Acne scars do not all look or behave the same, and identifying the type of scar is an important first step before choosing a treatment. Although acne itself may be temporary, the marks and texture changes it leaves behind can persist for a long time. According to Dr Ajay Rana, president of the Indian Society of Aesthetic Medicine and founder and director of ILAMED, acne scars are classified based on their appearance, depth and whether they are depressed or raised. Treating every scar with the same method can therefore lead to limited results or inappropriate care.

Ice-pick scars are among the deeper forms of acne scarring. They appear as narrow, sharply defined pits that extend deep into the skin, sometimes reaching the dermis, despite having a relatively small opening on the surface. Because of their depth, ordinary superficial resurfacing procedures may not produce significant improvement. Dr Rana said treatment options may include TCA CROSS, which uses a chemical reconstruction technique, as well as punch excision or punch elevation, depending on the scar’s structure and depth.

Boxcar scars, in contrast, are generally wider depressions with clearly defined, often vertical edges. Their depth can vary, meaning that the same treatment may not be suitable for every boxcar scar. Depending on the individual case, doctors may consider fractional CO₂ lasers, erbium lasers, microneedling, radiofrequency microneedling, punch techniques or a combination of procedures. The choice is influenced by the size, depth and distribution of the scars, as well as the patient’s overall skin condition.

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Rolling scars have a softer, uneven appearance and create gently undulating depressions across the skin. They are often linked to fibrous bands beneath the surface that tether the skin to deeper tissues. Dr Rana explained that subcision can be useful in carefully selected patients because the procedure releases these underlying fibrous attachments. Additional procedures, including microneedling, fractional laser resurfacing and collagen-remodelling techniques, may then be used to address remaining irregularities in skin texture.

It is also important to distinguish true acne scars from post-acne pigmentation. Dark brown or grey marks left after a breakout are usually post-inflammatory hyperpigmentation, while reddish or pink marks may be post-inflammatory erythema. These conditions require treatment approaches different from those used for depressed scars, and aggressive scar procedures may not be appropriate. Raised scars, such as hypertrophic scars and keloids, also need separate management, which may involve corticosteroid injections, 5-fluorouracil injections, silicone-based treatments or selected laser procedures.

Since acne scars can differ significantly in their appearance, depth and underlying cause, professional assessment is necessary before beginning treatment. A dermatologist or qualified aesthetic-medicine specialist can determine whether the concern is an ice-pick, boxcar, rolling, raised scar or pigmentation and recommend an approach suited to the diagnosis. Understanding the exact scar type can help avoid unsuitable procedures and improve the chances of achieving more consistent results while reducing the risk of further skin damage.

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