Why are multiple methods combined for acne scars?

U first part of the series We were talking about why acne scars are not the same for every person. Some are shallower and wider, some are narrow and deep, while certain scars feature fibrous bands that pull the skin inwards. Therefore, before choosing a treatment, it is important to understand not only how the scar looks on the surface, but also what is happening in the deeper layers of the skin. Once we know this, the next question is: which acne scar treatments make sense in a specific case? The answer is usually not a single treatment, a single device, or a single procedure. A scar often has to be treated in layers — in the depths, in the middle tissue layers, and on the skin's surface itself. In this section, Dr Marina discusses the methods used in treating acne scars: laser treatments, radiofrequency microneedling, traditional microneedling, subcision, skin boosters, polynucleotides, collagen stimulators, chemical and laser peels, as well as surgical excision for certain resistant scars. The goal is not just to list the treatments, but to explain why they are combined. One method may act on deeper adhesions, another may stimulate the production of new collagen, while a third can further smooth out the skin's surface. That is why acne scar therapy is usually built up gradually, according to the scar type, the depth of the changes, and the skin's response to the treatments.

How acne scars are examined and treated in Imedic is described on the page acne scars.

What do acne scar treatments have in common?

When we list all the treatments used for acne scars — CO2 lasers, erbium lasers, radiofrequency microneedling, traditional microneedling, chemical peels, skin boosters, collagen stimulators, and subcision — at first glance it seems as though we are talking about completely different procedures. However, what they have in common is that they all attempt to remodel the scar. The difference lies in the way they do it. One group of treatments uses devices, or machines that operate using energy. In professional literature, they are often referred to as energy-based devices, for short EBD. This group includes laser treatments and radiofrequency treatments. The second group of treatments does not work via device energy, but involves introducing certain substances into the tissue or mechanically releasing the scar. Therefore, the treatments mentioned in the therapy for acne scars also include skin boosters, polynucleotides, collagen stimulators and subcision. Therefore, the treatments are not the same and are not chosen at random. They all aim to affect the appearance of the scar, but each of them does so through a different mechanism.

Energy-based devices: how do laser and radiofrequency treatments work?

One treatment group for acne scars uses devices that employ a specific form of energy. In professional literature, the name frequently used is energy-based devices, or rather EBD treatments. This group includes laser treatments and radiofrequency treatments. These devices can use various energy sources, for example laser or radiofrequency energy. Their aim is to create controlled micro-destruction within the tissue, that is, very precise damage to a specific part of the tissue. This damage is neither accidental nor uncontrolled. It is created precisely so that the skin triggers a renewal process. When such micro-destruction is created in the tissue, an inflammatory reaction is triggered. In everyday speech, inflammation sounds like something bad, but in this context it plays a beneficial role. It activates cells that participate in tissue renewal and stimulate fibroblasts to produce new collagen. Which laser is chosen for which type of scar and how it is combined with other methods is described on the page laser acne scar treatment.

Classic microneedling: when can it help, and when is it not enough?

Classical microneedling works on a similar principle to treatments that create controlled tissue micro-destruction, but without using laser or radiofrequency energy. This group includes treatments such as Dermapen, SkinPen and other devices that use microneedles. These devices make tiny punctures in the skin at a certain speed and depth. Although described this way it may sound aggressive, in practice microneedling is classed as a minimally invasive treatment. For acne scars, classic microneedling can yield good results when the changes are milder. It can be particularly useful for enlarged pores, where it often has a very good effect on skin texture. However, when we are talking about more pronounced acne scars, microneedling is most often not sufficient as a sole method. The result depends on how it is performed, the working depth and the number of repetitions, but in practice it is most commonly used as part of a combination therapy. Therefore, it should not be viewed as a treatment that independently resolves all acne scars. Its role is important, but it is usually complementary — especially when there are deeper indentations, more pronounced tissue changes or scars that require stronger remodelling stimulation. This is important because we most commonly see an acne scar as an indentation on the skin's surface. To aesthetically soften that indentation, it is not enough to act only from the outside. It is necessary for the tissue beneath the scar itself to change and gradually fill up from within. That is why a large number of treatments performed with devices function on a similar principle: energy is directed into the tissue beneath or around the scar, controlled micro-destruction is created, and then inflammation, remodelling and the production of new collagen are triggered. In this way, over time, the scar tissue itself changes and better support is gained beneath the indentation.

