Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Management of acne scars

Nazanin Saedi, MD
Nathan Uebelhoer, MD
Section Editor
Jeffrey S Dover, MD, FRCPC
Deputy Editor
Abena O Ofori, MD


Acne vulgaris is a common skin disease that frequently results in scarring [1,2]. Scars secondary to acne can lead to physical disfigurement and the psychosocial impact can be profound. Early and effective treatment of acne is the best means to minimize and prevent acne scarring. (See "Treatment of acne vulgaris".)

Although a variety of therapies may reduce the prominence of acne scars, no therapy removes acne scars completely. A multimodality approach to scar treatment is usually necessary to achieve the best cosmetic results. The selection of an approach to treatment is based upon factors such as the type and degree of acne scarring, patient preference, side effects, cost, and treatment availability.

The management of scarring secondary to acne vulgaris will be reviewed here. The therapeutic approach to active acne is reviewed separately. (See "Treatment of acne vulgaris".)


Acne scarring represents an altered wound healing response to cutaneous inflammation that leads to an imbalance in matrix degradation and collagen biosynthesis. Although scarring is a common consequence of inflammatory acne vulgaris, not all patients develop scarring [3]. The reasons for discrepancies in the propensity to scar are not clear.

One theory focuses on a role for the nature of the inflammatory response in determining which patients develop scarring. This concept is supported by an immunohistochemical study of 8 patients not prone to acne scarring and 11 patients prone to acne scarring [3]. Specimens from early lesions from patients who were not prone to acne scarring demonstrated a large, active, nonspecific immune response that subsided with lesion resolution. In contrast, patients prone to acne scarring had a smaller, more specific immune response in early lesions that was increased and activated in resolving lesions. This persistent inflammation in healing tissue may contribute to scarring.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Jul 6, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Goulden V, Stables GI, Cunliffe WJ. Prevalence of facial acne in adults. J Am Acad Dermatol 1999; 41:577.
  2. Layton AM, Henderson CA, Cunliffe WJ. A clinical evaluation of acne scarring and its incidence. Clin Exp Dermatol 1994; 19:303.
  3. Holland DB, Jeremy AH, Roberts SG, et al. Inflammation in acne scarring: a comparison of the responses in lesions from patients prone and not prone to scar. Br J Dermatol 2004; 150:72.
  4. Levy LL, Zeichner JA. Management of acne scarring, part II: a comparative review of non-laser-based, minimally invasive approaches. Am J Clin Dermatol 2012; 13:331.
  5. Jacob CI, Dover JS, Kaminer MS. Acne scarring: a classification system and review of treatment options. J Am Acad Dermatol 2001; 45:109.
  6. Rivera AE. Acne scarring: a review and current treatment modalities. J Am Acad Dermatol 2008; 59:659.
  7. Wolfram D, Tzankov A, Pülzl P, Piza-Katzer H. Hypertrophic scars and keloids--a review of their pathophysiology, risk factors, and therapeutic management. Dermatol Surg 2009; 35:171.
  8. Brown JJ, Bayat A. Genetic susceptibility to raised dermal scarring. Br J Dermatol 2009; 161:8.
  9. Fife D. Practical evaluation and management of atrophic acne scars: tips for the general dermatologist. J Clin Aesthet Dermatol 2011; 4:50.
  10. Jordan RE, Cummins CL, Burls AJ, Seukeran DC. Laser resurfacing for facial acne scars. Cochrane Database Syst Rev 2001; :CD001866.
  11. Goodman GJ. Treatment of acne scarring. Int J Dermatol 2011; 50:1179.
  12. Zachariae H. Delayed wound healing and keloid formation following argon laser treatment or dermabrasion during isotretinoin treatment. Br J Dermatol 1988; 118:703.
  13. Saedi N, Petelin A, Zachary C. Fractionation: a new era in laser resurfacing. Clin Plast Surg 2011; 38:449.
  14. Al-Waiz MM, Al-Sharqi AI. Medium-depth chemical peels in the treatment of acne scars in dark-skinned individuals. Dermatol Surg 2002; 28:383.
