What procedure would reduce the texture of scars? (Photo)

Thank you for your question and for sharing the photos. Based on what I see and your history of scarring from picking, acne, and ingrown hairs, along with limited improvement from ResurFX, CoolPeel, microneedling, and topical tretinoin, it’s understandable that you’re seeking more effective treatment options. The texture and post-inflammatory changes appear to be persistent, which often means deeper or more targeted interventions are needed.

Here are some advanced options worth considering:

1. Fractional CO₂ Laser (Fully Ablative or Deep Fractional)
If you’ve only had light resurfacing (e.g., CoolPeel is a more superficial CO₂), a more aggressive fractional CO₂ laser could help. This type of laser penetrates deeper into the dermis, targeting scar tissue and stimulating more robust collagen remodeling. It typically provides better results for tougher or older scars, especially those with texture irregularities like yours.

2. Radiofrequency (RF) Microneedling – Insulated Needles
You may benefit from deeper RF microneedling using insulated needles, which can safely deliver energy to deeper skin layers while minimizing surface damage. Devices like Morpheus8 or Sylfirm X have shown good results in improving thickened texture and scarring from repeated inflammation (such as from ingrown hairs or chronic picking).

3. TCA Cross Technique
If your scarring includes ice-pick or enlarged follicular scars, a focused chemical reconstruction using TCA CROSS (Trichloroacetic Acid) can help improve depth and texture by inducing controlled damage and collagen regeneration.

4. Excision or Subcision (Surgical or Injectable)
For scars that are tethered or deeply indented, subcision can release fibrotic strands under the skin. It can be paired with filler or PRP to support healing and add volume. This is often underutilized but highly effective for chronic ingrown hair-related scarring.

5. Combination Therapy
Given the resistance to single treatments, a customized combination protocol (e.g., fractional CO₂ + subcision + RF microneedling + topical regenerative serums) is often needed over multiple sessions. Also, longer duration topical tretinoin use or switching to a higher strength or combination retinoid (e.g., Tretinoin + Clindamycin or Azelaic Acid) may enhance outcomes when paired with procedures.

Additional Suggestions:
Consider pigment-correcting agents if post-inflammatory hyperpigmentation is contributing to texture visibility.

Daily exfoliation and consistent sun protection are essential to maintaining results and preventing worsening.

Our treatments use combination therapy to improve the epidermis and dermis for most deep scars. The options available for acne scars depend on the character of your scars, in terms of topography and contour. We see atrophic and hypertrophic acne scars, as well as scars that have hypo and hyperpigmentation. We begin each scar evaluation with an assessment of scar quality and subtype. Our main concern is rebuilding collagen and that is why we use a HIDEF protocol that includes combination therapy. Morpheus 8, scar subcision, fibrous release, fractional laser, CO2 laser, Thulium laser, PDL Vbeam laser, and fractional resurfacing can be used in addition to TCA Cross and chemical peels to further improve skin. Patients should start Melarase AM and Melarase PM for active hyperpigmentation. Always begin with a consultation to decide whether early subcision should be started.

Best,
Dr. Karamanoukian
Realself100 Surgeon

At least from the photos provided, there appear to be many ice pick scars and dilated pores. Relatively inexpensive TCA CROSS treatment works well for precisely these kinds of scars and is safe and has proven safe effective in all skin types. I have been using this therapy for these kinds of issues for nearly a quarter of a century. I am not at all surprised by the lack of efficacy you had with the expensive "bells and whistles" gizmo treatments, as the hard science to support their use lags well behind the heavy marketing hype and social media buzz to hawk them. Sorry. And microneedling is not a particularly good first-line treatment and is best reserved as a final "polishing" step for better blending, in both color and texture, properly treated scars with the surrounding normal skin.
You would be wise to consult with an experienced, board certified cosmetic dermatologist scar treatment specialist and best of luck.