You’ve tried retinoids, you’ve tried chemical exfoliants, you’ve bought every “scar-fading” serum on the market—and your skin texture is still there. The pits, the shadows, the uneven surface that makeup can’t quite hide.
Here’s what most skincare content won’t tell you: topical products have real limits when it comes to acne scars. They can help with color and surface texture, but deep pits require mechanical intervention.
This guide breaks down what actually works, in what order, and how much you should realistically expect from each approach.
Step 1: Identify Your Scar Type (Quick Self-Check)
Not all scars respond to the same treatments. Before spending money on procedures, you need to know what type you’re dealing with.
Rolling Scars
- Look: Wavy, wave-like depressions with soft edges
- Feel: Skin looks shadowy in certain lighting, almost like gentle dunes
- Cause: Fibrous tethering under the skin pulling it down
- Best treated with: Subcision, followed by microneedling or laser
Boxcar Scars
- Look: Defined, sharp edges like small rectangular or oval craters
- Feel: Distinct borders around each scar
- Cause: Collagen destruction from inflammatory acne
- Best treated with: TCA CROSS for narrow ones, fractional laser or RF microneedling for wider ones
Icepick Scars
- Look: Tiny, deep, V-shaped holes
- Feel: Narrow openings that extend deep into skin
- Cause: Severe inflammation that destroyed tissue in a narrow column
- Best treated with: TCA CROSS, punch excision
Marks vs. Scars: PIH and PIE
These are NOT the same as pitting:
- PIH (Post-Inflammatory Hyperpigmentation): Brown or dark spots left after a pimple. More common in deeper skin tones. Responds well to topicals.
- PIE (Post-Inflammatory Erythema): Pink or red marks left after inflammation. More visible on lighter skin. Can take months to fade.
If your skin is flat and just discolored—that’s a mark, not a scar. Marks respond to sunscreen, azelaic acid, vitamin C, and time. Pits require procedures.
Mixed situation? Most people have a combination. Treat the marks topically while you address the pitting procedurally.
Step 2: Realistic Expectations (Home vs. Clinic)
This is the part most people don’t want to hear. Let’s be honest about what each approach can deliver.
What Skincare (Home) Can Do
✓ Improve surface texture and smoothness
✓ Fade marks (PIH/PIE)
✓ Prevent new scars by managing active acne
✓ Support healing after procedures
✓ Improve overall skin quality
Approximate improvement for scars: 10-20% at best
What Procedures (Clinic) Can Do
✓ Break up tethered scar tissue (subcision)
✓ Rebuild collagen at depth (microneedling RF, lasers)
✓ Fill deep narrow scars from below (TCA CROSS)
✓ Physically remove or elevate scar tissue (punch excision/elevation)
Approximate improvement for scars: 40-80% depending on scar type, number of sessions, and your skin’s healing response
The Reality Check
- Scars will improve, not disappear. Even multiple treatments rarely result in “perfect” skin.
- Multiple sessions required. Plan for 3-6+ procedures spaced months apart.
- Results take time. Collagen remodeling continues for 6-12 months after procedures.
- Investment is real. Budget several hundred to several thousand dollars over time.
Going in with realistic expectations protects you from disappointment and helps you appreciate visible improvements.
Best Procedure Order (The “Smart Stack”)
The order of procedures matters more than most clinics will tell you. Here’s the evidence-based sequence:
1. Subcision First (For Rolling/Tethered Scars)
If you have rolling scars or scars that are “tethered” (pulled down by fibrous bands underneath), subcision should come first.
- What it is: A needle or cannula is inserted under the scar to cut the fibrous bands pulling skin down
- Why first: If you don’t release the tethering, other treatments can’t lift the scar effectively
- Sessions: Usually 2-4 sessions, 6-8 weeks apart
- Downtime: Bruising for 1-2 weeks, swelling for a few days
Read more: Subcision vs Microneedling: Which First?
2. TCA CROSS for Icepick Scars
Icepick scars are too narrow and deep for most lasers or microneedling to reach effectively.
- What it is: High-concentration TCA (70-100%) applied precisely inside each ice pick scar
- How it works: Causes controlled destruction that triggers collagen production from the base up
- Sessions: 3-6 sessions, 4-6 weeks apart
- Downtime: Frosting and scabbing for 1-2 weeks per session
Read more: TCA CROSS for Icepick Scars: Who It’s For
3. Microneedling RF or Fractional Laser for Overall Texture
After addressing specific scar types, these broader treatments improve overall texture.
- Microneedling RF (Morpheus8, Genius, etc.): Needles + radiofrequency heat = deeper collagen stimulation with less surface damage
- Fractional CO2 / Erbium laser: Creates micro-columns of controlled damage to trigger collagen remodeling
- Sessions: 3-6 sessions, 4-6 weeks apart
- Downtime: 5-7 days redness and crusting for laser; 2-4 days for RF microneedling
4. Maintenance and Polish
After the main treatment series:
- Annual or biannual maintenance sessions
- Consistent retinoid use at home
- Rigorous sun protection to prevent PIH
Budget Paths (So It’s Actionable)
Let’s make this realistic for different financial situations.
Low Budget Path
Investment: $300-800 over 6-12 months
- Tretinoin or adapalene (prescription or OTC adapalene) – $10-50/month
- Sunscreen daily – $15-30/month
- 3-6 microneedling sessions (basic microneedling, not RF) – $150-300 each
Expected improvement: 20-30%
This path prioritizes consistency over intensity. Basic microneedling is much cheaper than RF microneedling but requires more sessions for similar results.
