Why are Ice Pick Acne Scars So Hard to Treat?

I began suffering from adult acne around age 29 and am now 32 with some improvement due to a combo of low dose doxycycline and Duac. As a result, I now have ice pick scars on my cheeks. I have read some of the posts from the docs regarding treatment and it appears that the only successful treatment is punch excision followed by resurfacing and even this only gives a 30% improvement. Why are these scars so difficult to treat and why hasn't an effective method been developed as of 2011?

Doctor Answers 8

All acne scars are difficult to treat

Yes, acne scars are very hard to manage but I believe I have a ton of experience treating them by combining silicone micro injections for large holes and CROSS TCA treatment for the small ice picks.  Like anything, the two things you need to find in a provider is the physician with the right technique but also with the experience level to get the great results.  CROSS can be very effective when done well and very dangerous in unskilled hands.  


Sam Lam
Dallas, Texas

Dallas Facial Plastic Surgeon
4.6 out of 5 stars 57 reviews

They are actually the easiest scars to treat.

TCA CROSS 70-100% and or punch excision followed by erbium laser is the way to go. I find these scars the easiest to treat, even in darker skin types. 

Harder scars are atrophic and rolling acne scars. 

Try TCA by a dermatologist and you maybe astounded. 


Dr Davin S. Lim
Dermatologist, Cosmetic and Laser

Davin Lim, MBBS, FACD
Brisbane Dermatologist
4.7 out of 5 stars 75 reviews

Ice Pick Acne Scar Treatment Options

Ice pick scars can be difficult to treat. Some patients have great results in minimizing them but others unfortunately will go through all treatment options with moderate results. Depending on the size of the scars your best option may be going to a board certified plastic surgeon and having them excised. There is a chance this can lead to additional scarring but an experienced plastic surgeon will guide you in the right direction and give you realistic options. Another treatment choice is to have the area filled with filler such as Juvederm or possibly even have dermabrasion done. There are definitely many treatment options out there its just a matter of finding the one that will work for you.

Jerome Edelstein, MD
Toronto Plastic Surgeon
5.0 out of 5 stars 176 reviews

Acne Scar Treatments

Acne scars are a challenge to physicians to treat due to the varied depths of the scar, area of the body that the scar is present in, and the skin type. Ice pick scars can be into the deepest layers of the dermis (the second layer of the skin). This area is a veritable "no man's land" as far as predictability of outcome. Hence the numerous treatments so far stated in this column. 

My experience has included some of all the above except using silicone. My most favorable results have occurred  after performing subcision for shallow to medium depth scars followed by fat grafting and either TCA peels or Fractional CO2 laser resurfacing. I have found it important to discuss with patients the need to have more than one procedure to accomplish their goals. For deep acne scars (ice pick scars), one must either excise by punch (because the scar is usually circular) and suture the wound closed, or replace the skin with a punch graft from an adjacent tissue with good color match. After this area heals, I find it helpful to wait a minimum of 6 weeks, resurfacing will reduce the appearance of the new graft.

Michael B. Lyons, MD, FACS
Mobile Facial Plastic Surgeon
4.0 out of 5 stars 5 reviews

Ice pick scars do quite well with punch grafting and a few dermabrasions.

Ice pick scars are annoying to have but they do respond well to punch grafting and a few dermabrasions all done under local anesthesia for about $350 per scar.

David Hansen, MD
Beverly Hills Dermatologic Surgeon
4.7 out of 5 stars 42 reviews

Treatment of ice pick acne scars

        Acne scars could be categorized into three broad categories, shallow, medium and deep( also known as ice pick scars). The goal of treatment is to reduce the visibility of the scar. The scars cast a shadow on underlying skin and can appear darker. The idea is to shallow out the scar and remove the shadow effect.  The treatment approaches are different for each of the type of scar. Shallow scars generally respond more favorably to medium to deep resurfacing techniques such as chemical peels or either fractionated or non fractionated lasers (CO2 or Erbium). Medium depth scars usually require more treatments and may respond to subscision where an underlying scar is lysed underneath pitted skin with or without filler placement. Filler injections alone may cause a "doughnut" effect, as filler preferentially will travel to areas of less resistance and will settle around the areas of dense scar tissue, thus accentuating the scar and create more shadow effect. Finally, the deep or ice pick scars respond best to excision with meticulous closure and eversion of skin edges. I find that a combination of all three modalities produces the best possible outcome. 

Joseph Shvidler, MD
Tacoma Facial Plastic Surgeon
5.0 out of 5 stars 8 reviews

Why Are Ice Pick Scars Hard to Treat?

Hi VJ.  The reason ice pick scars are generally difficult to treat is because they are deep.  

The deeper a scar resides in the skin, the more difficult it is to revise.  This is why punch excision is often recommended for this type of scar because by "punching" out the tissue, the practitioner can get to the bottom of the scar, thereby removing all the hard fibrous tissue that surrounds it and is underneath it.  Many resurfacing options, including CO2 resurfacing cannot get deep enough to address these types of scars.  

Regardless of which method you choose, ask for before and after pictures to indicate that the treatment being proposed has worked for patients with your skin type and type of scars in the past.  Good luck.

Harold J. Kaplan, MD
Los Angeles Facial Plastic Surgeon
4.3 out of 5 stars 6 reviews

Ice-pick acne scar treatment

A more conservative approach to treating ice-pick scars is the TCA-cross method, whereby a chemical peel solution such as TCA is applied to the scar to cause localized tissue injury and the formation of new collagen to help fill in the scar over time.

Bryan K. Chen, MD
San Diego Dermatologist
5.0 out of 5 stars 5 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.