Treatment of acne scarring

What it is

Each type answers to a different technique, so the work starts by typing and mapping the scars rather than by choosing a device. The plan is then staged over a course — releasing the tethering, treating individual deep points, and resurfacing with laser or radiofrequency needling.

What this page covers

• Acne scar assessment, subtype mapping and classification, separating true scarring from post-inflammatory pigment and erythema
• A written staged combination program matched to the scar map
• Subcision of tethered rolling scars, alone or supported with filler or a biostimulator
• TCA CROSS for ice-pick and narrow boxcar scars
• Fractional CO2 resurfacing for atrophic scarring
• Radiofrequency microneedling and medical microneedling for rolling and shallow boxcar scars
• Fractional picosecond for shallow post-acne marks and texture
• Platelet-rich plasma or polynucleotide used within the scar plan
• Pre-procedure candidacy screening: recent threading or waxing, unlabeled mixed creams, diabetes control, keloid tendency, herpes history and isotretinoin

Who it suits

• Someone whose acne has settled, since scar work begins after its cause has stopped
• Someone carrying more than one type of scar on one face — which is most people — and willing to accept a plan that combines techniques in stages rather than one procedure repeated
• Someone able to commit to sun protection between stages. Here it is a requirement rather than advice: light is what fixes the darkening the skin passes through after scar work
• Someone able to arrange life around a course of appointments and their spacing, and around days of visible bruising after some of the steps
• And not you if what bothers you is the color rather than the depth. Much of what is brought in as scarring is post-inflammatory pigment or redness that settles with time and photoprotection and needs no device at all. The examination decides which it is, and the plan is entirely different; post-inflammatory pigmentation takes a different route from scars

When we advise delaying or not treating

• Active inflamed acne. Scar work is not started over it: every new lesion undoes what was done and leaves a mark of its own. This includes the girl her mother brings to the clinic — the acne is treated to stability first, her own view is asked for and recorded even where it differs from her family's, and a request coming from the family alone is a reason to slow down rather than to proceed
• A known tendency to keloid or hypertrophic scarring, in you or in your family — meaning a scar that grew wider or thicker than the cut that made it, stayed raised rather than flattening, and often itched or stung for months. It changes the risk of every step that breaks the skin: subcision is avoided in a keloid tendency without careful discussion, and punch excision carries a keloid risk in predisposed skin. The history asks specifically about ear piercing, surgical and cesarean scars, cupping and traditional cautery, all of which are familiar local sources of a thickened scar
• Raised scars on the jaw, chest and shoulders. These are not managed as depressed acne scars and are not treated on that plan; they need a plan of their own. Skin on the trunk is keloid-prone and heals more slowly
• An active cold sore, or a history of cold sores unless antiviral cover has been arranged first — ahead of any peel, needling or laser around the mouth. A herpes flare across freshly resurfaced skin can itself scar; prophylaxis lowers that risk rather than removing it, so the session is arranged around that possibility rather than pushed through it
• Skin thinned by an unlabeled mixed cream used for months. It tears, bleeds and heals unpredictably under any needle or device, so the cream is withdrawn and the skin brought back to baseline first. It is not stopped all at once, and not on your own: many of these creams contain a steroid, and stopping one abruptly flares the skin, so it is tapered on a plan. That is a reason to delay, not a reason to lower the settings. Bring the container with you as it is
• An area threaded, waxed or sugared in the preceding days. All of them lift the surface layer, so a peel or a needling pass over it takes more than was intended, in the most visible place there is. The question is when it was done, not whether
• Fixed braces, a retainer, or metal in or near the area to be treated. Radiofrequency needling concentrates current at metal and can cause a focal burn on the lower face, so braces, wires and retainers are asked about by name before any work on the jawline or chin and the area is mapped around them — what comes out comes out, and what is fixed changes the plan. Piercings in the field are removed for the session
• Recent sun exposure, or an active tan on the area. Skin fresh from the sun takes energy differently and burns and pigments more readily, which on this skin is precisely the outcome the plan exists to avoid. We postpone until it has settled, and it is asked before every session rather than only at the first
• Diabetes that is not well controlled, before anything that breaks the skin. It raises the risk of infection and slows healing, and it is a candidacy decision rather than a footnote at the end of the form. Deferring until control improves is care rather than refusal, and it comes with a clear appointment to come back to
• Pregnancy and breastfeeding. Scar work is elective and it waits: several of the steps described on this page are not done at all while you are pregnant or breastfeeding, so tell us before the session and not in it. And recent isotretinoin — the timing is discussed rather than assumed
• A request to finish it in one visit, or before an event. We decline it. Mixed scar types need mixed techniques spaced apart, with healing between the stages, and compressing that into a short window is itself what causes harm
• A request for punch excision or grafting from someone who has not accepted the trade. Excision converts a pit into a small line and needs a suture removed; a graft can differ in color or texture from the skin around it and leaves its own small mark where it was taken from, behind the ear. Where excision or grafting is genuinely the right answer for a scar, that trade is put to you before anything is booked — here, or with whoever would perform it. If the trade is unacceptable, it is not done
• A request to laser the dark marks while they are still fading on their own. Treating them at that stage adds risk and corrects nothing, and waiting here is a treatment decision rather than a delay

