Indentations on the skin caused by acne, chickenpox, or injury may not be simple scars. They could be atrophic scars, a type of scarring caused by a loss of collagen. For many, these scars can feel impossible to improve. The good news? Understanding their causes and available treatments can help you manage and reduce the visibility of these scars.
This guide explains everything you need to know about atrophic scars, including their types, causes, treatment options and ways to prevent them from forming.
What Are Atrophic Scars?
Atrophic scars, often called ‘depressed scars,’ are formed when the body cannot regenerate enough collagen during the wound-healing process. This collagen deficiency results in scars that appear sunken or indented compared to the surrounding skin.
These scars are the direct opposite of hypertrophic scars, which are raised due to an overproduction of collagen as the wound heals. Identifying whether your scars are atrophic or hypertrophic is essential for deciding on the best acne scar treatment approach.
Types of Atrophic Acne Scars
Not all atrophic scars are the same. Below are the three main types, along with their characteristics and acne scar treatment considerations:
Ice Pick Scars
- Appearance: Deep, narrow scars that resemble small punctures.
- Causes: Often result from severe or cystic acne.
- Treatment difficulty: The most challenging to treat due to their depth and sharp edges. Common acne scar treatments include punch excision or laser resurfacing, which are useful in treating acne scars.
Boxcar Scars
- Appearance: Wider scars with sharp, defined edges and U-shaped indentations.
- Causes: Typically formed by inflammatory or prolonged acne, particularly on the cheeks and forehead.
- Treatment difficulty: Easier to treat than icepick scars, with options ranging from chemical peels to laser treatments.
Rolling Scars
- Appearance: Wavy, uneven skin texture caused by bands of fibrotic tissue pulling the skin down.
- Causes: Develop from long-term inflammatory severe acne or significant collagen loss.
- Treatment difficulty: These respond well to treatments like microneedling or subcision combined with fillers.
How Are Atrophic Scars Diagnosed?
Aesthetic practitioners assess atrophic scars by size, depth and severity. Two common methods are:
Scar Classification Systems
- Goodman and Baron Grading System categorises acne scars into four grades, from mild to severe.
- ECCA Scale (Echelle d’Évaluation Clinique des Cicatrices d’Acné) provides a more precise scoring system to evaluate scar severity.
Imaging Techniques for Scars
Advanced technology also aids diagnosis:
- Dermoscopy enables close-up visualisation of the skin’s surface to study scar patterns.
- 3D Imaging measures the depth and volume of scars, providing a detailed assessment for a tailored treatment of atrophic acne scars.
What Causes Atrophic Scars?
Atrophic scars develop when the body has difficulty rebuilding tissue after an injury or inflammation. These scars form due to reduced fibroblast activity during the healing process, resulting in lower collagen production and the characteristic appearance of atrophic scars.
Common Causes of Atrophic Scars
- Acne (the leading cause). Severe and inflammatory forms of acne are most likely to result in these scars.
- Chickenpox and other viral infections that damage skin layers.
- Surgery or medical procedures that fail to heal smoothly.
- Trauma from deep cuts or injuries.
Why Atrophic Scars Commonly Appear on the Face and Forehead
Facial skin is thinner and more prone to environmental damage, making it more susceptible to scarring. The constant movement of the forehead and expression lines also limits skin smoothness, complicating treatment of acne scars in this area.
Atrophic Scars Treatment and Removal Options
Treatment choice depends on the scar type, severity and the area affected. Below is an overview of effective treatment options:
Microneedling for Atrophic Scars
Microneedling uses fine needles to create micro-injuries on the skin’s surface, promoting collagen production. The results are typically more pronounced when paired with platelet-rich plasma (PRP) therapy.
- Downtime: Minimal (redness subsides in 1 to 2 days).
- Best For: Rolling scars or early-stage boxcar scars.
Laser Treatments for Atrophic Scars
Laser therapy removes damaged skin layers and stimulates new tissue growth.
- CO2 fractional laser resurfacing targets deeper scars, like ice pick scars.
- Erbium YAG Laser is recommended for mild, superficial scars.
Downtime varies with intensity, but most laser treatments require multiple sessions for noticeable results.
Tretinoin for Atrophic Scars
Tretinoin, a type of retinoid, accelerates skin cell turnover to smooth mild atrophic scars over time.
- Downtime: None (applied at home).
- Caution: Prolonged use can cause skin irritation or dryness. Apply moisturiser every day and at night to combat them.
Fat Grafting for Atrophic Scars
Autologous fat transfer, or fat grafting, uses the patient’s fat to fill sunken scars. This not only restores lost volume but may also stimulate collagen production.
- Downtime: 1 to 2 weeks (some bruising and swelling).
- Best for: Deep rolling scars.
Subcision and Punch Excision for Deep Scars
- Subcision involves using a needle to break the fibrotic bands tethering skin to deeper structures to improve rolling scars.
- Punch excision removes deep scars like ice-pick scars through minor surgical procedures.
Both methods typically require additional treatments to reduce the visibility of atrophic scars. These may include laser resurfacing or dermal fillers.
How to Prevent Atrophic Scars 
While some scarring after acne or skin injury may be inevitable, the following measures can reduce its risk:
Early Wound Care
Clean cuts, pimples or injuries promptly using gentle antiseptics to minimise inflammation and reduce the risk of infections. Avoid picking at scabs or squeezing acne, which can worsen scarring and slow healing.
Wear Sun Protection for Acne Marks Prevention
UV exposure can darken and worsen acne marks and scars. Apply sunscreen with SPF 30 or higher daily to shield vulnerable skin, even on cloudy days. Reapply it throughout the day. Consider wearing hats or protective clothing for additional coverage.
Seek Professional Help for Acne
Consult an aesthetic practitioner if over-the-counter treatments don’t work for severe or persistent acne. Early intervention can prevent long-term scarring and improve skin health.
Incorporate Collagen-Boosting Skincare into Your Routine
Use products with peptides, retinoids or vitamin C to enhance skin elasticity and strength during wound healing. Regularly applying these can also help improve your skin’s overall texture and appearance.
Stay Hydrated
Drinking plenty of water supports skin repair by keeping it hydrated and improving elasticity. Aim for at least eight glasses of water daily to aid the healing process.
Consume a Balanced Diet
Eating foods rich in vitamins and minerals like vitamins C and E, zinc and omega-3 fatty acids can promote faster healing and reduce the risk of scarring. Include leafy greens, nuts, fish and citrus fruits in your diet.
Avoid Smoking
Smoking can slow down the body’s natural healing process and worsen the appearance of scars. Quitting or reducing smoking can significantly improve skin recovery.
Use Silicone Sheets or Gels
Silicone sheets or gels can help flatten and reduce existing or healing scars over time. They’re especially effective when used consistently.
Keep the Wound Moist
Applying an appropriate wound ointment or petroleum jelly can keep the area moist, preventing it from drying out and forming a larger, more noticeable scar.
Do Atrophic Scars Go Away Naturally?
Some do, but most atrophic scars do not completely disappear on their own. However, their appearance can fade slightly over time as the skin regenerates. For significant improvement, targeted treatments are necessary.
Conclusion
Atrophic facial acne scars are not permanent, and treatments today offer hope for you to regain that smooth skin. Whether it’s microneedling, lasers or subcision, targeting those sunken marks that bother you is an option. Prevention begins with proper care and timely intervention, but consulting an aesthetic professional such as Sozo Clinic’s Dr Justin Boey can make all the difference when scars form.
Take the first step towards scar-free confidence – start exploring your options by getting in touch with us today.
