Old acne scars can be significantly improved, but the right approach depends on what type of scar you’re dealing with. No single treatment works for every scar, and most people see the best results from combining two or more methods over several months. The good news: even deep, long-standing scars respond to modern treatments that weren’t available a decade ago.
Identifying Your Scar Type
Before choosing a treatment, it helps to understand what you’re working with. Acne scars fall into two broad categories: depressed (atrophic) scars that sit below the skin’s surface, and raised (hypertrophic or keloid) scars that rise above it. Most old acne scars are depressed, and they come in three distinct shapes.
Ice pick scars are narrow, deep holes that are wide at the surface and taper to a point. They’re most common on the forehead and upper cheeks, where skin is thinner, and they’re among the most challenging scars to treat because of their depth. Boxcar scars have sharp, defined edges and tend to appear on the lower cheeks and jaw. Rolling scars also show up on the lower face, but their sloped edges create a wavy, uneven texture rather than distinct pits. Many people have a mix of all three.
Raised scars, including keloids that grow beyond the original wound, require a completely different treatment strategy. If your scars are raised and firm to the touch, treatments designed for depressed scars could make them worse.
Laser Resurfacing
Fractional CO2 laser is one of the most effective options for old atrophic scars. The laser creates thousands of microscopic channels in the skin, triggering a rebuilding process. As the skin heals, it rearranges collagen, strengthens the local blood supply, and essentially converts scarred tissue into something closer to normal skin. Think of it as controlled damage that forces the body to repair itself more evenly than it did the first time around.
Recovery from a CO2 laser session typically takes one to two weeks. During that time, the treated skin will crust over, and you’ll need to keep it clean with gentle washing, apply petroleum jelly or an antibacterial cream, and change dressings multiple times a day. Ice packs help with swelling for the first two to three days. You’ll need to avoid pools, saunas, and hot tubs for one to two weeks, skip makeup until the skin fully heals, and stay out of direct sun. The crust falls off on its own; picking at it can cause new scarring.
Non-ablative lasers are a less aggressive alternative. They heat the deeper layers of skin without breaking the surface, which means less downtime but also more gradual results. Most people need multiple sessions spaced weeks apart.
Microneedling and Radiofrequency Microneedling
Microneedling uses tiny needles to puncture the skin at controlled depths, prompting your body to produce new collagen as it heals. Radiofrequency (RF) microneedling adds heat energy through the needles, intensifying the collagen response. In a clinical study of RF microneedling for acne scars, 82.5% of patients rated their results as good to excellent after a standard course of four sessions spaced three weeks apart. Physician assessments were similarly positive, with 70% of cases rated good to excellent.
Quantitatively, the average scar severity score dropped by about 34%. Over half the patients improved by one full grade on a clinical scale, and about a quarter improved by two grades. That said, roughly 17.5% of patients in the study saw little to no change, a reminder that individual results vary depending on scar depth and type.
Traditional microneedling (without the radiofrequency component) is less expensive and still effective, especially for rolling scars and mild boxcar scars. It typically requires more sessions to reach comparable results.
Subcision for Tethered Scars
Some depressed scars, particularly rolling scars, are pulled downward by fibrous bands anchoring them to deeper tissue. Subcision addresses this directly. A needle is inserted beneath the scar to sever those bands, freeing the skin surface so it can rise to a more even level. The procedure also triggers new connective tissue formation underneath the scar without injuring the skin surface.
Subcision works best for rolling scars and some boxcar scars. It’s often combined with other treatments: subcision to release the scar, then filler or microneedling to rebuild volume underneath. For deep, tethered scars, this combination approach tends to produce noticeably better results than any single treatment alone.
Chemical Peels and the CROSS Technique
Standard chemical peels can improve overall skin texture, but for individual deep scars, dermatologists use a targeted method called CROSS (chemical reconstruction of skin scars). This involves pressing a high concentration of trichloroacetic acid (TCA) directly into each scar using a small applicator. The acid stimulates thickening and new collagen production at the base of the scar, gradually raising it closer to the surrounding skin level.
CROSS can normalize deep rolling and boxcar scars over repeated sessions, and it works on ice pick scars as well, sometimes with concentrations up to 100% TCA. Because the acid is applied only to the scar itself, the surrounding skin stays untouched. Sessions are typically repeated every few weeks. This is a particularly useful option for scattered ice pick scars that don’t respond well to laser treatments.
Dermal Fillers
Injectable fillers add volume directly beneath a depressed scar, physically lifting it to match the surrounding skin. Hyaluronic acid fillers provide immediate results but are temporary, lasting roughly six to eighteen months before the body absorbs them. Bellafill is the only filler with FDA clearance specifically for acne scars. In its clinical trial, about 71% of patients showed successful correction at the one-year mark. However, long-term safety and effectiveness beyond one year haven’t been formally established.
Fillers work best for broad, shallow scars like rolling scars. They’re less practical for narrow ice pick scars or numerous small scars spread across a large area.
What Works for Darker Skin Tones
If you have a darker skin tone, acne scars come with an extra layer of complexity. Inflammation from acne (or from harsh treatments) triggers melanin release, creating dark spots known as post-inflammatory hyperpigmentation that can last months to years. These dark marks are often more visually prominent than the scars themselves. Darker skin is also more prone to keloids, where scar tissue keeps growing beyond the original wound.
Aggressive treatments like ablative lasers carry a higher risk of worsening both scarring and discoloration if performed incorrectly. This doesn’t mean these treatments are off the table, but they should be performed by a dermatologist experienced with darker skin types. Microneedling and certain non-ablative lasers are generally considered lower-risk options. Chemical peels require careful concentration choices to avoid triggering more pigmentation.
Combining Treatments for Better Results
Because most people have a mix of scar types, a combination approach is standard practice. A typical plan might start with subcision to release tethered rolling scars, followed by a series of microneedling or laser sessions to rebuild collagen across the broader area, with targeted CROSS treatments for individual ice pick scars. Fillers can address any remaining deep depressions that don’t fully respond to collagen-stimulating treatments.
Realistic expectations matter. Even the most aggressive treatment plans rarely eliminate scars completely. A 50 to 70% improvement is considered an excellent outcome for moderate to severe scarring. That level of improvement, though, can be dramatic in practice, turning deeply pitted skin into a texture that reads as mostly smooth in normal lighting. Results continue to develop for three to six months after the final treatment session as new collagen matures and remodels.
Sunscreen is non-negotiable throughout the process. Healing skin is highly vulnerable to UV damage, which can darken scars and undermine your results. A mineral sunscreen with at least SPF 30 should become part of your daily routine from the first treatment onward.