What Is Atrophic Scarring?
Atrophic scarring is a type of scar that sits below the surrounding skin as a sunken pit or dent. It forms when the skin makes too little collagen to fill in the area while a wound or breakout heals. These scars often result from acne or chickenpox, and they develop most often on the face.
Atrophic scars are the most common kind of acne scar. In one review, 80% to 90% of people with acne scars had this type. Atrophic scars can fade, but they rarely go away completely on their own.
Atrophic Scarring at a Glance
| Also called | Depressed or sunken scars. Acne-related types are ice pick, boxcar and rolling scars. |
|---|---|
| Cause | Too little collagen made during healing, often after acne or chickenpox |
| Where it appears | Most often the face |
| Is it serious? | Most scars don't cause long-term health problems, but acne scarring is linked to depression and emotional distress. |
| Diagnosis | A skin exam to identify the type, number and location of scars |
| Treatment | Chemical peels, microneedling, lasers, radiofrequency, fillers and minor scar surgery, often combined |
| Goes away on its own? | Rarely. Treatment improves the look of scars but doesn't erase them completely. |
What Does Atrophic Scarring Look Like?
Atrophic scarring looks like dents, pits or a rough, uneven surface. Acne-related atrophic scars come in three main types, and many people have several:
- Ice pick scars: narrow (under 2 mm), deep pits. The American Academy of Dermatology (AAD) calls them the most common type of acne scar.
- Boxcar scars: round or oval dents with sharp, vertical edges. They are wider than ice pick scars but narrower than rolling scars.
- Rolling scars: wide, shallow dents, usually wider than 4 to 5 mm. Fibrous bands anchor the skin to deeper tissue, giving it a wavy look.
What Causes Atrophic Scarring?
Atrophic scarring is caused by deep inflammation or injury followed by healing that doesn't rebuild enough collagen. Too little collagen leaves a pit; too much leaves a raised scar.
Acne scars are more likely if you:
- Had deep, painful acne, such as cysts or nodules. In general, the deeper the breakout, the more likely it is to scar.
- Picked, popped, squeezed or scratched breakouts, which increases inflammation
- Have a close blood relative with acne scars
- Waited a long time for effective acne treatment, or had acne that kept coming back
In a US study of 1,972 people seeing dermatologists for acne, 43% had acne scars, and 69% of those with scars had mild or moderate acne at the visit.
Atrophic Scarring vs. Raised Scars and Dark Spots
Atrophic scarring is a loss of collagen, while raised scars come from too much collagen and dark spots aren't scars.
| What happens | Look | Does it fade? | |
|---|---|---|---|
| Atrophic scar | Too little collagen | Sunken pit, dent or wavy texture | Rarely goes away on its own |
| Hypertrophic scar | Too much collagen | Firm, raised scar that stays within the wound area | May shrink but never fully flattens |
| Keloid | Overgrown scar tissue | Raised scar that grows beyond the original wound | Hard to get rid of. Some return after treatment. |
| Post-inflammatory hyperpigmentation (PIH) | Not a scar | Flat red, pink, brown or bluish-gray spot | Usually fades over time |
How Is Atrophic Scarring Diagnosed?
Atrophic scarring is diagnosed with a skin exam. A clinician notes each scar's type, size and location, because ice pick scars need different treatment than rolling scars.
How Is Atrophic Scarring Treated?
Atrophic scarring is treated with procedures that rebuild collagen, add volume or lift scars, often in combination. The plan depends on the type and number of scars, your skin type and how much downtime you accept. If you still get breakouts, acne treatment comes first.
Treatment Options
- Chemical peels: help the skin make more collagen and elastin. Mild peels often take 3 to 5 sessions, every 2 to 4 weeks.
- Microneedling: tiny needles puncture the skin to trigger new collagen. The AAD says it is safe for all skin tones. Platelet-rich plasma (PRP) may be added.
- Radiofrequency microneedling: combines radiofrequency energy with microneedling. Using both can make scars less noticeable than either one alone.
- Laser resurfacing: skin makes collagen and elastin as it heals. In dark skin, lasers may cause darker or lighter patches.
- Dermal fillers: add volume under sunken scars. Most last 3 months to 2 years.
- Scar surgery: punch excision removes a scar; subcision frees it from underlying tissue so the skin rises.
- Topical treatments: a retinoid or salicylic acid can make mild scarring less noticeable.
