Rolling Acne Scars

Atrophic Acne Scars: Definition, Causes, and Treatment Options

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    Having atrophic acne scars deeply frustrates you. The sight of these blemishes being visible on your face leaves you feeling nothing but insecure. So many attempts you’ve tried to remove them, but nothing seemed to ever work.

    Healing acne scars is indeed a long journey filled with trials and errors, and you’re not alone in this. Many people are struggling with the same issue, especially with atrophic scars that are notoriously difficult to diminish.

    Now if you’re here to find the right solutions to heal your atrophic acne scars, you’ve come to the right place! In the following article, we’ll guide you through atrophic acne scars, all the way to the effective treatment options you can try.

    Keep on reading and heal your pesky atrophic acne scars today!

    What are Atrophic Acne Scars?

    atrophic acne scars

    Atrophic acne scars are indented breakout scars that heal beneath the skin’s surface. They occur when your skin is unable to regenerate sufficient tissues during the healing process, resulting in depression scarring.

    Aside from acne breakouts, other factors can contribute to this indented scarring. Skin trauma like chicken pox and more removal surgery may also lead to atrophic scars. The indentation can be further classified into the following forms:

    Boxcar Scars

    Boxcar scars are indented scars with a crater-like appearance. They have a depth of 0.1 to 0.5 mm, along with sharp vertical walls and a flat base with a width of 1 to 4 mm. The base of the scars appears squarish, which is why they are named ‘box’.

    This type of atrophic scar is the most common one, making around 20 – 30% of atrophic scars compared to icepick and rolling scars. They typically appear as a round or oval depression on your skin, but they can also have an uneven shape.

    In addition, due to the sharp vertical edges, it can be challenging to completely remove boxcar scars. Several atrophic acne scars treatments may be needed to minimise them and improve your skin appearance.

    Icepick Scars

    Icepick scars are distinguished by the narrow and pitted scars on your skin. They appear as if a tiny icepick has punctured a hole in your skin, which is how they got their name.

    The depth of icepick scars may vary. The width, on the other hand, is less than 2 mm, making it the narrowest atrophic scar compared to the boxcar and rolling scars. Despite the small size, ice pick scars have the deepest damage to the skin.

    The damage caused by icepick scars may reach deep into your dermis layer. This, in turn, makes removing icepick scars to be difficult. A combination of specialised treatments for atrophic acne scars may be required to heal them.

    Rolling Scars

    Rolling scars are identifiable by the sloping edges, making the skin surface appear wavy, uneven, or ‘rolling’. Aside from the sloping edges, you can also recognise them by their appearance which resembles the letter ‘M’.

    Around 15 – 25% of atrophic scars are rolling scars. They typically bear a size of 4 to 5 mm width, which is wider than boxcar scars, but shallower than icepick scars. Due to the wider diameter, it can be challenging to remove them.

    Several combinations of atrophic acne scars treatment may be required to lift the indentation and smoothen it out to the surrounding skin. It also demands your patience to wait until you see improvements in your skin.

    How Common Are Atrophic Acne Scars?

    Atrophic acne scars are very common, affecting a significant number of individuals who have experienced acne. It is estimated that approximately 95% of people with acne will develop at least one atrophic scar on their skin.

    The presence of atrophic acne scars can affect one’s self-esteem. These sunken scars are responsible for impairing self-confidence, social interactions, and overall well-being. This is why it’s essential to address them accordingly to regain your confidence.

    Understanding what causes the indentation is the first step in treating atrophic acne scars. From there, you will know how to treat the underlying causes to avoid scarring and how to reduce depression scarring if it is unavoidable.

    What are the Factors Causing Atrophic Acne Scars?

    person dealing with atrophic acne scars

    Atrophic scars are the scarring that may occur once acne heals. However, this is not always the case. Other factors may increase the risk of these depression scars, which we’ll discuss further in the following:

    Severe Breakout

    Severe breakout causes intense inflammation of the skin. This intense inflammation erodes the outermost layer of skin. When the outer layer of skin is eroded, it may be more difficult for your body to regenerate enough collagen and fibrous tissues during the healing process.

    This is why it is so essential to properly care for severely inflamed skin to prevent further damage. You may want to use calming skincare products, go through specialised acne treatments, and use sunscreen to protect your skin from UV rays.

