Am J Clin Dermatol

https://doi.org/10.1007/s40257-018-0358-5

SYSTEMATIC REVIEW

Acne Scarring Management: Systematic Review and Evaluation

of the Evidence
Shashank Bhargava1 • Paulo R. Cunha2 • Jennifer Lee3 • George Kroumpouzos2,3,4

Ó Springer International Publishing AG, part of Springer Nature 2018

Abstract and observational studies. Other modalities can be used as

Background Modalities for atrophic acne scarring can be an adjunct, the choice of which depends on the type,
classified depending upon the needs they satisfy; that is, severity, and number of atrophic scars. Minimally invasive
resurfacing, lifting/volumization, tightening, or surgical procedures, such as fractional radiofrequency and needling,
removal/movement of tissue that is required for correction. provide good outcomes with negligible risks in patients
A plethora of treatment options have resulted from the need with dark or sensitive skin types.
to treat various acne scar types, variability of responses Conclusions There is a lack of high-quality data. Frac-
noted in various skin types, and increasing popularity of tional lasers and radiofrequency offer significant
minimally invasive modalities. Still, there is a lack of improvement in most types of atrophic acne scars with
consensus guidelines on treatment or combination thera- minimal risks and can be combined with all other treatment
pies for various clinical scenarios. options. Combination therapies typically provide superior
Objective This systematic review includes a critical eval- outcomes than solo treatments.
uation of the evidence relevant to these modalities and
various multimodality therapies.
Methods We performed a systematic literature search in
Key Points
Medline and EMBASE databases for studies on acne scar
management. Also, we checked the reference lists of
There is a lack of high-quality data on acne scarring
included studies and review articles for further studies. A
management.
total of 89 studies were included in our quality of evidence
evaluation. Fractional lasers and radiofrequency offer significant
Results The efficacy of lasers and radiofrequency in improvement in most types of atrophic acne scars
atrophic acne scarring is confirmed by many comparative with minimal risks, and can be combined with all
other treatment options.
Combination therapies typically provide superior
outcomes than solo treatments.
& George Kroumpouzos
gk@gkderm.com
1
Department of Dermatology, R.D. Gardi Medical College
and C.R. Gardi Hospital, Ujjain, India
2
Department of Dermatology, Medical School of Jundiaı́,
São Paulo, Brazil 1 Introduction
3
Department of Dermatology, Alpert Medical School of
Brown University, Providence, RI, USA Severe scarring has been reported in 30% of acne patients,
4
Department of Dermatology, Rhode Island Hospital, APC 10, although mild to moderate scarring has been reported in up
593 Eddy Street, Providence, RI, USA to 95% of these patients [1]. Acne scarring is often the

result of delayed and/or inadequate medical treatment but
can develop despite appropriate medical therapy. Collagen
and other tissue damage, secondary to inflammation of
acne, leads to permanent skin texture changes and fibrosis.
Scars typically proceed through a cascade of wound heal-
ing phases: inflammation, granulation, and remodeling [2].
Acne scarring is a therapeutic challenge as many treat-
ments may be only partially effective, leading to patient
disappointment and frustration [2]. The detrimental effects
of acne scarring are not limited to impaired cosmetic
appearance. Rather, acne scarring has also been associated
with depression and other mental health disorders, suicidal
ideation, emotional debilitation, embarrassment, poor self-
esteem, and general social impairment [3, 4].
Recently, treatment of post-acne scarring has become
easier, with many newer modalities offering better efficacy
and safety than older treatments. Matching individual
patient needs and appropriate treatment is crucial. Health-
care providers need to review treatment options, including
comparing efficacies and safety profiles between treatment
modalities, and setting up realistic expectations about
treatment outcomes with their patients [5].
1.1 Acne Scar Types and Severity
Eighty to ninety percent of acne scars demonstrate asso-
ciated loss of collagen (atrophic scars) [1] whereas the
remainder demonstrate a gain of collagen (keloidal or
hypertrophic scars). Atrophic scars present as depressions
secondary to fibrous contractions. Atrophic acne scars are
classified into boxcar, icepick, and rolling (Fig. 1) [6].
Fig. 1 Common types and descriptions of post-acne scars; boxcar, icepick, and rolling are types of atrophic scars
S. Bhargava et al.
Rolling and boxcar scars can be further subclassified into
superficial or deep, depending on whether they are above or
below, respectively, the depth in the dermis reached with
conventional skin resurfacing options such as carbon
dioxide (CO2) laser [8]. The size of the scar(s) (narrow
[B 3 mm] vs wide [[ 3 mm]) is a factor in therapeutic
decisions, especially when surgery/movement-related pro-
cedures are involved (Sect. 8). The grading of acne scar
severity (Table 1) is crucial to choosing the appropriate
modalities or combination treatments [7].
In this review, we provide comprehensive, evidence-
based information on all monotherapies, including tradi-
tional treatments, but place emphasis on discussing recent
modalities and combination therapies.
2 Methods
We conducted a search of MEDLINE (from 1946) and
EMBASE (from 1974) databases up to November 2017 for
publications in all languages on acne scar management,
regardless of status of publication. Key words used in each
search engine included acne, atrophic, scar (with wildcard
truncation), therapy, surgery, intervention, treatment,
management, and outcome. Furthermore, we checked the
reference lists of included studies and review articles for
further studies. A total of 286 non-duplicate citations were
identified. Full texts of all articles were assessed indepen-
dently by two authors (SB, GK). We considered 119
studies on atrophic scars for quality of evidence (QOE)
assessment (Fig. 2).
Acne Scar Management

Table 1 Grading of acne scar severity (adapted from Goodman and Baron [7])
Grade Level of Clinical features
disease

1 Macular Erythematous, hyper or hypopigmented flat marks (color problem)

2 Mild Atrophy or hypertrophy may not be obvious at social distances of C 50 cm; covered by makeup or the shadow of
shaved beard hair (men) or normal body hair
3 Moderate Atrophic or hypertrophic scarring is obvious at social distances of C 50 cm; not covered by makeup or the shadow of
shaved beard hair (men) or normal body hair; atrophic scars can be flattened by manual stretching of the skin
4 Severe Atrophic or hypertrophic scarring is evident at social distances of C 50 cm; not covered by makeup or atrophic scars not
flattened by manual stretching of the skin

