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Treating acne scars

Treatments for all types of scars are now more than just skin deep


There are four main types of acne scars: Ice pick scars (above, left), boxcar scars (right), rolling scars and hypertrophic scars.

There are four main types of acne scars: Ice pick scars, boxcar scars, rolling scars (above left) and hypertrophic scars (right).

ACNE is very prevalent - it occurs in 80 per cent of adolescents, and persists into adulthood in 50 per cent. Permanent scars may occur during the healing of active acne, and hence early therapy of acne is the most effective way to prevent post-acne scarring. Severe acne scars may lead to psychological distress. In adolescents, it is associated with poor self-esteem, depression, anxiety, low academic performance and unemployment. Hence, treatment of acne scarring is very important.

Types of acne scars

Acne scars can present as ice pick scars, box car scars, rolling scars or hypertrophic scars. In most, you will find a combination of a few types of scars on the same person. Evaluating the scar type and its severity is very important to select the most appropriate therapy.

Ice pick scars are the most common. These are deep pinpoint scars that look as if the skin has been stabbed with an ice pick.

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Boxcar scars are round or oval in shape, which may be shallow or deep, and are usually found on the cheeks, giving them an uneven appearance.

Rolling scars are shallow and wide and look like waves. These differ from boxcar scars in that they aren't sharply defined.

Hypertrophic scars are raised, firm scars that grow above the surface of the skin, usually after a severe cystic or nodular acne lesion resolves.

Management of acne scars

Many different methods of treating acne scars have been performed and often, a combination of treatments is required to produce the best effect.

Chemical peels

Common chemicals used for acne scar treatments are glycolic acid, salicylic acid or trichloroacetic acid (TCA) peels. These provide a controlled, partial thickness chemical exfoliation of the epidermis and dermis, accelerating the skin's healing process. High concentration of TCA can also be applied locally on depressed scars, known as Chemical Reconstruction of Skin Scars (TCA CROSS). This stimulates collagen synthesis, thickening of the dermis and allows for improvement of depressed scars, especially for deep scars.


This is a non-operative technique to manage depressed scars, which are anchored down to deeper layers of your skin via scar tissue. The scar tissue is manually released via a needle inserted into the skin, and coupled with new collagen deposition caused by wound healing, thus leading to a cosmetic improvement of the scar. It can be safely performed in a clinic setting and is usually well-tolerated.


All patients with boxcar scars and rolling scars are candidates for lasers. Both ablative and non-ablative lasers can be used.

Ablative lasers are carbon dioxide lasers and Erbium YAG lasers, and these resurface the skin by removing outer layers and damaged scar tissue, through vaporisation or evaporation. Non-ablative lasers, for example, are "Nd:YAGlasers", which stimulate new collagen formation, without removing the epidermis - the outermost layer of the skin - and hence have less downtime. Ablative lasers are more effective for depressed acne scars compared to non-ablative lasers.

Other methods such as minor operations to excise the scar areas, microneedling, fractionated bipolar radiofrequency can also be used.

Skin resurfacing laser treatment

Fractional carbon dioxide (CO2) laser for atrophic acne scars is my go-to for rolling and boxcar scars. This skin resurfacing laser works by removing outer layers of damaged skin, via the production of multiple tiny microthermal zones, which reach deep into our skin surface, to where the depressed scars start from.

This stimulates your body's natural repair process to rebuild lost collagen in your skin, promoting efficient improvement in skin rejuvenation and scarring. Because of the fractional technology, there are intervening areas of healthy tissue between the microthermal zones, which is able to supply the proteins and cells needed to heal the microthermal zones. This shortens your recovery period and reduces side effects, such as post-inflammatory hyperpigmentation (PIH).

Fractional CO2 lasers have been extensively studied in the treatment of acne scarring, since the concept was co-invented in 2004 by Professor Dieter Manstein from Harvard Medical School. In a study by Elcin and Armagan, published in Lasers in Medical Science in 2017, they showed that fractional CO2 laser is an efficient treatment option for acne scars and more than half of the subjects still experienced at least mild improvement at the end of three years.

Depending on your skin condition, you may need around one to three sessions. They can be done at four to six-weekly intervals. A local anaesthetic cream is applied to numb your skin 20 to 25 minutes prior to the laser. This is followed by the procedure itself, which will take around 15 to 20 minutes.

Most patients find the pain minimal, and there will be some redness and swelling on the treated areas, appearing like a sunburn. You should also avoid intense sun exposure during the healing phase, for around two weeks.

Most of my patients respond very well to the fractional CO2 laser and have good improvement of their scars. It is a generally safe procedure which has five to seven days of downtime, including some redness, swelling, discomfort and scabs. But we do see some complications, albeit rarely, associated with fractional CO2 laser:

Prolonged redness: Immediate post-treatment redness is an expected consequence of fractionated laser skin resurfacing that usually resolves within three to four days. Prolonged erythema or post-treatment erythema persists longer than one month.

Post-inflammatory hyperpigmentation (PIH) : PIH is the most common complication of laser treatment in darker-skinned patients after fractional CO2 laser. It is a temporary pigmentation that occurs after an injury or inflammation to the skin. Risk of PIH can be minimised by avoiding sun exposure at least two weeks before and after fractional laser and using lightening creams, pre- and post-treatment.


The most common type of infection is with herpes simplex virus and has been reported in 0.3 per cent to 2 per cent of cases. The rate of bacterial infection is rarely observed after fractionated skin resurfacing, seen in only 0.1 per cent of all treated cases. Infections are rare but proper identification and treatment are essential to avoid further complications, including delayed wound healing, scarring and further spread of the infection.

At TAMC, we combine fractional CO2 laser with umbilical cord-lining stem cell conditioned media, Calecim Professional, which has been scientifically proven for skin regeneration and repair. Umbilical cord lining stem cells secrete proteins, growth factors and cytokines, which are collected in a conditioned media, and formulated into Calecim Professional products.

The stem cells are ethically harvested from umbilical cord lining of New Zealand deer. Calecim Professional serum contains 80 per cent stem cell-derived proteins within a sterile bottle.

Extensive research has been conducted on it and clinical observations found that it significantly reduces redness, swelling and discomfort, aids and accelerates the skin's healing cascade, and enhances aesthetic results.

  • This series is produced in collaboration with The Aesthetics Medical Clinic.