different acne scar types and treatments in singapore

Acne Scar Types

By knowing your acne scar type(s), you can plan on how to treat your scars.

Clinically proven, safe and effective customised treatment options for you.

deep acne scar type
Deep atrophic acne scars

Table of Contents

What Causes Acne Scars?

What causes acne scars? Understanding acne scars is the first step to prevent and minimise acne scarring.

There is a 10-15% chance of permanent acne scarring in individuals suffering from acne vulgaris. The risk factors that relate to what causes acne scars is higher when acne is severe, and when there is a delay in seeking medical treatment. Acne scars frequently result from severe cystic acne, long standing inflammatory acne or even from picking on your own scars. We cannot emphasize enough the importance of treating acne early. Early treatment of acne reduces the inflammatory assault on the skin and prevents permanent damage to the dermal layer.

Determining what causes acne scars will lead to appropriate acne scar removal treatments. When it comes to the treatment of acne scars, establishing the scar type is essential, because specific treatments work best for specific scar types.

Types of acne scars for acne scar removal
Acne scar classification based on appearance

What are the Most Common Type of Acne Scars?

Acne is a condition where inflammation and resulting scar tissue can arise from the superficial to the deeper layers of the skin. The most common acne scar type is usually a mixture of ice pick, boxcar and rolling scars. We call this Polymorphic Atrophic Acne Scarring.

Acne scars are frequently located in the forehead, temples, cheek, nose, jawline and back. The degree of scarring differs among individuals because the factors that contribute to what causes acne scars also differs.

Acne scar types

post inflammatory erythema red acne scar

What are Red Acne Scars?

A common scenario is red acne marks that persist after an outbreak. Similar to PIH, this red discolouration appears in flat patches are due to the inflammatory response. These form of acne blemishes are know as Post-inflammatory erythema (PIE), and are more common in individuals with lighter skin tone. While most cases resolve on its own, PIE may be further improved with anti-redness creams and Pulsed Dye Laser for red acne scars.

tca cross acne scars treatment for ice pick scars
Ice pick scars

What are Ice Pick Scars?

Representing 60-70% of atrophic acne scar, ice pick scars (also known as pitted scars) are narrow and deep, where the opening of the scar is wider than the base of the scar, forming a “V’ Shape. To give you an idea how deep ice pick scars can get, they sometimes reach the fatty layer of the skin. Laser resurfacing for ice pick scars will not yield a good result because of the depth of scarring. Instead, acne scar removal techniques such as TCA CROSS and punch excision allow the scars to resurface over time.

temple boxcar scars
Boxcar scars

What are Boxcar Scars?

Making up about 20-30% of atrophic acne scars, boxcar scars are wider than icepick scars, have a flat base and almost vertical edges. Boxcar scars do not go as deep as icepick scars, and are common on the temples and cheeks. They can be sub divided as:

  • Shallow boxcar scars 
  • Deep boxcar scars

Shallow boxcar scars respond well to fractional resurfacing techniques such as Genius and INFINI, but deeper ones seem to be more resistant to treatment.

face rolling acne scars
Rolling scars

What are Rolling Scars?

Contributing to 15-25% of atrophic acne scars, rolling scars are the results of bands of scar tissue pulling the skin downwards to the fatty layer of the skin, giving it an undulating appearance. They are wide, shallow and having diameters up to 5mm. A variety of acne scar removal methods to release the band of scar tissues include subcision, fractional resurfacing treatments and dermal fillers.

shoulder keloid scars
Keloids scars on back

What are Keloid Scars?

Keloid scars appear as raised scars that are red and can feel itchy and painful. Keloids arise due to abnormal wound healing of the skin due to inflammation from acne. The jawline, chest, shoulders are upper arm are especially prone to keloid formation. There are a variety of Keloid scar removal options, which include anti-inflammatory injections, laser resurfacing and silicon plaster.

post inflammatory hyperpigmentation on forehead
PIH on forehead

What are Pigmented Acne Scars?

After your acne has subsided, you may notice that the surrounding area is darkened. This discolouration is due to the inflammatory response, and is more common in darker skinned individuals. These acne blemishes are known as post-inflammatory hyperpigmentation (PIH). While many PIH may resolve over time, some stubborn ones do remain. A variety of prescription lightening creams may help speed the process. Pico-second laser is another option for more resistant cases. Remember to use a sunblock regularly to protect the skin from further pigmentation.

Papular acne scars

What are Papular Acne Scars?

A new variant of acne scars that has recently been described as it was under-reported and under-recognized.  These are appear as firm skin coloured bumps on the skin (called papules) which commonly occur on the nose, chin and back. They are more common in males and individuals of darker skin phototypes.

Notoriously difficult to treat, several methods have been attempted in a few case series. Treatments attempted include radiofrequency ablation via a thin hypodermic needle, Er:YAG laser (pin-hole method) and CO2 laser ablation. There is so far no consensus on the best treatment therefore it is wise to speak with your doctor regarding the  treatment options.

What is the Acne Scar Grading System?

acne scar grading
Goodman and Baron Acne Scar Grading System

The acne scar grading system facilitates an easy to understand communication about the severity of acne, and the most appropriate treatment for that degree of acne scarring. 

Grade 1: Flat scars that are discolored red, brown or even white. They are readily visible from a distance

Grade 2: Mild scarring that are only visible at a distance less than 50cm, and can be covered by make-up. E.g. mild rolling acne scars

Grade 3: Moderate scarring that is visible at distance more than 50cm, and is not easily covered by make-up or the shadow of a shaved beard. Stretching the skin can flatten the scar. E.g. deeper rolling scars, shallow boxcar scars.

