Atrophic acne scars are depressions in the skin where collagen was destroyed during inflammatory breakouts, and getting rid of them typically requires professional treatments that stimulate new collagen growth beneath the scarred tissue. No single treatment works for every scar. The best approach depends on the type, depth, and number of scars you have, and most people see the strongest results from combining two or more methods over several months.
Why Scar Type Matters
Atrophic scars fall into three categories, and each responds differently to treatment. Knowing which type you have (or which combination) helps you and a dermatologist choose the right approach from the start rather than wasting time and money on a method that won’t reach your particular scars.
Ice pick scars are the most common, making up 60 to 70 percent of atrophic scars. They’re narrow (under 2mm wide), V-shaped, and extend deep into the skin. Their depth makes them resistant to surface-level treatments like standard peels or gentle resurfacing.
Boxcar scars account for 20 to 30 percent. These are wider (1.5 to 4mm), round or oval, with sharp vertical edges that give them a punched-out look. Shallow boxcar scars respond well to resurfacing, but deeper ones need more aggressive intervention.
Rolling scars make up 15 to 25 percent. They’re the widest (up to 5mm) and create a wave-like, undulating texture across the skin. The cause is fibrous bands pulling the surface of the skin down toward deeper tissue, so treatment has to address that tethering underneath, not just the surface.
Subcision for Tethered Scars
If your scars look worse when you stretch the skin and the depression disappears, those scars are likely tethered by fibrous strands beneath the surface. Subcision is a minor procedure where a needle or small blade is inserted under the scar to physically shred those fibrous attachments apart. Once the skin is released from the tissue pulling it down, it lifts. The controlled injury also triggers a wound-healing response that promotes new connective tissue growth, filling in the pocket left behind.
Subcision is particularly effective for rolling scars but often requires multiple sessions. Bruising is common and can last a week or two. Some practitioners use blunt-tipped instruments instead of sharp needles, which tends to cause fewer side effects and higher patient satisfaction in the weeks following treatment. Subcision is frequently performed as a first step before laser or filler treatments, since releasing the tethered skin gives those follow-up procedures a better foundation to work with.
Fractional CO2 Laser Resurfacing
Fractional CO2 laser is one of the most studied treatments for atrophic scars. It works by creating tiny columns of controlled thermal injury in the skin, which triggers a cascade of growth factors and new collagen production. Studies show scar depth improvements averaging around 67 percent, with 35 percent of cases achieving complete scar reduction and another 40 percent seeing more than 50 percent improvement.
The number of sessions depends on your scar type. Ice pick scars typically need about 3 sessions, boxcar scars 3 to 4, and rolling scars 4 to 5. Sessions are spaced roughly one month apart, and some treatment plans extend to 6 sessions for more severe scarring. Recovery from each session involves redness, swelling, and peeling that can last a week or more, with full collagen remodeling continuing for months after your final session.
Non-ablative fractional lasers are a less aggressive alternative. They heat the deeper layers of skin without removing the surface, which means less downtime but generally more sessions to achieve similar results. These are often a better starting point for people with darker skin tones, since ablative lasers carry a higher risk of pigmentation changes when more melanin is present in the skin.
Microneedling and Radiofrequency Microneedling
Professional microneedling uses fine needles (typically 1.5 to 2.5mm deep for scar treatment) to create controlled micro-injuries across the scarred area. These tiny punctures trigger the same wound-healing response that drives collagen and elastin production, gradually thickening the dermis and filling in depressed scars from below. The key advantage is that microneedling doesn’t destroy the skin’s surface layer, which makes it safer across a wider range of skin tones.
Radiofrequency (RF) microneedling adds heat energy delivered through the needle tips, intensifying the collagen-stimulating effect at specific depths (typically 1.5 to 3.5mm). This combination tends to produce more dramatic remodeling per session than microneedling alone. Most treatment plans involve 3 to 4 sessions spaced 4 to 6 weeks apart, but the results aren’t instant. New collagen deposits slowly over time, and the most optimal results may take 8 to 12 months to fully develop after your last session. That slow timeline can feel discouraging, but it’s a sign the remodeling is happening at a structural level rather than just on the surface.
