Boxcar scars are one of the most common types of acne scarring for which patients seek treatment for. They can appear quite disfiguring and hard to cover with make-up.
Sozo Clinic’s Dr Justin Boey shares more about boxcar scars, how to prevent them and some effective treatments you can explore. Let’s get started!
What are Boxcar Scars?
Boxcar scars are atrophic scars that look like hollows in your skin.
The edges of the boxcar scars are sharp, and the base of the scar is broad. This can make your skin texture look irregular and rough.
Treatment of boxcar scars includes: subcision, fillers, laser resurfacing and micro-needling with radio frequency, amongst other treatments.
As an international expert in treating scars, deep boxcar scars due to acne is one of the most common atrophic scars that I treat.
Boxcar acne scars are typically seen on the cheeks and temple regions of the face.
How Do Boxcar Scars Form?
Boxcar scars are caused by skin injury and inflammation during severe acne like cystic acne.
After a severe flare of inflammatory acne, the skin heals with scar tissue that is disorganised and irregular. This appears as a depression in the skin tissue.
How to Identify Boxcar Scars?
Boxcar scars are characterised by their broad depressions with well-defined edges. These scars often appear wider and have distinct sharp borders, giving them a ‘box-like’ appearance.
They primarily affect areas like the cheeks and temples, where the skin is thicker. Unlike ice pick scars, which are smaller and deeper, boxcar scars have a shallower depth and clearly defined boundaries.
| Type of Scar | Characteristics | Common Locations | Depth | Appearance |
|---|---|---|---|---|
| Boxcar Scars | Broad, rectangular shape with sharp edges | Cheeks, temples | Shallow to moderate | Box-like depressions with defined edges |
| Ice Pick Scars | Narrow and deep with steep sides, resembling a puncture | Cheeks primarily | Deep | Small, pinhole-like indentations |
| Rolling Scars | Uneven and wave-like with poorly defined edges | Lower cheeks, jawline | Shallow to deep | Smooth, sloping depressions causing uneven texture |
| Hypertrophic Scars | Raised and firm, resulting from excessive scar tissue | Chest, back, elbow, shoulders | Above skin level | Thick, raised scars often associated with redness |
Identifying and understanding your scar type becomes easier with the above characteristics and comparison. Proper identification is the first step in pursuing targeted treatment options for smoother, healthier skin.
How Practitioners Diagnose Boxcar Scars
- Visual examination. Practitioners typically begin with a thorough visual inspection of the skin to identify the scars’ depth, shape and severity. This helps distinguish boxcar scars from other types of acne scars.
- Skin texture analysis. Advanced tools or manual methods may be used to assess the texture and elasticity of the skin to better understand how the scars have affected the surrounding tissue.
- Patient history. Gathering details about the patient’s acne history and previous treatments provides valuable context for accurately diagnosing the scars.
- Use of specialised lighting. Techniques like dermatoscopy allow practitioners to closely examine the fine details of the scars and their impact on the skin structure.
- Photographic documentation. High-resolution photographs may be taken to document the scars and aid in tracking improvements over time during treatment.
Causes of Boxcar Scars
Boxcar scars form from skin damage and inflammation caused by severe acne. When acne lesions harm the skin’s surface, they trigger the development of scar tissue.
Additionally, picking or squeezing pimples can significantly increase the likelihood of scarring, making proper care essential to minimise long-term skin damage.
8 Treatments for Boxcar Scars
Scar removal and treating boxcar scars is a multi-step, multi-treatment process that requires precise diagnosis, a wide range of treatment options and commitment.
Let’s analyse the options available for boxcar scar treatments.
Laser Therapy
Lasers are one of the most common treatments for boxcar scars. I have several skin resurfacing lasers in my clinic.
There are two main types of laser therapy for rolling scars- Ablative and Non-ablative laser therapy for scars.