Citaons excluded (n=74):

Non-duplicate citaons
reviews, commentaries, case
idenfied (n=286)
studies, leers, opinion papers
(n=48); abstract only/other
ineligible citaons (n=26)

Citaons excluded (n=60): acve

Citaons (n=212) acne (n=19); medical treatment of
acne scars (n=25); acne scar
evaluaon (n=11); modality
descripon paper (n=5)

Citaons excluded (n=33): other

Citaons (n=152) acne scar types (n=21); other
atrophic scars (n=12)

Full-text atrophic scar Citaons excluded (n=30): poor

studies screened (n=119) design/methodology (n=14);
small size studies (16)

Atrophic acne scar studies

in QOE analysis (n=89)

Fig. 2 Flow diagram of literature search and selection of studies in atrophic acne scarring for quality of evidence (QOE) analysis

2.1 Quality of Evidence (QOE) Analysis the treatment of atrophic acne scarring. The review meth-
ods and inclusion and exclusion criteria were established
We addressed whether there is high QOE from existing prior to conducting the review.
single-modality, comparative, and multimodality studies in

Inclusion Criteria: Studies on treatment of atrophic acne
scarring conducted in patients of any gender, age or ethnic
group that were examined by a dermatologist or an expe-
rienced investigator were included.
Exclusion Criteria: We excluded studies dealing only or
mostly with hypertrophic/keloidal scars or atrophic scars
unrelated to acne, those with poor methodology (e.g.,
outcome not well described or assessed, or no follow-up
reported), and small studies (i.e., studies on solo modalities
with \ 15 subjects and comparative/combination therapy
studies with \ 10 subjects), which can yield inaccurate
results.
Two review authors independently screened the spe-
cifics of studies, including type and severity of acne scar-
ring, types of interventions, limitations, risk of bias, and
outcome measures. Participant-reported scar improvement,
when available, was the primary outcome. Randomized
controlled trials (RCTs) that allocated participants (split-
face or placebo) to any modality (or a combination) for
treating acne scars as well as those RCTs that compared
interventions (split-face or parallel arms), controlled stud-
ies with no randomization, quasi-experimental studies, and
experimental descriptive studies were included in the QOE
analysis. QOE was rated according to the classification
(levels I–IV) by Shekelle et al. [8] that approximately
corresponds to the quality classification by Abdel Hay et al.
in a recent Cochrane review; that is, ‘high’, ‘moderate’,
‘low’, and ‘very low’ [9].
3 Results
3.1 QOE Evaluation
A total of 89 studies were included in the QOE analysis
(Fig. 2; Table 2, levels Ib–III). As shown in Table 2, there
is a limited number of single-modality but a good number
of comparative and combination therapy RCTs. Although
some modalities (i.e., needling, polymethylmethacrylate
filler, autologous fibroblast injections) were tested in RCTs
(level Ib QOE designation; ‘A’ grade of recommendation),
most single-modality studies bear a level II or III QOE
designation as there was no randomization. While there is a
good number of solo laser and radiofrequency (RF) studies,
most were uncontrolled (level III QOE).
3.2 Therapeutic Approaches to Different Types
of Acne Scars
Modalities for atrophic acne scars can be classified
depending upon the needs they satisfy; that is, resurfacing,
lifting/volumization, tightening, or surgical
removal/movement of tissue that is required for correction
S. Bhargava et al.
of scarring [10, 11]. Our systematic literature search
allowed assessment of the efficacy of common modalities
in the treatment of icepick, rolling, and boxcar scars
(Table 3). As shown in Table 3, fractional lasers (FLs) and
RF can treat all types of atrophic acne scars.
4 Resurfacing Modalities
4.1 Microdermabrasion
Microdermabrasion is a minimally invasive technique. It
provides a textural benefit, and superficial acne scars may
benefit from deeper and more aggressive settings [2]. It
offers certain advantages over chemical peeling, such as
greater control in the depth of exfoliation, comparatively
lesser discomfort, and minimal ‘downtime’ (post-proce-
dure peeling). In a small randomized study, combination
therapy of microdermabrasion with aminolevulinic acid
photodynamic therapy (ALA-PDT) was more effective
than microdermabrasion with placebo-PDT [12]. Recent
advances combine exfoliation with dermal infusion; that is,
percutaneous dermal drug delivery at the time of or
immediately after exfoliation. In a case series, the use of
microdermabrasion with a topical retinoid was associated
with some improvement in acne scarring [13].
4.2 Dermabrasion
Dermabrasion has been used for several decades with good
results [14]. This procedure removes the epidermis with or
without part of the dermis, and the subsequent wound
remodeling results in neocollagenesis, increased dermal
thickness, and enhanced hydration and epidermal barrier. It
allows the operator to precisely define scar edges [15] and
allows softening of scar edges. It is primarily used for well
defined superficial scars with distinct borders or broad-
based scars with indistinct borders [16]. However, it is
ineffective in treatment of icepick and deep boxcar scars
[17] and demonstrates fair to moderate efficacy in moder-
ate rolling scars [18]. Because it is an operator-dependent
procedure with a suboptimal safety profile, with adverse
effects including pain, erythema, dyspigmentation, signif-
icant recovery time, and scarring from the procedure,
dermabrasion has been largely replaced by FLs in the
treatment of acne scarring.
4.3 Chemical Peeling
Peels can improve skin texture, pigmentation, and tone.
However, adequate control of the peeling depth may be
difficult to achieve [16]. Thirty-five percent glycolic acid
(GA) peels were as efficacious as 20% salicylic–10%
Table 2 Quality of evidence (QOE) evaluation of single-modality, comparative, and combination studies for atrophic acne scars
Level of Definition Strength (grade) Single-modality studiesb Comparative studiesc Combination therapy studiesc
evidencea of
recommendation

