How to Get Rid of Indented Scars: What Actually Works

No single treatment erases indented scars completely, but several procedures can flatten them enough to make a visible difference, and combining treatments tends to work better than relying on any one alone. The right approach depends on the shape, depth, and location of your scars, as well as your skin tone. The science here is more encouraging than many people expect: newer combination protocols and regenerative add-ons are pushing results further than what was possible even a decade ago.

Why Indented Scars Form in the First Place

When skin heals after deep inflammation, like the kind caused by cystic acne, surgery, or certain injuries, it sometimes fails to rebuild enough structural tissue to fill the gap. Histological studies of indented scars show loose, disorganized collagen in about 71% of cases and reduced elastic tissue in 96%, which explains why these scars look sunken and feel different from surrounding skin.¹ The body’s repair process essentially skipped a step, leaving a deficit of collagen and elastin where it was needed most.

These scars are classified by shape and depth. Ice pick scars are narrow, deep, and V-shaped, like the skin was punctured by a sharp instrument. Boxcar scars are wider with defined vertical edges, resembling small craters. Rolling scars have gentle, undulating borders created by fibrous bands pulling the skin downward from below.² This classification matters because different scar types respond to different treatments. A procedure that works well for rolling scars may barely touch an ice pick scar, and vice versa.

Treatments Matched to Scar Type

The most common mistake people make is picking a treatment based on what they read about in general, rather than matching the procedure to the specific scar architecture. Here is how the main options line up.

Ice Pick Scars and the CROSS Technique

Ice pick scars are the hardest to treat because they extend deep into the dermis through a very narrow channel. Broad resurfacing tools like lasers have trouble reaching the bottom of these pits. The CROSS technique (chemical reconstruction of skin scars) was developed specifically for this problem. A dermatologist applies high-concentration trichloroacetic acid, typically 100%, directly into each individual scar using a toothpick or fine applicator. The acid triggers a controlled inflammatory reaction at the base, which provokes new collagen formation that gradually fills the scar from below.

In studies evaluating this method on ice pick scars, more than 70% improvement was observed in most patients, with the rest showing at least 50% improvement after a course of treatments.³ Results in darker skin types were similarly encouraging, with about three-quarters of patients achieving more than 70% improvement after four sessions.⁴ The technique is inexpensive compared to laser treatments and requires minimal downtime, though multiple sessions spaced weeks apart are standard.

For ice pick scars that are too deep or too rigid for chemical reconstruction, punch excision or punch elevation offers a surgical alternative. A small circular tool removes or lifts the scar tissue so it can be sutured level with the surrounding skin surface. One case report documented improvement from a severe grade to a milder grade after a single punch elevation procedure, with significant improvement in skin texture within nine days.⁵ These techniques leave a tiny scar themselves, but a small flat scar is usually preferable to a deep pit.

Rolling Scars and Subcision

Rolling scars are caused by fibrous bands that tether the skin surface to deeper tissue, pulling it down into a wave-like pattern. The most direct fix is subcision, where a needle or blade is inserted under the scar to physically release those tethering bands.⁶ Once the bands are broken, the skin can float back up to a more natural position, and the pocket of blood that forms underneath eventually fills in with new collagen. Subcision is often done as a first step before other resurfacing treatments, since freeing the tethered skin allows subsequent procedures to work on a more level surface.

Boxcar Scars and Fractional Lasers

Boxcar scars, with their defined edges and flat bottoms, respond well to fractional laser resurfacing. Rather than treating the entire skin surface, fractional lasers create tiny columns of controlled injury in the dermis with untreated skin left between them. This triggers a healing response that rebuilds collagen while the intact surrounding tissue helps speed recovery.⁷

Fractional CO₂ lasers operate at a wavelength that ablates tissue and generates significant heat in the dermis, which drives robust collagen remodeling. Erbium-based lasers offer an alternative: Er:YAG lasers also ablate tissue but with a different heat profile, while erbium-glass lasers work non-ablatively, heating the dermis without removing the surface layer at all.⁸ The more aggressive the laser, the better the scar improvement tends to be, but also the longer the recovery and the higher the risk of side effects like prolonged redness or pigmentation changes.

