Ice Pick scars: The most common atrophic acne scar type

Picture of By Ulrik knap, md, laser & acne scar specialist

By Ulrik knap, md, laser & acne scar specialist

Treating acne scars is a medical art that requires great skills and the use of the right methods. Not one method fits all acne scar types. Hence, I treat acne scars with different methods and choose the best methods for each individual acne scar. Combining different methods – when relevant – is the only way to achieve the highest cure rate. Therefore, patients come from most of the world to visit my office and have their acne scars treated by me personally.

How common is ice pick scars?

Atrophic acne scars are the type of acne scars that have a loss of volume and depression in the skin. Ice pick scars are the most frequent form of atrophic acne scars.

In total ice pick scars occur in 60%–70% of all patients with atrophic acne scars. Thus, this is the most frequent form of acne scar which I treat as a laser and acne scar specialist.

What are the different forms of ice pick scars?

As a general definition, ice pick scars are acne scars which are narrow (<2 mm), deep, and sharply marginated epithelial tracts that extend vertically to the deep dermis or fat tissue.

Ice pick scars can be divided into different severities and depths. Basically, we have deep pits, shallow pits, and enlarged pores. This would be the type of acne scars which are illustrated in figure 5, 6 and 7 in the illustration below:

Different acne scar types

What causes ice pick scars?

Ice pick scars are usually caused by severe acne, such as cysts and papules that occur deep in the pores. As you might already have read in the article, “What causes acne and acne scarring?”,  acne is an inflammatory disease with inflammation in and around the pores (i.e. in the oil glands and hair follicles in the skin). 

The inflammation is what makes the pimple get red and hurt when it is touched and is basically the body’s response to the bacterial growth in the pores.

When the bacteria have been defeated by the body’s own immune system, wound healing begins aiming to repair the damages after the fight between the bacteria and the body. During the wound healing, new tissue is created, but at the same time, the body also removes all the tissue which was damaged during the initial fight between the bacteria and the body. This is one of the most complex biological processes where new collagens are created and damaged collagens, elastins, and extracellular matrix are destructed.

Focal Volume loss causes ice pick scars

In patients who are prone to develop depressed acne scars, there is an imbalance between creation and degradation of tissue in favor of a tissue loss. Hence, acne scarring occurs.

When the tissue loss is concentrated just around the pores, the scars get deep and very narrow; hence ice pick scars develop. The longer the inflammation lasts, the more severe volume loss might occur.

Dr. knap about How to treat ice pick scars

To achieve the highest cure rate, I start every acne scar consultation by identifying the skin type, the different acne scar types, and the severity of the scars by a thorough examination. This is a 3-dimensional approach that requires good lighting, and that I see the patient’s mimic and touches the skin to identify any tethered scars (which should be treated with subcision). Matching the acne scar type with the right method is the key to success. 

My approach is always to target the deepest acne scars first, and to rebuild the skin from the ground and up. Hence, deep ice pick scars would be one of the acne scar types, I would treat first, either as a stand-alone treatment in the first session or in combination with other methods depending on the acne scar types the patient presents with.

These types of scars are excellently treated with a technique called TCA cross. In this method, I apply a tiny droplet of TCA (trichloroacetic acid) at the bottom of each scar. The delivery system can be as simple as a toothpick which has been dipped into a jar of TCA, where after the toothpick is placed into the scar. 

With this technique, I can treat multiple scars per minute. Hence, depending on the number of ice pick scars, the procedure typically lasts 5-15 minutes.

The method can be combined with other techniques as well. For very deep ice pick scars and deep boxcar scars, punch excision and minor skin surgery can be performed as well.

When the deep ice pick scars have been raised to a certain level, enlarged pores, shallow pits, and the overall skin texture can be improved with chemical peels and fractional lasers depending on the skin type. However, each individual case is different. I don’t have a standard approach. On the contrary, I tailor an individualized acne scar revision program for each individual patient which depends on skin type, acne scar types, and severity.

How does TCA cross work on ice pick scars?

TCA cross is a strong acid, which is very well-tolerated and pain-free. Hence, there is no need for local anesthetics. 

The mechanisms of action of TCA cross are:

  1. Local tissue damage occurs when the strong acid is applied at the bottom of the ice pick scar.
  2. The local tissue damage stimulates fibroblasts to create new collagen fibers
  3. The tissue starts to remodeling resulting in an increase in dermal volume as new extracellular matrix (glycosaminoglycans), collagen fibers, and elastins are created.

Hence, the benefit of this treatment is that you get an exact and very precise treatment that is targeting the very bottom of the ice pick scar. 

During a course of typically 2-4 treatments, it’s possible to lift the ice pick scars to a certain level to give a good cosmetic outcome. In ethnic skin types, an additional 1-2 treatments with TCA cross should be expected, since the TCA concentration I use, is weaker to reduce the risk of PIH (post-inflammatory hyperpigmentation).

How does punch excision work on ice pick scars?

Another method I use for very deep or large ice pick scars in selected patients is punch excision. This treatment is performed in local anesthesia, so the treatment is painless. I use a surgical knife to excise the fibrotic scar tissue. Thereafter, the wound is closed by sutures which should be removed after approximately 6 days when the wound has closed.

After 4-6 weeks, a fractional laser can be used to improve the overall skin texture and the surgical scar.

What is the result after TCA cross and punch excision

The cosmetic outcome is generally good. After each treatment with TCA cross, an average improvement of 20-30% can be expected. Thus, after 3 treatments an improvement of 60-80% is usually seen when treating deep ice pick scars, boxcar scars or larger pores. 

However, it’s important to understand that it takes some weeks for the final result to show; first, the scar tissue should be broken down, and thereafter a remodeling of the skin scars causes the skin to rise to a certain depth after the treatment. The result comes as the skin starts to create new collagen fibers, elastin, and extracellular matrix.

Before acne scar revision with punch excision and TCA cross.
After punch excision and TCA cross

Dr. Knap about treating ice pick scars

Ice pick scars are the most common form of acne scars, and thus the acne scar type which I most frequently treat in my clinic. Ice pick scars in combination with other acne scar types can cause a lot of distress in patients because they are very apparent and visual to the patient, especially in indirect lighting.

I really like to treat this kind of acne scars because the results are amazing when using the right methods.

Creating the perfect acne scar revision program for my patients is very important to me. An acne scar revision program typically lasts 4-8 months to achieve the best outcome. I use different methods to achieve the highest possible cure rate.

Targeting the deepest and most visual acne scars is essential since they are the most eye-catching scars. Treating deep ice pick scars might include different techniques including TCA cross and punch excision, while I use chemical peels, fractional lasers, and other energy-based devices to treat the more shallow pits and enlarged pores. 

Hence, there is no single method that can be used for all patients, and particularly not in patients with a mixture of different acne scar types.

My unique approach and high cure rate are some of the reasons why patients travel far to visit my clinic.

Best Regards

Ulrik Knap, MD., Laser & Acne scar specialist

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