Ia Meta-analysis of RCTs A
Ib C1 RCT A Needling [36] GA 70% peel [ 15% Phenol peel (1 session) = 20% TCA
Acne Scar Management

Filler (polymethylmethacrylate) [62] GA cream [20] peel ? needling [24]

Autologous fibroblast injections [128] TCA CO2 ? subcision [ CO2 [135]
CROSS = needling Fr CO2 ? PRP [ Fr CO2 [71, 72]
[37]
Fr CO2 ? punch elevation [ Fr CO2
Needling = 1340-nm [124]
Er NAFL [40]
1540-nm Er:Glass
Filler = subcision [64] NAFL = peeling ? needling [22]
Spot CO2 [ TCA FMR ? subcision [ FMR [138]
CROSS [30]
Fr CO2 [ 1064
Nd:YAG [83]
Fr CO2 = Fr Er:YAG
[75]
Fr CO2 = FRF
[81, 111]
1550-nm Er:Glass
NAFL = FRF
[96, 97]
1550-nm Er:Glass
NAFL [ asiaticoside
cream [94]
1540-nm
diode [ 1320-nm
Nd:YAG [105]
Long-pulsed
Nd:YAG = 585/
1.064 nm [103]
FMR [ bipolar RF
[118]
IIa C1 Well designed, controlled B 1550-nm Er-doped Needling ? PRP [ Needling ? Vit
study (no randomization) NAFL = Fr CO2 [78] C [68]
PRP ? needling [ PRP [38]
PRP ? needling = PRP [74]
PRP ? autologous fat ? Fr
CO2 = PRP ? autologous fat [69]
IIb C1 Well designed, quasi- B Er:YAG [45, 46]
experimental study
Table 2 continued
Level of Definition Strength (grade) Single-modality studiesb Comparative studiesc Combination therapy studiesc
evidencea of
recommendation

III Well designed, non-experimental B Microdermabrasion [18] CO2 (1 20% TCA ? subcision ? Fr CO2
descriptive studies (e.g., Dermabrasion (14) pass) = Er:YAG [48] [134]
comparative, correlation, and GA peel = salicylic- PRP ? Fr Er [70]
TCA CROSS [26–29]
case studies) mandelic acid peel
Microneedling [31–35] Fr CO2 ? PRP = Fr CO2 [73]
[19]
Laser resurfacing: CO2 [41, 42]; Er:YAG [44, 47, 49] Fr CO2 ? subcision [ Fr CO2 [136]
Subcision [52, 53] Subcision ? microneedling ? 15%
TCA [137]
Filler (poly-L-lactic acid) [60]
Bipolar RF/915-nm diode
Fractional lasers: CO2 [76, 77, 79, 80, 82, 84, 87];
laser ? sublative RF [131]
Er:YAG [89–91]; Er:YSGG [92]; 1540-nm Er:Glass
NAFL [99, 100]; 1550-nm Er-doped NAFL [95] Bipolar RF ? Fr CO2 [114, 132]
Nonfractional, nonablative lasers: 1320-nm Nd:YAG
[104]; 1450-nm diode [106]; sub-msec 1064-nm
Nd:YAG [107]; 1064-nm Nd:YAG [102]; 1540-nm
Er:Glass [108]
Picosecond 755-nm alexandrite laser [109]
FRF [110, 116, 117, 120–123]
IV Expert committee reports/ C Soft tissue augmentation [57] Combination therapies including
opinions and/or clinical Punch techniques [8, 10] energy-based modalities [112, 130]
experience of respected
Fr CO2 lasers [88]
authorities
[ more effective, = equally effective, CO2 carbon dioxide, CROSS chemical reconstruction of skin scars, Er erbium, Fr fractional, FMR fractional microneedling radiofrequency, FRF
fractional radiofrequency, GA glycolic acid, NAFL nonablative fractional laser, PRP platelet-rich plasma, RCTs randomized controlled trials, RF radiofrequency, TCA trichloroacetic acid, YAG
yttrium aluminum garnet, YSGG yttrium scandium gallium garnet
a
Level of evidence was adapted from Shekelle et al. [8]
b
Studies with C 15 subjects are included
c
Studies with C 10 subjects are included
S. Bhargava et al.
Acne Scar Management

Table 3 Efficacy of modalities per atrophic scar type

Type of Treatment Modality a Icepick Rolling Shallow Deep

Scars Scars Boxcar Boxcar

Scars Scars

Resurfacing Microdermabrasion

Dermabrasion

Peels

CROSS

Needling

Ablative laser

Liing-related Subcision

Volume-related Filler

Platelet rich plasma b

Skin Tightening Fractional/nonablative

lasers

Fractional

radiofrequency

Surgery/movement- Punch elevation

related
Punch excision

Effecve Less effective Ineffecve

CROSS chemical reconstruction of skin scars

a
Modalities with substantial quality of evidence data (Table 2) are included
b
Used as adjunct to other procedures