The TCA CROSS Technique for Deep Pits
For ice pick scars specifically, the CROSS technique (Chemical Reconstruction of Skin Scars) is a targeted approach. A dermatologist applies a high concentration of trichloroacetic acid, usually 70 to 100 percent, directly into each individual scar using a fine applicator. The acid causes a controlled chemical injury at the base of the scar, stimulating new collagen that gradually fills the pit from the bottom up.
Studies comparing 70 and 100 percent concentrations show that higher concentrations are significantly more effective for ice pick scars specifically. This isn’t a broad-surface peel. It’s a precision treatment applied scar by scar, which makes it practical even for scattered ice pick scars that wouldn’t justify full-face resurfacing. Multiple sessions are needed, typically spaced several weeks apart. The treated spots form small scabs that heal over 5 to 7 days.
Dermal Fillers for Immediate Volume
Fillers can lift depressed scars by adding volume directly beneath them. Hyaluronic acid fillers provide immediate improvement but are temporary, lasting 6 to 12 months before the body absorbs them. For a longer-lasting option, one filler containing tiny microspheres that act as a scaffold for your own collagen to grow around is FDA-approved specifically for acne scars and can last up to 5 years.
Fillers work best for broader, shallow-to-moderate scars like rolling or shallow boxcar types. They’re less practical for narrow ice pick scars. Many dermatologists use fillers as part of a combination plan: subcision first to release tethered scars, then filler injected into the newly created space to prevent the scar from re-adhering to the deeper tissue.
Combining Treatments for Better Results
Most people with atrophic scarring have a mix of scar types, and the strongest outcomes come from combining techniques that target different layers and mechanisms. A typical multimodal plan might start with subcision to release tethered rolling scars, followed by fractional laser resurfacing to rebuild collagen across the treated area, with TCA CROSS applied to any remaining ice pick scars. Some clinicians perform subcision and laser in the same session.
The order matters. Releasing tethered scars before resurfacing gives the laser a flatter surface to work with. Adding filler after subcision prevents re-tethering. Spacing treatments at least 6 weeks apart allows new collagen to form between sessions, so each subsequent treatment builds on the structural gains of the last one. A full treatment plan for moderate-to-severe scarring often spans 6 to 12 months, with continued improvement for several months after the final session.
What Topical Products Can Do
Prescription retinoids (tretinoin) promote collagen remodeling and skin cell turnover, and they can make a visible difference in shallow atrophic scars over time. One study found significant scar improvement in over 91 percent of patients after 12 weeks of consistent use combined with glycolic acid. Retinoids won’t eliminate deep scars, but they can improve skin texture, reduce the appearance of mild scarring, and enhance results when used alongside professional procedures.
Over-the-counter retinol products are weaker versions that work on the same principle but more slowly. If you’re planning professional treatments, starting a retinoid a few months beforehand can help prime your skin’s collagen-production machinery, though you’ll need to stop using it in the days before laser or chemical peel sessions to avoid irritation.
Risks for Darker Skin Tones
Post-inflammatory hyperpigmentation, where treated skin heals darker than the surrounding area, is a significant concern for people with medium to dark skin. This happens because the same inflammation that stimulates collagen can also activate melanin-producing cells. Ablative lasers pose the highest risk because higher energy settings are sometimes needed to penetrate skin with more melanin, which can inadvertently cause thermal injury and trigger further pigmentation changes.
Safer options for darker skin include microneedling, RF microneedling, and non-ablative fractional lasers, all of which cause less surface disruption. TCA CROSS can also be used carefully. If ablative laser is recommended, lower energy settings with more sessions is the typical strategy to reduce pigmentation risk. A test spot on a small, inconspicuous area before full treatment helps gauge how your skin will respond.