Types of Acne Scars and Treatment: Ice Pick, Boxcar and Rolling Scars Explained

Clinical guidance from Dr Nyla Raja MBChB (Hons), MRCGP (Dist), DFFP, DPDermatology - GMC No. 6057913

Ice pick, boxcar and rolling scars are all types of atrophic acne scars, meaning that they sit below the surrounding skin. They differ in shape, depth and the way scar tissue is attached beneath the surface, which is why one treatment is not suitable for every scar.

At Dr Nyla Medispa, acne-scar treatment planning starts by identifying the scar pattern rather than selecting a device in isolation. Many people have a mixture of scar types, alongside uneven texture, enlarged pores, redness or post-inflammatory pigmentation. The aim is meaningful improvement in skin texture and the visibility of scars, rather than a promise to remove every scar completely.

The three main types of atrophic acne scars

Atrophic scars develop when inflammation from acne disrupts normal collagen repair. The three recognised patterns are ice pick, boxcar and rolling scars. They can look quite different in changing light, so a close clinical assessment is more informative than a photograph alone.

Ice pick scars

Ice pick scars are narrow, sharply defined, V-shaped depressions which extend deeply into the dermis. Their opening may be small, but the scar can be substantially deeper beneath the surface. This is why treatments that work primarily by improving general texture may not fully correct pronounced ice pick scars.

For deep, isolated ice pick scars, specialist approaches that target the individual scar directly, such as chemical reconstruction techniques or carefully selected minor surgical procedures, may be considered. When ice pick scars occur alongside broader texture changes, collagen-remodelling treatment may also have a role in improving the surrounding skin, but expectations need to reflect the scar depth.

Boxcar scars

Boxcar scars are wider depressions with steep sides and a relatively flat base. They may be shallow or deep. Shallow boxcar scars are often more responsive to resurfacing and collagen-remodelling approaches than deep boxcar scars, which may need a more targeted or combined strategy.

Options may include radiofrequency microneedling, fractional laser resurfacing or, in selected cases, a focal procedure performed within an appropriate specialist setting. NICE guidance on acne-related scarring advises considering referral to a consultant dermatologist-led team with scar-management expertise for severe scarring which persists for a year after acne has cleared. It identifies CO₂ laser treatment, with or without punch elevation, as an option to consider in that setting.

Rolling scars

Rolling scars are broad, shallow-looking depressions which create an undulating or shadowed appearance, particularly across the cheeks. They are often caused by fibrous bands that pull the skin downwards. This underlying tethering is important: building collagen at the surface alone may improve texture, but may not fully release a scar that remains anchored below the skin.

Subcision is one procedure sometimes considered for tethered rolling scars because it addresses these fibrous attachments. Depending on the scar pattern, this may be followed by a collagen-remodelling treatment or, for selected individual depressions, volume support with dermal filler. The right sequence depends on the skin, the degree of tethering and the distribution of scars.

What about raised scars and acne marks?

Not every mark left by acne is an atrophic scar. Red or brown marks may be post-inflammatory erythema or hyperpigmentation rather than a change in skin structure. These can fade gradually, although pigmentation may persist for longer in some skin tones. Treatments chosen for colour changes are different from treatments designed to remodel depressed scars.

A smaller proportion of people develop raised hypertrophic or keloid scars, most often on areas such as the chest, shoulders or jawline. These need a different clinical approach and should not be treated as though they are depressed acne scars.

How collagen-remodelling treatments may fit into acne-scar treatment

Collagen-remodelling treatments create controlled stimulation within the skin to support gradual repair and improve texture. They can be particularly useful where acne scarring is mixed with general textural irregularity, enlarged pores or shallow depressed scars. Results develop progressively because collagen remodelling takes time.

Secret PRO combines RF microneedling with fractional CO₂ laser technology. These modalities work at different levels of the skin, allowing treatment to be tailored to the concern, skin type and appropriate recovery time. Fractional CO₂ laser generally involves more recovery than RF microneedling alone.

Morpheus8 is an RF microneedling treatment that can be considered for selected atrophic scars and uneven texture. Rolling, boxcar and tethered scars have different structural characteristics, however, so RF microneedling may form one part of a plan rather than being the complete answer for every scar.

Fractional CO₂ laser and radiofrequency microneedling have both been studied for atrophic acne scarring. Their suitability, expected recovery and potential for pigmentation changes vary according to scar type, skin tone, treatment settings and individual risk factors.

Why treatment plans are often staged or combined

Combination treatment is not about adding procedures unnecessarily. It reflects the fact that mixed scarring has more than one structural cause. For example, a person may have tethered rolling scars, deep ice pick scars and shallow boxcar scars in the same area. No single procedure addresses all three equally well.

A staged plan may first address active acne and skin inflammation, then focus on tethering or individual deep scars where appropriate, before using collagen-remodelling treatment to improve broader texture. Allowing adequate healing time between treatments also makes it easier to assess progress and adjust the plan safely.

Safety, recovery and skin tone considerations

Temporary redness, swelling and sensitivity are common after energy-based treatments. More intensive resurfacing may also cause temporary roughness, peeling or crusting while the skin heals. Your expected downtime depends on the technology used, its settings and the treatment area.

Skin type and any previous tendency towards post-inflammatory pigmentation are particularly important when planning laser or other energy-based treatment. Careful treatment selection, suitable settings, aftercare and sun protection are central to reducing avoidable risk. If you have active inflammatory acne, treatment should also address this because controlling ongoing breakouts can help reduce the risk of further scarring.

The key point

The best treatment for acne scars depends less on the label of a device and more on the structure of the scars being treated. Ice pick scars are narrow and deep, boxcar scars have defined edges, and rolling scars may be tethered below the skin. A detailed assessment makes it possible to choose a proportionate treatment plan, set realistic expectations and focus on smoother, more even, natural-looking skin over time.