mandelic acid peel for icepick scars, but less efficacious for
boxcar scars [19]. Biweekly GA peels have shown superior
results compared with daily low-strength GA cream over a
period of 24 weeks [20]. Medium-depth peeling with 35%
trichloroacetic acid (TCA) can improve acne scarring with
a short downtime in patients with skin types V–VI [21]. A
study by Leheta et al. showed that the combination of 20%
TCA peel with needling was as effective as fractional
1540-nm non-ablative Er:Glass laser in treating acne
scarring [22]. Deep chemical peels, such as phenol, can
effectively treat atrophic scarring but are limited by a
higher risk of complications, especially post-inflammatory
hyperpigmentation (PIH) and prolonged erythema [23]. In
a comparative study, one session of deep phenol peel was
as efficacious as four sessions of TCA 20% combined with
skin needling [24]. Similar risks are reported with medium-
depth chemical peels such as 35% TCA, especially in
patients with skin types IV–VI [25].
4.4 Chemical Reconstruction of Skin Scars
(CROSS)
Focal treatment of atrophic scars with very high TCA
concentrations (65–100%), has demonstrated high efficacy
with minimal adverse events [26]. Clinical and histological
improvement of icepick scars has been observed with focal
application of high-concentration trichloroacetic acid
(TCA CROSS) [27]. Seventy percent TCA CROSS works
dramatically on all kinds of atrophic scars, including severe
boxcar scars [28]. One-hundred percent TCA CROSS is a
cost-effective modality for icepick scars in darker skin
individuals. Priming with hydroquinone and tretinoin can
minimize complications [29]. TCA CROSS treatment of
icepick scars was found to be less efficacious than the CO2
laser pinpoint irradiation technique [30].
4.5 Skin Needling (Percutaneous Collagen
Induction Therapy)
Needling is based on the principle of percutaneous collagen
induction (PCI) therapy. This modality creates microclefts
in the dermis, and the subsequent dermal trauma initiates a
wound healing process that induces a cascade of growth
factors, resulting in collagen production. Skin needling is
contraindicated in the presence of anticoagulant therapies,
active skin infections, injections of collagen or other
injectable fillers within the past 6 months, and personal or
familiar history of hypertrophic or keloidal scars [31]. It
helps reduce the severity of atrophic scars by one or two
grades in almost all patients [32–36]. Induction of collagen
and elastin by needling improves the tethered rolling scars,
but deposition of new collagen happens slowly, and the
final result may only appear after 8–12 months [9]. Several
S. Bhargava et al.
sessions are typically required. Needling was as efficacious
as 100% TCA CROSS in a randomized trial [37]. Needling
shows better results when combined with platelet-rich
plasma (PRP) as it enhances the absorption of topical
agents including PRP [38, 39]. Needling demonstrated
efficacy in reducing atrophic scars similar to that of a
1340-nm nonablative laser [40].
4.6 Laser Resurfacing
Laser resurfacing for acne scars uses monochromatic light
to deliver thermal energy, which ultimately stimulates
dermal fibroblasts to replace lost collagen and elastin [16].
These lasers offer substantial improvement in acne scars
because of improved tone and texture, collagen contrac-
tion, remodeling, and skin tightening. Traditionally used
ablative lasers such as 10,600-nm CO2 and 2940-nm
Erbium:yttrium aluminum garnet (Er:YAG) offer impres-
sive clinical results, but have been associated with adverse
effects including peri-procedural discomfort, post-proce-
dural erythema, and prolonged recovery. Nevertheless,
performing spot (focal) ablation (i.e., ablating the acne scar
while leaving the surrounding normal skin untreated) can
decrease the adverse effects. The safety profiles of frac-
tional and nonablative lasers are superior to that of the
above traditional ablative lasers, which helps to explain the
increasing popularity of these lasers.
The traditional CO2 laser is available in a high-energy
superpulsed form or a very fast continuous form. An
18-month prospective, uncontrolled study of 60 patients
with moderate-to-severe atrophic facial acne scars
demonstrated significant immediate and prolonged
improvement in skin tone, texture, and appearance of
treated scars after a single treatment session of high-energy
CO2 laser [41]. Persistent collagen formation was shown on
histopathology 18 months post-procedure. The authors
recommend waiting up to 18 months prior to evaluating the
need for retreatment as collagen remodeling continues after
12 months. Koo and colleagues used a high-powered CO2
laser to resurface the shoulder area up to the same level as
the surrounding skin when treating moderate-depth acne
scars while, for the deepest and icepick scars, a laser
punch-out (which peels off the depressed area precisely
and deeply) was combined [42].
The traditional 2940-nm Er:YAG laser allows for
increased absorption of energy higher in the dermis and
decreased nonspecific damage to surrounding structures
when compared with traditional CO2 laser [16]. This
results in decreased post-procedure erythema for the
Er:YAG laser. However, hemostasis is incomplete with
Er:YAG laser, and treatment confers an increased bleeding
risk [43]. The Er:YAG laser shows comparable efficacy to
CO2 laser in the treatment of acne scarring [44–48]. Long-
Acne Scar Management
pulsed Er:YAG laser is very efficacious for pitted acne
scars in skin phototypes III–V, with good or excellent
results in 93% of cases [49]. Short-pulsed, variable-pulsed,
and dual-mode Er:YAG lasers are all efficacious in
improving acne scarring, but the dual mode shows the most
consistent results [46, 47]. The short-pulsed Er:YAG laser
was ineffective in deep boxcar scars [46].
Ablative FLs (Sect. 7.1.1) have a better safety profile
than the traditional lasers discussed in this section. How-
ever, they typically require more treatment sessions.
5 Lifting-Related Modalities
5.1 Subcision
Subcision is a technique in which a needle is inserted under
the acne scar to sever the fibrous tissue (tethers) that binds
down the scar [50]. This releases the fibrous tissue,
resulting in scar elevation. Additionally, the induced der-
mal trauma results in clot formation and neocollagenesis
with subsequent filling of the created space, which further
enhances scar elevation. An 18- or 20-gauge tri-beveled
hypodermic needle or an 18-gauge Nocor needle (Becton–
Dickinson, Franklin Lakes, NJ, USA) with a triangular tip
are typically employed [16], although cannulas have also
been utilized [51]. A refinement of the procedure includes
subcision at two different levels: upper dermis and sub-
cutaneous tissue (bi-level subcision). Subcision works
primarily in rolling and other tethered scars [52]. Deeper,
wider, and more noticeable rolling scars improve more
dramatically after subcision than scars that were initially
small or shallow, and boxcar scars improve much less than
rolling scars [52]. It can be combined with most other
procedures (Fig. 3). Adverse effects include bruising,
bleeding, infection and acne exacerbation if acne sinus
Fig. 3 a A skin type V patient
with a significant number of
rolling and boxcar scars.
b Significant improvement with
a combination treatment of
subcision and PRP (Courtesy of
Dr Renita Rajan). PRP platelet-
rich plasma
tracts are disrupted during the procedure, for which
intralesional corticosteroid may be required. A recent study
has shown marked improvement by using a combination of
subcision with skin suctioning therapy [53]. Frequent
suctioning increases its efficacy remarkably and prevents
recurrence of the depression [54].
6 Volume-Related Modalities
6.1 Soft Tissue Augmentation
Fillers are used to augment soft tissue and are most
effective in soft rolling or boxcar scars. Fillers can be used
alone or in combination with prior subcision to improve the
appearance of atrophic acne scars [55]. Fillers containing
hyaluronic acid, calcium hydroxyapatite, and poly-L-lactic
acid (PLLA) are increasingly used to correct atrophic acne
scarring. Injection of cross-linked hyaluronic acid enhances
collagen formation by dermal fibroblasts and improves the
quality of overlying skin [56]. The downfalls are that
multiple sessions are required, and results are only tem-
porary [57]. Calcium hydroxyapatite improves the
appearance of shallow, atrophic acne scars, such as rolling
scars, after a single injection, with a year-long duration of
correction [58]. Also, it has shown great results in boxcar
scars when performed 1 week after subcision [59].
Injectable PLLA is an effective filler in hill and valley acne
scarring, offering up to 2-year correction ranging from
45.5% to 68.2% [60]; it is particularly effective in rolling
scars [61]. Polymethylmethacrylate (PMMA) is a perma-
nent filler that showed significant efficacy in reducing
atrophic acne scarring in an RCT [62]. PMMA preceded by
subcision was efficacious in a small open-label pilot study
[63]. Natural source porcine collagen was as effective as
placebo in a small, split-face study [64].

