Acne Scars: Understanding the Causes and Treatment Options
Under low-angled light, or when you lean in close to the mirror, your skin is no longer smooth: where there were pimples, small indentations remain, sometimes a raised area, sometimes just a red or brown mark. These are not the same marks, and they are not treated the same way. An indented acne scar, known as an atrophic scar, changes the contour of the skin. Treatments aim to make it less visible, not to erase it, with limitations and risks that depend on the treatment and your skin. For acne scars on the face, as elsewhere on the body, the type of scar, the state of your acne and your skin tone guide the choice of options. An examination makes it possible to distinguish changes in colour from changes in contour.
In Brief
Five things to know before deciding- What it is: an indentation (ice pick, boxcar or rolling) when the skin produced too little collagen while repairing itself, a raised area when it produced too much. A red or brown mark that stays flat is generally not a scar.
- Acne first: new pimples can leave new scars. Treating active acne comes first; it limits new scars without erasing those that are already there.
- What the options do: treatments aim to make indentations less visible, not to erase them. Laser treatment and microneedling stimulate skin repair; a filler adds volume. After laser treatment, results can take months to appear. An ice pick scar may require a different approach from a rolling scar.
- Skin tone and what to expect afterwards: on brown or black skin, darker spots can appear after laser treatment or a technique that injures the skin; skin tone is one of the things the doctor examines, and it does not rule out a treatment on its own.
- Creams and assessment: a cream does not fill a deep indentation. The type of scar, the state of your acne and what is appropriate for your skin are determined during the assessment at CARE MD in Sainte-Thérèse.
How Do Acne Scars Form?
When an acne breakout heals, the skin repairs itself, and it is during this repair that the appearance of the mark is determined. Collagen, the protein that supports the skin, plays an important role: if the body produces too little of it, the skin sinks into a small depression or pit; if it produces too much, a raised scar forms.
The amount of collagen produced varies from person to person. Having a scar therefore does not mean that you did not care for your pimples properly.
Indented, Ice Pick or Atrophic Scars: How to Identify Them
An atrophic scar is an indented scar: the skin has sunk where it repaired itself. It takes three forms, which are distinguished by their width and depth.
Ice pick
It looks small on the surface, but it extends deep into the skin, hence its name.
Boxcar
It is a round or oval depression, wider than an ice pick scar but not as wide as a rolling scar.
Rolling
It is wide and shallow; when there are many, the skin takes on a wavy appearance. Fibrous bands under the skin can hold these scars down: this is what subcision targets.
Raised
Raised scars are the other group. A raised scar forms a firm bump, and the jawline, chest and back are where it usually appears. It is not treated like an indentation: hypertrophic scars have their own options, and the doctor determines on examination whether a firm raised scar is hypertrophic or keloid.
The type matters, because an ice pick scar and a rolling scar are not necessarily treated the same way. Recognizing your scars in one of these descriptions helps you prepare your questions; only the doctor, on examination, determines the type of each of your scars.
Red Marks After Acne: Scar or Redness?
A mark that stays flat and only changes colour, red or brown, is generally not a scar. The red mark that remains after a pimple is called post-inflammatory erythema: it is residual redness. The brown mark is a change in pigment, post-inflammatory hyperpigmentation, which remains in the skin after the pimple.
Both tend to fade over time, whereas a true scar persists. All three can also occur together: redness, a brown mark and an indented scar on the same cheek. On examination, the doctor therefore separates colour from contour, so that redness is not mistaken for an indentation.
- What you see
-
A mark that stays flat, red or brown
- What only the doctor can tell on examination
-
- Post-inflammatory erythema
- Post-inflammatory hyperpigmentation
- Indented scar
Why Active Acne Is Treated Before Scars
Acne first
As long as new pimples appear, each one can leave a mark.
The plan therefore usually starts with acne treatment: stopping flare-ups reduces inflammation and prevents new scars, and scars are treated once acne is under control. This treatment does not erase existing scars; it prevents new ones from being added.
Your acne treatments
Tell the doctor which acne treatments you are using or have used recently: this can change the choice of treatment and when it is done.
Do not change how you use a prescribed treatment or stop it on your own; discuss this with the doctor who prescribed it.
Before microneedling or laser treatment
Timing also matters for the skin.
Active pimples, an infection or a recent sunburn must have cleared up before microneedling, and laser treatment must not be performed on tanned or sunburned skin.
