Rolling Scars: What Is It, Causes, Treatments & Prevention

Rolling scars, a form of atrophic scar, are one of the most common forms of acne scarring. These scars tend to form after a breakout of severe acne. 

In this article, Sozo Clinic’s Dr Justin Boey will discuss everything you need to know about rolling scars, their causes and treatments. Let’s begin!

What are Rolling Scars?

Rolling scars are atrophic facial scars that look like shallow hollows in your skin. The edges of the rolling scars are sloping and the base is broad. These scars can make the skin look irregular and rough.

Treatment of rolling scars includes subcision, fillers, laser resurfacing and micro-needling with radio frequency, amongst other treatments.

As an international expert in treating scars, rolling scars due to acne is one of the most common scars that I treat.

Rolling scars are typically seen on the cheeks and temple regions of the face.

How Do Rolling Scars Form?

Rolling scars are a type of atrophic acne scars that create uneven depressions on the skin, giving it a wavy or rippled appearance. Unlike boxcar acne scars, which have sharply defined edges, rolling scars have sloping borders. These scars develop when the skin’s natural healing process is disrupted, leading to inadequate collagen formation. The top layer of the skin is pulled downward, resulting in a sunken appearance.

The Biological Process Behind Rolling Scars

Think of rolling scars like a wrinkled sheet held down by pins underneath. These ‘pins’ are bands of fibrous tissue that form beneath the skin when the body tries to heal deep acne inflammation. Here’s a more detailed look at how this type of scar forms.

1. Collagen breakdown. When acne causes deep inflammation, it damages the underlying skin structure, disrupting collagen formation that keeps the skin smooth and firm.
2. Fibrosis and tissue anchoring. As the skin attempts to heal, it forms fibrous bands of scar tissue beneath the surface. Instead of allowing the skin to regenerate evenly, these bands pull the skin downward, creating the characteristic rolling effect.
3. Skin texture and dark spots. Along with the uneven surface, rolling scars are often accompanied by dark spots left behind from previous breakouts, further affecting skin tone.

Risk Factors for Developing Rolling Scars

Not everyone who experiences acne will develop rolling scars. Several risk factors increase the likelihood the formation of these scars, and these include:

• Severe or long-lasting acne. Prolonged inflammation increases the chances of deep tissue damage.
• Genetics. Some people are more prone to atrophic acne scars due to their genetic predisposition.
• Delayed or improper treatment. Leaving acne untreated or picking at pimples can worsen scarring.
• Skin type. Individuals with thinner skin or reduced collagen formation may be more susceptible to atrophic scarring than others.

Understanding how rolling scars form and who is most susceptible to them can help you choose the right treatments.

How to Identify Rolling Scars?

Many people self-diagnose their acne scars but may struggle to distinguish between different types. Here’s a handy guide to help you determine which type of atrophic acne scar you’re dealing with. 

Characteristics of Rolling Scars

• Appearance. Rolling scars have wave-like depressions that make the skin look uneven.
• Edges. These scars have soft, sloping borders that merge into the surrounding skin.
• Cause. Severe inflammation leads to uneven skin healing and rolling scars.
• Common areas. Rolling scars are more common in cheeks and jawline, where the skin is thicker.

Causes and Risks of Rolling Scars

Why Do Rolling Scars Form?

Here are some of the most common reasons why rolling scars form:

• Inflammation and tissue damage. Deep acne lesions and inflammation can disrupt collagen production, preventing smooth healing.
• Scar tissue formation. The body produces fibrous bands that pull the skin downward.
• Picking or squeezing pimples. This increases the risk of deeper scarring.

Who Is More Prone to Rolling Scars?

Not everyone with acne develops rolling scars. People who are more prone to rolling scars share these key risk factors:

• Genetics. Some people naturally heal with more scarring, while others tend to develop acne scars, including rolling scars.
• Severity of acne. Deeper and more severe inflammation increases the risk of atrophic acne scars like rolling or boxcar acne scars.
• Skin type and healing response. Poor collagen formation can lead to uneven skin repair.
• Delayed treatment. Delaying treating acne raises the chance of scarring.

8 Treatments for Rolling Scars

Rolling scars treatment involves stimulating collagen production using lasers and energy base devices as well as release of acne scar tissue using manual treatments like subcision.

Multiple treatments using a combination of treatments are usually required.

The final treatment plan will depend on the types of acne scars that you have. Other possible scars include boxcar scars, ice pick scars and hypertrophic scars.

Treating acne scars is as much an art as it is a science.