  15. Abdel Hay R, Shalaby K, Zaher H, et al. Interventions for acne scars. Cochrane Database Syst Rev 2016; 4:CD011946.
  16. Alster TS, McMeekin TO. Improvement of facial acne scars by the 585 nm flashlamp-pumped pulsed dye laser. J Am Acad Dermatol 1996; 35:79.
  17. Glaich AS, Goldberg LH, Friedman RH, Friedman PM. Fractional photothermolysis for the treatment of postinflammatory erythema resulting from acne vulgaris. Dermatol Surg 2007; 33:842.
  18. Lee JB, Chung WG, Kwahck H, Lee KH. Focal treatment of acne scars with trichloroacetic acid: chemical reconstruction of skin scars method. Dermatol Surg 2002; 28:1017.
  19. Alam M, Omura N, Kaminer MS. Subcision for acne scarring: technique and outcomes in 40 patients. Dermatol Surg 2005; 31:310.
  20. Barikbin B, Akbari Z, Yousefi M, Dowlati Y. Blunt Blade Subcision: An Evolution in the Treatment of Atrophic Acne Scars. Dermatol Surg 2016.
  21. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles. Dermatol Surg 1995; 21:543.
  22. Walia S, Alster TS. Prolonged clinical and histologic effects from CO2 laser resurfacing of atrophic acne scars. Dermatol Surg 1999; 25:926.
  23. Hu S, Gold MH. Treatment of facial acne scars in Asian skin with the single-spot, 2940-nm Er:YAG dual-mode laser. J Drugs Dermatol 2010; 9:1341.
  24. Wanitphakdeedecha R, Manuskiatti W, Siriphukpong S, Chen TM. Treatment of punched-out atrophic and rolling acne scars in skin phototypes III, IV, and V with variable square pulse erbium:yttrium-aluminum-garnet laser resurfacing. Dermatol Surg 2009; 35:1376.
  25. Woo SH, Park JH, Kye YC. Resurfacing of different types of facial acne scar with short-pulsed, variable-pulsed, and dual-mode Er:YAG laser. Dermatol Surg 2004; 30:488.
  26. Jeong JT, Kye YC. Resurfacing of pitted facial acne scars with a long-pulsed Er:YAG laser. Dermatol Surg 2001; 27:107.
  27. Tanzi EL, Alster TS. Treatment of atrophic facial acne scars with a dual-mode Er:YAG laser. Dermatol Surg 2002; 28:551.
  28. Tanzi EL, Alster TS. Single-pass carbon dioxide versus multiple-pass Er:YAG laser skin resurfacing: a comparison of postoperative wound healing and side-effect rates. Dermatol Surg 2003; 29:80.
  29. Bernstein LJ, Kauvar AN, Grossman MC, Geronemus RG. The short- and long-term side effects of carbon dioxide laser resurfacing. Dermatol Surg 1997; 23:519.
  30. Ong MW, Bashir SJ. Fractional laser resurfacing for acne scars: a review. Br J Dermatol 2012; 166:1160.
  31. Cho SB, Lee SJ, Cho S, et al. Non-ablative 1550-nm erbium-glass and ablative 10 600-nm carbon dioxide fractional lasers for acne scars: a randomized split-face study with blinded response evaluation. J Eur Acad Dermatol Venereol 2010; 24:921.
  32. Hedelund L, Moreau KE, Beyer DM, et al. Fractional nonablative 1,540-nm laser resurfacing of atrophic acne scars. A randomized controlled trial with blinded response evaluation. Lasers Med Sci 2010; 25:749.
  33. Cachafeiro T, Escobar G, Maldonado G, et al. Comparison of Nonablative Fractional Erbium Laser 1,340 nm and Microneedling for the Treatment of Atrophic Acne Scars: A Randomized Clinical Trial. Dermatol Surg 2016; 42:232.
