Indented acne scars form when inflammation destroys collagen beneath the skin’s surface, leaving depressions that don’t fill in on their own. Getting rid of them typically requires treatments that either rebuild collagen from within, physically release tethered skin, or resurface the top layers to smooth out depth differences. Most people see meaningful improvement through a combination of professional procedures rather than any single treatment, and results develop gradually over three to six months as new collagen forms.
Why Scar Type Matters for Treatment
Not all indented scars respond to the same approach. There are three distinct types, and identifying yours helps you avoid wasting time and money on the wrong procedure.
Ice pick scars are narrow, deep pits that can extend up to 2mm into the skin. They look like someone pressed a sharp point into the surface. Their depth and narrow opening make them resistant to most resurfacing treatments, which is why they often need targeted chemical reconstruction or punch excision rather than broad surface treatments.
Boxcar scars are wider depressions with sharply defined vertical edges, almost like a chickenpox scar. They respond well to laser resurfacing and microneedling because the walls of the scar can be blended into surrounding skin.
Rolling scars create a wave-like, undulating texture across the skin. These are caused by fibrous bands that pull the surface downward from underneath. Because the problem is structural, rolling scars respond best to subcision, a procedure that physically cuts those tethering bands beneath the surface.
Subcision for Tethered, Rolling Scars
Subcision is one of the most effective starting points if your scars pull inward when you stretch your skin. A provider inserts a small instrument beneath the scar to manually detach the dermis from the tissue pulling it down. This lifts the depression immediately, and the controlled injury also triggers connective tissue growth that fills the space over the following weeks. Fat beneath the skin gets redistributed more evenly, reducing the contour irregularity that makes rolling scars so visible.
Subcision alone improves scars in roughly 67% of patients. But combining it with other treatments pushes results significantly higher. When followed by hyaluronic acid filler injections, 94% of patients in one study saw significant clinical improvement. Adding suction sessions every other day for two weeks after subcision boosted average improvement from about 44% to nearly 72%. The takeaway: subcision works best as the foundation of a multi-step plan, not a standalone fix.
Laser Resurfacing: Ablative vs. Non-Ablative
Laser treatments work by creating controlled zones of damage in the skin, prompting your body to replace scarred tissue with fresh collagen. The two main categories differ in intensity and downtime.
Ablative fractional lasers (CO2 and erbium YAG) remove thin columns of skin entirely and heat the surrounding collagen, forcing the body to rebuild. CO2 lasers are the more aggressive option. In clinical studies, about 40% of patients treated with fractional CO2 achieved 50% or greater scar improvement, and roughly 80% saw at least mild to significant improvement overall. Erbium YAG lasers are gentler, with most patients (about 67%) reporting 25 to 50% improvement and only 10% reaching the 50 to 75% range. A typical course involves three sessions spaced one month apart.
Non-ablative lasers leave the skin surface intact and work by heating deeper layers to stimulate collagen without visible wounds. These are safer for darker skin tones, where excess heat at the surface can trigger pigmentation changes. Newer 1550nm non-ablative lasers with advanced cooling technology have shown prolonged hyperpigmentation rates as low as 2.1%, compared to 40 to 57% with older versions of the same wavelength. If you have medium to deep skin tone, non-ablative options with built-in cooling are worth discussing with your provider.
Expect about five to seven days of social downtime after ablative treatments, with redness, swelling, and peeling. Visible improvement starts around two to three weeks, but true collagen remodeling continues for three to six months. The average cost for a laser resurfacing session is approximately $1,829, though this varies by location, provider, and the specific laser used.
Microneedling and RF Microneedling
Traditional microneedling creates thousands of tiny punctures in the skin, triggering a healing response that deposits new collagen. It works well for mild to moderate scarring and mostly affects the upper skin layers. Results are real but tend to be more subtle, refining texture without dramatically restructuring deeper tissue.
Radiofrequency (RF) microneedling adds thermal energy to the equation. Each needle delivers heat deep into the dermis, causing collagen fibers to contract and triggering a stronger regenerative response than punctures alone. Because it reaches deeper tissue, RF microneedling produces more visible tightening, smoother scars, and longer-lasting results. It also treats both surface texture and underlying skin laxity in a single session. RF microneedling typically causes slightly more initial swelling than standard microneedling due to the heat component, but overall downtime remains relatively short.