Micro-needling Radiofrequency

Micro-needling radio frequency devices improve rolling scars and other acne scarring by stimulating effective collagen production in areas that previously developed acne scars.

The radio frequency energy that is emitted from the tips of the micro-needles stimulates your skin’s production of collagen to improve rolling scars.

In addition, micro-needling, by itself, is a form of collagen induction therapy.

Subcision

Subcision is one of the most technically demanding treatments in the clinical and aesthetic dermatology domain.

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 improve acne scars in a very significant magnitude. Rolling scars and boxcar scars will benefit from this treatment.

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

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 rolling 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 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.

Laser Therapy

Lasers are one of the most common treatments for rolling 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.

Cryotherapy

Cryotherapy is said to improve skin healing. However, this is not a commonly offered treatment due to variable results on rolling scars.

Chemical Peeling

Chemical peels such as medium depth peels like TCA Cross can potentially treat rolling 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 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.

Skin Grafting

Skin grafting one of the effective treatments that can work with punch excision. However, this treatment might result in new scars. Hence, it is not commonly offered.

How to Prevent Acne from Causing Scars

Preventing scars while managing acne requires early intervention and proper skincare to support skin healing. Here are some easy-to-follow tips for preventing rolling scars and other types of marks from forming on your skin.

Actionable Tips for Scar Prevention

• Treat acne early. Prevent severe scarring by managing breakouts with prescription medications or topical creams.
• Reduce inflammation. Anti-inflammatory skincare ingredients like niacinamide and ceramides help calm redness.
• Avoid picking at your pimples. Picking at your lesions damages skin cells, increasing the risk of depressed scars. Picking can also push bacteria deeper into the inflamed skin, worsening your condition.
• Use SPF daily. Sun exposure worsens scarring, especially in darker skin types. Broad-spectrum sunscreen prevents hyperpigmentation in dark skin.

Best Skincare Routine for Scar Prevention

A consistent routine helps prevent depressed scars, dark spots and severe scarring by supporting skin healing and strengthening the skin barrier.

Morning Routine

• Use a gentle cleanser. Mild skincare products can remove excess oil without damaging the skin barrier.
• Antioxidant serum. Serums containing vitamin C or niacinamide help prevent acne and resulting scars.
• Slather on some gentle moisturiser. Moisturisers hydrate the skin and support collagen formation.
• Sunscreen (use SPF 30+). Consistent and daily application of sunscreen prevents the formation of acne marks and post-inflammatory hyperpigmentation, especially in darker skin types.

Evening Routine

• Double cleanse with gentle cleansers, as these products remove makeup and dirt.
• Exfoliate 2 to 3 times weekly. Use medium-depth peels or acids to refine the skin surface.
• Apply retinoids. These chemicals help boost skin cell turnover, reducing the visibility of rolling acne scars.
• Apply night cream as it strengthens the skin barrier.
• Banish zits before they become scars with spot treatment. These are topical creams to calm breakouts.

Extra Tips

• Seek professional treatments. Explore non-ablative laser therapy or surgical procedures for persistent scars. 
• Eat a healthy diet. Load up on fibre-rich foods and drink at least eight glasses. Eat plenty of berries, tomatoes, chicken, fatty fish and more to boost collagen production.

Comparison: Rolling Scars vs. Other Acne Scars

How Practitioners Diagnose Rolling Scars

Aesthetic practitioners use different tools and techniques to assess the scar’s depth and determine suitable treatment options:

Clinical Diagnosis Methods

• Visual inspection. During the consultation, your practitioner or doctor will conduct a visual inspection to examine the scars’ shape, edges, and texture.
• Stretch test. The skin is pinched and stretched to see if the depressions flatten.
• Dermatoscopy. A magnified view helps assess scar characteristics and surrounding skin.
• 3D Imaging. Some practitioners may provide detailed scar depth analysis for tailored treatment options.

When to Consult a Doctor?

You should consult a doctor 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.

Conclusion

While rolling scars can be challenging to treat, various treatment options are available. Non-ablative laser therapy, medium-depth peels, subcision and dermal fillers can help improve skin texture by promoting collagen formation and releasing scar tissue.

However, prevention is still key – treating acne early, avoiding picking at breakouts, and protecting your skin from post-inflammatory hyperpigmentation can reduce the risk of severe scarring. A consistent skincare routine, including topical creams and sunscreen, supports skin healing and minimises future scarring.

Since every scar’s depth and severity vary, Sozo Clinic’s Dr Justin Boey recommends a personalised approach. Consulting an aesthetic specialist for an accurate diagnosis and tailored scar treatments is the best step toward achieving smoother skin.a