  34. Geronemus RG. Fractional photothermolysis: current and future applications. Lasers Surg Med 2006; 38:169.
  35. Alster TS, Tanzi EL, Lazarus M. The use of fractional laser photothermolysis for the treatment of atrophic scars. Dermatol Surg 2007; 33:295.
  36. Lee HS, Lee JH, Ahn GY, et al. Fractional photothermolysis for the treatment of acne scars: a report of 27 Korean patients. J Dermatolog Treat 2008; 19:45.
  37. Magnani LR, Schweiger ES. Fractional CO2 lasers for the treatment of atrophic acne scars: a review of the literature. J Cosmet Laser Ther 2014; 16:48.
  38. Hedelund L, Haak CS, Togsverd-Bo K, et al. Fractional CO2 laser resurfacing for atrophic acne scars: a randomized controlled trial with blinded response evaluation. Lasers Surg Med 2012; 44:447.
  39. Yuan XH, Zhong SX, Li SS. Comparison study of fractional carbon dioxide laser resurfacing using different fluences and densities for acne scars in Asians: a randomized split-face trial. Dermatol Surg 2014; 40:545.
  40. Bjørn M, Stausbøl-Grøn B, Braae Olesen A, Hedelund L. Treatment of acne scars with fractional CO2 laser at 1-month versus 3-month intervals: an intra-individual randomized controlled trial. Lasers Surg Med 2014; 46:89.
  41. Nirmal B, Pai SB, Sripathi H, et al. Efficacy and safety of erbium-doped yttrium aluminium garnet fractional resurfacing laser for treatment of facial acne scars. Indian J Dermatol Venereol Leprol 2013; 79:193.
  42. Hu S, Hsiao WC, Chen MC, et al. Ablative fractional erbium-doped yttrium aluminum garnet laser with coagulation mode for the treatment of atrophic acne scars in Asian skin. Dermatol Surg 2011; 37:939.
  43. Shumaker PR, Kwan JM, Landers JT, Uebelhoer NS. Functional improvements in traumatic scars and scar contractures using an ablative fractional laser protocol. J Trauma Acute Care Surg 2012; 73:S116.
  44. Fife DJ, Fitzpatrick RE, Zachary CB. Complications of fractional CO2 laser resurfacing: four cases. Lasers Surg Med 2009; 41:179.
  45. Mahmoud BH, Srivastava D, Janiga JJ, et al. Safety and efficacy of erbium-doped yttrium aluminum garnet fractionated laser for treatment of acne scars in type IV to VI skin. Dermatol Surg 2010; 36:602.
  46. Lee JW, Kim BJ, Kim MN, Mun SK. The efficacy of autologous platelet rich plasma combined with ablative carbon dioxide fractional resurfacing for acne scars: a simultaneous split-face trial. Dermatol Surg 2011; 37:931.
  47. Gawdat HI, Hegazy RA, Fawzy MM, Fathy M. Autologous platelet rich plasma: topical versus intradermal after fractional ablative carbon dioxide laser treatment of atrophic acne scars. Dermatol Surg 2014; 40:152.
  48. Leheta TM, Abdel Hay RM, El Garem YF. Deep peeling using phenol versus percutaneous collagen induction combined with trichloroacetic acid 20% in atrophic post-acne scars; a randomized controlled trial. J Dermatolog Treat 2014; 25:130.
  49. Moy LS, Kotler R, Lesser T. The histologic evaluation of pulsed carbon dioxide laser resurfacing versus phenol chemical peels in vivo. Dermatol Surg 1999; 25:597.
  50. Garg VK, Sinha S, Sarkar R. Glycolic acid peels versus salicylic-mandelic acid peels in active acne vulgaris and post-acne scarring and hyperpigmentation: a comparative study. Dermatol Surg 2009; 35:59.
  51. Erbağci Z, Akçali C. Biweekly serial glycolic acid peels vs. long-term daily use of topical low-strength glycolic acid in the treatment of atrophic acne scars. Int J Dermatol 2000; 39:789.