Ablative lasers are lasers that remove the epidermis. There are two sub-types: fractional ablative lasers and fully ablative lasers. The most commonly used ablative lasers nowadays are fractional ablative lasers like fractional CO2 Lasers, which remove “fractions” of the top layer of the skin to resurface your skin while leaving the surrounding skin intact. The skin surface heals faster in fractional lasers than fully ablative lasers.
I also have an ECO2 Plus laser (link) that is more powerful yet has a faster recovery time than a traditional CO2 laser. This allows patients to have more results whilst having less social downtime.
Non-ablative lasers deliver energy to the skin without damage to the top layer of the skin. They include micro-needling radio frequencies like INFINI.
Compared to ablative lasers, the benefit of non-ablative lasers is the faster recovery time and less risk of post-inflammatory hyperpigmentation.
Non-ablative energy devices like INFINI can penetrate deeper into the skin – up to 3.5mm deep. This allows for collagen stimulation at the deep layers of the skin to improve deep, depressed scars. Ablative lasers target the top layer of the skin – usually within 1.5mm deep.
Both ablative and non-ablative lasers have their pros and cons.
I typically use both types of lasers as they are synergistic and complement each other to give my patients superior results.
Often times, at least 5 to 10 sessions of each type of laser treatment is required to achieve results.
Subcision
Subcision can be used to treat deep boxcar scars.
Subcision is one of the most technically demanding clinical and aesthetic dermatology treatments.
It involves using tiny needles or micro-cannulas to break down face scar tissues in multiple directions. The needles used can vary in size.
It requires expert knowledge of the reconstruction of skin scars, an understanding of your skin’s surface and a precise estimate of your scar’s depth.
If performed well, subcision can significantly improve acne scars. Rolling scars and boxcar scars will benefit from this treatment. This treatment is also safe for darker skin as it does not affect the pigment cells at the top layer. Results are seen days after the treatment and can continue to improve for several months. Better results can be achieved by combining subcision and dermal fillers, as this gives your skin a boost in collagen production.
To minimise discomfort from this treatment, I use a topical analgesia (numbing cream) that is a very high dosage. A skin pharmacist specially compounds this numbing cream to improve comfort levels during treatments. This highly effective numbing cream may not be offered by clinics that do not specialise in scar augmentation.
Dermal Fillers
Dermal fillers are often used with subcision to improve atrophic scars via two mechanisms. Firstly, fillers can support the skin during scar therapy.
Secondly, fillers also act as collagen stimulators in the scars. Collagen stimulation in the depressed scars helps your skin to produce “new” skin so that the boxcar scars can be “filled up”.
Apart from being able to treat depressed scars, acne scar fillers are also a treatment that is suitable for most skin types as it does not have the risk of causing post-inflammatory hyperpigmentation.
A wide range of fillers can be used to improve skin scars.
Collagen-stimulating fillers include Rejuran S, Ellanse, and Sculptra.
Volumising fillers include hyaluronic acid fillers. These types of fillers form a scaffold to allow the skin to recover. However, they do not have a significant effect on stimulating collagen in the area of depressed scars.
Some patients prefer the long-lasting results of collagen-stimulating fillers, while others prefer the immediacy of volumising effects of acne scar fillers.
The choice depends on the patient’s expectations, budget and availability of the type of acne scar fillers in the doctor’s clinic. It also depends on the urgency and speed at which the patient requires the results to be seen.
Dr Boey has vast experience with dermal filler injections for scar augmentation and anti-ageing as an appointed physician trainer and key opinion leader for several leading filler companies.
Scar treatment using filler is a highly technical procedure which requires dextrous hands and precision. You should always see an expert for this treatment to ensure you get the best results.
Multiple sessions of acne scar filler treatments are often needed to achieve optimal results.
Micro-needling Radiofrequency
Micro-needling radio frequency devices improve shallow boxcar scars and other acne scarring by stimulating collagen production in areas that previously developed acne scars.