How is it decided whether microneedling is sufficient?

The decision is based on the type and depth of scarring, the presence of adhesions, active acne and the response to previous treatments. For scars associated with deeper tissue, or narrow and deep lesions, repeating microneedling on its own may not help sufficiently; the doctor will also consider other targeted methods.

The number of sessions and intervals are determined individually, and the plan is assessed during follow-up appointments. Combining multiple procedures is not mandatory for everyone and does not guarantee complete removal of scars.

Injectable treatments: why are they added alongside lasers and microneedling?

On the other hand, there are treatments that do not cause tissue destruction, but instead involve the introduction of certain substances into the skin. These can be amino acids, polynucleotides, collagen stimulators, skin boosters and other preparations used to further stimulate tissue replenishment. In this group of treatments for acne scars, the most commonly mentioned are skin boosters, polynucleotides and collagen stimulators. Many of these preparations are found in solutions or gels that also contain hyaluronic acid. This additionally hydrates the tissue and creates a better base for the action of the active substances. These treatments play an important role because they enhance the effect of procedures that involve controlled tissue destruction. When a laser, radiofrequency microneedling or another similar treatment triggers inflammation and remodelling, the skin also needs to recover, return to balance and receive additional support for collagen production. Therefore, injectable treatments are not just for “injecting something” into the scar. Their role is to help the tissue recover after more intensive procedures, to restore its moisture, nutrients and additional stimulating substances, such as collagen stimulators, polynucleotides, amino acids and peptides. In this way, destructive and regenerative treatments complement each other: some trigger changes in the scar, while others help the tissue to regenerate better and gradually fill out.

Subcision: when the scar is pulled by fibrous bands

A special place in the treatment of acne scars is held by subcision. It is most commonly mentioned in the context of scars where there is an inward pulling of the skin, that is, when fibrous bands beneath the skin keep the scar tethered down. Although subcision often sounds to patients like something very aggressive, the procedure itself does not look as dramatic as it is usually imagined. It is performed using a thin, blunt, and flexible cannula—an instrument used to enter beneath the skin's surface through a small opening. The aim of subcision is to use this instrument to sever the fibrous bands that are pulling the skin inwards. Once these are released, the skin's surface can lift and the scar can become flatter. The problem arises when subcision is performed as a standalone method. The fibrous bands can be severed and the skin can lift temporarily, but if nothing is introduced into that space to help modify and fill the tissue more permanently, those connections may form again over time. In that case, after the initial improvement, the scar may become visible again much like before. For this reason, subcision is rarely used alone. It is much more frequently combined with injectable treatments, particularly with collagen stimulators. After the fibrous bands are broken down with a cannula, a collagen stimulator can be injected into those spaces using the same cannula. In this way, the freed-up space is not left empty; instead, tissue filling and the leveling of the previously depressed area are encouraged.

Chemical and laser peels: the finishing touch on the skin's surface

All the treatments we have mentioned so far mostly work on the part of the scar that lies beneath the skin's surface. Of course, laser treatments can also work on the surface, depending on the type of laser and the settings used, but acne scars are often discussed in terms of a deeper action within the scar tissue itself. When we move towards the surface of the skin, that is where chemical peels and laser peels. They are used to smooth out fine textural changes that scars cause on the skin's surface. In other words, when working on the deeper parts of the scar, it is also necessary to pay attention to what the patient sees on the outside: unevenness, a coarser texture and minor surface irregularities of the skin. Laser peels work using energy. Most of the time, thermal damage is caused to the skin's surface, after which this surface layer peels off and is replaced by a new layer of skin, namely normal epidermis. Chemical peels work differently. They use acids which, through their chemical or rather caustic action, lead to the denaturation of proteins, the breakdown of the surface layer of the skin and peeling. Depending on the peel used, they can work superficially, medium-deeply or deeper. These treatments can be done independently, but for acne scars they are very often combined with other methods. In such cases, they have a synergistic effect: while other treatments work on the deeper parts of the scar, peels help to further smooth the skin's surface and improve the final aesthetic appearance.

Why are scars treated in multiple layers of the skin?

