Skin & hair

Treating Boxcar Scars

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Shallow boxcar scars often respond to resurfacing on its own, but wider or deeper ones typically need a procedure that addresses the tethered scar tissue underneath before the surface is treated. This piece walks through what actually works for boxcar scars specifically — subcision, punch techniques, fractional lasers, and fillers — what combining them looks like in practice, and how to avoid new scars forming while treating the old ones.

Last updated: July 2026

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What Makes a Scar a Boxcar Scar

Boxcar scars are round-to-oval depressions with sharply defined vertical edges and a flat or slightly uneven base, giving them a punched-out look that's visually distinct from the other two common atrophic scar types. Ice pick scars are narrower and deeper, tapering to a point beneath the surface, while rolling scars have soft, sloping edges that create a wavy texture rather than a sharp step-down — the difference between ice pick, boxcar, and rolling scars matters because each responds better to different techniques, and mismatching treatment to scar type is a common reason people feel a procedure didn't work. Boxcar scars themselves range from shallow (often called shallow boxcar) to deep, and that depth is usually the single biggest factor in which treatment a clinician recommends.

Why Combining Treatments Outperforms Any Single Method

A narrative review of atrophic acne scar treatments found that combination approaches — pairing two or more techniques rather than relying on one — consistently outperform single-modality treatment, while also noting that the overall quality of evidence in this area is limited compared to what's available for many medical treatments 1. In practice, that usually means a subcision or punch procedure to address the structural tethering beneath a deep scar, followed by resurfacing to smooth the surface texture over subsequent sessions, rather than one visit that's expected to resolve everything. Anyone comparing options is better served starting from acne scar treatment comparison across modalities than fixating on a single procedure's reputation.

Subcision: Releasing the Scar from Below

Subcision uses a needle or blunt cannula inserted under the skin to physically break the fibrous bands tethering a boxcar or rolling scar to the tissue beneath it, which allows the depressed skin to lift and the body's healing response to fill in some of the resulting space with new collagen 1. It's most useful for scars that feel tethered or move oddly when the skin is stretched, a sign that fibrous bands rather than just missing volume are holding the depression in place. Bruising and swelling for several days afterward are typical, and most people need more than one session spaced weeks apart before the full effect is visible.

Punch Techniques: For the Deepest, Sharpest-Edged Scars

For boxcar scars too deep or sharp-edged for resurfacing alone to soften, punch excision removes the scarred tissue entirely and closes the resulting hole, while punch elevation lifts the scarred skin up to the level of the surrounding surface and lets it heal in place — both are counted among the established techniques for atrophic scarring in dermatology reviews 1. These are more invasive than subcision or laser alone and are typically reserved for isolated, well-defined deep scars rather than widespread ones. Mild numbness around a scar treated this way is common in the days afterward and usually resolves as the area heals, though it's worth mentioning to the treating clinician if it persists well beyond that window.

Fractional Laser Resurfacing: Smoothing What's Left

Fractional lasers — which treat a grid of microscopic columns of skin rather than the entire surface at once — are one of the better-supported resurfacing options for softening the sharp edges and surface irregularity of boxcar scars, whether used alone for shallower scars or after subcision or punch techniques for deeper ones 1. Ablative fractional lasers penetrate more deeply and produce more dramatic results but come with more downtime and higher risk in darker skin tones, while non-ablative versions are gentler with a shorter recovery and more modest results — the specifics of fractional laser resurfacing for acne scars, including that ablative-versus-non-ablative tradeoff, matter more for outcome than which brand of device is used.

Fillers: A Temporary Option for Shallow Scars

Dermal fillers injected beneath a shallow boxcar scar can lift the depressed skin to the level of the surrounding surface, offering a faster, less invasive option than subcision or laser resurfacing, though the effect is temporary and typically needs repeating every six months to two years depending on the filler used 1. Fillers work best on shallow, isolated scars rather than widespread or deep ones, and they don't address the underlying tethering that subcision targets — for scars caused by fibrous bands rather than simple volume loss, filler alone tends to disappoint.