6.2 Dermal Grafting
Dermal grafting, the implantation of appropriately dis-
sected deep dermis (graft) into recipient areas, is an old
procedure that is used to treat atrophic scars. Dermal
grafting can be used to treat any round/oval facial scar that
is soft, prominent, and at least 4–5 mm [65]. It is advisable
to perform subcision first. The procedure is not indicated in
large, depressed scars or scars with prominent surface
irregularities; in the latter case, it should be combined with
a resurfacing modality [65]. A disadvantage of the proce-
dure is that it involves multiple incisions that generate new
scars, which will require another procedure for resurfacing
down the line. Also, occasional granuloma formation can
occur secondary to transplantation of epidermis from the
donor site into the recipient site. For these reasons, dermal
grafting has been largely replaced by dermal fillers com-
bined with FLs.
6.3 Fat Transplant
This newer modality is indicated for severely atrophic scars
in which there is destruction of deeper tissues [10]. Lipo-
suction is performed from a viable donor site, and the fat
removed is then injected into the atrophic scar. As with
fillers and dermal grafting, it is advisable to perform sub-
cision first. The process requires virtually no downtime.
However, some fat may not survive the transfer process,
and the procedure is operator-dependent. The longevity of
correction is doubtful. Fat transfer has significantly
improved atrophic acne scars and texture [66]; however,
there are currently no studies on the value of this modality
in atrophic acne scarring. It has been more effective than
ablative fractional CO2 laser for treatment of acne scars in
a small comparative study [66]. In a series, condensed
nanofat combined with fat grafts was an effective approach
for treating atrophic scars [67].
6.4 Platelet-Rich Plasma
Platelet-rich plasma (PRP) injection is a modality that
utilizes patient’s own blood to correct acne scars. PRP
contains a plethora of beneficial growth factors, which
promote collagen and elastin regeneration. It is helpful in
boxcar and rolling scars but shows limited efficacy in
icepick scars [68]. As mentioned above, it can be effec-
tively combined with needling for better outcomes [38].
Most studies have shown a synergistic effect when PRP is
combined with other modalities (see Sect. 10) [69–72]. In
these authors’ experience, PRP can decrease the downtime
associated with other modalities. However, the studies by
Faghihi et al. [73] and Ibrahim et al. [74] showed that there
S. Bhargava et al.
is no advantage in adding PRP to fractional CO2 laser or
needling, respectively.
7 Skin-Tightening Modalities
7.1 Lasers
7.1.1 Fractional Lasers
FLs were developed to balance the undesirable side effects
of ablative lasers with the limited efficacy of nonablative
lasers. This technology treats only fractions of skin by
creating columns of thermal injury, known as microthermal
zones, thus enabling column-like denaturation of the epi-
dermis and dermis (ablative lasers) or dermis only (non-
ablative lasers). The intervening areas of untouched skin
begin a rapid process of repair with epidermal stem-cell
reproduction and repopulation of the ablated columns of
tissue with fibroblast-derived neocollagenogenesis. Some
are nonablative dermal injuries only, whereas others are
associated with ablative changes in the skin, causing both
epidermal and dermal injury patterns. Optimal outcomes
require multiple treatments. Fractional CO2 laser substan-
tially improves moderate to severe acne scarring [75–82]
and yields superior outcomes when compared with non-
ablative lasers, such as Q-switched 1064-nm Nd:YAG [83].
The effects of CO2 laser on acne scarring are long
lasting; a study demonstrated ongoing efficacy when
evaluated 3 years after the last session of treatment [84].
Ortiz et al. conducted a long-term follow-up study on 10
subjects who had previously received fractional CO2
treatments. Subjects were seen in follow up at 1 year and
2 years after the treatment, and an average 74% mainte-
nance of improvement was reported [85]. Higher-pulse
CO2 laser improves scar depth in two-thirds of the cases
within 3 months [86]. It is a safe and effective treatment
option in Asian patients [87]. Uniform treatment parame-
ters should be used to report CO2 laser treatment outcomes
to establish greatest scar improvement [88]. Reduction in
number of passes and treatment density also reduces risk of
PIH, and the clinical efficacy can be maintained by
