Icepick, Boxcar and Rolling Acne Scars: How to Identify Your Scar Type and Match It to the Right Treatment

If you have ever bought a treatment for “acne scars” and been disappointed, the problem may not have been the treatment. It may have been the match. Acne scars come in distinct shapes, and a technique that smooths one type barely touches another.

When I evaluate scarring, I use angled lighting and look at the skin from several directions, because shadows reveal the scar architecture. In this guide I’ll walk you through the main scar types, what each one responds to, and why nearly everyone with significant scarring ends up with a combination plan.

First, make sure it is a scar

Flat brown or purple marks after acne are usually post-inflammatory hyperpigmentation, and flat pink or red marks are often post-inflammatory erythema. Neither is a true scar, and both tend to fade with time and gentler treatment. True scars change the surface of the skin: they are sunken (atrophic) or raised (hypertrophic or keloid). This guide focuses on the sunken kind, which makes up the large majority of acne scarring.

One more essential point: active acne should be controlled before we work on scars. Every new deep breakout can create a new scar, so treating the cause comes first.

The three main types of atrophic acne scars

Icepick scars

These are narrow, deep, pointed pits, often less than two millimeters wide, that look as if the skin was punctured with a sharp tool. Because they are narrow at the surface and extend deep, surface treatments alone rarely improve them much.

Boxcar scars

These are wider, round-to-oval depressions with sharp, vertical edges, like a small crater. They can be shallow or deep. Shallow boxcar scars are among the most responsive to resurfacing.

Rolling scars

These have soft, sloping edges that create an undulating, wavy texture across the cheeks. They are caused by fibrous bands that tether the skin down to deeper tissue. They often look worse in overhead lighting and better when you stretch the skin.

Most people have a mixture of all three, which is why a single-treatment approach often falls short.

Matching treatment to scar type

• Icepick scars: focal techniques that target each scar individually work best. One example is the TCA CROSS technique, where a high-strength acid is applied precisely into the scar to stimulate collagen from the bottom up. Small surgical punch techniques are another option. These are procedures to discuss at a consultation; we can refer when a surgical approach fits best.
• Boxcar scars: resurfacing is the workhorse. Fractional and deep CO2 laser resurfacing on our laser skin page softens the sharp edges and rebuilds collagen. Morpheus8 radiofrequency microneedling delivers heat deeper in the skin with less surface injury, which makes it useful for a broader range of skin tones.
• Rolling scars: the tethering bands need to be released. Subcision, a technique that uses a needle beneath the skin to cut those bands, is often the key step, and it is something to discuss at a consultation. Collagen-building treatments like microneedling and, in select cases, volume from dermal fillers can lift the depressed areas.

Why combination plans work best

Scarring is three-dimensional. Resurfacing addresses the surface; collagen stimulation addresses the middle layers; release and volume address what is pulling the skin down. A typical plan might start with release or focal treatments for the deepest scars, then follow with a series of microneedling or radiofrequency microneedling sessions, and finish with resurfacing to refine texture.

Improvement is gradual because collagen remodeling takes months. I tell patients to think in terms of meaningful improvement, often a clear shift in how the skin looks in photos and in person, rather than complete erasure. Before-and-after comparisons should always be taken in consistent lighting.

Who should wait or proceed carefully

• Active acne should be treated first.
• Recent isotretinoin use: timing of procedures after isotretinoin is individualized and should be reviewed with your prescribing physician and our team.
• History of keloids makes aggressive resurfacing riskier.
• Deeper skin tones carry a higher risk of post-inflammatory hyperpigmentation with heat-based lasers, so we choose devices and settings with that in mind and often pretreat the skin.
• Pregnancy, active infections, cold sores and certain medications require a pause or preventive steps.

Frequently asked questions

What is the best treatment for rolling acne scars?

Rolling scars usually respond best to releasing the fibrous bands that tether the skin, followed by collagen stimulation with microneedling or radiofrequency microneedling. Fillers can help in select cases.

Can a laser fix icepick scars?

Lasers alone often have limited effect on deep icepick scars because they are narrow and deep. Focal techniques that treat each scar individually usually work better, with resurfacing added afterward.

How many sessions will I need?

It depends on scar depth and type. Many people need three or more collagen-building sessions spaced several weeks apart, and some benefit from one deeper resurfacing treatment.

Will my acne scars disappear completely?

Complete removal is uncommon. The realistic goal is a significant, visible improvement in depth and texture that makes scars much less noticeable.

Find out what your scars need

At Serene Med Spa, treatments are performed or supervised by trained medical professionals under my oversight. Schedule a complimentary, no-commitment consultation and we will identify your scar types together and build a step-by-step plan.

• Hudson, OH: 50 W Streetsboro St, Suite 2 · (330) 460-5915
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References: Jacob CI, Dover JS, Kaminer MS. Acne scarring: a classification system and review of treatment options. Journal of the American Academy of Dermatology. 2001. · Goodman GJ, Baron JA. Postacne scarring: a qualitative global scarring grading system. Dermatologic Surgery. 2006. · American Academy of Dermatology. Acne scars: diagnosis and treatment. aad.org.

This article is for general information only and is not medical advice. Treatments are provided only after consultation and evaluation by a licensed provider. Individual results vary.