  52. Landau M. Cardiac complications in deep chemical peels. Dermatol Surg 2007; 33:190.
  53. Garg S, Baveja S. Combination therapy in the management of atrophic acne scars. J Cutan Aesthet Surg 2014; 7:18.
  54. Orentreich D, Orentreich N. Acne scar revision update. Dermatol Clin 1987; 5:359.
  55. Picosse FR, Yarak S, Cabral NC, Bagatin E. Early chemabrasion for acne scars after treatment with oral isotretinoin. Dermatol Surg 2012; 38:1521.
  56. Alam M, Han S, Pongprutthipan M, et al. Efficacy of a needling device for the treatment of acne scars: a randomized clinical trial. JAMA Dermatol 2014; 150:844.
  57. Fabbrocini G, Fardella N, Monfrecola A, et al. Acne scarring treatment using skin needling. Clin Exp Dermatol 2009; 34:874.
  58. Cohen BE, Elbuluk N. Microneedling in skin of color: A review of uses and efficacy. J Am Acad Dermatol 2016; 74:348.
  59. Pahwa M, Pahwa P, Zaheer A. "Tram track effect" after treatment of acne scars using a microneedling device. Dermatol Surg 2012; 38:1107.
  60. Cameli N, Mariano M, Serio M, Ardigò M. Preliminary comparison of fractional laser with fractional laser plus radiofrequency for the treatment of acne scars and photoaging. Dermatol Surg 2014; 40:553.
  61. Rongsaard N, Rummaneethorn P. Comparison of a fractional bipolar radiofrequency device and a fractional erbium-doped glass 1,550-nm device for the treatment of atrophic acne scars: a randomized split-face clinical study. Dermatol Surg 2014; 40:14.
  62. Brauer JA, Kazlouskaya V, Alabdulrazzaq H, et al. Use of a picosecond pulse duration laser with specialized optic for treatment of facial acne scarring. JAMA Dermatol 2015; 151:278.
  63. Orentreich DS. Liquid injectable silicone: techniques for soft tissue augmentation. Clin Plast Surg 2000; 27:595.
  64. Barnett JG, Barnett CR. Treatment of acne scars with liquid silicone injections: 30-year perspective. Dermatol Surg 2005; 31:1542.
  65. Rapaport MJ, Vinnik C, Zarem H. Injectable silicone: cause of facial nodules, cellulitis, ulceration, and migration. Aesthetic Plast Surg 1996; 20:267.
  66. Milojevic B. Complications after silicone injection therapy in aesthetic plastic surgery. Aesthetic Plast Surg 1982; 6:203.
  67. Mastruserio DN, Pesqueira MJ, Cobb MW. Severe granulomatous reaction and facial ulceration occurring after subcutaneous silicone injection. J Am Acad Dermatol 1996; 34:849.
  68. Munavalli GS, Smith S, Maslowski JM, Weiss RA. Successful treatment of depressed, distensible acne scars using autologous fibroblasts: a multi-site, prospective, double blind, placebo-controlled clinical trial. Dermatol Surg 2013; 39:1226.
  69. Mustoe TA, Cooter RD, Gold MH, et al. International clinical recommendations on scar management. Plast Reconstr Surg 2002; 110:560.
  70. Sawada Y, Sone K. Hydration and occlusion treatment for hypertrophic scars and keloids. Br J Plast Surg 1992; 45:599.
  71. Puri N, Talwar A. The efficacy of silicone gel for the treatment of hypertrophic scars and keloids. J Cutan Aesthet Surg 2009; 2:104.
  72. Borgognoni L. Biological effects of silicone gel sheeting. Wound Repair Regen 2002; 10:118.
  73. Phillips TJ, Gerstein AD, Lordan V. A randomized controlled trial of hydrocolloid dressing in the treatment of hypertrophic scars and keloids. Dermatol Surg 1996; 22:775.