increasing the number of treatment sessions [89]. Frac-
tional 2940-nm Er:YAG and Er:yttrium scandium gallium
garnet (Er:YSGG) lasers have shown comparable results to
fractional CO2 laser after multiple treatments [70, 90–92].
However, fractional CO2 laser was associated with greater
treatment discomfort than fractional Er:YAG [75].
Nonablative 1550-nm Er:Glass laser treatment for
atrophic acne scars in high energy parameters has yielded
better results when compared with treatment results of
post-burn or keloidal scars [93]. The treatment is well
tolerated in Asian patients [94]. In another study, almost
Acne Scar Management
80% of patients experienced substantial improvement in
atrophic scarring with 1550-nm erbium-doped nonablative
laser [95]. A 1550-nm Er:Glass laser was found to be more
effective than fractional microneedle RF (FMR) for
atrophic acne scars, but the latter offered a shorter down-
time [96]. Rongsaard and Rummaneethorn found 1550-nm
erbium-doped laser and bipolar fractional RF (FRF) to be
equally efficacious, with a higher pain score with laser
[97]. Practitioners must be aware of higher incidence of
pain and PIH with 1550-nm erbium-doped YAG FL in
subjects with skin types IV–VI [98]. In studies by Bencini
et al. [99] and Yoo et al. [100], 1540-nm Er:Glass laser
improved more than 50% of atrophic scars in 87 Italian
patients after 6 months of treatment and 16 Asian patients,
respectively, with only transient erythema. A 1540-nm
Er:Glass nonablative fractional laser (NAFL) can be
combined with other modalities (Fig. 4). As mentioned
above, non-ablative fractional 1340-nm erbium laser and
needling yield similar treatment results for atrophic acne
scars [40].
7.1.2 Nonfractional, Nonablative Lasers
Short pulsed 1064-nm Nd:YAG laser showed 29.4% mean
cumulative acne scar improvement after eight treatment
sessions, which, although slow, was associated with mini-
mal downtime [101]. It was effective in smoothing the skin
in 39.2% of cases [102]. Combination 585/1064-nm laser
has slightly superior outcomes in acne scar treatment when
compared with long-pulsed Nd:YAG laser [103]. Nd:YAG
1320-nm laser also works for atrophic acne scarring [104].
A 1450-nm diode laser and a 1320-nm Nd:YAG laser have
shown mild to moderate efficacy in treatment of atrophic
facial scars, with the diode being more effective [105]. A
1450-nm diode laser and sub-millisecond Nd:YAG
1064-nm laser are safe modalities for mild to moderate
atrophic scars in skin types IV and V [106, 107]. Use of a
cooling-vacuum-assisted Er:Glass 1540-nm laser has
Fig. 4 a A skin type II patient with erythematous rolling and boxcar scars. b Erythema resolved with IPL (MaxG, ICON, Palomar) and scars
improved with 1540-nm Er:Glass laser (ICON, Palomar). IPL intense pulsed light
yielded moderate to significant improvement in atrophic
acne scars [108].
7.1.3 Picosecond 755-nm Alexandrite Laser
Recently, a 755-nm alexandrite picosecond pulse duration
laser with diffractive lens array has been introduced for
treatment of acne scars [109]. The histologic findings
indicate improvement in scarring, which is beyond colla-
gen remodeling. This is evidenced by additional improve-
ments in pigmentation and texture of the surrounding skin.
The 755-picosecond laser has been used for rolling scars
[109].
7.2 Fractional Radiofrequency
FRF uses an array of electrodes that create micro-thermal
dermal injuries with intervening zones of unaffected skin,
thus stimulating dermal remodeling with neocollagenesis
and neoelastogenesis, as evidenced by increased levels of
procollagen types I and III and elastin [110]. A significant
improvement in elasticity, along with melanin/erythema
index, contributes to improvement of acne scars. Various
radiofrequency (RF) modalities, such as FMR and bipolar
FRF, provide excellent results in the treatment of acne
scars, especially icepick and boxcar scars. Compared with
FLs, FRF is better for patients who are sensitive to pain,
and treatment has a shorter downtime [96]. Also, because
of its lower risk of PIH, FRF is a preferred modality in
darker individuals [110–112]. FRF can be combined with
fractional CO2 laser for synergy [113], and devices com-
bining both technologies have yielded excellent results
[114]. Side effects of RF include transient pain, edema,
minimal scabbing, and erythema that resolve within
3–5 days [115, 116].
Bipolar FRF reduces scar depth and sebum levels and
improves skin texture [117]. It was as effective as a frac-
tional erbium-doped glass 1550-nm laser [96] but less