Possible effects

Stated in full, because the decision is not sound without them:

• Bruising and swelling — expected after subcision and sometimes extensive, and a small nodule can form at the released site
• Post-inflammatory hyperpigmentation: the commonest of them in Fitzpatrick IV to VI, and reducing it is what the whole plan is built on. See the note on darker skin below
• Infection on a surface that has just been broken, or reactivation of cold sores. Both need a same-day appointment rather than waiting for the next one — see the box at the top of this page
• Focal high-strength acid (TCA CROSS): each treated point can darken temporarily in deeper skin, and over-applying it can widen a scar or leave a pale dot in its place
• The small steps done scar by scar, each with its own trade: punch excision converts a pit into a small line and carries a keloid risk in predisposed skin; punch elevation can leave a disc that differs in color or texture and needs blending later; a graft can differ in color and texture and leaves its own mark where it was taken from
• A new scar, or worsening of an existing one, after resurfacing — uncommon. It is associated with energy or density that did not suit the skin type, and also with an infection or a herpes flare across skin that is still healing, and with crusts lifted before they were ready
• Loss of color in places, meaning patches paler than the skin around them: slower to change than darkening, and the color may not even out completely
• Corticosteroid injected into a raised scar: local thinning, visible vessels and loss of color at the site, which shows more plainly on darker skin. And keloids often come back, so they need a follow-up plan rather than one injection
• The numbing cream itself: high-strength preparations over wide areas and under an occlusive cover carry a genuine risk of systemic toxicity, which is why it is applied and timed inside the clinic and is not dispensed for use at home before a session. Do not buy numbing cream and apply it yourself before you come, and do not cover it with plastic wrap or a dressing — a strong cream, a wide area, and something sealed over the top is the combination that makes it dangerous
• Where filler or a biostimulator is placed to support a scar base after release, the risks of any injection into the face apply. Any room where that is done has to be able to recognize a vascular occlusion and act on it without delay, and you are entitled to ask how that is handled before you agree to it
• Some scars not responding as much as hoped even after the stages are complete. The assessment is then redone against the photographs and the plan adjusted, rather than the same session repeated in hope

A note on darker skin

Most of the skin treated here is Fitzpatrick III to VI, and that is the fact the scar plan is built on rather than a footnote added to it. On Fitzpatrick IV to VI, scar work frequently darkens the area for a period before it improves — which is said before starting, not after. What suits deeper skin better: radiofrequency microneedling, because it comparatively spares the surface — better here does not mean without risk, since too much energy or stacked passes still darken this skin and can leave the grid of needle tracks visible for a while; subcision, because it works beneath the scar rather than through its surface; and non-ablative fractional laser and fractional picosecond at lower density with wider spacing between sessions. What needs more caution: ablative fractional CO2 and erbium, medium-depth peels, and repeated passes over the same area in one sitting — their settings all calibrated on lighter skin, and not transferable as they stand. Focal high-strength acid is precision-dependent by nature, and every point treated with it can darken for a time. And the line that a device is suitable for every skin tone, which appears in the advertising, is not a reason to raise the energy. Two further things belong specifically to these skin types: a tendency to keloid is more common in them and changes the plan on its own, and loss of color, where it happens, shows more plainly and is slower to change. Skin type is judged for each individual in the clinic, and never inferred from nationality.

Afterwards

• Sun protection daily on the treated area, between the stages and after the course ends. Here it is part of the treatment itself: light is what fixes the darkening the skin passes through after scar work
• Let the crusts and the grid marking come away on their own. No scratching, no rubbing, no exfoliants and no scrubs until the skin settles; whatever is lifted by hand leaves color in its place
• Bruising after subcision is expected and changes color before it clears. The small nodule at a released site is different: tell us if it is still firm after the period you were given, or if it grows
• Report any darker patch as soon as you notice it, not at your next appointment. It is treatable, and it is more straightforward the earlier it is seen
• Report any new inflamed spot. Acne returning mid-course changes the order of the stages, and there is no sense in continuing to work on the marks while their cause is starting up again
• Photograph the area in the same light and from the same angle before each stage. Assessment rests on a record rather than an impression, and that alone is what prevents repeating sessions for little gain
• Tell us before the next session about anything that changed: a new medicine, isotretinoin, pregnancy, threading, waxing or sugaring of the area, a cold sore, or a change in your diabetes control. The screening is repeated before every session and is not taken once at the first visit
• Come to the review appointment even if you think nothing has changed. The interval between one stage and the next is a decision made at that appointment, not a period that passes on its own

Honestly

Active acne is brought under control first or new lesions undo the work, ice-pick scars respond poorly to laser or needling alone, and the stated aim is smoother and shallower rather than erased.

Common questions

See also

Skin rejuvenation, Texture & pores