Mid Budget Path
Investment: $1,500-3,000 over 12 months
- Everything in low budget, plus:
- 2-3 subcision sessions – $300-500 each
- RF microneedling instead of basic microneedling – $400-800 per session
Expected improvement: 40-50%
Adding subcision makes a significant difference for rolling scars. RF microneedling treats deeper than standard microneedling.
Higher Budget Path
Investment: $4,000-8,000+ over 12-18 months
- Subcision – 3-4 sessions
- TCA CROSS (if icepick scars present) – 4-6 sessions
- RF Microneedling or Fractional CO2 laser – 3-4 sessions
- PRP or filler (optional) – to fill remaining volume loss
Expected improvement: 60-80%
This is the comprehensive approach. Multiple modalities targeting different aspects of scarring.
At-Home Routine to Support Results
Your daily routine supports healing and maintains results. It doesn’t replace procedures for pitting, but it’s essential for overall skin health.
Morning (AM)
- Gentle cleanser – Avoid stripping the barrier
- Moisturizer – Keep skin hydrated and resilient
- Sunscreen SPF 30+ – Critical. Sun exposure worsens scarring and causes PIH.
Evening (PM)
- Gentle cleanser – Remove sunscreen and debris
- Retinoid – Tretinoin (prescription), adapalene (OTC), or retinal
- Moisturizer – Buffer if retinoid is irritating
Optional Add-Ons
- Azelaic acid (10-20%) – Excellent for PIH/PIE (marks), less useful for actual pits
- Vitamin C (morning) – Antioxidant, helps with marks and overall tone
What to AVOID
- DIY high-strength peels – Risk of burns, PIH, and uneven results
- At-home dermarollers – Infection risk, inconsistent needle quality, doesn’t go deep enough
- Aggressive exfoliation – Over-exfoliation impairs healing
- Skipping sunscreen – Especially critical after any treatment
When to See a Derm Sooner
Don’t wait to get professional advice if:
Active Cystic Acne Is Still Ongoing
Treating scars while still getting new cysts = treating a moving target. Get the active acne controlled first. Treatments like isotretinoin (Accutane), spironolactone, or prescription topicals may be necessary.
Keloid Tendency
If you’ve had keloids (raised, growing scars) from injuries, piercings, or surgeries, you need a careful treatment plan. Procedures that work for most people can trigger keloids in those predisposed.
Signs of keloid tendency:
- Raised scars that grew beyond the original wound area
- Family history of keloids
- Keloids from ear piercings (common indicator)
Darker Skin Concerns (PIH Risk)
Deeper skin tones are at higher risk for PIH from procedures. This doesn’t mean you can’t do treatments—it means you need:
- Pre-treatment preparation (hydroquinone, tretinoin, etc. for 4-6 weeks before)
- Lower energy settings initially
- Longer intervals between sessions
- Religious sun protection
- A provider experienced with skin of color
Mitigating PIH Risk
- Tyrosinase inhibitors pre- and post-treatment (hydroquinone, arbutin, kojic acid)
- Avoid sun exposure for 2+ weeks after procedures
- Use mineral sunscreen (less irritating)
- Don’t pick at healing skin
FAQ
Can scars improve after 5+ years?
Yes. Old scars can still respond to treatment. Collagen remodeling can be triggered at any time—it just takes patience and the right procedures. Many people with decade-old scarring see significant improvement.
Microneedling vs. laser—which is better?
It depends on your skin.
- Microneedling (especially RF): Safer for darker skin tones, less downtime, good for shallow-moderate scars
- Fractional laser (CO2/Erbium): More aggressive, potentially better results for lighter skin, more downtime, higher PIH risk for darker tones
For most people, RF microneedling offers the best balance of results and safety.
How painful is subcision?
Manageable. The area is numbed with local anesthesia (lidocaine injections). You’ll feel pressure and tugging, not sharp pain. Some people describe it as “weird but not painful.” Bruising afterward can be sore for a week or two.
What’s the downtime for subcision?
7-14 days of visible bruising. Plan accordingly—you won’t want to attend important events. Swelling subsides in 2-3 days. Full bruise resolution in 1-2 weeks depending on your tendency to bruise.
What’s the best time of year for treatment?
Fall or winter (or whenever you have minimal sun exposure for 2-4 weeks after). Less sun = lower PIH risk. If you live somewhere sunny year-round, time it around indoor periods or vacations where you can stay out of the sun.
Do fillers work for acne scars?
Sometimes. Hyaluronic acid fillers (like Restylane) can volumize certain scars, but:
- Temporary (6-18 months)
- Works better for boxcar than icepick
- Doesn’t address tethering
- Best as a finishing touch after other treatments
Can I do my own TCA peel for scars?
No, and please don’t. TCA CROSS requires precise application of high-concentration acid into individual scars. Done wrong, it causes burns, hyperpigmentation, and potentially worsening scars. This is a clinic-only procedure.
Build a Routine That Supports Your Skin
Managing acne scars is a marathon, not a sprint. While procedures do the heavy lifting, your daily routine keeps skin healthy and helps you heal faster between treatments.
If you want a routine that adapts to your skin’s current state—sensitivity, weather, and progress—skncoach builds a personalized plan for you. We’ll guide you through what to use, when to pause for procedures, and how to adjust as you heal.
This content is for informational purposes only and does not replace professional medical advice. Consult a board-certified dermatologist for personalized treatment recommendations.
