There is no single best treatment for acne scars. The most effective approach depends on the type of scar you have, because different scar shapes respond to different techniques. Depressed (atrophic) scars, which account for the majority of acne scarring, fall into three categories: ice pick, rolling, and boxcar. Each has a different structure beneath the skin, and matching the right treatment to the right scar type is what produces the best results.
Why Scar Type Matters More Than Brand Name
Atrophic acne scars are divided into three main types. Ice pick scars are narrow, deep pits that extend into the dermis. Rolling scars create a wave-like texture caused by fibrous bands pulling the skin downward. Boxcar scars are wider depressions with sharply defined edges, and they can be shallow or deep. A fourth category, hypertrophic or keloidal scars, involves raised tissue rather than lost tissue, and requires a completely different treatment strategy.
Most people have a mix of scar types across their face. That’s why dermatologists frequently combine two or three techniques in a treatment plan rather than relying on one procedure alone. A combination approach that targets each scar type independently tends to outperform any single treatment used across the board.
Laser Resurfacing: The Strongest Evidence
Fractional lasers are the most widely studied treatment for atrophic acne scars. They work by creating thousands of microscopic columns of damage in the skin, triggering your body’s wound-healing response and stimulating new collagen production. There are two main categories: ablative lasers, which vaporize thin layers of skin, and non-ablative lasers, which heat tissue beneath the surface without removing it.
Fractional CO2 lasers (ablative) are considered the gold standard. A 2024 meta-analysis of eight studies comparing fractional CO2 to fractional erbium lasers found that CO2 had a significantly higher effectiveness rate and, surprisingly, shorter overall downtime. The trade-off is more pain during treatment and a higher chance of temporary darkening of the skin afterward, which is an important consideration for people with darker skin tones. The erbium laser is gentler, with similar rates of pain duration and post-treatment pigmentation risk, making it a reasonable alternative when skin color or pain tolerance is a concern.
Ablative laser treatments average around $2,000 per session, while non-ablative sessions average about $1,100. Ablative treatments typically require about two weeks of recovery, with significant redness and peeling during that time. Non-ablative fractionated lasers need three to five sessions to see meaningful results, but downtime drops to three to five days per session. Some non-ablative, non-fractionated devices cause as little as a few hours of redness with no peeling at all, though their results are more modest.
TCA CROSS for Ice Pick Scars
Ice pick scars are notoriously difficult to treat with lasers alone because they’re so narrow and deep. The most effective targeted treatment is a technique called CROSS, which stands for Chemical Reconstruction of Skin Scars. A high-concentration trichloroacetic acid solution is applied directly into each individual scar using something as precise as a wooden toothpick. This causes a controlled chemical injury at the base of the scar, prompting collagen to fill it in from below.
In a study using 100% TCA concentration, 80% of patients showed excellent improvement and 20% showed good improvement after four sessions spaced two weeks apart. Earlier research found that 94% of patients treated with 100% TCA had a good clinical response, compared to 82% of those treated with a lower 65% concentration. The procedure is inexpensive relative to laser treatments and requires minimal downtime, though each scar develops a small white frost and then a scab that heals over several days.
Subcision for Rolling Scars
Rolling scars look the way they do because fibrous bands of scar tissue tether the skin surface down to deeper layers. Subcision directly addresses this by breaking those bands. A needle or specialized device is inserted beneath the scar and moved back and forth to physically sever the tethering fibers, releasing the skin so it can rise to a more normal level.
The technique works through both mechanical disruption and the subsequent healing response, which fills the space with new connective tissue. When combined with fractional CO2 laser in a recent study, patients improved by an average of nearly two full points on a five-point severity scale (from about 4 out of 5 down to 2.4), and patients rated their own improvement at 7 out of 10 on average. Subcision paired with dermal fillers is another well-supported combination for rolling scars, since the filler adds immediate volume while subcision prevents the bands from pulling the skin back down.
Dermal Fillers for Volume Loss
Fillers work best for rolling scars and broader areas of volume loss. They physically raise depressed tissue back to the level of surrounding skin. Several types are available, and the main difference between them is how long they last.
- Hyaluronic acid fillers (brands like Restylane and Juvederm) are temporary, lasting up to 18 months. They’re reversible, which makes them lower risk.
- Calcium hydroxylapatite (Radiesse) is semi-permanent, lasting up to 18 months, and also stimulates some collagen production.
- Poly-L-lactic acid (Sculptra) is a collagen stimulator rather than a traditional filler. Its effects build gradually and last two to three years.
- Polymethylmethacrylate (Bellafill) is the only dermal filler with FDA approval specifically for moderate to severe atrophic acne scars, granted in 2014. It’s classified as long-lasting, with effects persisting beyond three years.
Fillers provide the most immediate visible improvement of any treatment on this list. Many patients see results the same day. The limitation is that fillers don’t permanently restructure the skin, so most options require repeat treatments over time.
Topical Retinoids: Helpful but Limited
Prescription retinoids like adapalene stimulate the skin’s fibroblasts to produce new collagen, the same basic mechanism that makes laser treatments work. In a 24-week study of adapalene 0.3% gel, investigators noted improvement in skin texture and atrophic scars in 50% of subjects, while over 80% of subjects themselves reported improvement. The gel works by increasing epidermal thickness and activating collagen production in the dermis.
Retinoids are worth considering if procedures aren’t accessible or affordable, since the invasive treatments that dominate acne scar management aren’t realistic for everyone. But topical products face a fundamental challenge: persistent dermal tissue loss is difficult to reverse from the surface. Retinoids can soften shallow scarring and improve overall texture, but deep ice pick or tethered rolling scars generally need a procedural intervention to see meaningful change.
Matching Treatment to Scar Type
If you’re trying to figure out where to start, this is the practical framework dermatologists use:
- Ice pick scars: TCA CROSS or punch excision (a minor surgical technique that removes the scar entirely and closes the tiny wound). Lasers alone often can’t reach the depth of these scars.
- Rolling scars: Subcision to release the tethering bands, often combined with fillers for immediate volume or fractional laser to stimulate long-term collagen remodeling.
- Boxcar scars: Fractional CO2 laser for shallow ones. Deep boxcar scars may benefit from punch elevation (a surgical technique that lifts the depressed base) or TCA CROSS.
- Mixed scarring: A combination protocol. Most treatment plans involve two or three modalities used in sequence or at different visits.
Realistic expectations matter. Even the best treatments typically improve scarring rather than erase it. Multiple sessions spaced weeks or months apart are standard, and the full effect of collagen-stimulating treatments like lasers and subcision continues to develop for three to six months after the last session. Starting with a clear assessment of your scar types gives you the best chance of choosing treatments that will actually make a visible difference.