Microneedling and Radiofrequency Microneedling

Microneedling works across all three scar types, making it one of the more versatile and accessible options. The device creates hundreds of tiny punctures in the skin without destroying the surface layer. These micro-injuries trigger a wound-healing cascade that results in increased dermal elastin and collagen, collagen remodeling, and thickening of both the outer and inner layers of skin.⁹ Multiple sessions are needed, typically three to six, spaced about a month apart.

Radiofrequency (RF) microneedling adds an electrical energy component delivered through the needle tips. This combination not only triggers the same mechanical wound-healing response but also promotes additional collagen remodeling while reducing inflammation in the scar tissue.¹⁰ Systematic reviews have found RF microneedling consistently reduces scar scores and performs comparably to fractional lasers, with a favorable safety profile: mostly temporary redness, swelling, and mild pain, with pigmentation changes being infrequent and self-resolving.¹¹

A word about home microneedling devices: derma rollers and consumer-grade pens use shorter needles (typically 0.25–0.5 mm) that can improve product absorption and may modestly improve skin texture over time, but they do not reach the depth needed to remodel scar tissue in any meaningful way. Professional microneedling uses needle depths of 1.5 mm or more and is performed with sterile, single-use cartridges under controlled conditions. The two are not comparable in terms of results.

Picosecond Lasers and a Different Kind of Injury

Picosecond lasers represent a newer approach that works through a fundamentally different mechanism than traditional lasers. Instead of heat-based tissue damage, they deliver ultra-short pulses that create microscopic cavitation bubbles in the dermis through a process called laser-induced optical breakdown. These tiny vacuoles form without injuring the skin surface or the layer between the epidermis and dermis, and the resulting shock waves trigger collagen and elastin production as the tissue repairs itself.¹² The disruption is photomechanical rather than thermal, which is why these treatments cause less redness and crusting.¹³

In a head-to-head trial comparing a 755-nm picosecond laser to a 1565-nm non-ablative fractional laser for acne scars, both achieved around 20–23% improvement in scar severity scores after 20 weeks. The picosecond laser produced higher patient satisfaction and significantly shorter periods of redness and swelling. Crusting did not occur in the picosecond group at all, compared to about 70% of patients in the non-ablative fractional laser group.¹⁴ The trade-off is clear: picosecond lasers offer a gentler experience and shorter downtime, but the scar improvement is modest compared to more aggressive ablative options.

Why Combinations Outperform Single Treatments

The evidence consistently shows that combining treatments produces better results than relying on any single modality. A network meta-analysis comparing laser, microneedling, and combination approaches for moderate to severe scars found that combinations generally outperformed monotherapies, with fractional CO₂ laser combined with subcision or platelet-rich plasma (PRP) showing the most consistent benefits.¹⁵

This makes intuitive sense when you consider what each treatment does. Subcision releases tethered scars so they can rise. Lasers or microneedling then trigger collagen rebuilding across the newly freed surface. PRP or other biologics amplify the healing response. Combination protocols have shown good results even in severe scarring.¹⁶ A typical plan might involve subcision first, followed by fractional laser sessions, with PRP applied during or after the laser procedure.

Platelet-Rich Plasma as a Booster

PRP is not a standalone scar treatment. Its value lies in amplifying other procedures. Your own blood is drawn, spun down to concentrate the platelets and growth factors, and then applied to the treatment area during or after a procedure like microneedling or fractional laser resurfacing. A split-face study found that microneedling combined with PRP produced better scar improvement than microneedling alone, though the authors noted the evidence base still needs larger trials.¹⁷ A systematic review of PRP combined with ablative fractional CO₂ laser found enhanced scar remodeling and reduced complications compared to laser treatment alone.¹⁸

Injectable Fillers and Fat Grafting

For scars that need immediate volume, injectable fillers offer a different strategy. Instead of waiting months for collagen to rebuild from below, fillers physically raise the depressed area to the level of surrounding skin. Beyond this instant result, filler therapy can also stimulate longer-term collagen production, which means the improvement may partially persist even after the filler itself is absorbed.¹⁹ Hyaluronic acid fillers are the most commonly used for this purpose, partly because they can be dissolved if the result is not right.

