Skip to main content

Health condition

Acne scarring, a scar-type map and a combined plan that actually works.

Not one problem but several - ice pick, boxcar, rolling, hypertrophic, PIH and PIE. Each responds to a different tool, and stacked treatment beats any single device.

Jump to treatment
A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Why trust this guide

  • 01

    Editorial team

    Written by our editorial team from the UK sources listed on each page.

  • 02

    Sourced from guidance

    Checked against BAD, BCDG and peer-reviewed dermatology sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK practice including TCA CROSS, subcision, RF microneedling and fractional lasers.

Key facts

Acne scarring at a glance.

Six essentials, in plain English - the different scar types, what they respond to, and why prevention matters most.

  • What it is

    Permanent skin change after inflammatory acne - either loss of collagen (atrophic) or excess collagen (hypertrophic and keloid).

  • Atrophic scars

    The most common pattern - ice pick, boxcar and rolling scars, each responding to a slightly different technique.

  • Hypertrophic scars

    Raised, firm scars sitting within the original wound - common on the jaw, chest and back.

  • PIH and PIE

    Post-inflammatory hyperpigmentation and erythema look like scars but are not true scars - both fade with the right plan.

  • Prevention wins

    Early acne control, sun protection and no picking prevent far more scarring than any device can fix later.

  • Active acne first

    Scar treatment only starts once active acne is controlled - typically after isotretinoin or a settled topical regimen.

Why this guide matters

Prevention first, then a scar-type plan.

Scar work is stacked and staged - not a single miracle device. The three points below shape everything else on this page.

  • Prevention beats correction

    Early, effective acne care - including isotretinoin where indicated - prevents more scars than any device will ever fix.

  • Match the tool to the scar

    Ice pick, boxcar and rolling scars each respond to a different technique - the plan should name them.

  • Stack, don’t chase

    Subcision plus RF microneedling plus TCA CROSS, spaced over months, beats jumping between single treatments.

How the assessment is done

From consultation to a staged plan.

The steps a UK dermatologist or specialist clinician will normally follow, in order - so you know what to expect and why.

  1. 01

    Assessing

    Confirm acne is controlled

    Scarring procedures start only when active acne is settled - fresh breakouts create fresh scars and blunt results.

  2. 02

    Assessing

    Goodman and Baron grading

    A qualitative and quantitative scoring system that grades scars from mild macular change through to disabling severity.

  3. 03

    Assessing

    Scar-type mapping

    Ice pick, boxcar and rolling scars are counted and mapped - each responds to a different tool, so the mix drives the plan.

  4. 04

    Refining

    Fitzpatrick skin typing

    Skin types IV to VI carry higher risk of post-inflammatory hyperpigmentation - it shapes device settings and topical prep.

  5. 05

    Refining

    PIH and PIE assessment

    Brown pigment (PIH) and red vascular marks (PIE) are separated from true scars - they need pigment or laser strategies, not resurfacing.

  6. 06

    Planning

    Realistic goal setting

    Improvements of 50 to 70 percent are typical with a combined plan - not perfection, but a meaningful, lasting change.

  7. 07

    Planning

    Staged treatment plan

    A written plan sequencing subcision, TCA CROSS, RF microneedling or laser over several months - with prep and downtime built in.

Typical timeline: a first consultation to a staged plan in a single visit, with treatment across several months.

Scar types

What acne scarring actually looks like.

Not one problem but several - each with its own shape, its own biology and its own best treatment.

  • Ice pick scars

    Narrow, deep, V-shaped pits - the sharpest, hardest scars to resurface and the target for TCA CROSS or punch excision.

  • Boxcar scars

    Round or oval depressions with sharp vertical edges - respond well to subcision, RF microneedling and fractional laser.

  • Rolling scars

    Wavy, tethered depressions from fibrous bands - subcision releases the tether, then volume and remodelling smooth the surface.

  • Hypertrophic and keloid scars

    Raised, firm and sometimes tender - common on the jaw, chest and back and treated very differently to atrophic scars.

  • Post-inflammatory hyperpigmentation

    Flat brown marks after inflammation - not a true scar, but often the most visible concern in skin of colour.

  • Post-inflammatory erythema

    Persistent red or purple marks after inflammation - especially in fair skin, treated by pulsed dye laser and KTP.

  • Texture and shadowing

    Uneven texture that reads worst in side light - a marker of atrophic disease and a target for combined resurfacing.

  • Red flag - active inflammatory acne

    Fresh papules, pustules or nodules mean scar treatment is on hold - control the acne first, then plan the scars.

Treatment

How acne scarring is treated in the UK.

Ice pick gets TCA CROSS or punch excision. Boxcar and rolling get subcision, RF microneedling and fractional laser. Hypertrophic gets steroid, silicone and vascular laser. PIH and PIE each get their own plan.

  • TCA CROSS (70 to 100%)

    Chemical reconstruction of skin scars - focal high-strength trichloroacetic acid applied to ice pick scars to trigger controlled remodelling.

  • Punch excision or elevation

    Surgical removal or lifting of deep ice pick and boxcar scars - trades a pit for a fine linear scar that fades over months.

  • Subcision

    A blunt cannula or needle releases fibrous bands under rolling and tethered boxcar scars - the foundation step before volumising or resurfacing.

  • Dermal filler

    Hyaluronic acid or biostimulatory filler placed under atrophic scars after subcision - restores volume and holds the release open.

  • RF microneedling (Morpheus8, Sylfirm, Secret)

    Insulated needles deliver radiofrequency into the dermis - remodels collagen with a low risk of pigment change, useful across all skin types.

  • Fractional non-ablative laser

    Fraxel 1550 and 1927 create microscopic columns of injury that stimulate collagen - a workhorse for boxcar, rolling and pigment.

