Which procedure would be best for treating hyperpigmentation and boxcar scars after wart removal? (photo)

Thank you for sharing your experience. It’s not uncommon for CO₂ laser procedures to leave behind both pigmentation changes and textural scars, especially if the treated area was delicate.

For hyperpigmentation, topical lightening agents (such as hydroquinone, azelaic acid, or tranexamic acid), combined with strict sun protection, can help fade discoloration over time. Chemical peels or gentle resurfacing treatments may also improve pigmentation gradually.

For the boxcar scars, treatment depends on their depth and whether they are tethered. Shallow scars often respond well to fractional resurfacing lasers or microneedling with radiofrequency. If there is significant tethering (where the scar is pulled down by underlying fibrous bands), subcision may be helpful before resurfacing. TCA CROSS can be effective for ice-pick type scars, but as you mentioned, it may carry risks in certain scar types.

A combination approach, addressing both pigment and texture—typically yields the best improvement, often over multiple sessions.

Our office has many different treatments for scars depending on the depth of atrophy or hypertrophy. Scars require a combination approach using our HI DEF protocol which uses a combination of lasers, topical scar modulation, and RF treatments to pixelate scars, improve contour, reduce hyperpigmentation, and improve the visibility of the scars so that they are no longer visible in ambient light. Everyone has a unique pattern of scarring and we employ our HIDEF technique to improve texture, color, contour, and topography. We often use a combination of treatments that begin with a careful examination to examine the micro texturing of the acne scars. Atrophic scars and indented scars can benefit from injectable fillers such as Radiesse, Sculptra, and Restylane with or without subcision to remove tethered scars and atrophic depression. Hyper-redness in scars can be improved with V beam laser, Excel V, BBL, IPL, and Venus RF to improve the redness and reduce the visibility of deep scars. Fractional Thulium laser and clear & brilliant can also reduce the inflammation and redness of the scar when combined with topical therapy. Fractional lasers such as Fraxel, erbium, and CO2 laser can be combined with radio frequency and also fractional RF to improve textual issues and microtopography. Subcision and TCA cross are also used for deep ice pick scars and narrow valley scars in order to improve the micro texture. Above all, our combination approach with our clinical nurses and board-certified plastic surgeons can improve the quality of your skin by using at home Melarase creams combined with PRP treatments in our office to improve your skin quality and tone. I recommend getting a formal evaluation with an experienced team of experts in order to reduce your scarring.

Finally, hyperpigmentation of scars can be improved with at-home Melarase AM, Melarase PM, and Melapads to help reduce active PIH and melanin deposition.

Best,
Dr. Karamanoukian
Realself100 Surgeon

At least from the one photo provided, there appear to be a predominance of ice pick-type scars. If this is indeed so, then TCA CROSS would be an appropriate choice. TCA CROSS HAS a proven track record of nearly a quarter of a century for both safety and efficacy in all skin types for treating ice pick scars and dilated pores, It was in fact developed by South Korean doctors for treating South Korean women with ice pick scars. I have personally been using this approach for ice pick scars for twenty-four years.
If there are also broader-based, tethered boxcar or rolling scars, then subcision, which I have been performing since 1995, when it was first introduced, would be useful for elevating and smoothing them.
And finally, manual microneedling (no need for the added expense and risks of RF microneedling) can be performed to better blend in both color and texture the treated scars with the surrounding normal skin.
You would be wise to consult with a board certified cosmetic dermatologist scar treatment specialist.
Hope this helps and best of luck.