily to keep the skin hydrated from within.
• Get enough rest, as the body repairs the skin best during sleep.
• Consume foods rich in Zinc, Vitamin A, C, E to aid new collagen production.

Additional Tip: The first 7 days after treatment are the “golden period for skin rejuvenation.” The better you care for your skin, the higher the chance of it becoming smooth, even, and for redness to fade quickly.

How Much Does Acne Scar Treatment Cost?

The price of acne scar treatment can vary widely depending on several factors, such as the technology used, the doctor’s experience, and the number of sessions required for clear results.

Are Acne Scars Dangerous?

In terms of the “acne scars themselves,” they are not dangerous. However, the potential problems are the “psychological impact,” such as lack of confidence or stress due to appearance, and importantly, side effects from treatment if performed without knowledge or under medical supervision.

Possible Side Effects from Acne Scar Treatment:

• Skin burns / Permanent hyperpigmentation (PIH): Often caused by lasers used at too high energy, especially on darker skin tones.
• Infection after procedure: If performed in an unsanitary environment or if post-treatment care is inadequate.
• Allergic reactions or irritation: Some individuals may be allergic to anesthetic or products used after laser.
• Worsening of scars or new indentations: Can occur from incorrect procedural techniques, such as TCA CROSS applied beyond the scar’s edge or inaccurate subcision.

Will I See Results After the First Acne Scar Treatment?

Some people might feel their skin is slightly smoother from the first session, especially if Subcision or filler injection is also performed. However, generally… significant changes will start to be seen after 2–3 treatment sessions or more.

This is because the skin needs time to create new collagen, which usually takes about 4–8 weeks per cycle, depending on the technique.

How Many Sessions Are Needed for Clear Results?

Conclusion:

Acne scars are a skin problem caused by deep acne inflammation that prevents the skin from producing new collagen quickly enough, leading to indentations that cannot heal on their own. Effective treatment must be based on the type of scar (e.g., Ice Pick, Boxcar, or Rolling) using specialized technologies such as lasers, RF Microneedling, Subcision, or TCA CROSS, combined with proper post-treatment skincare. Results will gradually improve with continuous treatment, with noticeable changes appearing after 2–3 sessions or more. Most importantly, choose a clinic that uses authentic, certified equipment and is under the supervision of a doctor to ensure safety and real results.