What to Expect
You may need three or more sessions. Treated skin may be swollen or discolored for a few days. Afterward, use broad-spectrum, water-resistant SPF 30+ sunscreen daily and limit sun for 6 to 8 weeks.
Can Atrophic Scarring Be Prevented?
You may lower your risk of atrophic scarring from acne by treating acne early and limiting inflammation.
- Treat acne when breakouts first appear, especially if a parent or sibling has acne scars.
- Don't pick, pop, squeeze or scratch breakouts.
- See a clinician for deep, painful acne. AAD guidelines strongly recommend oral isotretinoin for acne that is severe, scarring or not responding to standard therapy.
When Should You See a Clinician About Atrophic Scarring?
See a clinician about atrophic scarring when:
- Scars bother you or affect your social life, work or school
- You still get breakouts, especially deep, painful ones
- A scar changes or becomes painful, itchy or infected
- A mole, freckle or growth appears on or near a scar
Atrophic Scarring Evaluation at GENEVA
At GENEVA Primary Care & Med Spa in Alpharetta, GA, a provider evaluates your scars, skin type and any active acne, then recommends treatment at GENEVA or a referral to a dermatologist.
Learn more about acne scar treatment, or raise active acne during a primary care visit. GENEVA serves patients from Alpharetta, Johns Creek, Milton, Roswell and Cumming.
Related Terms
- Microneedling
- RF microneedling
- Collagen stimulation
- TCA peel
- Dermal fillers
- Platelet-rich plasma (PRP)
- Post-inflammatory hyperpigmentation (PIH)
- Retinoid therapy
- Morpheus8 RF Microneedling | Skin Tightening and Rejuvenation Treatment
Atrophic Scarring FAQs
Do atrophic scars go away on their own?
No, atrophic scars rarely go away completely on their own, though they can fade. Redness or discoloration around a new acne scar usually clears with time, but the dent remains. Treatment can reduce a scar's appearance, yet the scar never completely disappears, and acne scars may become more noticeable with age as skin loses collagen and elasticity. A flat spot of color after acne is usually post-inflammatory hyperpigmentation, not a scar, and it tends to fade.
What causes atrophic scarring?
Atrophic scarring happens when skin makes too little collagen while healing, leaving a pit or dent. Acne and chickenpox are common causes. Deep acne cysts and nodules cause intense inflammation, and the deeper the breakout, the more likely it is to scar. Picking pimples, having a close relative with acne scars and delaying effective acne treatment raise the risk. Still, no one can predict exactly who will scar, and some people scar after blackheads or whiteheads.
What is the best treatment for atrophic acne scars?
No single treatment is best for atrophic acne scars. The right choice depends on scar type and number, skin type and downtime, and combining treatments is common. A 2023 review found stronger evidence for lasers, chemical peels, hyaluronic acid fillers and microneedling, with PRP as an add-on, and lower-quality evidence for subcision and microdermabrasion. A 2016 Cochrane review found a lack of high-quality evidence, with moderate-quality evidence that injectable fillers might help. Ask what improvement to expect before starting.
How long does atrophic scar treatment take to work?
Atrophic scar treatment usually takes more than one session, and results build gradually because the skin needs time to make new collagen and elastin. The AAD says treatment is rarely one and done, and three or more sessions may be needed. Mild chemical peels, for example, often take 3 to 5 sessions, every 2 to 4 weeks. Swelling or discoloration usually clears within a few days. Most filler results last 3 months to 2 years and need touch-ups.
What is the difference between atrophic and hypertrophic scars?
Atrophic scars are sunken because the skin made too little collagen while healing, while hypertrophic scars are raised because it made too much. Hypertrophic acne scars feel firm, often form on the jawline, chest or back, and usually appear 1 to 2 months after a breakout clears. Raised scars are more common in darker skin tones. Treatment differs: sunken scars need collagen building or volume, while raised scars may be treated with injections, lasers or prescription medicine.
Can a primary care provider treat atrophic scarring?
Yes, a primary care provider can evaluate atrophic scarring and recommend next steps. At GENEVA in Alpharetta, a provider examines your scars, skin type and any active breakouts, then recommends treatment at GENEVA or a referral to a dermatologist. If you still get breakouts, acne treatment usually comes first, and scar treatment typically begins once acne is under control. Before any procedure, list every acne medicine used in the past two years, because some can cause side effects with scar treatments.