Boxcar scars are one of the most common type of acne scarring that patients seek treatment for. This is because boxcar scars can appear quite disfiguring and hard to cover with make-up.
Dr Justin Boey, international speaker on acne scar treatments and aesthetic procedures, shares more about boxcar scars, how you can prevent them and effective treatments for these scars.
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 include: 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 scar are typically seen at the cheeks and temple regions of the face.
What causes this?
Boxcar scars are caused by skin injury and inflammation during severe acne.
The skin surface is damaged by the acne lesions which results in scar tissue formation.
Picking or squeezing a pimple can also worsen the risk of scarring.
How do they 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 can we prevent boxcar scars?
One of the best ways to prevent boxcar scars from forming is to minimise inflammatory acne lesions. This is because deep inflammation leads to an increased chance of atrophic scar and deep scars. Boxcar scars form from intense injury in the top layer of skin which destroys collagen production.
The second most important way to prevent boxcar scars is to avoid squeezing or picking at your pimples. This is to minimise additional injury to your skin which will lead to deep inflammation and deep scars.
Certain areas of the face tend to develop boxcar scars like the cheeks and temples. Hence, it is very important that you manage acne in these areas of the face early and aggressively.
Boxcar Scars Treatment
Scar removal and treating boxcar scars is a multi-step, multi-treatment process that requires precise diagnosis, wide range of treatment options and commitment.
Let’s analyse the options available for boxcar scar treatments.
Lasers are one of the most common treatments for boxcar scars. In fact, I have several skin resurfacing lasers in my clinic.
There are two main types of laser therapy for rolling scars- Ablative laser therapy and Non-ablative laser therapy for scars.
Ablative lasers are lasers that remove the epidermis. There are 2 sub-types: fractional ablative lasers and fully ablative lasers. The most commonly used ablative lasers nowadays are fractional ablative lasers like fractional CO2 Lasers 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 as compared to fully ablative lasers.
I also have an ECO2 Plus laser (link) that is more powerful yet has faster recovery time as compared to a traditional CO2 laser. This allows patients to have more results whilst having less social down time.
Non-Ablative lasers are lasers that deliver energy to the skin without damage to the top layer of the skin. They include micro-needling radio frequency like INFINI (link to infini).
The benefit of non-ablative lasers as compared to ablative laser is faster recovery time and less risk of post-inflammatory hyper-pigmentation.
Non-ablative energy devices like INFINI are also able to 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 tend to 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 can be used to treat deep boxcar scars.
Subcision is one of the most technically demanding treatments in the clinical and aesthetic dermatology domain.
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 on reconstruction of skin scars, understanding of your skin’s surface and precise estimate of your scar’s depth.
If performed well, subcision can improve acne scars in a very significant magnitude. 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 of skin. 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 very high dosage. This numbing cream is specially compounded by a skin pharmacist 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 are often used with subcision to improve atrophic scars via 2 mechanisms. Firstly, fillers can be used to support the skin during the 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 is also a treatment that is suitable for most skin types as it does not have the risk of causing post-inflammatory hyperpigmentation.
There are a wide range of fillers that can be used to improve skin scars.
Collagen stimulating fillers include Rejuran S, Ellanse, Sculptra.
Volumising fillers include hyaluronic acid fillers. These type 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.
As an appointed physician trainer and key opinion leader for several leading filler companies, Dr Boey has vast experience with dermal filler injections for scar augmentation as well as anti-aging.
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 that you get the best results.
Often times, multiple sessions of acne scar filler treatments are needed to achieve optimal results.
Micro-needling radio frequency devices improve shallow boxcar scars and other acne scarring by stimulating collagen production at areas that previously develop acne scars.
The radio frequency energy that is emitted from the tips of the tiny needles stimulate your skin’s production of collagen 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 used effectively for acne scars, skin tightening and anti-aging.
I strongly recommend INFINI for older patients who want to concurrently treat acne scars and aging signs like saggy skin, open pores and fine lines.
Micro-needling radiofrequency, which is non-ablative, is also safer for patients who are prone to hyperpigmentation or who have pre-existing pigmentation like melasma.
Dermapeeling/ Chemical peels
Chemical peels such as medium depth peels like TCA Cross can potentially treat boxcar scars. This is known as 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 work similarly to other facial resurfacing techniques which remove the outer layer of your scar to stimulate wound healing. This results in smoother texture after your skin heals.
Some chemical peel 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 superceded these treatments for acne scar. This is because dermabrasion cannot resurface skin as effectively as lasers. As such, most doctor and dermatologist will not suggest this treatment.
Punch excision was previously a very popular treatment offered by specialist dermatologist and doctor. However, it has fallen out of favor due to the invasiveness and risk of further scarring like hypertrophic scars.
Punch elevation was one of the popular dermatology treatments used to treat boxcar scars. Although an effective treatment even for darker skin, the results vary very widely. Hence, it is also not a popular treatment nowadays.
When Should You See a Doctor?
You should consult a doctor/ dermatologist as soon as you develop acne and acne scarring to improve your chances of treating these scars effectively.
There are many treatments available and each treatment has its unique advantages and disadvantages.
Often times, it is also important to combine several types of treatments to improve your acne scars synergistically.
Multiple treatment sessions are also required to achieve satisfactory results.
In general, treating your scars early would give better results as compared to targeting the scars when you are older.
Speak to an expert acne scar doctor to understand your best options early.