Atrophic scars are indented below the skin surface
Ice-pick scars are narrow and deep; boxcar scars have round or oval borders; and rolling scars are wide and shallow, making the skin appear wavy. Multiple types may be mixed.
Acne scar symptoms: Distinguish between pitted scars, raised scars, and flat discoloration
Acne scar symptoms are divided into atrophic scars, where the skin is pitted or indented, and hypertrophic or keloid scars, which are firm and raised. Pitted scars may be a mix of ice-pick (narrow and deep), boxcar (relatively distinct borders), or rolling (wide and wavy) types. On the other hand, red or brown changes that remain flat after acne may be post-inflammatory erythema or hyperpigmentation and should be distinguished from scars where the skin structure has changed. If new acne continues to appear, or if you experience pus, heat, rapid swelling, lesions that look like scars growing rapidly, bleeding, or ulceration, a dermatology evaluation should come first.
Acne Scar Symptoms Guide
Key points
- 1Atrophic scars appear with different depths and borders, such as ice-pick, boxcar, and rolling types.
- 2Hypertrophic scars and keloids are raised, and keloids can grow beyond the original area of inflammation.
- 3Flat red or brown marks may be post-inflammatory color changes rather than scars.
Verification Criteria by Shape
First, distinguish between pitting, raising, and flat color changes
Do not refer to all marks as the same scar simply because they were the site of acne; check the surface height, borders, color, and current inflammation.| Visible Change | Distinguishing Feature | Next Step |
|---|---|---|
| Small holes that are narrow and deep | Possible ice-pick atrophic scar | Evaluation of depth and mixed types at a dermatology clinic |
| Round or oval indentations with visible borders | Possible boxcar atrophic scar | Record distribution using photos with consistent lighting |
| Wide and shallow depressions; skin appears wavy | Possible rolling atrophic scar | Check range and shadows based on light direction |
| Firmly raised; itchy or painful | Possible hypertrophic scar or keloid | If growing, seek prompt dermatology evaluation |
| Flat surface; red or brown in color | Possible post-inflammatory erythema or hyperpigmentation | Distinguish from structural scars for UV care and diagnosis |
| New pus, heat sensation, rapid swelling, or sudden growth | Active acne, infection, or other skin lesions | Do not perform self-treatment; seek prompt medical evaluation |
What the clinic checks first
Are all red or brown marks after acne considered scars?
No. Changes where the surface is flat and only the color remains may be post-inflammatory erythema or hyperpigmentation, which can fade over time. Have a dermatologist determine if there are structural changes, such as pitting or raising.Understanding the symptoms
Acne scars are commonly atrophic, where the skin is indented. In some cases, excessive collagen production causes raised scars, such as hypertrophic scars or keloids. While color changes may occur, post-inflammatory erythema or hyperpigmentation—where the surface remains flat—differ from structural scars. If you have painful nodules, new pus, or raised lesions of uncertain diagnosis that are growing, a dermatology evaluation takes priority over scar management.
Common patterns
Hypertrophic and keloid scars are raised
These may feel firm to the touch and can be itchy or painful. Hypertrophic scars tend to stay within the boundaries of the original lesion, whereas keloids can grow beyond them.
Flat color changes differ from structural scars
Red, pink, brown, or bluish-gray changes at the site of acne may be post-inflammatory erythema or hyperpigmentation. Check for any palpable indentations or elevations.
Conditions that may look similar
Active inflammatory acne
If red and painful papules, nodules, or new pus appear, it is not an old scar. To reduce the formation of new scars, seek treatment for active acne first.
Post-inflammatory erythema and hyperpigmentation
The skin level remains the same, but red or brown discoloration may persist. Since the progression and management differ from structural scars, do not decide on a procedure based on photos alone.
Other raised skin lesions
If a lesion appeared unrelated to acne, is growing rapidly, or shows bleeding or ulceration, do not self-diagnose it as a keloid. A dermatology examination is necessary if the diagnosis is uncertain.
What to note before your visit
- When indentations or elevations first appeared after the acne subsided
- Location of the scars (e.g., face, jawline, chest, or back)
- Whether they are narrow and deep, have clear borders, or are wide and wavy
- Whether raised lesions are growing beyond the original acne area
- Presence of itching, pain, tenderness, and how often they are touched in daily life
- Whether the surface is flat and only the color is red or brown
- Presence of new papules, nodules, pus, heat sensation, or swelling
- Photos showing changes in size and texture, taken with the same lighting, distance, and angle
More detail
Pitted scars vary in shape and depth
Ice-pick scars appear narrow but deep
These are indentations that look like small holes and extend deep into the skin. Depth should be evaluated through a skin examination rather than by surface area alone.