When the story of acne scar treatments is rounded off, the bottom line is that a scar most often has to be treated in multiple layers. It is not enough to treat just one level of the skin and expect all scars to behave in the same way. For scars that have a deeper component, the treatments must act on the deeper layers of tissue. This involves remodelling, collagen stimulation, releasing fibrous bands or filling the space that keeps the scar tethered downwards. This is the part of the therapy that is not immediately visible from the outside, but is important for changing the scar itself. On the other hand, in the end it is also necessary to work on the skin surface itself. This is where fine textural changes, unevenness and surface roughness that scars can leave behind are treated. This is precisely why chemical or laser peels are often used as a final step, or as a fine resurfacing of the skin. The aim of this approach is not to treat the scar merely “from above”, but to repair what makes it depressed, uneven or resistant to simpler treatments. Only when deeper treatments and skin surface resurfacing are combined can a better aesthetic result be expected.

When is surgical scar excision performed?

In some cases there are scars that are particularly deep, particularly wide or large in surface area. These are scars where rapid or marked improvement is not expected from treatments alone such as lasers, radiofrequency microneedling, injectable methods or subcision. Then one may consider surgical excision of scar. This means that the specific scar is excised, and then the edges of the healthy skin are stitched together. At first glance, this may sound like the most unfavourable option to patients, as a small surgical incision is made on the face. However, the healing of facial skin often yields a much better result than expected. This method is not intended to “excise all acne scars”. It is performed selectively, for individual scars that are particularly stubborn, deep, or respond poorly to other treatments. For example, if a scar does not respond sufficiently to a CO2 laser, injectable methods, subcision, or a combination of subcision with a collagen stimulator, then surgical removal may be a better solution than repeating a large number of aggressive procedures without a sufficiently good response. Therefore, surgical excision is most commonly viewed as part of a broader acne scar treatment plan. It is used when, among a larger number of scars, there are individual scars that stand out in terms of depth, width, or resistance to therapy. With such blemishes, the goal is not to continue indefinitely with the same treatments, but to remove the problematic scar and replace it with a significantly more discreet surgical scar.

Punch excision for deep ice-pick scars

A special form of surgical removal can be used for deeper and larger ones ice-pick scars. These are narrow, deep scars that often do not respond well enough to milder methods and sometimes require a more direct approach. In such cases, it is possible to perform punch excision. It is performed using a small instrument called a punch. This is used to make a small, circular, drill-like excision that removes the specific scar. This results in a very small wound which is closed with a single small stitch. Such a wound usually heals in six to seven days, leaving a small, barely visible line in its place. This small line can later be treated further, for example with a CO2 laser. Therefore, punch excision can be useful for particularly stubborn, resistant, large or deeper scars, where repeating other treatments would yield a slower or weaker result.

Why are acne scar treatments planned individually?

When all these methods are viewed together, it is clear why there is no single treatment that resolves all acne scars. Some scars require action in the deeper tissue layers, some respond better to treatments that stimulate collagen, while with others, additional work must be done on the surface texture of the skin. That is why different methods are often combined in practice. Laser treatments, radiofrequency microneedling, classical microneedling, injectable treatments, subcision, chemical peels and surgical excision do not have the same role. Each method works in a different way and is chosen according to what the scar is like, how deep it is, how wide it is and how it responds to previous treatments. With milder changes, less aggressive treatments and gradual skin stimulation are sometimes sufficient. With more pronounced scars, a combination of methods that work both in the depths and on the surface is often necessary. And with particularly stubborn, deep or resistant scars, surgical removal of an individual scar may also be considered. Among injectable treatments, collagen stimulators are also used, such as Juvelook, which gradually restore tissue density at the site of the depression and thereby reduce the visibility of the scar. This is why an examination is an important part of therapy planning. Only once the type of scars, their depth, distribution, and skin condition have been assessed can it be determined which treatments make sense and in what order they should be performed. With acne scars, the most important thing is not to choose a procedure just because it is popular, but because it suits the specific type of scar.

An overview of features and booking information can be found on the page acne scar treatment at Imedic.

Watch the whole video about acne scar treatments

In the text we have highlighted the most important parts, but in the video Dr Marina explains in more detail how treatments for acne scars are chosen, why different methods are often combined, and in which cases lasers, microneedling, subcision, collagen stimulators, or surgical removal of individual scars are considered. If you have acne scars and are unsure which treatment would make the most sense in your case, watch the full video below. In it, it is explained why therapy is not chosen solely by the name of the treatment, but according to the type, depth, and appearance of the scar itself.

Expert sources

American Academy of Dermatology – treatment options for various acne scars