Acne Scars: Ice Pick, Boxcar & Rolling Scars — Treatment Options

Acne scars are harder to treat than the acne that caused them. One of the biggest reasons people spend money on treatments that don't work is this: not all acne scars are the same, and no single treatment addresses all types. Here is how to identify each type, and what actually works for each.

First — scars vs post-acne marks

Before anything, understand the difference between scars and post-inflammatory hyperpigmentation (PIH):

• PIH is a flat brown or red mark left after a pimple heals. It is not a scar. It fades on its own in 3 to 12 months and responds well to sunscreen, retinoids, azelaic acid, and chemical peels — see our pigmentation treatment page.
• True acne scars are permanent changes in skin texture — a depression, a raised bump, or an uneven surface — that will not fade without a treatment that physically rebuilds the dermis.

Run a finger over the area. If you feel a dip, pit or bump, it is a scar. If the skin feels smooth and only the colour differs, it is PIH.

The three main types of atrophic (depressed) acne scars

Atrophic scars form when the body does not produce enough collagen during healing. They fall into three well-defined patterns:

1. Ice pick scars

Look: narrow (less than 2 mm wide), deep, V-shaped punctures that extend into the deeper dermis. Looks like a tiny puncture from an ice pick.

Where: most often on the cheeks and temples.

Why they are hard: their depth is far greater than their width, so surface treatments like microneedling and laser cannot reach their base.

2. Boxcar scars

Look: wider (2–4 mm) depressions with sharply defined vertical walls. The base is flat. Think of them as little craters.

Shallow boxcar scars (less than 0.5 mm deep) respond well to resurfacing. Deep boxcar scars have steeper walls and often need combined treatment.

Where: commonly on the cheeks and jawline.

3. Rolling scars

Look: broad, shallow depressions with sloping edges that give the skin a rolling, wave-like appearance. Caused by fibrotic bands tethering the skin from below.

Where: typically on the lower cheeks and jawline.

Key insight: rolling scars won't resolve unless the tethering band under them is released.

Hypertrophic and keloid scars (raised scars)

Less common but important: some people — especially on the jawline, chest and back — develop raised, firm scars after acne. These need a different approach: intralesional steroid injections, pressure therapy, silicone sheets or specific laser treatments.

Treatment matched to scar type

For ice pick scars

• TCA CROSS (Chemical Reconstruction of Skin Scars) — a tiny drop of high-concentration trichloroacetic acid is placed inside each scar. The controlled injury triggers collagen remodelling that lifts the base over multiple sessions. Gold standard for ice pick scars.
• Punch excision — the scar is surgically removed and the edges sutured, converting it into a thin, easier-to-treat line.
• Fractional CO2 or Er:YAG laser — useful in combination for surrounding texture, but not sufficient alone.

For boxcar scars

• Fractional ablative laser (CO2 or erbium) — the gold standard for shallow-to-moderate boxcar scars. Delivers tiny columns of controlled injury that stimulate collagen remodelling.
• Punch elevation — for deeper boxcar scars with intact bases: a punch tool lifts the scar base to skin level, where it heals flush.
• Microneedling with RF (radiofrequency) — effective for medium-depth boxcar scars; delivers heat energy into the dermis to tighten and remodel.
• TCA peels (medium depth) — useful adjunct in a treatment series.

For rolling scars

• Subcision — the single most important treatment for rolling scars. A specialised needle is inserted under the scar to break the fibrotic bands tethering it. Often combined with filler to prevent re-tethering.
• Microneedling (RF or standard) — layered on top of subcision over several sessions to improve surface texture.
• Dermal fillers — hyaluronic acid or biostimulatory fillers temporarily or semi-permanently lift the depressed area.
• PRP or exosomes — adjuncts to boost collagen response (see our article on exosomes for hair and skin).

For raised (hypertrophic / keloid) scars

• Intralesional triamcinolone injections — the standard first-line treatment
• Silicone gel sheets or gels for ongoing suppression
• Pulsed dye laser or long-pulsed Nd:YAG for vascular reduction
• Combination treatment for keloids — never a single modality

The reality of combined treatment

Most patients have more than one scar type. A typical plan therefore combines techniques — for example:

1. Session 1: Subcision for rolling scars + TCA CROSS for ice picks
2. Session 2 (6 weeks later): Fractional CO2 laser for overall texture
3. Session 3–4: Microneedling with growth factors or PRP for continuous remodelling
4. Ongoing: strict sunscreen, retinoid, and barrier care

Three to six sessions over 6 to 12 months is typical for noticeable improvement. Expectations matter: a 60–80% improvement is realistic; 100% erasure is not.

What to do before any procedure

• Make sure active acne is well controlled first — treating scars on active acne can worsen them
• Stop isotretinoin at least 6 months before fractional lasers and chemical reconstruction
• Use broad-spectrum SPF 50 daily for at least 4 weeks before treatment
• Discuss history of PIH or keloid tendency — this changes the treatment plan
• Prepare for downtime: fractional laser typically means 5–7 days of redness and peeling

Home care that actually helps between sessions

• Daily sunscreen SPF 50+, reapplied every 3–4 hours
• A topical retinoid (adapalene, tretinoin or retinaldehyde) at night — stimulates collagen turnover
• Niacinamide and vitamin C for even tone
• Peptide-containing serums for ongoing dermal support
• Oral collagen and adequate protein intake (see our protein article)

Common mistakes

• Starting treatment while acne is still active
• Expecting a single microneedling session or facial to clear scars — it will not
• Treating ice pick scars with only lasers — depth matters
• Choosing clinics based on price rather than scar-type matching
• Skipping sunscreen between sessions — PIH worsens and masks progress

Bottom line

Acne scars respond to the right treatment for the right scar type — rarely to a single machine or a one-off facial. A proper assessment that classifies your scars first, then designs a staged plan combining subcision, TCA CROSS, fractional laser and microneedling as needed, is what delivers durable improvement.

At Rewind Veda, every acne-scar consultation starts with a detailed scar mapping, so you know exactly what you have and what each treatment is doing — before any session begins. See our acne treatment page and laser treatment page for related options.

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