Indented scars form when your skin loses collagen during the healing process, leaving depressions that don’t fill back in on their own. In 80 to 90 percent of cases, the scarring involves a net destruction of collagen in the deeper layers of skin. The good news: multiple treatments can rebuild that lost volume and smooth the skin’s surface, though the best approach depends on the type and depth of your scars.
Why Indented Scars Don’t Heal on Their Own
When skin is damaged by acne, injury, or surgery, the body launches an inflammatory repair process. Normally, new collagen fills in the wound evenly. But when inflammation is severe or prolonged, that repair goes wrong. Instead of rebuilding collagen to its original level, the body breaks down more than it replaces. The result is a permanent dip in the skin’s surface where the structural support has been lost.
Inflammatory cells are found in about 77 percent of indented scars, which helps explain why the worst scarring tends to follow the most inflamed breakouts or wounds. The collagen that does form in scar tissue also arranges itself differently, laying down in flat, parallel bundles rather than the woven lattice pattern of healthy skin. This disorganized structure is part of what makes scars look and feel different from surrounding tissue.
The Three Types of Indented Scars
Not all indented scars respond to the same treatment, so identifying your type matters. Dermatologists classify them into three categories:
- Ice pick scars are narrow, deep, and V-shaped, like a small puncture in the skin. They’re the hardest to treat because they extend deep into the dermis.
- Boxcar scars have sharp, defined edges and a flat bottom, almost like a small crater. They can be shallow or deep.
- Rolling scars are broad and shallow with sloping edges, giving the skin an uneven, wave-like texture. These tend to respond best to stretching, and if your scar looks better when you pull the skin taut, it’s likely a rolling scar.
Most people have a mix of all three types, which is why treatment plans often combine multiple approaches.
Topical Retinoids for Mild Scarring
For shallow scars, prescription-strength retinoids (tretinoin) can make a meaningful difference over time. Tretinoin at 0.05% concentration encourages the skin to produce new collagen in a healthier lattice pattern rather than the flat, parallel arrangement typical of scar tissue. It essentially reprograms how your skin rebuilds itself.
This isn’t a quick fix. Retinoids are typically used nightly for a year or longer, alongside daily sunscreen of at least SPF 30. They work best as a complement to professional treatments rather than a standalone solution, and they’re most effective on shallow, broad scars rather than deep ice pick types. Many dermatologists also use a two-week course of tretinoin to prep the skin before procedures like chemical peels or laser treatments.
Microneedling
Professional microneedling uses a device studded with fine needles to create hundreds of controlled micro-injuries in the skin. These tiny punctures trigger your body’s wound-healing response, stimulating fresh collagen production that gradually fills in depressed scars from below.
Results build over multiple sessions. In clinical evaluations, patients saw mild improvement (15 to 20 percent) after two sessions over one month. After six sessions spread over three months, improvement jumped to 51 to 60 percent, with overall patient satisfaction rated at 80 to 85 percent. Sessions are typically spaced two to four weeks apart, and collagen remodeling continues for months after the final treatment.
Radiofrequency microneedling adds heat energy to the needling process, pushing the collagen-stimulating effect deeper into the skin. It’s particularly useful for moderate rolling and boxcar scars.
Laser Resurfacing
Fractional lasers are among the most effective tools for indented scars. They work by delivering tiny columns of energy into the skin, destroying old scar tissue and triggering the production of new, healthy collagen. The “fractional” part means the laser treats only a fraction of the skin at a time, leaving surrounding tissue intact so healing is faster.
Two main types dominate scar treatment. CO2 fractional lasers penetrate deeper and deliver stronger results. A meta-analysis of eight studies covering 418 patients found CO2 lasers were significantly more effective than the alternative (Erbium:YAG lasers) and actually had shorter overall downtime. The trade-off: CO2 treatments are more painful during the procedure and cause redness that lasts longer afterward.
Erbium:YAG lasers are gentler, with less pain and less post-treatment redness. They’re a better fit for people with darker skin tones, who face a higher risk of pigmentation changes from more aggressive lasers. Most patients need three or more sessions spaced about two months apart, with improvement continuing for up to six months after the final treatment as new collagen fills in. The average cost for laser skin treatments runs about $697 per session, though full resurfacing procedures average $1,829, not including facility fees or anesthesia.
TCA CROSS for Deep Ice Pick Scars
Ice pick scars are notoriously resistant to lasers and microneedling because they’re so narrow and deep. The TCA CROSS technique was designed specifically for them. A dermatologist dips a sharpened wooden applicator in high-concentration trichloroacetic acid (typically 100%) and presses it directly into each individual scar. Within 10 to 15 seconds, the acid causes a visible “frosting” as it destroys the damaged tissue lining the scar walls.
This controlled chemical injury triggers an aggressive healing response. Over the following weeks and months, the body produces new collagen, along with other structural proteins, that gradually fills the scar from the bottom up. Because the acid is applied only to the scar itself, the surrounding healthy skin is spared, which speeds healing and reduces complications. Sessions are repeated every two weeks for four or more rounds. Clinical studies show that 94 percent of patients treated with 100% TCA experienced a good response, though full collagen remodeling can take six months or longer.
Subcision for Rolling Scars
Rolling scars have a specific structural problem: fibrous bands of scar tissue tether the skin’s surface down to the deeper layers, creating visible depressions. Subcision directly addresses this by physically cutting those bands loose.
After numbing the area, a dermatologist inserts a needle into the space between the skin and underlying tissue, then moves it in a fanning motion to shred the fibrous tethers apart. This does three things at once: it releases the skin so it can rise back to its normal level, it triggers a wound-healing response that fills the treated pocket with new connective tissue, and it redistributes tension forces under the skin to smooth out contour irregularities.
Subcision works best on broad, soft, rolling scars that visibly improve when you stretch the skin. It’s often combined with fillers or microneedling for better results.
Dermal Fillers for Immediate Volume
While most scar treatments require weeks or months to show results, dermal fillers provide instant improvement by physically injecting volume beneath the scar. Hyaluronic acid fillers are the most common choice. They plump the depressed area immediately and also stimulate your skin’s own collagen production over time. Results typically last up to 18 months before the filler is gradually absorbed.
Semi-permanent fillers last up to two years, while permanent options like medical-grade silicone can last indefinitely, though they carry higher risks. Fillers are best suited for broad, shallow scars rather than narrow ice pick types, and they’re frequently used alongside subcision. The filler material helps prevent the released skin from re-tethering to the tissue below.
Combining Treatments for Best Results
Because most people have a mix of scar types, the most effective approach is usually a combination plan. A typical strategy might pair subcision for rolling scars with TCA CROSS for ice pick scars and fractional laser for overall skin texture. Fillers can address any remaining volume loss, and a long-term retinoid regimen supports ongoing collagen remodeling between procedures.
Expect the full process to take six months to a year. Most procedures require three to six sessions spaced weeks apart, and collagen continues remodeling for months after your last treatment. Improvement of 50 to 70 percent is a realistic goal for moderate scarring. Complete elimination of deep scars is rare, but the combined effect of multiple treatments can dramatically smooth the skin’s surface and reduce the visibility of scars under normal lighting conditions.