Depressed acne scars: understanding the types is the first step to treatment

There is no single treatment that eliminates depressed acne scars all at once. Frankly speaking, that is the honest conclusion. Depressed scars (atrophic scars, Atrophic Acne Scar) are a state in which the surface of the skin has sunk because of a lack of collagen after the inflammation has subsided. Therefore, the starting point of treatment is not choosing the equipment, but accurately diagnosing what type of scar my scar is.

Depressed scars are commonly divided into three types: ice-pick, boxcar, and rolling (Jacob classification, 2001). Each type has a different shape under the skin, so the approach is completely different. The realistic goal is not a "complete cure," but an improvement to make the depression shallower, soften the boundaries, and lighten the shadows. Usually, it does not end with just one session but improves gradually over multiple sessions. I will break it down step-by-step below, by type and even post-treatment care.

🔍 What Type of Scar is Mine?

Depressed scar treatment starts with this question. If you choose the equipment first without knowing the type, the progress may be slow despite spending time and money.

The three types are distinguished as follows.

(Percentages vary by study.) Ice-pick is the most common, but it is also a tricky type that is narrow and deep, making it difficult to reach the bottom with lasers alone.

There is something you must distinguish here. Depressed scars are different from "marks." Brown marks are post-inflammatory hyperpigmentation (PIH), and red marks are post-inflammatory erythema (PIE), both of which fade over time or are approached differently. If only color remains instead of a depression, there is no reason to shave it with a laser.

📌 Key Summary: Depressed scars are divided into three types: ice-pick, boxcar, and rolling. The first step is to distinguish them from pigment and erythema marks, and then design a treatment plan suitable for the type.

🧩 How Do We Approach Each Type?

The answer is "combination therapy." Rather than trying to solve all scars with a single device, we combine the methods that best fit each type.

Ice-pick: Dot Application and Excision for Narrow, Deep Holes

TCA CROSS is a method that uses high-concentration TCA (mainly 70-100%) to precisely dot only the ice-pick scar holes, inducing collagen regeneration at the bottom. It is effective for narrow, deep scars that are difficult to reach with lasers. However, because of the high concentration, it must be handled only by medical institutions. If you copy this at home, there is a high risk of chemical burns or worsening the scars.

In truly deep cases, the scar is physically carved out using punch excision, or the bottom is lifted using punch elevation before smoothing the surface.

Boxcar: Fractional Laser for Angular Grooves

For boxcar scars, which are characterized by angular boundaries, fractional lasers are considered first. They are divided into ablative types like CO₂ and Er:YAG, and 1550nm non-ablative types, and the principle is to create microscopic thermal columns to rebuild collagen. The reported improvement rate is about 25–50% based on multiple treatments (varies by study).

Rolling: Cut the Pulling Band to Lift It Up

Rolling scars are caused by fibrous adhesion bands beneath the skin pulling the surface downward. Therefore, the key is to cut those bands with **Subcision** to lift the scar. If you **combine hyaluronic acid fillers or PRP** to prevent the space from reattaching after cutting, the effect lasts longer. Fillers also provide immediate volume, but since they are absorbed in 6–18 months, repetition is required.

In addition to this, RF microneedling, which delivers radiofrequency to the dermis, skin boosters that help produce collagen, and topical retinoids that play an auxiliary role when used consistently for 6–12 months are added depending on the situation.

📌 Key Summary: TCA CROSS and punch are standard for ice-pick, fractional laser for boxcar, and subcision for rolling. A complex design adding fillers, PRP, and microneedling is realistic.

🌏 Things to Check for Korean Skin

We cannot leave out skin tone here. Fitzpatrick types IV–VI, to which many East Asians belong, have a relatively high risk of post-inflammatory hyperpigmentation (PIH) after laser procedures.

Therefore, for darker skin tones, the energy settings are set conservatively, or RF microneedling, which has less risk of pigmentation, is considered first. This is because radiofrequency targets the deep dermis while less irritating the epidermis. This is exactly where the formula "expensive and strong device = better result" breaks down. Scar type, skin tone, and treatment design influence results much more than equipment specifications.