Fig. 5 a A skin type II patient with large numbers of icepick and boxcar scars. b Scars improved with two sessions of 1540-nm Er:Glass (ICON,
Palomar) followed by two sessions of microneedling RF (Factora, Inmode); the latter modality enhanced skin tightening. RF radiofrequency
effective that FMR in split-face studies [96, 118]. FMR
results in reduction of sebum excretion along with
decreased expression of nuclear factor-jB and interleukin-
8 and increased expression of tumor growth factor-b and
collagen I [118]. Three to four treatment sessions are
usually required at intervals C 3 weeks and yield 25–75%
improvement 3 months after the final session. FMR has
dramatic effect on post-inflammatory erythema [119].
Also, as it enhances dermal matrix regeneration, it results
in improvement of skin roughness in [ 70% of patients
with acne scars and large pores [120]. It is a safe and
effective modality for scars in skin types III and IV and
helps maintain skin texture [121]. FMR combined with
sublative FRF is an effective and safe treatment for
atrophic acne scarring in Asians [122]. FMR can be suc-
cessfully combined with other minimally invasive tech-
nologies, such as 1540-nm Er:Glass FL (Fig. 5), with
minimal risks. Recently, nanofractional RF has shown
excellent results in rolling and boxcar scars [123]. The
efficacy of FMR and nanofractional RF monotherapy
[120–123] (Table 3, level IIIb) needs validation by
prospective controlled studies.
8 Surgery/Movement-Related Modalities
8.1 Punch Techniques
Punch techniques such as punch excision, elevation,
grafting, or float techniques are considered the criterion
standard for punched-out scars up to 3–4 mm in width
(deep boxcar and larger icepick scars) [10]. These scars do
not improve substantially with resurfacing procedures. The
use of fractional resurfacing laser after punch techniques
helps blur the margins of the scars and enhances the aes-
thetic outcome [124].
S. Bhargava et al.
8.1.1 Punch Elevation
Punch elevation is a technique in which the scar is punched
down to the subcutaneous tissue without being discarded.
The punched scar is then elevated and sutured in place at a
level slightly higher than the surrounding skin to account
for contraction during wound healing [8]; alternatively, the
scar is not sutured but held in the appropriate position with
adhesive skin closure material such as a surgical tape [10].
It is best suited for broad ([ 3 mm) boxcar scars with sharp
edges and normal bases [6, 8, 16]. Punch replacement
grafting is an older technique [125]; it is best suited for
sharp or deep icepick scars with dystrophic or white bases
[10].
8.1.2 Punch Excision
The scar is excised down to the subcutaneous fat with the
help of a punch instrument that is slightly larger than the
scar, and the defect is closed with sutures along relaxed
skin tension lines [2]. Punch excision is best suited for
icepick and narrow (B 3 mm) boxcar scars [17]. For
scars [ 3.5 mm, elliptical excision or punch elevation
provide better cosmetic results than punch excision [16].
8.2 Elliptical Excision
As mentioned in Sect. 8.1.2, elliptical excision can be used
for scars [ 3.5 mm [16]. Also, it may be the only treatment
for very deep irregular-shaped scars in difficult locations.
8.3 Botulinum toxin
As severely atrophic (grade 3) acne scars can be aggravated
by normal muscle movement, several authors find that
botulinum toxin can be beneficial, especially for acne scars
in areas such as the forehead, glabella, and chin [10].
Acne Scar Management
Fig. 6 a A skin type V patient with severe mixed acne scarring. b Response to subcision followed by a combination of fractional CO2 (Fraxis
Duo, Ilooda) and PRP (Courtesy of Dr Renita Rajan). CO2 carbon dioxide, PRP platelet-rich plasma
8.4 Facelift
Facelift procedures can help if age-related soft tissue laxity
makes atrophic scarring more noticeable, especially in
patients with numerous rolling scars. A modification of the
standard sub-superficial musculoaponeurotic system lift
has been used in combination with PLLA filler with
excellent results [126].
9 Novel Modalities
Autologous bone marrow stem cell intradermal injection
has been found to be safe and effective for all types of
atrophic scars [127]. Intradermal autologous fibroblast
injections are a well tolerated treatment option for
depressed distensible acne scars (Table 2, level 1b) [128].
Topical epidermal growth factor (EGF) was recently used
to improve atrophic acne scars in patients with skin of color
[129]. The results of autologous bone marrow stem cells
and EGF need to be confirmed in larger prospective
studies.
10 Combination Treatments
Combination therapies are more effective than monother-
apies because scars often require volume restoration,
enhanced tightening, and/or tissue movement (e.g., surgical
modalities) along with resurfacing [10]. Zaleski-Larsen
et al. showed that combination modalities can be per-
formed safely, and the synergism among various modalities
contributes to optimal outcomes [130]. Combination of
energy-based technologies, such as lasers or RF, with
modalities such as TCA CROSS, subcision, fillers,
needling, and/or punch excision can provide better and
faster outcomes compared with solo treatments [131].
Lasers have been the mainstay of treatment for most
scars [42]. FR technology, although less efficacious than
ablative lasers such as CO2 and Er:YAG, can provide good
outcomes with little risk to darker and more sensitive skin
types [112]. These energy-based modalities can be com-
bined with all other modalities for optimal and faster out-
comes (Fig. 6), especially in patients with moderate to
severe rolling and boxcar scarring. A combination of
fractional CO2 laser with RF intensifies the thermal effects,
thus providing better results in less time and with fewer
sessions without increasing the side effects [113, 114].
Treatment with a device combining bipolar RF and 915-nm
diode laser followed by sublative bipolar RF provided
excellent results for both superficial and deep atrophic
scars [131]. The efficacy of devices combining RF and
diode laser is supported by additional studies [132, 133].
Subcision is the first procedure to be performed in
rolling scars and is also very helpful as an initial procedure
for other bound-down scars associated with tethering.
Rolling scars were effectively treated with a single session
of TCA 20% peel, subcision, and fractional CO2 laser
[134]. Performing subcision before CO2 laser (Fig. 6) has
yielded better outcomes for all scar types [135]. Fractional
CO2 laser can be preceded by subcision or punch elevation
to optimize results [124, 136]. Subcision followed by
needling and 15% TCA peel alternatively at 2-week
intervals have shown excellent results for rolling and
boxcar scars [137]. Finally, MFR combined with prior
subcision provides better results than MFR alone and is a
safe combination in Asian patients [138].
NAFLs can be used in patients with mild to moderate
scarring that desire only little downtime and minimal risks.
The combination of a fractional nonablative with spot