Reducing the Odds of New Scars While Treating Old Ones

Treating existing boxcar scars while acne is still active tends to produce disappointing, short-lived results, since new inflammation can create new scarring even as old scars are being addressed — which is why controlling active acne is usually the first step, not an afterthought. For acne severe or scarring enough to warrant it, oral isotretinoin carries a strong recommendation in current guidelines specifically because of its ability to prevent the kind of ongoing inflammatory damage that creates boxcar scars in the first place 2. A common concern about isotretinoin is its supposed link to inflammatory bowel disease, but a large-scale study found no clinically meaningful increased risk, which is worth knowing for anyone weighing that option against continued scarring 3.

What a Realistic Outcome Looks Like

Improvement, not erasure, is the honest goal for most boxcar scar treatment — combination approaches meaningfully soften depth and surface irregularity, but complete disappearance is uncommon, and scar reviews are consistent that expectations should be set around visible improvement over several sessions rather than a single transformative procedure 1. Most treatment plans run over months, not weeks, both because individual procedures like subcision and laser need spacing to heal properly and because the skin's own collagen remodeling after these treatments continues gradually for months afterward. A clinician examining the scars directly — their depth, tethering, and distribution — is the only reliable way to build a plan suited to a specific case rather than a generic one.

Common questions

Complete disappearance is uncommon, especially for deeper scars, but meaningful improvement is realistic with combination treatment. Shallow boxcar scars respond better than deep ones, and setting expectations around visible softening rather than erasure leads to less disappointment with the overall result.

It varies by depth and technique, but most treatment plans involve multiple sessions spaced weeks to months apart, whether that's several rounds of subcision, a series of laser sessions, or a combination. Single-visit fixes are unusual for anything beyond the shallowest scars.

After — treating scars while acne is still active risks new scarring forming even as old scars are being addressed. Getting active acne under control first, sometimes with a stronger treatment like isotretinoin for severe or scarring acne, is generally the recommended sequence.

It's typically done with local numbing, so the procedure itself is usually tolerable, though bruising, swelling, and tenderness for several days afterward are common. Most people describe the recovery as uncomfortable rather than severely painful, and it eases noticeably within about a week.

Professional in-office microneedling and resurfacing procedures have more evidence behind them than at-home rollers, which typically don't penetrate deeply enough to meaningfully affect scar tissue. For boxcar scars specifically, the tethering and depth involved usually need a clinician-performed procedure rather than a home device.

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Before starting scar treatment

  • —Active, ongoing acne breakouts alongside the scarring — treating scars before this is controlled often gives disappointing results
  • —A scar or mark that's changing in color, shape, or texture, which should be evaluated on its own rather than assumed to be an old acne scar
  • —Signs of infection after a scar procedure — increasing pain, spreading redness, warmth, or discharge
  • —Very dark or very light skin considering ablative laser resurfacing, which carries higher risk of pigment changes and benefits from a clinician experienced in treating that skin type

This article describes general categories of boxcar scar treatment; it cannot determine which approach fits a specific case. An in-person evaluation by a dermatologist is the only way to match scar depth and type to the right treatment plan.

References

  1. 1.Boen M, Jacob C (2024). Atrophic Postacne Scar Treatment: Narrative Review. JMIR Dermatology. link ✓Narrative review of atrophic acne scar treatment modalities including subcision, punch techniques, fractional lasers, and fillers, and its finding that combination approaches outperform single modalities amid overall limited evidence quality.
  2. 2.Reynolds RV, Yeung H, Cheng CE, et al. (2024). Guidelines of care for the management of acne vulgaris. Journal of the American Academy of Dermatology. PMID 38300170 ✓AAD guideline strongly recommending oral isotretinoin for severe, scarring, or refractory acne, supporting the statement that controlling active inflammatory acne reduces the risk of new scarring.
  3. 3.Tan NKW, Tang A, Lim RK, et al. (2023). Isotretinoin and the risk of inflammatory bowel disease and irritable bowel syndrome: A large-scale global study. Journal of the American Academy of Dermatology. PMID 36529376 ✓Large-scale study finding isotretinoin is not associated with a clinically meaningful increased risk of inflammatory bowel disease, supporting the article's address of a common concern about isotretinoin as a scar-prevention option.

3 sources, numbered by first appearance. General health information, not medical advice. AI-assisted editorial content — every citation independently verified. Editorial policy

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