Boxcar scars show rounded indentations and borders
These are wider and more rounded or oval than ice-pick scars, and may have relatively distinct edges like walls.
Rolling scars create wide, wavy shadows
These are wide, gentle depressions that make the skin look uneven or wavy depending on the direction of the light. Different types may be mixed in the same area.
Distinguishing raised scars from color marks
Hypertrophic scars are firmly raised
The skin may become thick and feel firm within the original area of inflammation, and may be accompanied by itching or pain.
Keloids can grow beyond the original area
Raised tissue on the jawline, chest, or back may expand beyond the original acne area. Seek medical evaluation early if it continues to thicken or causes discomfort.
Flat redness and brown tones may be color changes
If there is no difference in height when touched, it may be post-inflammatory erythema or hyperpigmentation. Do not assume it is the same as a scar; record the color and texture separately.
Prioritize current inflammation and risky changes
Persistent new acne can increase scarring
If painful nodules and pus recur, it is important to treat active acne first to reduce additional damage rather than focusing only on the shape of the scars.
Pus, heat, and rapid swelling require infection checks
If pain and redness spread, and pus, heat, or fever occur after a procedure or self-extraction, seek prompt medical evaluation instead of waiting for it to be a scar reaction.
Rapid growth, bleeding, or ulceration may mask other lesions
If a lesion that looked like a scar suddenly grows, bleeds easily, or becomes ulcerated, do not assume it is a keloid and confirm the diagnosis at a dermatology clinic.
Baekrokdam's perspective on acne scar consultations
We prioritize the flow of acute inflammation and the formation of new scars over the shape of existing scars
For lesions characterized by pus, heat sensation, rapid swelling and fever, or those that grow rapidly with bleeding or ulceration, an acute evaluation by a dermatologist takes precedence over herbal medicine treatment at Baekrokdam. We distinguish between indented/raised structures and flat color changes, while maintaining plans for active acne treatment and scar procedures. We consult on the scope and limitations of how herbal medicine can assist only when new acne recurs chronically alongside sleep or digestive discomfort.First, we rule out infections and other skin lesions
We check for new pus, heat sensation, rapid swelling, fever, rapid growth, bleeding, or ulceration to ensure that dermatological care is not delayed.
Indentations, protrusions, and colors are recorded separately
Using photos taken under the same lighting, as well as tactile feel and the presence of itching or pain, we distinguish between atrophic/hypertrophic scars and flat post-inflammatory pigment changes.
We track new inflammation and daily lifestyle changes together
While maintaining standard treatment for active acne, we examine the number of recurring lesions and sleep/digestive health to consult on the supportive role of herbal medicine.
Please prepare photos taken from the same lighting and distance, the onset timing of indentations, protrusions, or color changes, recent new inflammation (pus, pain, itching), and your current history of dermatological medications and procedures before consulting with Baekrokdam.
Frequently asked questions
What types of pitted acne scars are there?
There are ice-pick scars (narrow and deep), boxcar scars (round or oval with visible borders), and rolling scars (wide and gentle, appearing like waves). These types can be mixed in a single area.
Are brown acne marks also permanent scars?
Flat brown or red changes may be post-inflammatory hyperpigmentation or erythema, which differ from structural scars. Please have the exact type confirmed before managing them.
Should I seek medical evaluation if raised acne scars become itchy or grow larger?
Hypertrophic scars or keloids can be itchy or painful, and keloids may grow larger than the original lesion. If they continue to grow or the diagnosis is uncertain, seek prompt dermatological evaluation.
Sources
- American Academy of Dermatology — Acne scars: Signs and symptomsBasis for distinguishing ice-pick, rolling, and boxcar atrophic scars from hypertrophic and keloid scars, and from non-scarring post-inflammatory hyperpigmentationOpen source
- DermNet — Acne ScarringClinical characteristics of atrophic, hypertrophic, and keloid scars; post-inflammatory erythema and pigmentary changes; and basis for medical evaluation of uncertain raised lesionsOpen source
Content reviewed:
This information supports, but does not replace, diagnosis or treatment by a qualified healthcare professional.