The informal term “crater face” describes the appearance of severe, pitted facial skin texture resulting from past acne. This condition is medically known as atrophic acne scarring. These scars are a lasting consequence of inflammatory acne that caused significant damage to the skin’s underlying structures. While atrophic scarring can be a source of psychological distress, modern dermatological science offers various effective solutions to improve skin texture and contour.
Understanding Atrophic Acne Scarring
Atrophic acne scars develop when the skin’s natural healing response to severe inflammation is insufficient. They begin with cystic or nodular acne lesions that extend deep into the dermis. Inflammation causes the enzymatic degradation of the underlying collagen fibers and subcutaneous fat.
When the inflammatory lesion finally resolves, the repair mechanism fails to produce enough new collagen and elastic fibers to replace the lost tissue. The skin heals below the surrounding surface level, resulting in a depressed, sunken area. This net loss of structural support, primarily collagen, is the biological basis for all atrophic scars.
Classifying Deep Scars
Effective treatment for atrophic scarring depends heavily on correctly identifying the scar type, as different scars require targeted interventions. They are divided into three main classifications based on morphology.
Ice Pick Scars
Ice Pick Scars are deep, very narrow, V-shaped indentations. They are often less than 2 millimeters wide but extend deep into the dermis, making them the most challenging type to treat with simple surface procedures. They are the most common type of atrophic scar, accounting for an estimated 60% to 70% of cases.
Boxcar Scars
Boxcar Scars are wider than ice pick scars, presenting as round or oval depressions with sharply defined, vertical edges. They resemble chickenpox scars and can be shallow or deep, with a diameter usually ranging from 1.5 to 4.0 millimeters.
Rolling Scars
Rolling Scars are broad depressions with sloping, undulating edges. These scars are caused by fibrous bands of tissue that form between the dermis and the subcutaneous fat, pulling the overlying skin downward.
Professional Treatment Methods
The treatment of atrophic scars is often a customized process that combines several procedures. Procedures are selected based on the scar’s depth and shape to achieve optimal results.
For rolling scars that are tethered to the underlying tissue, a minor surgical procedure called subcision is commonly used. A specialized needle or cannula is inserted beneath the scar to sever the fibrous bands. This release allows the skin to rise, and the controlled trauma stimulates new collagen production, further smoothing the surface.
Ice pick scars, due to their deep and narrow nature, are often best treated with the TCA Cross technique. This method involves applying a high concentration of trichloroacetic acid (TCA), typically 50% to 100%, directly into the scar’s base. The TCA causes a controlled chemical burn that stimulates the formation of new collagen to fill the pitted area from the bottom up.
Fractional laser resurfacing or microneedling with radiofrequency are used. Laser treatments work by delivering thermal energy that stimulates dermal fibroblasts to replace lost collagen and remove damaged surface layers of skin. Dermal fillers, often hyaluronic acid-based, can also be injected into depressed scars, particularly rolling or boxcar types, to immediately restore volume and elevate the skin.
Preventing Future Scar Development
Prevention of new severe lesions is key. This begins with seeking immediate and effective treatment for active acne, especially the inflammatory forms like nodules and cysts. The longer a lesion remains inflamed, the higher the likelihood of permanent tissue destruction.
Avoid picking, squeezing, or popping pimples, as this trauma increases inflammation and forces bacteria deeper into the skin. Topical retinoids, available both over-the-counter and by prescription, can help manage inflammation and promote cell turnover, which supports a healthier healing process. Protecting the skin from sun exposure is important, as ultraviolet light can darken scars and slow down the skin’s natural healing capabilities.