The radio frequency energy emitted from the tips of the tiny needles stimulates your skin’s collagen production to improve rolling scars.
In addition, micro-needling, by itself, is a form of collagen induction therapy.
The brand of Micro-needling radiofrequency that we offer is INFINI by Lutronic. This system has been well-studied for decades and is used effectively for acne scars, skin tightening, and anti-ageing.
I strongly recommend INFINI for older patients who want to concurrently treat acne scars and ageing signs like saggy skin, open pores and fine lines.
Micro-needling, non-ablative radiofrequency is also safer for patients prone to hyperpigmentation or with pre-existing pigmentation like melasma.
Derma peeling/ Chemical peels
Chemical peels such as medium-depth peels like TCA Cross can potentially treat boxcar scars. This is known as the chemical reconstruction of skin.
While we rarely can consider the scars completely healed, permanent scarring can improve to a large extent with multiple treatments.
Chemical reconstruction using chemical peels works similarly to other facial resurfacing techniques, which remove the outer layer of your scar to stimulate wound healing. This results in a smoother texture after your skin heals.
Some chemical peels that contain salicylic acid can also improve acne lesions.
Dermabrasion and Microdermabrasion
Dermabrasion and microdermabrasion have been used in the past to improve boxcar scars. However, in current times, laser treatments have superseded these treatments for acne scars. This is because dermabrasion cannot resurface the skin as effectively as lasers. As such, most doctors and aesthetic practitioners will not suggest this treatment.
Punch Excision
Punch excision was previously a popular treatment by aesthetic practitioners and doctors. However, it has fallen out of favour due to the invasiveness and risk of further scarring like hypertrophic scars.
Punch Elevation
Punch elevation was one of the popular aesthetic treatments used to treat boxcar scars. Although an effective treatment even for darker skin, the results vary widely. Hence, it is also not a popular treatment nowadays.
How to Prevent Acne from Causing Scars
One of the best ways to prevent boxcar scars from forming is to minimise inflammatory acne lesions. This is because deep inflammation increases the chance of atrophic and deep scars. Boxcar scars form from intense injury in the top layer of skin, destroying collagen production.
The second most important way to prevent boxcar scars is to avoid squeezing or picking at your pimples. This minimises additional injury to your skin, leading to deep inflammation and deep scars.
Certain areas of the face tend to develop boxcar scars, like the cheeks and temples. Hence, you must manage acne in these areas early and aggressively.
Best Skincare Routine for Scar Prevention
Incorporating the right skincare ingredients into your routine is crucial to prevent the formation of boxcar scars.
- Salicylic acid. Exfoliates the skin, unclogs pores and reduces inflammation.
- Retinoids. Boost cell turnover, minimise acne formation and promote collagen production.
- Niacinamide. Soothes skin, reduces inflammation, improves skin barrier function and diminishes redness.
- Hyaluronic acid. Maintains hydration, supporting the skin’s healing process.
- Sunscreen. Protects against UV exposure, which can worsen redness, delay acne healing and increase the risk of scarring.
When to Consult a Doctor?
You should consult a doctor / aesthetic practitioner when you develop acne and scarring to improve your chances of treating these scars effectively.
There are many treatments available, each with unique advantages and disadvantages.
It is often important to combine several types of treatments to synergistically improve your acne scars.
Multiple treatment sessions are also required to achieve satisfactory results.
Treating your scars early would give better results than targeting the scars when you are older.
Speak to an expert acne scar doctor early to understand your best options.
Conclusion
Boxcar scars are atrophic acne scars that can be effectively treated with various methods, such as dermal filler, microneedling, chemical peel and punch excision. It is important to consult an aesthetic practitioner early on when experiencing acne to prevent scarring. With advancements in skincare technology and techniques, more options are available for treating boxcar scars.
Speak to an expert doctor or aesthetic practitioner to find the best treatment plan for your needs. Remember to always seek professional help and avoid self-treatment for best results.