In-Clinic Treatments for Acne Scars
For indented acne scars, there are lasers, microneedling, peels, subcision and fillers. Each works differently and is appropriate for different indentations, and what to expect afterwards is specific to each one. The goal is to make indentations less visible, without promising that they will disappear. An ice pick scar may require a different approach from a rolling scar, depending on its depth and your skin. CARE MD does not offer all of these treatments.
Resurfacing lasers.
The fractional CO2 laser is an ablative laser: it treats microscopic columns in the superficial and deeper layers of the skin, while leaving intact tissue between them.
As it heals, the skin produces collagen and elastin, which can make scars less visible. A laser can be both ablative and fractional: the first term describes its action on the tissue, the second how the treated zones are distributed. Ablative CO2 laser resurfacing is therefore not necessarily a treatment of the entire surface. The treatment mode matters as much as the name of the laser. The fractional Er:YAG laser is another option for atrophic scars. With some systems, it can provide improvement comparable to that of fractional CO2, with less discomfort; this does not mean faster recovery or a better choice for all skin types.
- Which scars it is used for
-
Atrophic indentations on the face.
- What to expect
-
A less visible scar, not an erased one. Results take months to appear, with little change at first, and a series of sessions may be needed.
- What to expect afterwards and risks
-
The skin needs to heal, and darker spots can appear. A tan or a recent sunburn increases the risk of a burn or a change in skin colour; protect your skin from the sun before and after treatment.
- Who performs it
-
It is a medical procedure, performed by a physician, or a nurse supervised by a physician.
Microneedling.
Microneedling pierces the skin with fine needles.
These micro-punctures stimulate the body to produce new collagen and elastin, and results appear gradually.
- Which scars it is used for
-
Atrophic indentations. Fractional CO2 laser and microneedling both stimulate skin repair, but the laser works through heat and microneedling through small punctures. For atrophic facial scars on medium to brown skin tones, fractional CO2 can reduce indentations more, but with slightly longer healing and more dark spots. This trade-off depends on the scars and how the treatment is carried out; it does not rank the two techniques for all skin types.
- What to expect afterwards
-
Your skin can feel uncomfortable, look red if your skin tone is fair, or look darker if it is brown or black. A sunburn-like sensation, a slight burning sensation or swelling are also possible.
- Risks
-
If performed incorrectly, it can cause infection, scarring or a lasting change in colour. A minimally invasive technique is still not risk-free.
- Skin tone
-
No skin tone rules out microneedling on its own, and no treatment suits everyone.
Peels and the CROSS technique.
A full-area peel applies acid to the entire treated area.
The CROSS technique applies high-concentration trichloroacetic acid (TCA) only inside the depression of an atrophic scar: it is not a full-area peel, and the two are not interchangeable. It can worsen scars, with more pronounced indentations and persistent redness, and it must not be attempted at home. A peel can leave redness that lasts for months, temporarily darken the skin and, for medium and deep peels, lighten it; once the skin has healed, protect it from the sun every day.
Subcision.
A needle is passed under the skin to release the fibrous bands that hold a scar down.
Subcision targets the bands under rolling scars: it releases the skin; it does not fill an indentation. Swelling, bruising and pain are temporary, but firm bumps can remain at the treated site.
Fillers.
An injected product adds volume beneath a depressed scar.
How long its effect lasts varies depending on the product, and additional visits may be needed. The most serious complication is accidental injection into a blood vessel: it can cause tissue death (necrosis), damage to vision that can lead to blindness, or a stroke.
PRP.
It is prepared from a small amount of your blood, which is drawn and then centrifuged to separate its layers, and it is sometimes combined with microneedling.
Whether adding it to microneedling is worthwhile, rather than having microneedling alone, is a question to ask the doctor; the combination does not guarantee additional improvement.
Combining several treatments. Techniques can be combined depending on the scars present, for example subcision and a filler. A combination is not automatically better, and each added treatment brings its own risks.
What to Expect: Slow Results, Sessions and What Comes Afterwards
The goal is to make indentations less visible, not to guarantee a return to perfectly smooth skin. After laser treatment or microneedling, the skin produces collagen as it heals: improvement is gradual. Results from laser treatment can take months to appear, with little change at first. Filler works differently, by adding volume; how long its effect lasts depends on the product. You and the doctor decide on the number of sessions, how far apart they are and any maintenance, based on your scars.
What to expect afterwards depends on the treatment.