    Picking or Popping Acne

    Do you feel the urge to pick or pop your pimple bumps? If so, never, ever pick or pop your pimples, no matter how badly you want to. Picking or popping pimples can disrupt your skin’s natural healing process, which in turn can lead to atrophic scars.

    When you pick or pop pimples, your skin’s top layer hasn’t finished regenerating the fibrous tissues and collagen that aid in wound healing. If this occurs, your skin will force itself to cover the wound, resulting in sunken scarring.

    If you have trouble resisting the urge to pick or pop your pimples, consider using a pimple patch instead. The pimple patch will cover your pimples and reduce the possibility of you accidentally scratching them.


    Some people are genetically predisposed to have atrophic scars compared to others. Their skin naturally has a lower ability to regenerate fibrous tissues and collagen after experiencing inflammation from acne, chickenpox, and so on.

    In this case, skin care products and specialised acne treatments can be the rescue. Clinically prescribed products, combined with in-office treatments, may aid in the improvement of skin texture following an acne breakout.

    Delayed Treatments

    Proper acne healing is key to preventing atrophic scars from developing. However, some people are unaware of its importance, causing the inflammation to exacerbate and lead to depression scarring.

    If you are currently struggling with an acne breakout, don’t let yourself fall into the same cycle. You may want to opt for clinically prescribed skincare products, formulated to suit your skin type and concerns to aid in the acne healing process.

    However, if you see no significant improvements, you may want to combine the skincare products with laser treatments. Some of the techniques that can help you heal your breakout include Sciton Broadband Light (BBL), Revlite, Agnes Radio Frequency, and more.

    Does Acne Always Cause Atrophic Scars?

    Even though atrophic scars are common, not all acne will leave indented scars after it heals. Other kinds of scarring may also occur if the breakout doesn’t heal properly. We’ll explain more about them in the following:

    Other Types of Acne Scars

    Post-Inflammatory Hyperpigmentation

    Post-inflammatory hyperpigmentation (PIH) is a type of hyperpigmentation that develops following inflammation, including acne breakout. The infected area may turn brown, purple, or black, making it stand out from the surrounding skin tone.

    People with darker skin complexions (i.e., Fitzpatrick IV-VI) are more likely to experience this inflammatory-induced hyperpigmentation. This is because their bodies naturally produce more melanin, which can be increased when triggered by inflammation.

    Other factors, such as bacterial skin irritation, may worsen hyperpigmentation. This leaves the dark discolouration to last longer and becomes more difficult to remove.

    In addition, post-inflammatory hyperpigmentation (PIH) can present alone or in combination with atrophic acne scars such as boxcar, icepick, and rolling scars. When a combination of either indented scars occurs, healing the scars becomes even more challenging.

    Post-Inflammatory Erythema

    Post-inflammatory erythema (PIE) is a type of skin discolouration that occurs after the skin has been inflamed. Acne breakout and rosacea are the most common factors that contribute to PIE, resulting in redness around the affected area.

    People with lighter skin tones (i.e., Fitzpatrick I – III) are more prone to experience post-inflammatory erythema (PIE). This condition occurs as a result of damaged blood vessels that manifest as redness on the skin that stays for months, even years.

    Though post-inflammatory erythema is harmless, having it with a combination of atrophic scars can make the scarring more visible. This leaves you feeling self-conscious about your skin. Hence why getting treatment is necessary to reduce the blemishes.

    Hypertrophic scars

    Hypertrophic scars appear as raised lesions that develop as a response to wound healing. They occur as a result of fibrous tissue overgrowth around the inflamed area. Acne, in this case, is one of the factors that contribute to the raised scars.

    Furthermore, hypertrophic scars can be difficult to remove. Home remedies take time to take effect and have a lower chance of producing optimal results than a combination of specialised treatments.

    Despite making you feel self-conscious, these scars are completely harmless. They typically rise no more than 4 mm above the skin and have no chance of growing larger. This makes these scars differ from keloids, which appear darker and may grow larger over time.

    Can Skincare Help Atrophic Acne Scars?

    Skin care products for Atrophic acne scars

    Skincare products can help to reduce acne inflammation. They protect your skin from further damage by providing acne treatment properties. But, once atrophic scars have formed, there’s nothing much skin care can help to lift the indentation.

    That being said, it’s essential to take care of your acne before it goes too severe and forms depression scarring. Below are some of the skincare ingredients that can help to reduce your breakout inflammation:


    Retinoid is a vitamin A derivative that is commonly used to treat acne. It works by exfoliating dead skin cells, removing dirt, and regulating oil production on the skin’s outermost layer. This will cleanse your pores and prevent pimples from forming.