There is also one contraindication. If you have a keloid or hypertrophic scar constitution, you must carefully select the intensity and type of procedure. Unlike atrophic scars, this is a type where tissue rises excessively, so irritation can actually enlarge the scar. This is information that must be disclosed during consultation.

📌 Key Summary: Darker skin tones require adjustment of energy and treatment considering the risk of pigmentation, and those with a keloid constitution must inform the clinic beforehand.

⏳ How Many Treatments and How Long Will It Take?

It is best to let go of impatience. Depressed scar treatment is typically a long journey, repeated at intervals of 4–8 weeks for a total of 3–6 times or more.

The reason is collagen remodeling. The results are completed gradually within the skin over 3–6 months, not immediately after the procedure. So, there is no need to be disappointed when looking in the mirror right after the treatment. The true time of evaluation is several months later.

The recovery period varies for each method.

Although overall improvement rates up to 50–75% have been reported in combination therapy, individual differences and study deviations are large. Rather than obsessing over numbers, it is correct to look at the trend of your scars getting slightly shallower with each session.

And here is an important misconception. Just because many scabs have formed does not mean the effect is good. Excessive damage can lead to pigmentation or secondary scarring instead.

📌 Key Summary: 3–6 sessions at 4–8 week intervals are common, and because collagen remodeling takes 3–6 months to complete, the results should be evaluated slowly.

🛡️ Post-treatment Care Determines the Results

Honestly, home care often influences the results more than the procedure itself.

Sun protection is the number one priority. This is the most reliable way to prevent PIH after the procedure. We recommend applying a product with SPF 30 or higher and a PA rating every 2 to 3 hours. On top of this, keeping the skin barrier protected with sufficient moisturizing makes recovery much smoother.

There are also two premises to keep in mind.

• If you have active acne, acne control comes before scar treatment. If you try to erase only the marks when the fire is not put out, new scars will form again.

• Be sure to inform them of any medications you are taking. In particular, for isotretinoin (Roaccutane), fully ablative lasers or deep chemical peels during or for a certain period after taking it should be approached with caution. However, there are also latest opinions that non-ablative lasers and microneedling are possible depending on the situation, so it is correct to confirm during treatment rather than making a self-judgment.

If signs of infection such as severe pain, oozing, pus, increased heat sensation, or blisters appear during recovery, do not delay and visit the clinic immediately.

For reference, most acne scar treatments are for cosmetic purposes, so health insurance is difficult to apply, and lasers and fillers are non-reimbursable items.

📌 Key Summary: Sun protection and moisturizing are keys to PIH prevention, and active acne control, notification of medications, and checking for signs of infection are the basics of safety.

💬 Ask These Questions During Consultation

When you actually go, you might feel lost about what to ask. Preparing just this much is enough.

• What type of scar is my scar, and why do you recommend this treatment?

• What is the risk of pigmentation for my skin tone?

• Approximately how many sessions and at what intervals will it proceed?

• How long is the recovery period, and when can I return to daily life?

• What level of improvement can realistically be expected?

Onlif Clinic does not lump scars together as depression, adhesion, or stretch marks, but aims for a 1:1 customized method of first diagnosing the condition and then designing the treatment scope and regeneration components according to the site and depth. With a doctor specialty system where each doctor takes charge of the procedure they do best, we prioritize the direction of restoring the natural texture without overdoing it. It centers around a non-surgical approach that relieves adhesions in the skin and aids regeneration, rather than incision surgery with a scalpel.

📌 Key Summary: Asking about the type, skin tone, number of sessions, recovery, and expectations, and receiving a customized diagnosis and design that does not lump things together is the starting point of good results.

❓ Frequently Asked Questions (FAQ)

Do depressed acne scars go away naturally?

Depressed scars are in a state where the surface is sunken due to a lack of collagen, so there is almost no change in size over time. On the other hand, brown or red marks (pigmentation, erythema) can fade with sun protection and the passage of time. Distinguishing between the two is the first step.

How many treatments do I need to see results?

