Acne scars can vary in type, depth, and how they affect the skin’s surface. Doctors use clinical grading systems that classify scars based on their appearance and distribution to guide treatment planning. These tools help determine which procedures may be suitable for specific scar types and severity.
At Sozo Aesthetic Clinic, Dr Justin Boey conducts clinical assessments to determine the severity and type of acne scarring. This guides the selection of treatment options based on your skin’s condition and history of inflammation.
This guide explains how acne scars are graded and why accurate assessment is an essential first step in achieving safe and targeted results.
Understanding Types and Formation of Acne Scars
Acne scars develop when the skin undergoes an inflammatory response during or after a breakout. The intensity of inflammation and how your skin heals influence both the type and severity of the scar.
Atrophic vs Hypertrophic Scars
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- Atrophic scars result from tissue loss. They appear as indentations or depressions on the skin’s surface.
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- Hypertrophic scars, including keloids, are caused by excess collagen production. These scars are raised and may extend beyond the original site of the breakout.
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Common Subtypes of Acne Scars
| Scar Type | Description |
|---|---|
| Icepick | Deep and narrow scars that extend into the dermis. Often difficult to treat and usually require energy-based or surgical intervention. |
| Boxcar | Broad, sharply defined edges, typically found on the cheeks or temples. May respond well to resurfacing treatments. |
| Rolling | Wave-like indentations with sloping edges, often linked to fibrous tissue bands pulling down on the skin. These may require subcision. |
| Keloid | Raised and firm scars that can grow beyond the boundary of the initial injury. More common on the chest, shoulders, and jawline. |
Each scar type may respond differently to treatment. Understanding the morphology helps determine which treatment options are most suitable.
Clinical Grading Systems: How Severity Is Measured
To ensure safe and effective treatment planning, acne scars are assessed using validated clinical grading scales. These tools allow for consistent evaluations and help track progress across multiple sessions.
Goodman and Baron Qualitative Grading
This widely used system classifies acne scars into four grades based on visibility and how easily they can be concealed:
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- Grade 1 (Macular): Scars are mild and can be covered easily with makeup or natural lighting.
- Grade 2 (Mild Atrophic): Scars are visible but still light enough to fade under makeup or direct lighting.
- Grade 3 (Moderate Atrophic): Scars are obvious and not easily concealed.
- Grade 4 (Severe Atrophic): Scars are severe, extensive, and remain visible even under concealment.
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This grading system helps clinicians determine whether non-invasive treatments (e.g., resurfacing lasers, peels) are sufficient or whether procedural interventions (e.g., subcision, minor surgery) are necessary.
Goodman and Baron Quantitative Global Scarring Scale
This scale uses a point system, where different scar types are assigned specific values based on depth, size, and distribution.
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- Macular atrophic: 1 point each
- Mild depression: 2 points each
- Deep depressed: 3 points each
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Scores are added to form a total, which places scarring into defined severity categories:
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- Mild: 1–18 points
- Moderate: 19–30 points
- Severe: 31–38 points
- Very Severe: ≥39 points
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Quantitative grading enables more precise treatment monitoring and outcome tracking, particularly when evaluating progress over time.
ECCA (Echelle d’Évaluation Clinique des Cicatrices d’Acné) Scale
The ECCA scale assigns weighted scores to different scar types based on their visibility and distribution. Scars that are more prominent on visual examination receive higher values, helping clinicians assess scar severity systematically.
| Scar Type | Weighting Value |
|---|---|
| Atrophic scars < 2 mm | 15 |
| U-shaped atrophic scars (2–4 mm) | 20 |
| M-shaped atrophic scars (>4 mm) | 25 |
| Superficial elastolysis | 30 |
| Hypertrophic scars < 2 years old | 40 |
| Hypertrophic scars > 2 years old | 50 |
Scar counts for each type are rated on a 0–3 scale, and the product of count score and type weight yields a subtotal. Summing across all scar types produces a total ECCA score ranging from 0 to 540.
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- 0: No scars
- 1: Fewer than five scars
- 2: Between 5 and 20 scars
- 3: More than 20 scars
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The ECCA system differentiates atrophic versus hypertrophic subscores for targeted treatment planning and provides a standardised, quantitative framework for clinical trials and practice.
Why Severity Grading Directly Affects Treatment Strategy
Acne scar severity plays a critical role in guiding which treatments are recommended, how they’re sequenced, and what outcomes you can realistically expect.
For example, using only superficial peels for deep rolling scars is unlikely to produce meaningful change. Likewise, overly aggressive interventions for mild scarring may result in unnecessary downtime or complications.
A professional skin assessment, supported by clinical grading tools, ensures each treatment is matched precisely to the type and severity of your scars.
Treatment Planning by Grade
Each severity grade provides insight into the extent of scarring and suggests which treatment options may be most suitable. Here’s how grading typically maps to treatment tiers:
| Grade | Description | Treatment Approach |
|---|---|---|
| Grade 1 | Mild, shallow scarring | Light chemical peels, mild resurfacing lasers, and skincare |
| Grade 2 | Slightly more visible, but concealable | Non-ablative fractional lasers, microneedling |
| Grade 3 | Clearly visible, harder to conceal | Subcision, fractional lasers, combination therapies |
| Grade 4 | Deep, widespread, and often resistant to basic methods | Punch excision, TCA-CROSS, ablative resurfacing, and surgical approaches |
Scar Type-Specific Approaches
Different types of acne scars require tailored interventions. Tailoring treatment based on scar type helps ensure the approach is aligned with your skin’s characteristics and needs.
| Scar Type | Recommended Treatments |
|---|---|
| Icepick | TCA-CROSS (a targeted chemical reconstruction technique), punch excision |
| Rolling | Subcision to release tethered bands, microneedling, and dermal fillers to restore volume |
| Boxcar | Fractional lasers, subcision, ablative resurfacing |
| Hypertrophic / Keloid | Intralesional corticosteroids, cryotherapy, and surgical revision (when appropriate) |
Note: Treatment suitability depends on a thorough clinical evaluation. This table is for informational purposes only.
Each scar type reflects different levels of dermal damage. Identifying your scar type helps clinicians plan treatments that take into account how your skin responds to past inflammation and the specific characteristics of your scarring.
FAQs for Acne Scar Grading
Why is scar grading important before treatment?
Grading helps match your scar type and severity with the most effective treatment, avoiding under- or over-treatment.
How do I know which acne scar treatment is right for me?
A clinical assessment will identify your scar type and severity so a personalised treatment plan can be created.
Do I need to treat acne before addressing acne scars?
Yes. Active acne should be under control before starting scar treatments, or new breakouts may cause more scars.
Get the Grade Right, Get the Treatment Right
Accurate acne scar grading plays a critical role in developing an effective treatment plan. It is not a cosmetic detail but a clinical step that allows your doctor to match the right treatments to the specific types and severity of scarring. Without proper assessment, treatments may not address the full extent of the damage. This can result in minimal improvement or repeated sessions that do not lead to meaningful results.
At Sozo Clinic, we support our patients through this process by providing a clinical assessment that forms the foundation of a personalised treatment plan. We take the time to understand your skin concerns and recommend options that are guided by medical evaluation and your individual needs.
A structured evaluation helps identify what your skin truly needs, whether it involves light resurfacing or procedural interventions.
