Ice pick scars
As the name suggests, ice pick scars are very deep acne scars that look like the skin has been punctured with… an ice pick. When the body produces too little collagen in response to an injury, depressed scars such as ice picks can form. “Ice pick scars represent the result of infected sebaceous gland openings on the skin. They are usually the most difficult to correct,” says New York City plastic surgeon Gerald Imber, MD.
Acne scar treatment: “Treatment may include excising the scar with a small ‘punch,’ and suturing the defect closed, but this only works for isolated ice pick scars,” he says. New York City dermatologist Judy Hellman, MD, adds: “We can also do skin grafts and take skin from behind the ear to fill the scar, and then we can use a laser or radiofrequency device to smooth it out.”
If there are multiple ice pick scars, acne scar treatment devices that use radiofrequency energy are Dr. Hellman’s first choice. “These treatments help build collagen from the inside out, and collagen helps to fill the scars from within,” she says. Several treatments are usually needed. The procedures are done using local anesthesia, and it’s effective in all skin types, she says. In one study, published in a 2015 issue of the Journal of Cosmetics, Dermatological Sciences and Applications, Dr. Hellman found that approximately four treatments with a radiofrequency device produced significant improvement in the depth of the scars. A follow-up study in a 2016 issue of the same journal showed that these results held for up to two years, although some people had touch-ups.
Boxcar scars are also depressed, but they tend to be broader and boxier than ice picks. Everyone heals differently, and depressed acne scars like boxcars form when too little collagen is produced during wound healing.
Acne scar treatment: Energy-based skin resurfacing with a laser, radiofrequency, or an ultrasound device can help treat boxcar scars, according to Nada Elbuluk, MD, an assistant professor at the Ronald O. Perelman Department of Dermatology at New York University Langone Medical Center in New York City. “They all work by creating new collagen beneath the surface of the skin.” A series of treatments is likely needed based on the extent of scarring, she says. Chemical peels can also help but to a lesser extent. With either procedure, using a retinoid to increase cell turnover and further boost collagen can help improve results, Dr. Elbuluk adds.
There is also a role for Bellafill and other injectable fillers, including fat, for some depressed scars. Bellafill is currently the only filler that’s approved by the U.S. Food and Drug Administration to help raise depressed scars. It packs a one-two punch by adding volume, and also encouraging collagen formation beneath the surface by creating a supportive scaffold. “Bellafill and other injectables can fill in scars but these tend to be better for one scar,” adds New York City facial plastic surgeon Jennifer Levine, MD. Filler results can last up to 18 months. “If you have a cheek full of depressed scars, it’s better to resurface the face with laser, radiofrequency, or another energy-based treatment,” she adds.