It is usually repeated 3 to 6 times or more at intervals of 4 to 8 weeks. Because collagen remodeling takes place over 3 to 6 months, the final result can be properly evaluated only after a few months have passed since the last procedure.

What is the most difficult type of scar to treat?

Narrow and deep ice-pick scars are on the difficult side. Since it is hard for lasers to reach the bottom, separate approaches such as TCA CROSS or punch excision are required.

Which is better, fractional laser or RF microneedling?

Rather than one being better, it depends on the scar type and skin tone. For darker skin tones, RF microneedling, which has a relatively lower risk of pigmentation, is sometimes considered first. It is correct to decide after a diagnosis.

Can I do TCA CROSS at home by myself?

No, you cannot. High-concentration TCA of 70–100% has a high risk of chemical burns and worsening scars, so it must be handled only by medical institutions.

Can I receive laser treatment while taking isotretinoin?

Fully ablative lasers or deep chemical peels during or for a certain period after taking it should be approached with caution. There are opinions that non-ablative lasers and microneedling are possible depending on the situation, so be sure to inform them of your medication and check during your consultation.

I have active acne; can I receive scar treatment together?

If inflammatory acne is active, acne control comes before scar control. Otherwise, new scars may form even during treatment.

I have a keloid constitution; is depressed scar treatment possible?

Keloids are a type where tissue overgrows, unlike atrophic scars, so caution is needed in selecting the intensity and type of procedure. You must inform them of your constitution during the consultation.

Does health insurance or actual cost insurance apply to scar treatment?

Most acne scar treatments are classified for cosmetic purposes, making health insurance difficult to apply. Lasers, fillers, etc., fall under non-reimbursable items.

Can old scars be treated as well?

Yes, it is possible. Since whether the current tissue state is atrophic or hypertrophic is a more important criterion than the time of occurrence, a direction can be set even for old scars after diagnosis.

Depressed Acne Scars: Good Things to Check Before Choosing a Clinic

Even for the same procedure, the results and recovery process differ depending on where, who, and how it is done. Asking these items directly during the consultation will help you make a decision.

• Is it a place that performs that procedure frequently? — The main procedures handled vary by clinic. Check if it is a place that regularly performs depressed acne scar treatments.

• Can I check the products and equipment used? — Ask if you can verify the product name and authenticity (whether it is an imported authorized product, and if there is an unboxing verification process) during the consultation.

• Do they explain the composition of the cost? — Rather than just hearing the total amount, you should hear explanations about which products are used, how much, and in what scope to make a judgment.

• Do they design looking at the entire face? — Even for the same procedure, the injection location and amount vary depending on the face shape, skin condition, and left-right asymmetry.

• Do they explain adverse reactions and the recovery process first? — It is better to choose a place that informs you of possible adverse reactions and coping methods together, rather than a consultation that only speaks of expected changes.

• Is there a way to verify after the procedure? — Check if the timing for confirming progress, the method for contacting if there is a problem, and the criteria for re-visiting are established.

Onlif Clinic Does Acne Depressed Scars This Way

• We divide responsibilities — With the thought that a single doctor cannot handle all procedures, Onlif divides medical treatments with responsible doctors by field.

• We check products and equipment together in the consultation — We guide you through the products used and the unboxing verification process during the consultation process.

• Costs are guided along with the composition after diagnosis — Since the site, volume, and scope differ for each person, we explain what costs how much together.

• We design looking at the overall balance of the face — We look at the face with three axes: texture, balance, and signals of youth, and establish a plan in a direction that cleans up the parts obscuring the natural impression rather than changing the shape.

• We speak of adverse reactions and the recovery process first — Along with the expected changes, we guide you through individual differences, possible adverse reactions, and coping methods before the procedure.

• We look at the progress after the procedure together — If verification is needed during the recovery period, we guide you through re-visiting and contact routes.

If you are worried about depressed acne scars, it is better to check first what is possible and what is difficult in your current condition. An accurate diagnosis and procedure plan can only be determined through an in-person consultation. Check it out through a consultation at Gangnam Onlif Clinic.