Best Treatment for Ice Pick Acne Scars?

What is the best treatment for ice-pick acne scarring? I am interested in doing Fraxel Re:pair, and maybe punch excision beforehand but would like more input.

Doctor Answers 21

You have a few good options for ice-pick acne scars

Punch excision followed by a laser such as Fraxel re:pair which is a fractionated CO2 laser device is a reasonable strategy for ice-pick type scars in Fitz type I and II (lighter) skin types. I would caution you that in darker skin types, the risk of pigmentary problems is high. Lasers alone for acne scars in general are not that helpful, and much less so for pitted acne scars. Fillers while helpful for rolling scars, spoon-shaped scars, are usually not appropriate for ice-pick scars.

You do have a couple other options as well, including:

Saline subcision which involves breaking up the scar tissue under the ice-pick scars as one method to promote collagen growth.

The "Cross" method which involves spot application of a very strong chemical peeling agent to stimulate the growth of collagen can help "fill in" the ice-pick depressions over time.

To appreciate the results of saline subcision and the "Cross" method requires patience, since the final results are not fully achieved until a year after starting treatment.

I would consult with a qualified physician to review what option(s) would be most appropriate for you.

San Diego Dermatologist
5.0 out of 5 stars 5 reviews

Ice Pick Scars and Punch Excision

Ice pick scars are characterized by punctate deep scars that are usually caused by deep cystic acne. These scars are difficult to resurface with laser or chemical peels because the base of the scar is deep with very steep sidewalls. The most effective treatment has remained punch excision with suturing despite many advances in lasers and chemical peels over the years.

Fraxel may diffusely improve the overall quality of the skin but there is no clinical evidence to support the claim that it will improve deep punctate ice pick scars. However, Fraxel laser resurfacing may improve more superficial scarring associated with chronic acne.

If you are considering a treatment for acne scars, you should discuss options with a physician who is familiar with the use of chemical peels, lasers, subcision, and punch excision of scars.

Raffy Karamanoukian, MD, FACS
Los Angeles Plastic Surgeon
4.8 out of 5 stars 94 reviews

Ice Pick Acne Scars and Treatment with Fraxel and eMatrix

The gold standard for treating these ice pice acne scars is the Fraxel laser.  I have had great results with the Fraxel in treating these difficult scars.  However, if you have type III skin or darker, I reserve treatment with the eMatrix.  It is a "color blind" laser and can best treat these scars without any risk of hyper pigmentation.  Sculptra may also need to be injected to increase the collagen naturally in the skin.  PRP also has some added benefits as well.  Please consult a board certified dermatologist with expertise with these lasers and cosmetic injections and acne scars.  Best, Dr. Green

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Acne scars- TCA CROSS or punch excision followed by laser

Ice pick scar....sounds deep, and hard to treat, but they are one of the easiest acne scars to treat....and treat well. I usually use TCA CROSS  70-100% , several sessions, or 1-2 mm punch, suture, then heal. This is then followed by total or full laser resurfacing.

Ideally I use erbium, with a downtime of 8 days. One treatment and its done and dusted. This combination of treatments can improve ice pick acne scars by upto 90-95%, in some cases, we can totally remove scars all together. 

In summary, one of the easiest types of acne scars to treat, no matter what colour of skin you have. Review my before and afters on acne scarring for an idea or watch the video in the web reference. 


Dr Davin Lim
Consultant Laser Dermatologist

Davin Lim, MBBS, FACD
Brisbane Dermatologist
4.7 out of 5 stars 61 reviews

Treatment for Ice Pick Acne Scars

There are a few options for treatment of acne scars. Small, deep acne scars can be treated with surgical excision, which will ideally trade a depressed and discolored scar for a thin, flat scar.

Other techniques to improve the base of large or numerous scars involve resurfacing the skin by intentionally traumatizing it in order to stimulate collagen production. This thickens the skin and shrinks the surface area of the scar, and color may be improved as well. The Cross technique uses a very concentration of TCA peel. Lasers and dermabrasion (surgical resurfacing) are other techniques that are used to resurface large areas. Often, several techniques are used over time to get the best result. Patience is key since the full effect is often not seen for several months, and multiple procedures are usually necessary for a significant improvement.

Risks include temporary or permanent lightening or darkening of treated skin, crusting, scabbing, scarring, reactivation of cold sores, infection, redness, acne flares, milia formation.

Dana Goldberg, MD
Jupiter Plastic Surgeon
5.0 out of 5 stars 32 reviews

TCA CROSS works for ice pick acne scars.

For deep ice pick scars, I use TCA - CROSS, a technique which involves spot peeling with TCA 50% or 100%, applied at the base of the scar using a blunt, but fine probe. Results typically start showing around 6 to 8 weeks, with more improvement over 3 - 6 months,  and it works fine even in darker skin, which is the type I predominantly get to treat. A test area targeting say, 5 to 10 lesions, should always be treated before going onto a larger area. This technique does have a downtime of about a week, during which time the treated areas may be covered with concealer/ make up.

Renita (Lourdhurajan) Rajan, MD, DNB
India Dermatologist
4.9 out of 5 stars 16 reviews

Treatment of ice-pick acne scars

i follow a simple rule that has been great for my patients. 

Light skin tone: pro-fractional laser or TCA localized treatment

Darker skin: subcision surgery or fraxel

Best of luck!

Joseph Doumit, MD
Montreal Dermatologist
5.0 out of 5 stars 2 reviews

Ice pick scars

Thank you for your question and for sharing your concerns with us. Your approach is very reasonable. I would recommend that consider a direct excision of an icepick scar. It will certainly help create a flatter scar. Afterwards, you can consider lasers to help blend it in to the background.  The right laser for you would depend on your skin type.

Acne scar treatment with Fraxel

Yes, Fraxel is the gold standard for reducing ice pick acne scars. For extremely deep scars, a punch excision may be warranted as well. Consult with your dermatologist for more info!

Joshua L. Fox, MD
Long Island Dermatologic Surgeon
4.9 out of 5 stars 19 reviews

Ice Pick Acne Scars

Punch excision is an excellent method for icepick scars. This procedure uses a circular biopsy tool which is basically a round, sharp "leather punch" type tool that comes in diameters ranging from 1.5 mm to 3.5 mm (rarely larger). The size of the tool is matched to the size of the scar to include the walls of the scar. Under local anesthesia the scar is removed with the punch biopsy tool and the skin edges are sutured together. The newly produced scar eventually fades and may not be noticeable. If it is noticeable, it is more amenable now to resurfacing techniques.
My favorite treatment is a strong focal chemical peel using the “cross hatch” technique. Trichloroacetic Acid (TCA) is the peel typically used. TCA peels are considered medium-depth peels (with 100% concentration being the strongest). In the treatment, the solution is applied to the bottom of the scar with a wooden instrument (like a toothpick) pressed into the base of the pit. A white crust forms on the scar base after the procedure is complete. This superficially deconstructs the bottom of the scar to stimulate collagen neogenesis and the healing process. This can fill in the scar, decreasing scar depth ideally helping the skin “blend in”.
Always consult with a board certified dermatologist for best results catered to your specific condition.

David J. Myers, MD
Salt Lake City Dermatologic Surgeon
5.0 out of 5 stars 4 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.