Autologous fat grafting takes a similar concept further. Fat harvested from elsewhere on your body is processed and injected under the scar. The fat adds volume and also delivers adipose-derived stem cells that can improve skin quality over time.²⁰ Fat grafting produces a filling effect that can address scar depression directly,²¹ though some of the transplanted fat is reabsorbed, so results vary and repeat sessions are sometimes needed.

What Topical Products Can and Cannot Do

Adapalene, a retinoid available both by prescription (0.3%) and over the counter (0.1%), is one of the few topical treatments with any evidence behind it for indented scars. Research has shown that 24 weeks of adapalene 0.3% gel slightly increased collagen gene expression and thickened the epidermis, which can modestly improve the appearance of shallow scars.²² The key word is “modestly.” The collagen increases observed were not statistically significant, and topical retinoids are best understood as a maintenance or supportive measure rather than a primary treatment for established scars.

Products marketed as “scar creams” or “scar serums” containing ingredients like vitamin C, niacinamide, or peptides may improve overall skin quality, but there is little rigorous evidence they can restructure the deep collagen deficit that creates an indented scar. If you have shallow, relatively new scars, a retinoid may help at the margins. For anything deeper, professional intervention is where the meaningful results come from.

Skin Tone and Treatment Safety

Darker skin tones face additional challenges when treating indented scars. A prospective analysis of scar healing across different Fitzpatrick skin types found that favorable pigmentation outcomes at 12 months were seen in about 78% of the lightest skin types but only 30% of the darkest types. Patients with the darkest skin were significantly less likely to achieve good pigmentation outcomes after procedures that disrupt the skin surface.²³

This does not mean people with darker skin cannot treat their scars. It means the treatment plan needs to be adjusted. Lower-energy laser settings, more conservative treatment intervals, and procedures with less surface disruption (like RF microneedling or picosecond lasers) tend to carry lower risk of post-inflammatory hyperpigmentation. The CROSS technique has shown effectiveness specifically in darker skin types, as noted earlier. A dermatologist experienced in treating skin of color can navigate these decisions, and the conversation about pigmentation risk should happen before any procedure, not after.

Emerging Approaches Worth Watching

Exosomes, tiny vesicles derived from stem cells or plant sources, are generating early excitement as add-on treatments. In a randomized trial, fractional CO₂ laser combined with exosome-mimetic nanovesicles and polynucleotides improved scar scores by about 47% compared to roughly 36% with the laser alone. The combined approach showed particular benefit for ice pick, boxcar, and rolling scars alike.²⁴ A case series using plant-derived exosomes for various scar types reported dramatic improvements, including one facial scar that resolved with topical exosome application alone, without any device-based treatment.²⁵

These results are promising but still early. Case reports and small trials are a starting point, not a finish line. The exosome field also has a regulation problem: many products marketed commercially have not been standardized or independently verified. If your provider offers exosome-based treatments, ask what specific product they use, whether it has been studied in controlled trials, and whether it has any regulatory clearance in your country.

The Collagen Remodeling Timeline

One of the most common frustrations people have with scar treatment is how long results take to appear. After any collagen-stimulating procedure, the skin enters a remodeling phase where looser, weaker collagen is gradually replaced with denser, stronger collagen. This phase can last several months to up to two years.²⁶ You will not see the final result of a fractional laser session for months after the redness has faded. Judging a treatment’s effectiveness at the two-week mark is like judging a building when the foundation has just been poured.

This timeline also explains why treatment plans are spread over many months and why patience is genuinely part of the protocol. Most practitioners recommend waiting at least four to six weeks between sessions to allow the initial healing cascade to establish itself before triggering the next round. Stacking aggressive treatments too quickly can overwhelm the skin’s repair capacity and lead to worse outcomes.

When Scars Affect More Than Appearance

Research from a cross-sectional study found that as scar severity increases, both body image concerns and scar-specific quality of life scores worsen in a dose-dependent way, with moderate positive correlations between scar severity and psychological burden.²⁷ If your indented scars are affecting how you feel about yourself or how you move through social situations, that is a legitimate reason to pursue treatment regardless of whether someone else considers the scars “mild.” The psychological component also means that even partial improvement, not perfection, can produce a meaningful change in quality of life. Setting realistic expectations with your provider about what percentage of improvement is likely matters as much as choosing the right procedure.