Would do anything if it will help with my acne scars - is there any solution? (Photo)

Question

Can anyone help? I never had "bad" cystic acne but breakouts in teens/early 20s led to numerous scars. Over years I've tried SO many things, which haven't helped & actually increased/created new scarring. 6+ Microneedling: caused crepiness/small icepick scarring/new atrophic scars. TCA peel 20% created new atrophic areas. 1 subcision + Sculptra: no help; 1 area of atrophy is worse. Is laser only option? My skin seems to heal with scars so I'm worried but want help.

Anna Chacon, MD, FAAD · Answer

I’m really sorry you’ve had such a frustrating experience. What stands out to me is not just the acne scarring itself, but the fact that several treatments appear to have made your skin texture worse rather than better. That can be incredibly discouraging, and it’s understandable that you’re now worried about doing anything else.

Looking at your photo and reading your history, I would not assume that “more aggressive treatment” is the answer. In fact, I think the most important clue is this pattern:

Microneedling → crepiness and new tiny scars
TCA 20% → new atrophic areas
Subcision + Sculptra → little benefit and possible worsening in one area

That suggests your skin may have a tendency toward impaired wound remodeling, where even controlled injury can heal with additional textural change or atrophy.

Is Laser the Only Option?

No — and in your situation, I would actually be very cautious about jumping straight to ablative laser resurfacing (such as fully ablative CO₂ or aggressive erbium laser). Those treatments can produce excellent results in the right patient, but they also rely on the skin’s ability to heal predictably after significant injury. Given your history of worsening after relatively moderate procedures, I would want to proceed much more conservatively.

What I See in Your Photo

Your scarring appears to be a mixture of shallow rolling and boxcar-type atrophic scars with some overall textural irregularity, rather than deep, isolated icepick scars alone. That’s important because different scar types respond to different treatments.

A Safer Strategy for “Reactive” Skin

If this were my patient, I would think about minimizing trauma while improving collagen remodeling gradually.

1. Focus on Skin Quality First

Before any procedural treatment, I’d want the skin barrier to be as healthy as possible:

Gentle cleanser
Ceramide-rich moisturizer
Daily mineral sunscreen
Avoid overuse of retinoids, acids, scrubs, and exfoliating devices for several weeks before considering any procedure.

Many patients who have undergone repeated procedures develop a degree of chronic irritation and barrier dysfunction, which can make scars look more prominent.

Treatments I Would Consider More Carefully
Low-Energy Non-Ablative Fractional Laser

This is different from aggressive resurfacing. A 1550/1540 nm non-ablative fractional laser can sometimes improve shallow atrophic scars with less risk of worsening texture than ablative CO₂, especially when performed at conservative settings over multiple sessions.

RF Microneedling (With Caution)

Ordinarily I use RF microneedling for acne scars, but because you reported worsening after standard microneedling, I would be very cautious. If considered at all, it would need to be:

Low energy
Shallow depth
Small test area first
One Thing I Would Specifically Avoid

I would avoid high-concentration TCA CROSS or additional medium-depth chemical peels until there is a much clearer understanding of why you developed new atrophic areas after a 20% TCA peel. That is not a typical response and suggests your skin may be unusually susceptible to over-treatment.

Could This Be More Than Simple Acne Scarring?

Occasionally, patients who develop new depressions after procedures have contributing factors such as:

Underlying connective tissue fragility
Excessive inflammation during healing
Overly aggressive treatment parameters
Repeated procedures performed before full recovery
Less commonly, conditions that affect collagen production or wound healing

Your history is unusual enough that I would take that possibility seriously rather than assuming you simply need a stronger laser.

My Honest Opinion

I do think there is potential for improvement, but I would redefine the goal. Instead of trying to erase the scars, I would aim to:

Improve the overall texture
Reduce the visibility of the shallow depressions
Avoid creating any new scars

The biggest mistake I see in patients with treatment-related worsening is continuing to escalate to more aggressive procedures out of desperation. Your skin has already given several signals that it may not tolerate standard acne-scar protocols in the usual way.

Based on your photo and history, I would lean toward a very conservative, staged approach — prioritizing barrier repair and possibly a low-energy non-ablative fractional laser test treatment rather than aggressive resurfacing. The fact that your acne was never severely cystic is actually somewhat encouraging, because the scars appear moderate rather than extreme, and moderate scars often have room for improvement even when the skin is sensitive to procedures.

Most importantly, please don’t interpret your past experiences as meaning that nothing can help. I think the key is that your skin likely requires a different treatment philosophy, one that emphasizes gentle remodeling and preservation of healthy tissue rather than repeated injury in hopes of forcing collagen production.

Raffy Karamanoukian, MD, FACS · Answer

Acne scar treatments require precision and attention to detail. There are several types of acne scars, including atrophic, hypertrophic, PIH hyperpigmented, and hypopigmented scars. Depending on the types of scars you have, our office can recommend a Hidef treatment protocol that can recontour existing scars and reduce complexion irregularities. The results are simply life-changing.
 
As a general rule, we recommend fillers, subcision, acne surgery, RF ablation, and laser ablation to help with atrophic scars. Hypertrophic and keloid acne scars require pulsed dye laser and IIT SC. PIH scars require chemical peels, Melarase creams (AM and PM) and laser.
If you have ice-pick scars, we recommend RF ablation and TCA Cross.
Best,
Dr. Karamanoukian
Realself100 Surgeon

Nelson Lee Novick, MD · Answer

I'm not at all surprised by the lack of success with the treatments here; there are so many issues that need to be cleared up. First, one does not necessarily have to have had severe acne to develop acne scars. Secondly, traditional microneedling (no need for the added expense and risks of RF microneedling), which I have been performing for over twenty-three years, is best reserved for treating residual superficial, surface color and texture irregularities, like a final "polishing" step; it is not particularly effective as a primary treatment for acne scars. TCA CROSS, which involves using concentrations of TCA between 80-100%, and which I have also been performing for nearly a quarter of a century, is a treatment of choice for ice pick scars and dilated pores. TCA 20% is a mild peel that would not have been expected to do much of anything for boxcar, rolling or ice pick scars. So, again, no surprises with the lack of success there. Subcision, on the other hand, which I have been performing since 1995, has an excellent track record for elevating and smoothing boxcar and rolling scars in all skin types. However, only RARELY is one treatment session sufficient to achieve any visible or optimal results; typically two to six treatment sessions may be required to do so. So, even if your physician was an experienced scar treatment specialist, you should have been told in advance that you were unlikely to realize much benefit from just one treatment. So, again, no surprises. Finally, when considering expensive "bells and whistles" gizmo treatments, such as fraxel lasers and RF devices, keep in mind that the hard science to back up the use of these devices lags well behind the heavy marketing hype and social media buzz to promote them. You would be wise to make sure to consult an experienced, board certified cosmetic dermatologist scar specialist and best of luck going forward.

Would do anything if it will help with my acne scars - is there any solution? (Photo)

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