    Retinoid also goes under your skin surface. It blocks several inflammatory substances in your body, boosts collagen production, and stimulates the formation of new blood vessels. As a result, you will gradually have less inflammation and a more even skin tone.

    If you wish to add retinoid into your skincare routine, make sure to only use it at night and wear sunscreen during the day. Since retinoid accelerates skin regeneration, the new skin cells may be sensitive and prone to sunburn, which sunscreen can protect from.

    Azelaic Acid

    Azelaic acid is a skincare ingredient that helps to soothe inflamed skin. It works by neutralising free radicals that cause inflammation and blocking melanin production, which causes discolouration.

    This makes Azelaic acid an ideal property to improve the appearance of PIH, PIE, rosacea, and other discolouration associated with acne breakout. Adding this ingredient to your skincare routine will gradually smoothen out your skin tone.

    However, using Azelaic acid should be followed by sunscreen. Due to the blocked melanin production, this ingredient may make your skin more sensitive. Sunscreen will keep your skin protected from sunburn, which is prone to cause further discolouration.

    Tea Tree Oil

    Tea tree oil is one of the most well-known acne treatment ingredients. It has anti-microbial and anti-inflammatory properties that can help fight bacteria and swelling caused by acne breakouts.

    As a result, tea tree oil is an ideal ingredient for reducing the severity of acne lesions. Including it in your skincare routine will gradually reduce mild to moderate breakouts, and you can use it both day and night.

    Always use tea tree oil together with moisturising agents like hyaluronic acid, ceramides, or glycerin. This is because this ingredient may cause dryness on your skin, which moisturisers can help to balance out.

    Centella Asiatica

    Centella asiatica is a natural ingredient with anti-inflammatory properties that fights acne and reduces redness and hyperpigmentation. It provides a gentle skin-calming effect, making it suitable for all skin types, including sensitive ones.

    Due to centella asiatica’s gentle properties, consistency is key if you want to see results on your breakout. If you have acne-prone skin, it’s even better if you include this ingredient in your routine even when you are not having a breakout.

    Just like tea tree oil, centella asiatica may cause skin dryness in some people. That’s why it’s essential to add moisturising ingredients like ceramides, hyaluronic acid, or glycerin following the application of centella asiatica.

    Snail Essence

    Snail essence makes a headliner in the Korean beauty industry. Its properties are known to give multiple benefits at once, including fighting acne inflammation, providing ample skin hydration, and fighting off discolouration caused by severe breakouts.

    The snail extract is also light and does not clog pores. This makes snail essence suitable for all skin types, particularly acne-prone skin. There’s no need to be concerned about it over-hydrating your skin and causing more breakouts.

    Furthermore, snail essence has been found to possess antioxidant properties. Antioxidants are essential to neutralise free radicals, which can damage the skin and accelerate the ageing process. Using snail essence, in turn, keeps your skin healthy for a long time.


    Niacinamide is a type of vitamin B3 that is widely available in skincare products. It’s known to provide numerous skin health benefits, namely fighting off acne inflammation, minimising blotchiness, improving skin barrier, and many more.

    This ingredient is also gentle, making it suitable for all skin types, including sensitive ones. You can also safely combine it with other acne-fighting agents, such as retinoid, centella asiatica, or tea tree oil to see more prominent results for your acne.

    Furthermore, using niacinamide alone or in combination with other properties should also be followed by sunscreen. This is to ensure that your skin remains protected from UV rays, as well as allowing you to see optimal results from the ingredient.

    Alpha Arbutin

    Alpha arbutin is a derivative of hydroquinone, making it less potent and poses less risk to the skin. It provides brightening properties, which help to reduce redness, hyperpigmentation, melasma, and other blotches caused by acne breakouts.

    This ingredient lightens your skin by inhibiting the production of melanin. As your melanin production is inhibited, your skin will produce less pigmentation, causing your scars to gradually smooth out to the surrounding skin.

    Due to how alpha arbutin works, you need to use sunscreen in the daytime. This is to protect your skin from sunburn. It’s recommended that you use at least 30 SPF to prevent further discolouration from harmful UV rays.

    Clinical Atrophic Acne Scar Treatments

    Clinical Atrophic Acne Scar Treatments

    The series of skincare products that we mentioned earlier has the benefit of relieving the inflamed acne that you experience. In addition to reducing inflammation, some products also help reduce redness and hyperpigmentation caused by breakouts.