ablative resurfacing laser allows for global improvement
(complexion/texture) as well as significant improvement in
acne scars with minimal downtime [112]. TCA CROSS,
punch techniques, or excision should be performed before
resurfacing procedures in those patients with punched out
scars, such as icepick and boxcar scars. However, punch
procedures are not possible in patients with numerous
icepick scars, and an ablative fractional CO2 or erbium is
recommended in this case [130]. PRP can be used only as
an adjunctive therapy as it can help with neocollagenesis
and decreases downtime. It can be combined with frac-
tional CO2 laser [69, 71, 72], fractional erbium laser [70],
or needling [68].
Concomitant problems, such as large pores, pits, and
oily skin can be a major nuisance to patients with acne
scars. These can substantially improve with technologies
such as fractional CO2 laser, needling, or FRF [117, 130].
11 Treatment of Hypertrophic/Keloidal Acne
Scars
Erythematous hypertrophic scars are treated first with a
vascular laser such as pulsed dye laser (PDL) (see
Sect. 13.1.1), with concomitant intralesional triamcinolone
acetonide (TAC) 20 mg/mL or 5-fluorouracil (5-FU)
50 mg/mL [139]. Intralesional 5-FU 50 mg/mL can be
used alone (0.1–0.3 mL per scar; 1 mL total per session) or
mixed 80:20 with a low-strength steroid [10]. Other authors
perform NAFL immediately after PDL and ultimately
inject 0.1 mL TAC 10 mg/mL along with 0.9 mL of 5-FU
[130]. Each scar should not be injected with more than
0.1 mL [140]. NAFL with intralesional TAC or 5-FU can
be repeated at 3-week intervals [141]. Most authors treat
keloids with intralesional TAC and/or 5-FU and avoid laser
treatment because of a lack of data on long-term efficacy
[130, 142].
12 Special Considerations
12.1 Treatment of Discolored Scars
Color alteration may be the main visual clue to the pres-
ence of scarring and is often the main concern of the
patient [143]. As such, color alteration often needs to be
addressed before the treatment of acne scarring.
12.1.1 Erythematous Scars
Scar-associated erythema (SAE) can respond to intense
pulsed light (IPL) [144] (Fig. 4) and vascular lasers such as
PDL [143]. A 68% reduction in SAE was observed 6 weeks
S. Bhargava et al.
post-treatment of half of the face with 585-nm flashlamp-
pumped PDL compared with the untreated half [145].
Erbium-doped 1550-nm FL has more satisfied patients than
595-nm PDL when it comes to treatment results for erythe-
matous scars; however, these modalities show similar effi-
cacy [146]. A greater improvement of SAE was obtained
with microsecond-pulsed Nd:YAG laser that delivers energy
through a small spot size, short pulse durations, low fluence,
and quick laser bursts [16, 103, 147].
12.1.2 Hyperpigmented Scars
Medical therapy with bleaching preparations, chemical
peels, pigment lasers, and fractionated lasers may be
helpful [143]. A QS 755-nm alexandrite laser, occasionally
preceded by IPL, has been used for skin types I–IV, while a
755-nm Pico laser or a 1064-nm QS Nd:YAG laser has
been used for skin types V and VI [130].
12.1.3 Hypopigmented Scars
Improving hypopigmented scars is a challenge and may
require ablative fractional laser or NAFL followed by
bimatoprost 0.03% twice daily and tretinoin 0.25% at
night. An erbium-doped 1550-nm fractional laser enhances
drug delivery of bimatoprost, tretinoin, or pimecrolimus
[130]. Excision may be the most cost-effective option for
hypopigmented scars.
12.2 Treatment Options in Skin of Color
FL resurfacing has been associated with PIH in skin types
IV–VI, especially at higher treatment densities [148]. As
mentioned above, FRF is not chromophore dependent, and
can be safely used in skin types IV–VI [110–112]. Need-
ling may offer a more advantageous safety profile, partic-
ularly in the skin-of-color population (Fitzpatrick skin
types IV–VI), compared with more conventional resurfac-
ing modalities [149]; however, it is usually less effective
than the fractional technologies. Other modalities, such as
subcision and PRP, can be safely used in multimodality
therapies with minimal risks (Figs. 3 and 6). Treatment
with a topical lightening agent (e.g., hydroquinone, treti-
noin, vitamin C, glycolic acid) for approximately 2 weeks
prior to performing energy-related modalities or peels
helps prevent hyperpigmentation and improves healing
times in patients with darker skin types [112].
12.3 Acne Scar Treatment during Concomitant
Isotretinoin Therapy
Although it was previously recommended to avoid acne
scar treatment during isotretinoin therapy and for 6 months
Acne Scar Management
thereafter, recent reports have shown successful treatment
of several patients on isotretinoin with fractional modali-
ties, needling, TCA CROSS, subcision, and punch tech-
niques without any complications [112]. NAFL treatment
for acne scarring appears to be well tolerated within
1 month of completing isotretinoin treatment [150]. A
consensus group recently indicated that there is insufficient
evidence to support delaying manual dermabrasion,
superficial chemical peels, cutaneous surgery, or fractional
ablative and nonablative laser procedures for patients
receiving or having recently completed isotretinoin therapy
[151].
13 Discussion
There is a lack of high-quality evidence for many modal-
ities and a need to conduct RCTs with larger numbers of
participants and a standardized set of core outcome mea-
sures [9, 11]. In a Cochrane review, FL was more effective
than non-fractional, non-ablative laser, and as effective as
FRF [9]. The results of our QOE evaluation confirm the
efficacy of FLs and FRF in atrophic acne scarring. Mini-
mally invasive procedures such as FRF and needling are
safe in skin of color. Our QOE evaluation shows that
energy-based modalities such as FLs and FRF, needling,
and PRP can be used in multimodality therapies with
excellent results. The choice of multimodality therapy
depends among others upon the severity and type of acne
scarring, skin type, and safety profile of modalities.
Patient education is vital and helps establish realistic
expectations. The provider should consider the patient’s
ability to accept risk, possibility of a prolonged treatment
process, limitations of the patient’s budget, intellect, social
circumstances, and work requirements [143]. A thorough
discussion with the patient about a carefully mapped out
treatment plan, the minimum number of sessions required,
and relevant cost, promotes compliance. The patient’s
preferences on which modalities to pursue and how to
incorporate the treatment sessions in their life and work
schedules should be considered.
14 Conclusions
Acne scarring has a profound psychological impact on
patients. With the plethora of modalities for acne scarring,
but lack of high QOE, it is recommended that the health-
care provider spend sufficient time with the patient to
review the specifics of applicable modalities, including
anticipated results, safety, and number of sessions required.
Patients with moderate to severe acne scarring most often
need multimodality therapies for optimal and faster results,
and the cost of such is an important aspect to discuss from
the beginning. Acne scar type and severity, dyspigmenta-
tion, textural issues and patient’s skin type need to be
considered to optimize outcomes.
Compliance with Ethical Standards
Funding None declared.
Conflict of interest SB, PRC, JL and GK declare that they have no
conflict of interest.
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