Grade 4: Severe scarring as in Grade 3, and scars cannot be flattened by stretching the skin. E.g. deeper boxcar scars, ice pick scars, keloids.

Knowing Your Scar Type and Scar Grade leads to Better Treatment outcomes

No two individuals are ever completely alike, not even twins. The factors that correspond to what causes acne scar and the resultant skin damage differs greatly. Every individual will have a unique distribution, depth and pattern of scarring. One patient may have predominantly keloids and red acne marks on his chest and back, while another may have a combination of ice pick, boxcar and rolling scars on his face.

An approach that takes into account your skin quality, skin colour and medical history to match the specific treatment to the specific scar type will give the best improvement to your acne scars.

Acne Scar Removal Treatments

At our clinic, the approach to acne scarring is highly tailored to the individual; no two individual will receive exactly the same treatment protocol. There is no gold standard method to treat acne scars. In so far as it’s a dynamic process, it also depends on factors such as scar type, scar depth, skin phototype and response to treatment amongst other factors. Generally, in the case of mixed acne scarring, our approach would be to first resurface the deep acne scars. Once the initial treatment of deep scars is satisfactory, we resurface the skin to even out the texture, tone and improve collagen remodeling within the skin.

The Acne Scar Removal Program is crafted to put together a variety of treatments to improve your acne scars. A combination approach of the different modalities will give the best results.

Frequently Asked Questions

  • Inflammation: Severe inflammation from acne can damage the skin’s structure, leading to scar formation.
  • Picking or Squeezing Acne: Manual interference can worsen inflammation and increase the risk of scarring.
  • Genetics: A family history of acne scars can predispose individuals to develop scars more easily.
  • Skin Type: Certain skin types are more prone to specific scar types, such as darker skin being more susceptible to hypertrophic and keloid scars.
  • Early Treatment: Treating acne early can prevent severe breakouts that lead to scarring.
  • Avoid Picking: Refrain from picking or squeezing pimples to reduce inflammation and skin damage.
  • Proper Skin Care: Using appropriate skincare products to manage acne and protect the skin can help minimize scarring.
  • Topical Treatments: Include retinoids, alpha hydroxy acids (AHAs), and other over-the-counter creams that can help improve skin texture.
  • Chemical Peels: Remove the outer layer of skin to reduce scar depth and improve appearance.
  • Microneedling: Uses tiny needles to stimulate collagen production, improving skin texture.
  • Laser Therapy: Resurfaces the skin and stimulates collagen production.
  • Dermal Fillers: Injectable fillers that raise depressed scars to the level of the surrounding skin.
  • Subcision: A minor surgical procedure that breaks up scar tissue under the skin.
  • Punch Excision: Surgical removal of individual scars, followed by suturing or skin grafting.

The timeline for seeing results varies depending on the treatment type:

  • Topical Treatments: Several months of consistent use.
  • Chemical Peels and Microneedling: Noticeable improvements after several sessions, typically spaced weeks apart.
  • Laser Therapy: Improvement can be seen within a few weeks, with full results after several sessions.
  • Dermal Fillers: Immediate results, but they are temporary and may need regular maintenance.
  • Subcision and Punch Excision: Healing and improvement are gradual, typically noticeable within a few months.
  • Topical Treatments: May cause irritation, redness, and peeling.
  • Chemical Peels: Can cause redness, peeling, and sensitivity to sunlight.
  • Microneedling: Possible redness, swelling, and minor bleeding.
  • Laser Therapy: Redness, swelling, and temporary changes in skin color.
  • Dermal Fillers: Risk of allergic reactions, lumps, and bruising.
  • Subcision and Punch Excision: Risk of infection, bleeding, and temporary swelling or bruising.
  • Healthy Diet: Eating a balanced diet rich in vitamins and minerals can support skin health.
  • Hydration: Drinking plenty of water helps maintain skin elasticity and overall health.
  • Sun Protection: Using sunscreen can prevent scars from becoming more noticeable.
  • Stress Management: Reducing stress can help manage acne and prevent scarring.
Dr Moses Ng dermatologist

Acne Scar Types

Know your scar type. Know your treatments. Matching the most appropriate treatment to your acne scar type will lead to better results. Acne scar revision is more of a marathon rather than a sprint. I treat deeper scars first so that they are more levelled before considering fractional resurfacing procedures.

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Related Information:
  1. C.I. Jacob, J.S. Dover. Acne scarring: A classification system and review of treatment options. J Am Acad Dermatol 2001;45:109-17
  2. Lee JB, Chung WG, Kwahck H, Lee KH. Focal treatment of acne scars with trichloroacetic acid: Chemical reconstruction of skin scars method. Dermatol Surg 2002;28:1017-21.
  3. Cho SB, Lee JH, Choi MJ, Lee KY, Oh SH. Efficacy of the fractional photothermolysis system with dynamic operating mode on acne scars and enlarged facial pores. Dermatol Surg 2009;35:108-14
  4. Fonseka, Sanjeewani; Wickramaarachchi, Dasun Chathumina; Bandara, Dilan Dileepa Jayarathne Ablative Carbon Dioxide Laser Treatment for Papular Scars of Nose and Chin Due to Acne: A Case Series, International Journal of Dermatology and Venereology: September 2021 – Volume 4 – Issue 3 – p 182-184 
  5. Zaleski-Larsen LA, Fabi SG, McGraw T, Taylor M. Acne scar treatment: a multimodality approach tailored to scar type. Dermatologic Surgery. 2016 May 1;42:S139-49.