  • Fractional ablative laser

    CO2 or erbium resurfacing for the most severe atrophic disease - powerful, with real downtime and pigment risk in darker skin.

  • Intralesional steroid (Kenalog)

    Triamcinolone injected into hypertrophic and keloid scars - flattens raised tissue over a series of visits, often with silicone and laser.

  • Silicone sheets and gel

    Occlusive silicone worn nightly on hypertrophic scars for months - modest but real evidence, and the safest home step.

  • Pulsed dye laser and KTP

    Vascular lasers that target the red or purple of post-inflammatory erythema and reduce hypertrophic scar redness and thickness.

  • Topical pigment plan

    Retinoid, hydroquinone, azelaic acid and tranexamic acid for PIH - paired with daily sunscreen and gentle skincare.

  • IPL and fractional 1927

    Broad-band light and non-ablative fractional treatment for stubborn PIH - staged carefully in higher Fitzpatrick types.

What this guide is based on

The sources behind every claim on this page.

UK national guidance, specialist society standards and peer-reviewed dermatology sources, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP or dermatologist knows your skin and history and can tell you which parts apply to you. If in doubt, get seen.

  • British Association of Dermatologists (BAD). Guidance and patient information on acne and acne scarring.

  • Goodman GJ, Baron JA. Postacne scarring: a qualitative global scarring grading system.

  • European Dermatology Forum. Guideline on acne treatment.

  • NICE. Acne vulgaris: management (NG198) - context on scar prevention through active acne control.

Red flags

When scar treatment should wait.

Most acne scarring is safe to treat in a specialist clinic. These are the situations where a plan should pause, adjust or escalate first.

  • Active inflammatory acne

    Fresh nodules or cysts mean scar treatment is on hold - device work on inflamed skin worsens pigment and scarring.

  • Recent isotretinoin

    A traditional 6 to 12 month gap after isotretinoin is often used before ablative resurfacing - discuss timing with your dermatologist.

  • Keloid tendency

    A personal or family history of keloids raises the risk of ablative and surgical treatment - safer plans use RF microneedling, steroid and silicone.

  • Skin of colour - PIH risk

    Fitzpatrick IV to VI need cautious device settings and topical pre-treatment - ablative laser is rarely first choice.

  • Psychological distress

    Scars carry a real mental-health burden - low mood or body-image distress deserves compassionate mental-health support alongside dermatology.

  • Skin dysmorphia

    When perceived severity outstrips clinical severity - treatments rarely help until the underlying concern is addressed.

  • Sudden new scarring

    A sharp rise in scarring, particularly with new nodules, is a signal to escalate acne treatment - not the scar plan.

  • Unregulated providers

    Deep chemical peels, aggressive lasers and needling in non-medical settings can worsen scarring - stick to CQC-regulated clinics.

  • Sun exposure and tanning

    Recent tanning or planned sun holidays make pigment change more likely - most protocols pause device work.

Living with it

Prevention, protection, and a staged plan.

Four things that make the biggest difference - treat acne early, protect the skin daily, combine techniques over months, and give collagen time.

A quiet reminder

Scars fade in months, not weeks.

Collagen remodelling takes time - judge results at three to six months, not after one session.

  1. 01 Prevent

    Treat acne early, hard

    Every prevented breakout is a prevented scar - a topical retinoid, timely oral therapy or isotretinoin is the best scar strategy you have.

  2. 02 Protect

    Daily SPF, no picking

    Sunscreen prevents PIH; keeping fingers off active lesions prevents both PIH and true scars.

  3. 03 Plan

    Combine techniques, stage them

    The best results come from stacked treatments - subcision plus RF microneedling plus TCA CROSS, spaced over months.

  4. 04 Patience

    Expect months, not weeks

    Collagen remodelling takes 3 to 6 months to show - judge results at the end of a plan, not after one session.

Frequently asked

Everything we get asked about acne scarring.

Quick answers on scar types, TCA CROSS, RF microneedling, PIH and what to expect.

  • What causes acne scarring?

    Inflammatory acne damages the dermis. When healing loses collagen you get atrophic scars - ice pick, boxcar and rolling. When healing overshoots you get hypertrophic or keloid scars. Post-inflammatory hyperpigmentation and erythema look like scars but are pigment and vessel changes rather than true collagen loss.

  • Can acne scars be removed completely?

    Realistically no - but a well-designed plan can improve scars by 50 to 70 percent. Ice pick scars respond to TCA CROSS or punch excision; boxcar and rolling scars respond to subcision, RF microneedling and fractional laser; hypertrophic scars flatten with steroid injections, silicone and vascular laser.

  • What is TCA CROSS?

    Chemical reconstruction of skin scars - a focal, high-strength trichloroacetic acid (70 to 100 percent) is placed inside each ice pick scar. It triggers controlled remodelling and, over several sessions, narrows and lifts the scar.

  • Do I need to finish acne treatment first?

    Yes. Active inflammatory acne must be controlled before scar work begins - fresh lesions during device treatment create fresh scars and blunt results. Most clinicians treat the acne first, then wait for the skin to settle before starting a scar plan.

  • Are these treatments safe for darker skin?

    They can be, but the plan is different. RF microneedling and subcision are relatively safe across all Fitzpatrick types. Ablative laser and stronger chemical peels carry higher pigment risk in skin of colour - topical pre-treatment, cautious settings and staged sessions reduce that risk.

  • How is post-inflammatory hyperpigmentation different from a scar?

    PIH is a flat brown mark from excess pigment after inflammation. It is not a true scar and it fades - usually over months to a year - with a topical retinoid, hydroquinone, azelaic acid, tranexamic acid and daily sunscreen. IPL and fractional 1927 laser can accelerate stubborn cases.

Related content

Keep reading.