Skin Care Education

Atrophic Scars

Depressed or sunken scars that develop when the skin heals without fully rebuilding the tissue beneath. The most common type of scar associated with acne.

What Are Atrophic Scars?

Atrophic scars are a category of scarring characterised by a depression or indentation below the level of the surrounding skin. They form when the healing process following an injury or inflammatory skin condition does not produce sufficient new tissue to fully replace what was lost or damaged, leaving a pit or hollow in the skin surface.

They are most commonly caused by inflammatory acne, particularly the deeper, more severe forms such as nodules and cysts. Chickenpox is another well-known cause, particularly when the lesions are scratched during healing. Any condition or injury that causes significant inflammation in the deeper layers of the skin can potentially leave atrophic scars.

Atrophic scars are permanent in the sense that they represent a structural change to the skin. The depression does not resolve on its own over time, though its visible appearance can be improved with professional treatment. They are distinct from hypertrophic and keloid scars, which involve an overproduction of tissue that sits above the skin surface rather than below it.

Types of Atrophic Scars

Rolling scars: broad, shallow depressions with gently sloping edges that give the skin a wavy or undulating appearance. Often the most responsive type to treatments that stimulate collagen production, due to their wider surface area.
Boxcar scars: wider depressions with sharply defined vertical walls, resembling a small crater or box. Common on the cheeks and temples. Depth varies and influences how well they respond to treatment.
Ice pick scars: narrow, deep pits that extend straight down through the skin layers, often resembling the mark left by a sharp instrument. The most challenging type to improve due to their depth and narrow diameter, which limits access from the surface.

Causes and Contributing Factors

Factor	Description
Inflammatory acne	The deeper and more inflamed a breakout, the greater the damage to the surrounding tissue and the higher the likelihood of atrophic scarring. Nodular and cystic acne carry the highest scarring risk because they involve inflammation at a deeper skin level.
Chickenpox	Chickenpox lesions that are scratched or become secondarily infected can leave atrophic scars, most commonly on the face. The mechanical trauma of scratching drives additional damage into the deeper tissue during healing.
Skin trauma or injury	Any injury or condition that causes significant inflammation in the deeper layers of the skin can result in atrophic scarring during the repair process, including cuts, burns, and certain skin infections.
Picking and squeezing	Introducing additional mechanical trauma to an already inflamed lesion drives damage deeper into the surrounding tissue and dramatically increases both the likelihood and severity of atrophic scar formation.
Delayed or absent treatment	Allowing inflammatory acne to persist without management increases the cumulative damage to the skin tissue over time, raising the overall risk and extent of scarring.
Genetics	Individual differences in how skin heals in response to inflammation influence the likelihood, type, and severity of scar formation. Some individuals are naturally more prone to atrophic scarring regardless of acne severity.

Frequently Asked Questions: Atrophic Scars

Atrophic scars are depressed below the skin surface. They result from insufficient tissue production during the healing process, leaving a deficit of skin structure. Hypertrophic scars are raised above the skin surface, caused by an overproduction of collagen during healing. Keloid scars are a more extreme form of raised scarring that extends beyond the original wound boundary. All three represent different outcomes of the skin’s repair process in response to injury or inflammation.

Atrophic scars represent a structural change to the skin and do not resolve on their own without intervention. The visible depth and appearance of the scar can however be significantly improved with appropriate professional treatment over a course of sessions, though complete elimination of deeper scars is rarely achievable. The degree of improvement possible depends on the scar type, depth, and individual skin characteristics.

Ice pick scars are narrow and extend deep into the skin, making them difficult to access and remodel from the surface. Treatments that work by stimulating collagen production in the surrounding tissue are effective for broader, shallower scar types because there is more surface area to engage. The narrow, deep geometry of ice pick scars limits how readily surface-based treatments can influence the full depth of the scar.

Yes. While acne is the most common cause, atrophic scars can result from any condition or injury that causes significant inflammation in the deeper skin layers. Chickenpox is a well-known non-acne cause, particularly where lesions are scratched. Other causes include certain skin infections, surgical wounds, and traumatic injuries. The underlying mechanism is the same: insufficient tissue regeneration during the healing process.