Los Angeles patient with acne scars*

Acne scars are a common result of severe acne breakouts and subsequent inflammation.  They appear as indentations and craters on the skin which are made of scar tissue, which is slightly different in composition from the surrounding areas.


Acne inflammation is a form of injury to the skin.  In an attempt to heal itself, the fibrous tissue (fibrosis) replaces normal tissue resulting in acne scars.

According to Sherratt et al, scar tissue is made of the same collagen as the unaffected surrounding areas. The only difference is the fiber composition.  In normal tissue, collagen fibers are arranged in a basket weave configuration.  In the case of scar tissue (fibrosis) the collagen forms cross links. This new tissue is characterized by weaker resistance to UV rays. And there is also the absence of hair follicles.

Collagen accumulates as a dense buildup due to the proliferation of fibroblasts, which are cells that synthesize collagen.


There are four basic classifications of acne scars.

1. Ice Pick Scars

Ice Pick scars appear as indented pits in the skin’s surface

2. Box Car Scars

Box Car Scars resemble chicken pox scars.  They occur on the temples and cheeks and they are angular in shape.

3. Rolling scars

Rolling scars have a wave like appearance due to bands that form between deeper skin structures and the skin’s surface.

4. Hypertrophic scars

Hypertrophic scars are similar to keloid scars. They are red and raised from the skin’s surface.


Acne scars are relatively permanent because of the collagen restructuring that has taken place.

Treatments work to reduce the deepness of the recessions and pits in the skin and improve the overall texture.

Punch graft surgery

Punch graft surgery involves the use of a small tool to remove the scar tissue.  This area is replaced by a skin graft that is usually taken from behind the ear to create a smooth surface.  Once full healing from the procedure has occurred, microdermabrasion and chemical peels can help address any irregularities that remain.


As the name implies, microdermabrasion  involves sanding the skin’s surface to reduce the appearance of acne scars.  The abrasion occurs through the use of  microscopic particles, such as finely ground magnesium salt crystals which are shot onto the skin to cause a gently removal of the outer skin layer and allow new cells to surface. This is a mild process that would not significantly improve the appearance of acne scars.


Dermabrasion is a process of actually sanding the skin. A diamond fraise or textured metallic surface is rubbed on the skin at varying pressure and speed either using an electromechanical device or a manual procedure. The process results in the excoriation of the top skin layer, which ends up being quite bloody. Downtime is significant. Also complication rates of scarring, skin discoloration (temporary or permanent) are rather common.

Patients of color are discouraged from undergoing dermabrasion, since there is a very high risk of permanent skin discoloration. For example, the phenomenon of “racoon eyes” is a common occurrence with dermabrasion in individuals with darker skin tones.

In qualified candidates, however, dermabrasion is highly effective in the treatment of acne scars. Consult your dermatologist to find out if this treatment method is appropriate for you.

Fraxel For Acne Scars

1. Fraxel Repair:

Fraxel Repair is a fractionated CO2 laser that can improve scarring in a single treatment. It works by causing fractionated and microscopic zones of photo thermolysis (light induced burns) of the superficial and deep layers of the skin and acne scars. The new skin that develops fills in the depressed acne scar trough. Because it is fractionated, this laser has less downtime that is typically 7-14 days as opposed to dermabrasion and the older fashioned CO2 lasers, which can take up to 4-8 weeks to heal.

Fraxel Repair is recommended only for patients of lighter skin, which is clinically defined as Fitzpatrick I-III types. It is contraindicated in people of color.

2. Fraxel Dual:

Unlike other techniques used to treat acne scars, Fraxel Dual works with deeper  layers of the dermis to induce collagen remodeling.  This is accomplished using the Erbium fiber component of the laser, which uses a 1550 nm wavelength to normalize the collagen density.  Because of its precision, surrounding areas are able to remain undisturbed in contrast to ablative techniques which uniformly remove the full outer layer of both affected and non affected areas.

The more superficial wavelength, 1927 nm, used by the Thulium fiber component, is used to help refine the skin’s surface.

Most patients see immediate and significant changes with Fraxel Dual.

Dr. Umar who is based in Los Angeles, treated both the existing acne and the acne scars of this patient using specialized lasers to customize a comprehensive treatment for this patient. Take a look at the before and after images in this video.

First, he used a series of 3 Spectra Laser procedures as a preliminary acne treatment.  Fraxel Dual was then applied to this patient’s face to help clear brown spots, blemishes and acne scars.  There are two inherent wavelength settings associated with Fraxel Dual.

1. 1927 nm Thulium wavelength

By itself, it is equivalent to an older Fraxel modality referred as the Re:fine procedure. As the word, refine implies, this component of Fraxel Dual treats surface issues. For this particular patient, it was very effective in clearing her brown spots and blemishes.

2. 1550 nm Ergium wavelength

This is equivalent to Fraxel’s Re:store procedure. This wavelength is capable of penetrating deep into the dermis to treat the underlying conditions contributing to the acne scars of this patient.

Overall, two Fraxel Dual treatments were applied in this specific case study to give the final results shown.

Recent advances in laser skin treatments give patients more effective solutions for acne scar issues that address deeper core issues (i.e. collagen structures) as opposed to ablation or abrasion.  Additionally, there is the added benefit of minimal downtime allowing patients to experience quick results without much disruption to their normal lifestyle.

Read more here about the Fraxel laser.