    Since those skincare products are only useful for calming down your acne, they can’t help anything if atrophic acne scars have already formed. Now the question is, how to reduce the appearance of the indentation?

    To reduce the appearance of indented scars, you will need to undergo a series of treatments specifically designed to even out the skin’s surface. The following are treatment options that you can choose from or you can combine one with the other:

    Fractional CO2 Laser

    The fractional CO2 laser is a non-surgical skin resurfacing treatment. It works by delivering photo thermolysis energy into the deep skin layers, which will gradually lift the indentation caused by atrophic acne scars.

    The photo thermolysis energy lifts the indentation by removing old skin cells and promoting the growth of newer skin cells. It also stimulates collagen remodelling, which is necessary for giving your skin structure, especially after it has been lost due to atrophic scars.

    Furthermore, this technique is suitable to perform on all types of atrophic acne scars, including boxcar, icepick, and rolling scars. This allows you to have an improved skin texture, no matter what type of atrophic scar you’re struggling with. 

    However, it’s important to note that a fractional CO2 laser requires several sessions before you see optimal results. Patients should ideally receive 3 to 4 treatments until the indented skin surface begins to resurface and blend with the surrounding skin.

    Dermal Peels

    Dermal peels or chemical peels contain acid solutions that serve to promote cell regeneration. The acid solution works by removing the dead skin cells, stimulating new cell production and increasing collagen production in patients with atrophic acne scars.

    The removal of dead skin cells entails the solutions to temporarily damage the skin’s outermost layer. Collagen and fibrosis tissues will begin to produce beneath the damaged skin, resulting in the gradual resurfacing of the indented scarring.

    Dermal peels are suitable to perform on all types of atrophic acne scars, such as boxcar, icepick, and rolling scars. The effects, however, are subtle and may require multiple sessions before you see the optimal results.

    Aside from requiring multiple sessions, dermal peels also require your careful attention to the side effects. This treatment will cause peeling that lasts for 7 days. Avoid pulling the dead skin and use sunscreen to protect your skin from sun damage.

    Intracel Microneedling

    Intracel microneedling is a non-surgical skin resurfacing treatment. It works by combining the microneedling technique with radiofrequency energy to deliver more prominent results in atrophic acne scars.

    Microneedling entails introducing fine microneedles into the damaged areas. On the other hand, radiofrequency provides heat energy into the deep skin layers. When used together, these properties effectively stimulate collagen and fibrosis tissue production to resurface the indented scars.

    Furthermore, this treatment is suitable to perform on any type of atrophic acne scars, such as boxcar, icepick, and rolling scars. It’s also advantageous to minimise the appearance of blemishes that may be present along with the atrophic scars.

    However, it takes time before you see optimal results from this treatment. Patients mostly will have to undergo 6 sessions with a 4 – 6 weeks interval until they see the resurfacing effects on their atrophic acne scars.

    Dermal Fillers

    Dermal fillers are injectable hyaluronic acid, performed to rejuvenate volume loss. The hyaluronic acid solutions will fill out the sunken area and smoothen it out to the surrounding skin.

    Dermal fillers are typically used to minimise ageing signs or to accentuate certain parts of the face. However, it’s now also popular to use them on atrophic acne scars, as they effectively lift the indentation and reduce the appearance of depression scarring.

    The effects of dermal fillers on atrophic scars are also immediate. You can see the results right after getting the injections. However, it’s important to note that the results won’t stay permanently, as the solutions will subside after a year or two.

    If you wish to receive a quick fix for your atrophic acne scars and don’t mind the temporary effects, dermal fillers make an ideal choice. The treatment is now available in Restylane and Juvederm brands, which you can choose from based on your personal preferences.


    Sculptra is an injectable poly-L-lactic acid (PLLA). It’s primarily used to treat ageing signs, such as wrinkles, fine lines, and sagging skin. But as time progresses, the volumising effects are now proven to reduce the appearance of atrophic acne scars as well.

    Furthermore, choosing Sculptra as a part of treatment for your depression scarring gives you plenty of benefits. The PLLA properties from Sculptra will stimulate your body’s natural collagen production, which in turn, will gradually rejuvenate the sunken areas of your skin.

    Unlike dermal fillers that use natural ingredients (i.e., hyaluronic acid), Sculptra uses a main substance that lasts longer. Most patients can enjoy the lifting effects on their skin for approximate time of 2 years or more.