Microneedling
After microneedling, the skin can be red, uncomfortable and swollen;
Subcision
after subcision, swollen, bruised and painful;
Laser
after laser treatment, it needs to heal before it returns to its usual appearance.
In all cases, the doctor gives you skin care and sun protection instructions suited to your skin. Anything that gets worse instead of better is not what you should expect afterwards.
Skin Tone and Dark Spots After Treatment
After laser treatment, microneedling or a peel, the skin can be left with darker spots, and this risk influences the choice of treatment.
After microneedling, the skin can turn red or look darker depending on skin tone. This reaction after treatment does not necessarily mean that a lasting spot has formed: a persistent change in colour is also a risk, particularly if the treatment is performed incorrectly. A peel can temporarily darken the skin, and fractional CO2 laser treatment can also leave dark spots.
A tan or a recent sunburn adds to the risk of dark spots; protect your skin from the sun before and after treatment.
- Dark spots depending on skin tone
- Fair skin toneBrown or black skin tone
Skin tone alone is not enough to rule out a treatment: the doctor takes it into account, along with the type and number of scars, and no treatment suits everyone.
What the Doctor Examines During the Assessment
During the Global Aesthetic consultation at CARE MD in Sainte-Thérèse, the doctor examines your scars: their type, depth, number and location, and whether each one is an indentation, a raised area or only a change in colour. The doctor looks at your skin tone and your skin: combination, oily or sensitive skin does not on its own point to a particular treatment. These characteristics are discussed along with the type of scar and the condition of your skin.
Each of these factors can change the choice of treatment and when it is done. During the assessment, the doctor may also conclude that your acne first needs to be better controlled, or that colour, not contour, is what bothers you.
Creams and Home Care: What They Do Not Do
For mild scars, a prescribed treatment applied to the skin can make the mark less visible; the doctor checks whether it is appropriate for you. A cream does not fill a deep indentation. Microneedling devices sold for home use carry a risk of infection or scarring when they pierce the skin.
After a Treatment: When to Seek Care Right Away
Seek care right away
After a peel
- Burns
- Itches
- Swells
After a filler injection
- Unusual pain
- Change in vision
- White, grey, bluish skin
- Stroke
After a peel, if your skin burns, itches or swells, contact the person who performed it; after a filler injection, if you have unusual pain, a change in vision, white, grey or bluish skin near the injection site or any sign of a stroke, get immediate medical help rather than writing to CARE MD or filling out a form. After another treatment, contact the person who performed it if a change worries you. In the meantime, do not treat your skin yourself.
Ask Us About Your Acne Scars
Frequently Asked Questions
Can a cream or home remedy erase an acne scar?
A cream does not fill a deep indentation. For mild scars, a prescribed treatment applied to the skin can make the mark less visible; the doctor checks whether it is appropriate for you. A flat red or brown mark is a different matter: it is a change in colour, not in contour, and it tends to fade over time. As for microneedling devices sold for home use, they carry a risk of infection or scarring when they pierce the skin; the CROSS technique and other medical treatments must not be attempted at home.
Sources6 references
What about acne scars on the back?
On the back, three things should be considered separately: pimples that are still active, flat red or brown marks that remain after them, and scars that change the skin's contour. The back, like the chest, is a common site for a firm raised scar, known as a hypertrophic scar. For pimples that are still active, acne treatment comes first; controlling flare-ups limits new scars without erasing old ones. CARE MD does not offer any aesthetic treatment on the back: what applies to scars on the face does not apply to scars on the back, and a doctor examines the skin to identify the nature of these marks.
Sources3 references
Are ice pick scars the hardest to make less visible?
An ice pick scar looks small on the surface but extends deep into the skin. It may require a different approach from a rolling scar. The depth of the indentation and your skin are factors in choosing a treatment; the name of the technique is not enough to predict the result. The CROSS technique, which applies acid point by point inside an atrophic depression, is one of the options for these indentations; it carries its own risks, including worsening of the scar.
Sources4 references
Can an indented acne scar disappear completely?
Treatment aims to make the indentation less visible, not to guarantee that it will disappear. Laser treatment can make a scar less visible without erasing it; results can take months to appear, with little change at first and sometimes several sessions. Microneedling also stimulates collagen production, gradually. A filler instead adds volume, for a length of time that depends on the product. What you can expect depends on the type of scar, its depth and your skin: perfectly smooth skin cannot be promised.
