By Dr Davin S. Lim
Consultant Laser and cosmetic dermatologist

Assessing acne scarring is THE most important step in planning a treatment program. How do I do it? Well, it depends on the type of scarring.

Simple scars such as box car scarring, and ice pick scars can easily be seen with incident light, so picking up these scars are as simple as looking at your skin under bright lights, and mapping them out.

Some scars are tricky to pick - these include the tiny divots and dings you see under angled lighting- these include puckered, tethered and atrophic – rolling acne scars. These scars are most visible under poor lighting and angled lights- like the ones you see in the mirror in your bathroom, or through the front mirror of your car at night. This is when I use angled lighting to reveal scars, then map them.

A quick review of scars will reveal optimal treatments, and once again, this is balanced between your scar type, skin type and downtime.

acne scar types

Box car scars

As the name suggests, are boxy and have a sharp edge or drop off. They usually occur on the temples, but also on the cheeks. Treatment of choice for box car acne scars? Full Laser Resurfacing using erbium laser followed by CO2 CORE, all in the one sitting.

Rolling and atrophic scars

These scars are the ones best viewed with angled lighting. They are also the most difficult to treat with lasers, as collagen needs to be remodelled, and reformed. Fractional CO2 is the most promising, but combining this with Juvaderm filler can give great results. Patients can expect significant improvement with a combination of treatments.

Tethered and anchored acne scars

These present as scars mainly seen around the chin and mouth area and move with muscle movement. These scars are ‘tethered’ to the deep and superficial layers of the skin. A process called subscision will usually do the trick, expect 30% or more improvement with one treatment. Subscision is a minor surgical procedure that can break the bonds that ‘tie down’ the acne scar.

Macular acne erythema

This is a term we use to describe red scars that usually are flat. Very rarely we get redness with depressed scars. These scars can take some time to settle (usually 6-8 months), but using the V Beam laser combined with sunscreen can shorten recovery times to 2-3 months at most.

Raised acne scars

These are either keloid or hypertrophic scars, and usually arise on the chest, back, shoulders and jawline. They are very easy to identify, as they can be painful, itchy and raised. The use of V Beam laser and steroid injections can reduce this form of scarring.

Ice pick scars

As the name suggests, are very deep indented scars that usually occur on the cheeks. Even though they lie deep in the dermis, they are one of the easiest scars to treat. A technique called TCA CROSS can markedly improve scarring. Additionally punch excision can remove ice pick scars.

Mixed acne scars

These are the most commonly seen scars. Most patients will present with a mixture of ice pick, box-car, rolling, atrophic, and tethered scars, and hence several treatment modalities are needed to manage this form of scarring.

Now you can understand why it is so very important to assess acne scar subtypes, as they all will have optimal treatment options.

davin lim

Dr Davin Lim
Consultant Laser and Cosmetic Dermatologist
Westside Laser Dermatology