How do I improve atrophic acne scars and orange peel texture? (photos)

Question

I've tried microneedling with Skin Pen, profractional and microlaser peel targeted at the larger atrophic scars, and PRX Derm Perfexion. I feel as though the treatments have made my skin worse. I received conflicting recommendations regarding further treatment options. One doctor suggested Helix Fusion laser, while another recommended subcision. Given the disparity in recommendations, I am not sure how to move forward or who to trust. I am 49.

Anna Chacon, MD, FAAD · Answer

I can understand why you're feeling uncertain. You've already invested time in several treatments, and receiving different recommendations from experienced physicians can be frustrating. The reality is that both recommendations may be appropriate, depending on the specific type of scars you have.

From your photos and treatment history, it appears that you have a combination of atrophic acne scars and an overall "orange peel" texture. These are often caused by different underlying issues, which is why a single treatment rarely addresses everything.

One important question is whether your scars are tethered. Rolling scars are often held down by fibrous bands beneath the skin. If that's the case, subcision is one of the most effective treatments because it releases those bands, allowing the skin to lift naturally. If tethering is present, performing repeated laser treatments without first releasing the scar may not produce the improvement you're hoping for.

On the other hand, Helix Fusion laser is designed to stimulate collagen remodeling and improve skin texture. It may help soften the overall appearance of the skin and improve superficial scarring, but it does not address tethered scars beneath the surface. That's why some physicians recommend subcision first and laser afterward—they're treating two different components of the problem.

Your history also suggests that your skin may have reached a point where additional resurfacing alone is unlikely to provide significant benefit. After treatments such as SkinPen microneedling, ProFractional laser, MicroLaserPeel, and PRX Derm Perfexion, it's reasonable to reassess the underlying scar anatomy rather than continuing to repeat similar procedures.

At 49, it's also important to recognize that normal age-related collagen loss and changes in skin elasticity can make acne scars appear more noticeable than they did years earlier. Sometimes a small amount of structural support—such as carefully placed filler after subcision in selected cases—can further improve the result, although this depends on the individual scar pattern.

My recommendation would be to avoid thinking of this as an "either-or" decision. Acne scar treatment is often most successful when it is customized to the scar type. If your scars are tethered, subcision may be the missing step. Once those scars are released and allowed to heal, a collagen-stimulating laser can then refine the surface texture much more effectively than either treatment alone.

Finally, if you feel your skin actually became worse after prior procedures, I would proceed cautiously before undergoing another aggressive resurfacing treatment. Allowing your skin to fully recover and ensuring that the next procedure specifically targets the cause of your remaining scars is often more beneficial than repeating treatments that have already provided limited improvement.

While complete removal of acne scars is rarely possible, a carefully planned combination approach can often produce substantial improvements in both texture and scar depth, even after previous treatments have not met expectations.

Paul Flashner, MD · Answer

When it comes to atrophic acne scarring and texture there are many ways to approach treatment. Doing a dual combination of 1540 non ablative and co2 ablative laser is always the best when treating scars.

Raffy Karamanoukian, MD, FACS · Answer

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

Best, 
Dr. Karamanoukian 
Realself100 Surgeon

Nelson Lee Novick, MD · Answer

Please note; Not more than ten minutes ago, I wrote the following response to another Realself inquiry that I believe applies very much to your question and even addresses the disappointments and complications you have had with your previous treatments.
"At least from the photos provided, it would appear that you might profit from a Field Subcision to improve the generalized facial acne atrophy related to the loss of the collagen and elastic fibers. Individual subcisions can then be performed to elevate and smooth boxcar and rolling scars, and TCA CROSS may be used to improve ice pick scars and dilated pores. Finally, manual, professionally performed microneedling (no need for the added expense and risks of RF microneedling) to better blend in both texture and color, the aforementioned treated areas with the surrounding normal skin. I have personally been performing each of these procedures for more than twenty-five years in all skin types with gratifying results. 
In general about three or four treatment sessions on average are required to achieve a 60-80% overall improvement in appearance for all scars that are over twelve weeks old (so-called "mature" scars). 
No doubt you will be barraged with offers for all kinds of expensive "bells and whistles" fraxel laser and RF gizmo treatments. But, you should be aware that the hard science to support the use of these supposedly "next big thing" devices lags woefully behind the heavy marketing hype and social media buzz to promote them. As for the use of ablative lasers, these are much like old-style aggressive dermabrasion insofar as they go deep, have prolonged downtime, and run the risk of infection and scarring and an unnatural-looking glossy, orange peel appearance. So, buyer beware when considering these. Hope this helps and best of luck."

Camille Cash, MD · Answer

You may want to consider Morpheus8.  This treatment combines RF technology with microneedling to improve overall skin tone and texture.  Generally three treatment sessions spaced a month apart are recommended for optimal results.  I've included a video I hope you find helpful.

Leonard Grossman, MD · Answer

In your case, I would treat your skin with fractionated CO2 laser to begin with. Once your face is healed completely which is approximately between one and two weeks, I would inject wider saucer shaped scars with Medical grade Silicone Oil using a micro droplet technique. This procedure will even out, the level of the craters with the healthy skin, providing you with a permanent and natural looking result. I hope this helps and good luck from New York City Plastic Surgery.

How do I improve atrophic acne scars and orange peel texture? (photos)

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