Sources3 references
Can acne scars be treated on brown or black skin?
Skin tone alone does not rule out a treatment, but it matters. After fractional CO2 laser treatment, microneedling or a peel, the skin can be left with darker spots: after microneedling, your skin can look red if your skin tone is fair, or look darker if it is brown or black. This change after treatment and a persistent spot are not the same thing. The doctor weighs your skin tone along with the type and number of scars, and takes it into account when choosing the treatment and precautions, including sun protection before and after.
Sources5 references
What does the doctor check during the assessment, and what should you prepare?
The doctor examines the type, depth, number and location of your scars, distinguishes indentations, raised areas and colour, looks at your skin tone and your skin, then reviews your acne, your recent treatments, any history of raised scars, your general health and your expectations. Each of these factors can change the choice of treatment and when it is done. To prepare for the consultation, note the acne treatments you are using or have used, and have your questions ready: which scar does the treatment target, what are the risks for your skin tone, what should you expect afterwards, how many sessions are involved, and what improvement can you hope for?
Sources4 references
Is a red or brown mark after a pimple a scar?
Generally not, if it stays flat and only the colour changes. The red mark is residual redness, the brown mark a change in pigment, and both tend to fade over time, whereas a true scar persists. Sometimes all three are present on the same skin: redness, a brown spot and an indented scar. On examination, the doctor separates colour from contour, so that redness is not treated as an indentation.
Sources2 references
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- American Academy of Dermatology — Acne scars: Causes (opens in a new tab)
- American Academy of Dermatology — Acne scars: Signs and symptoms (opens in a new tab)
- American Academy of Dermatology — Acne scars: Consultation and treatment (opens in a new tab)
- American Academy of Dermatology — 10 things to know before having laser treatment for your scar (opens in a new tab)
- American Academy of Dermatology — Microneedling: scars and skin tone (opens in a new tab)
- American Academy of Dermatology — Chemical peels: FAQs (opens in a new tab)
- U.S. Food and Drug Administration — Dermal Fillers (Soft Tissue Fillers) (opens in a new tab)
- Bae-Harboe and Graber, Journal of Clinical and Aesthetic Dermatology — Post-inflammatory erythema (opens in a new tab)
- Agrawal et al., Indian Dermatology Online Journal — Evaluating the Pros and Cons of Fractional CO2 Laser Versus Microneedling in Atrophic Acne Scars in the Skin of Color: A Split Face Study (opens in a new tab)
- Manuskiatti et al., Dermatologic Surgery — Fractional Er:YAG and CO2 lasers for atrophic scars (opens in a new tab)
- Vaishnani, Indian Journal of Dermatology, Venereology and Leprology — Subcision for rolling scars (opens in a new tab)
- Alam, Omura and Kaminer, Dermatologic Surgery — Subcision for acne scars (opens in a new tab)
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- Veenstra, Fakhoury and Ozog, Journal of Clinical and Aesthetic Dermatology — Worsening of acne scars after the CROSS technique (opens in a new tab)
Acne Scars: Limitations and Precautions
At CARE MD, the doctor examines your scars to choose what is appropriate for your skin: a description alone is not enough.
Limitations and precautions
Have your active acne treated first. Mention your current or recent treatments, and leave any change to a prescription to your doctor.
If you have brown or black skin, laser treatment, microneedling or a peel can leave dark spots; your skin tone is a factor in the choice of treatment.
Wait before having laser treatment if you have recently tanned or had a sunburn, and before microneedling if you have active pimples or an infection. Protect yourself from the sun before and after treatment.
At home, microneedles that pierce the skin can cause an infection or leave a scar. Do not attempt the CROSS technique at home either.
Seek care right away: after a peel, contact the professional if your skin burns, itches or swells. After a filler injection, get immediate medical help for unusual pain, a change in vision, white, grey or bluish skin near the injection site or a sign of a stroke. For any other treatment, tell the professional about any change that worries you.
You can hope to make your indentations less noticeable, but there is no assurance that they will disappear. Your ice pick scars and rolling scars may require different treatments.
With laser treatment, you sometimes need to plan for several sessions and months before you see a result; with microneedling, improvement is also gradual. Filler adds volume, and how long it lasts varies depending on the product.
Your flat red or brown marks are related to colour, not to scarring: treating the indentations does not necessarily correct them.
Combining treatments exposes you to the risks of each one and does not ensure a better result.
You cannot fill a deep indentation with a cream.