    However, the lifting effects from Sculptra may not be as immediate as dermal fillers. Sculptra takes time to settle on your skin and begin the collagen remodelling process. Considering the benefits it offers, it remains an adept choice for treating atrophic scarring.

    Rejuran Healer

    Rejuran healer is a skin booster made of salmon DNA and polynucleotides (PN) as the main ingredients. These ingredients are biocompatible and work effectively in promoting collagen production to revitalise your damaged skin structure.

    Rejuran healer is best combined with other treatments such as Fractional CO2 laser, dermal peels, or Intracel microneedling. As these other treatments remove the dead skin cells on the outermost layer, Rejuran healer will stimulate collagen production from deep within.

    Ensuring that your skin has levels of sufficient collagen is necessary to gradually minimise the atrophic acne scars. This can be achieved through the combination of dead skin cell removal with collagen-boosting properties from a Rejuran healer.

    As a result, when you undergo Rejuran healing alongside other treatments, the improvements in your depression scarring will be more noticeable. This allows you to enjoy smoother, luminous skin, free of blotchiness.


    Subcision is a treatment in which needles are inserted beneath the atrophic acne scars. The needles cut the fibrous tissues that hold down the depression scarring. The scar will gradually lift and look more even to the surrounding skin as these fibrosis tissues are cut.

    Furthermore, subcision is regarded as an invasive procedure. Most patients will experience painful sensations during the procedure, which varies depending on their pain tolerance. 

    As a result, if you prefer less invasive procedures with comparable results, we recommend Fractional CO2 laser, chemical peeling, or Intracel microneedling. These procedures work effectively in lifting the indentation and reducing the appearance of your atrophic acne scars.

    Final Thoughts

    Finally, our discussion about atrophic acne scars has come to an end.

    Let’s do a quick recap before we finish this article. From what has been discussed, atrophic acne scars form as a result of an improper acne-healing process, resulting in depression scarring. Using only skincare products to remove depression scarring isn’t enough.

    To effectively lift the indentation, you will need to undergo specialised atrophic acne scars treatment, varying from Fractional CO2 laser, Dermal peels, Intracel microneedling, and more. These treatments are performed by a professional at a reputable aesthetic clinic.

    If you wish to receive atrophic acne scars treatment, let us help you out! Celevenus is an aesthetic clinic led by Dr Dylan Chau, a professional medical aesthetic doctor who will guide you through the appropriate treatment plans suitable for your skin concerns and condition.

    Contact us today and regain your confidence with smoother skin!


    Do atrophic acne scars go away?

    Atrophic acne scars hardly go away on their own. However, clinical treatments like Fractional CO2 laser, dermal peels, or Intracel microneedling can help to minimise the depression scarring appearance.

    How do you know if a scar is atrophic?

    Your scar belongs to the atrophic scarring if it appears indented. The indentation can look like tiny icepicks poking your skin (icepick scars), sharp vertical edges with a square flat base (boxcar scars), or a shallow depression that causes your skin to appear wavy (rolling scars).

    What do atrophic scars look like?

    Atrophic acne scars look like depression on your skin. The affected areas will appear sunken compared to the surrounding skin, which varies in size and shape.

    How do you fix concave acne scars?

    Concave acne scars, also known as boxcar scars, require clinical atrophic acne scar treatments to be removed. Treatments such as fractional CO2 laser, dermal peels, and Intracel microneedling will remove the damaged surface, resulting in smoother skin texture over time.

    About Celevenus Wellness & Aesthetic Clinic

    Celevenus is an aesthetic clinic in Singapore that offers a variety of signature treatments to rejuvenate the body and skin. Our series of treatments use non-surgical methods, so they are suitable for anyone unsure about going under the knife.

    Led by Dr Dylan Chau, who is an expert in blending science and artistry, we are here to provide several face enhancement methods, such as Sculptra, dermal fillers, HIKO nose threadlift, and acne scar treatments, that are safe and provide optimal results for our patients.

    What’s more, we also perform non-surgical body contouring using the Venus Legacy method. This treatment makes an ideal choice for anyone who dreams of having a slimmer body silhouette but fear undergoing an invasive procedure that takes longer to heal.

    Overall, we strive to be a trustworthy aesthetic clinic that prioritises the right solutions for our patients through the variety of face and body enhancements we offer.

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