Pitted vs Raised Acne Scars

What's the Difference Between Pitted and Raised Acne Scars?

Pitted, or atrophic, scars form when inflamed acne destroys collagen faster than the skin can rebuild it, leaving a shallow crater once the lesion heals. Raised, or hypertrophic and keloid, scars form the opposite way: the skin overproduces collagen during healing, building a firm mound above the surrounding surface. Both start from the same event, an inflamed acne lesion, and end in opposite outcomes.

The direction of the scar, in or out, is what determines which treatment category applies. A treatment aimed at rebuilding lost volume does nothing for a scar that already has too much tissue, and the reverse is just as true.

Why Some People Pit and Others Raise

How a scar turns out depends on how deep the original inflammation reached and how an individual's skin tends to heal. Deep, cystic acne that damages collagen structures below the surface is more likely to leave a pit once it resolves. Some people, and some body sites, are simply more prone to overproducing collagen during healing, which is why raised scars appear more often on the jawline, chest, back, and shoulders than on the cheeks.

Genetics plays a real role in which direction someone's skin defaults to, which is part of why two people with similarly severe acne can end up with very different scarring patterns.

The Three Shapes of a Pitted Scar

Pitted scars are generally grouped into three shapes: icepick scars, which are narrow and go deep like a puncture; boxcar scars, which are wider with sharply defined edges, like a shallow box cut into the skin; and rolling scars, which have sloped, undefined edges that give the skin a wavy texture rather than a distinct pit. A full breakdown of ice pick boxcar rolling scars and how each is identified lives in a companion article, since the distinctions guide which procedure is likely to help.

Most people have more than one shape present at once, which is part of why a single-technique approach often falls short and why treating rolling acne scars, in particular, tends to call for a different technique than treating a narrow icepick scar.

Raised Scars: Hypertrophic vs Keloid

Raised acne scars split into two categories that look similar but behave differently: hypertrophic scars stay within the boundary of the original wound and often soften somewhat over time, while keloid scars grow beyond that boundary and tend to keep growing without treatment. Keloid or hypertrophic? The difference matters covers this distinction in full, since it changes both the urgency and the treatment approach.

Acne-related raised scars are most common on the chest, back, and jawline, and they are more likely to appear in people who scar this way from other injuries too, such as piercings or cuts.

How Pitted Scars Are Treated

Treatment for pitted scars generally aims to either lift the depressed tissue, resurface the surrounding skin so the depth is less visible, or both. A narrative review of atrophic acne-scar treatment found that combination approaches, pairing two or more techniques such as fractional lasers, subcision, microneedling, or fillers, tend to outperform any single modality used alone, though the overall quality of evidence in this area remains limited 1Ref 1Boen M, Jacob C (2024).Atrophic Postacne Scar Treatment: Narrative Review.Supports that combination treatment approaches, pairing techniques such as fractional lasers, subcision, microneedling, and fillers, outperform single modalities for atrophic (pitted) acne scars, while noting overall evidence quality is limited..

Ablative vs non-ablative fractional scars is a useful comparison for anyone weighing laser options, since the two approaches differ in downtime and intensity. Fillers are a separate route: when fillers help acne scars covers how injectable volume can temporarily soften a pit without changing the surrounding skin's texture. For a fuller side-by-side, acne scar treatments, compared honestly lays out how these options stack up against each other.

How Raised Scars Are Treated

Raised scars are approached differently, since the goal is reducing excess tissue rather than rebuilding lost volume. Options include corticosteroid injections directly into the scar to soften and flatten it, silicone sheeting or gel worn over the area, and in some cases laser treatment aimed at reducing redness and bulk rather than resurfacing depth. Because keloids in particular can regrow after removal, treatment is usually approached conservatively rather than with excision alone.

The full detail on how hypertrophic and keloid scars are distinguished and managed differently is covered in the dedicated comparison rather than repeated here, since the two categories carry different timelines for improvement and different risks if treated the wrong way.

Does Treating Acne Early Prevent Scarring?

Acne treatment guidelines recommend addressing inflammatory acne before it becomes severe, and they specifically identify scarring potential as one of the factors that raises the priority of treatment: oral isotretinoin is strongly recommended for acne that is severe, scarring, or psychosocially burdensome, rather than something to try only after milder options fail 2Ref 2Reynolds RV, Yeung H, Cheng CE, et al. (2024).Guidelines of care for the management of acne vulgaris.Supports that oral isotretinoin is strongly recommended for acne that is severe, scarring, or psychosocially burdensome, tying scarring risk to how quickly acne treatment should escalate.. The logic is straightforward even without a scarring-specific trial: tissue that is never destroyed by deep inflammation cannot leave a pit, and inflammation that never escalates is less likely to trigger the overproduction behind a raised scar.

This doesn't mean every case of scarring was preventable, since some people scar easily even from modest acne. It does mean that scarring risk is a real factor in how quickly acne treatment escalates, not just a cosmetic afterthought.

Matching the Treatment to the Scar

The starting question for any acne scar is the same one this article opened with: is tissue missing, or is there too much of it? Getting that direction right before choosing a treatment avoids the common mistake of resurfacing a raised scar, which can aggravate it, or injecting filler into what is actually a boxcar scar with sharp, non-sloped edges that filler doesn't smooth as well. A dermatologist examining the scar in person, rather than a description of it, is the most reliable way to confirm which category applies before committing to a procedure that assumes the wrong direction.