Face scars from picking or acne. What to do if you’re not seeing results from lasers and treatments

Hello! In my early 30's I suffered from Dermatillomania (skin picking) for several years. I went to therapy and am happy to say I worked through my issues and once and for all closed my facial wounds and no longer pick. Unfortunately, I went from having perfect, smooth skin to having rolling and boxcar scars on my cheeks, in between my eyes and nose. I went to a dermatologist and put together a plan for me: 6 sessions of Fraxel 1550, Radiesse and punch, subcision. However, after having 3 Fraxel sessions and out $2,100, I wasn't seeing improvement whatsoever and got really discouraged. Especially since the dermatologist, I went to see didn't even treat me ( only saw assistants) and felt I wasn't getting the care I was paying for. I decided to stop and reconsider my options and was wondering if I should continue to spend thousands more with the fear this won't correct my scars or figure out another treatment plan that is hopeful with another doctor? I am 36 years old now. What treatments are best at treating rolling and boxcar scars? Thank you! Rorie

Thank you for writing and sharing your story.  We see this all too often when a treatment plan is put together, but there’s no one checking to see if it’s working!  Regarding your question about facial scarring, I’m not clear if they did the punch excisions, subcision and filler (in your case Radiesse) first, and then followed with the Fraxels?

For face scars, this is the order of treatments I’d generally recommend:

  1. First, treat the deep face scars
  2. Tighten the skin if possible (for loss of elasticity)
  3. Then, finally deal with the superficial face scars and texture.

This order makes sense for acne scarring, but can vary individually. Go to a board certified, laser experienced dermatologist. We have much more experience with acne and acne scarring. Take your time and do at least 2-3 consults before you decide on a doctor or a laser (here are my tips for getting a good laser treatment from a great doctor);

Some more general guidelines below.

Treatment options for deeper face scars (“ice pick” or deep rolling):

  • Excision: (just removing or “punching” out a deep ice pick scar. There is also a way to use a very strong TCA solution for these, but experts only, please.
  • Subcision: which is breaking up scar tissue deep under a scar with a special needle or other tools.
  • CO2 (carbon dioxide laser): which can penetrate deeper than other lasers.  (Usually 1-3 needed) Experts only, please. More information on this laser here.
  • Fillers: as needed. More about these here.
  • Tightening devices (see below): These may help if you’re over 40, and have some sagging.

Treatment options for medium scars (medium rolling, “boxcar scars”):

  • CO2 (carbon dioxide) or other deeper ablative lasers.  (Usually 1-2 needed). More info about these here.
  • Fraxel: if done on higher settings and 8 passes.
  • Fillers: as needed
  • Tightening Devices: If over 40, and skin is saggy, consider radiofrequency to tighten like Thermage, Thermismooth or Exilis
  • Limited subcision: may be helpful
  • Boxcar scars can be stubborn, no matter what is done.

Tips for shallow scars and texture:

  • Fraxels: or other lighter lasers (usually a series of 3-5 needed)
  • IPL: if needed for getting rid of red and brown spots. More on these here.
  • Fillers: as needed but not usually needed.
  • Tightening Devices: If over 45-50, radiofrequency (see above) to help tighten and improve skin sagging.
  • Consider CO2 if over 45-50, with acne scars, wrinkles, sun damage and need tightening.

Hope this helps, Dr. I



Dr. Brandith Irwin, MD

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Hi, I’m Dr. Irwin. I believe that consumers deserve a medically trained and unbiased skin care advocate.

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