TCA CROSS for Ice Pick Scars
Ice pick scars are notoriously stubborn because they’re so narrow and deep that broad resurfacing treatments can’t reach the bottom. The CROSS technique (Chemical Reconstruction of Skin Scars) addresses this by applying high-concentration trichloroacetic acid directly into individual scars. The acid causes controlled destruction of the scarred tissue, and as the skin heals, new collagen gradually fills the depression from the bottom up.
Studies using 100% TCA concentration found that 94% of patients experienced a good clinical response. The 65% concentration also worked, though the response rate was lower at 82%. Multiple sessions are typically needed, spaced several weeks apart, because collagen remodeling continues for months after each application. This is one of the few treatments specifically designed for ice pick morphology, and it can be combined with laser resurfacing for boxcar or rolling scars elsewhere on the face.
Dermal Fillers for Immediate Volume
If you want visible improvement quickly, injectable fillers physically raise depressed scars by adding volume beneath them. Several filler types are FDA-approved for this purpose, and they differ mainly in how long they last.
- Hyaluronic acid fillers are temporary, lasting up to 18 months. They’re reversible if you don’t like the result, which makes them a lower-risk starting point.
- Poly-L-lactic acid (Sculptra) is semi-permanent, with results lasting two to three years. It works gradually by stimulating your own collagen production rather than just filling space.
- Calcium hydroxylapatite (Radiesse) is also semi-permanent, lasting up to 18 months.
- Polymethylmethacrylate (Bellafill) is the only permanent filler FDA-approved for acne scars, with effects lasting more than three years. It was specifically approved for moderate to severe atrophic acne scars in 2014.
Fillers work best for broader, shallower depressions and rolling scars. They don’t address the underlying collagen deficit, so temporary options will eventually need maintenance. Combining fillers with subcision tends to produce better outcomes than either treatment alone.
Topical Retinoids as an Adjunct
Prescription tretinoin won’t replace professional procedures for deeper scars, but it can meaningfully improve shallower ones. In one clinical study, tretinoin applied via iontophoresis (a method that uses mild electrical current to push the medication deeper into skin) flattened scars in 79% of patients. Results were best for newer scars and for superficial or ice pick types. Older, well-established scars responded less dramatically.
Even without iontophoresis, consistent use of prescription retinoids accelerates skin cell turnover and supports collagen production, which can enhance results from other treatments. Think of it as a long-term maintenance strategy that amplifies what procedures accomplish.
Special Considerations for Darker Skin
Acne scarring disproportionately affects people with darker skin tones, and treatment carries additional risks. Up to 90% of acne patients with deeper skin tones experience post-inflammatory hyperpigmentation, the dark marks that can linger for months after any skin injury, including treatment itself. Excess heat from lasers can stimulate pigment-producing cells and make discoloration worse.
Non-ablative lasers with integrated cooling systems are generally the safest laser option. Chemical peels and microneedling at conservative settings also carry lower pigmentation risk than aggressive ablative resurfacing. Your provider should adjust energy levels and may recommend pre-treatment with a topical that suppresses melanin activity. The goal is to stimulate enough collagen remodeling to improve scars without triggering a pigmentation flare that creates a new cosmetic concern.
Combining Treatments for Best Results
The most effective scar revision plans layer multiple approaches based on scar type. A common strategy starts with subcision to release tethered scars, follows with filler to maintain lift, and adds laser resurfacing or RF microneedling to improve overall texture and stimulate long-term collagen growth. TCA CROSS can be performed on ice pick scars during the same period. One study combining subcision, chemical peels, and fractional CO2 laser in a single session reported a mean improvement score of 2.9 out of 4 across 114 patients.
Plan for a process, not a single appointment. Most people need three or more treatment sessions spaced four to six weeks apart, with final results becoming apparent three to six months after the last session. Total cost depends on which procedures you combine, but a realistic multi-session plan with laser and subcision can range from several hundred to several thousand dollars. Since acne scar treatments are considered cosmetic, insurance typically does not cover them.