Understanding Rolling Scars: What Treatments Are Available?

Struggling with rolling scars? This guide covers the causes of these wave-like skin depressions and discusses treatment options such as subcision, fillers, and lasers that are available for rolling scars.

What Are Rolling Scars

Rolling scars are a common type of atrophic, or depressed, scar that forms as a result of damage to the underlying collagen and fat beneath the skin. Often associated with long-term inflammatory acne, these scars give the skin surface an uneven, wave-like, or "rolling" appearance. Understanding their unique structure is helpful when considering available treatment options.

Defining the Appearance of Rolling Scars

Rolling scars are characterized by their wide, shallow depressions in the skin. Unlike other acne scars with sharp borders, rolling scars have sloping, indistinct edges that blend into the surrounding skin. They are typically wider than 4 to 5 millimeters and may contribute to uneven skin texture, especially under certain lighting conditions. The overall look is often described as undulating or wavy due to the way the skin is tethered to deeper structures.

The Underlying Cause How Rolling Scars Form

The formation of rolling scars is directly linked to the healing process following significant skin inflammation, such as that from nodular acne or cystic acne. When deep inflammation damages the collagen and subcutaneous tissue, the body attempts to repair the area. During this process, fibrous bands of tissue can form between the skin's surface (epidermis) and the deeper structures (subcutaneous tissue). These fibrous tethers pull the epidermis downward, creating the characteristic rolling depressions on the surface.

Identifying Rolling Scars vs Other Atrophic Scars

Atrophic scars are categorized by their depressed appearance, but not all are the same. Differentiating rolling scars from other types, like boxcar and ice pick scars, can inform the selection of appropriate treatment options.

Comparison with Boxcar Scars

While both are depressed scars, boxcar scars have sharply defined, vertical edges, creating a box-like or crater-like appearance. They resemble chickenpox scars and have a flatter base. In contrast, rolling scars lack these sharp borders; their edges are sloped and less defined, contributing to a softer, undulating texture on the skin.

Comparison with Ice Pick Scars

Ice pick scars are distinctly different from rolling scars. They are deep, narrow, V-shaped pits that extend far into the dermis, appearing as if the skin was punctured with a small, sharp object. Rolling scars, on the other hand, are much wider and shallower, affecting a broader surface area with a gentle depression rather than a narrow puncture.

Professional In-Clinic Treatments

While topical treatments can support skin health, while topical treatments may support skin health, professional treatments are options that may be considered for rolling scars. A registered medical practitioner or qualified healthcare professional can perform advanced procedures that target the structural issues causing these depressions. These in-office treatments are intended to address scar tissue and may support collagen production and volume restoration.

Subcision: A Foundational Treatment for Tethered Scars

Subcision is often the first and most crucial step in treating rolling scars. This minor surgical procedure specifically targets the fibrous bands that tether the skin's surface to the deeper tissue, creating the characteristic rolling depression. A registered medical practitioner inserts a special hypodermic needle or cannula horizontally beneath the scar, using a fanning motion to cut and release these fibrous cords. By breaking the tethers, the skin is freed, allowing the surface to lift and level out. This process may promote natural healing processes that may support skin texture changes over time. Individual results vary and treatment outcomes cannot be guaranteed.

Microneedling for Collagen Induction

Microneedling, also known as collagen induction therapy, is a minimally invasive procedure that uses fine, sterile needles to create thousands of micro-injuries in the skin. This controlled trauma activates the body's natural healing cascade, potentially supporting the production of collagen and elastin. For rolling scars, this helps to rebuild the skin's dermal framework from within, gradually plumping and lifting the depressed areas over a series of treatments. The result is improved skin texture, firmness, and a reduction in scar depth.

Traditional Microneedling Pens

Traditional microneedling is performed with a motorized pen-like device, such as a SkinPen or Dermapen. The device's sterile, single-use needle tip rapidly punctures the skin at a controlled depth. This mechanical action aims to break down old scar tissue and may support skin matrix regeneration. Multiple sessions, typically spaced 4-6 weeks apart, are necessary to achieve optimal results.

Radiofrequency (RF) Microneedling

Radiofrequency microneedling enhances the effects of traditional microneedling by delivering RF energy through the needles deep into the dermis. This targeted heat intensifies the collagen and elastin remodeling process, which may enhance collagen and elastin remodeling, potentially supporting skin texture improvement. Radiofrequency microneedling devices are used in clinical practice (subject to regulatory approval), which is particularly effective for atrophic acne scars by providing both dermal thickening and surface texture improvement with less downtime than more aggressive lasers.

Dermal Fillers to Lift Depressions

Dermal fillers are a treatment option that may temporarily address rolling scar depressions. During this procedure, a gel-like substance is injected directly beneath the scar depression to add volume and lift the skin, making it flush with the surrounding surface. This method may be used in combination with subcision to potentially enhance results, as the filler not only provides physical support but can also help prevent the fibrous tethers from reattaching.

Hyaluronic Acid Fillers like Juvederm or Restylane

Hyaluronic acid (HA) is a substance that occurs naturally in the skin, making HA fillers a safe and popular choice. Brands like Juvederm and Restylane offer various formulations that can be precisely placed to fill the volume deficit under rolling scars. Treatment effects may be observed following the procedure, with duration varying among individuals from several months up to 18 months.

Biostimulatory Fillers like Sculptra

Unlike HA fillers that simply add volume, biostimulatory fillers work by encouraging your body to produce its own collagen. Sculptra, which contains poly-L-lactic acid (PLLA), is injected into the dermal layer where it acts as a scaffold. Over the following months, it stimulates collagen synthesis, gradually and naturally filling in the depressions. Treatment effects may be sustained for extended periods, potentially up to two years or more in some cases, with individual variation in response.

Laser Resurfacing for Skin Texture

Laser resurfacing uses focused beams of light to improve skin texture and tone. By targeting water in the skin cells, lasers can either remove thin layers of skin or heat the underlying dermis to trigger a healing response and stimulate collagen growth. This helps smooth the edges of rolling scars and improve the overall skin surface.

Ablative Lasers: CO2 and Erbium

Ablative lasers, such as CO2 and Erbium lasers, are the most powerful resurfacing tools. They work by vaporizing the outer layers of damaged skin, which may remove superficial layers of damaged skin. This treatment approach may support collagen remodeling processes, with individual variation in treatment response. However, it also requires considerable downtime for healing, which involves redness, swelling, and peeling.

Non-Ablative Fractional Lasers like Fraxel

Non-ablative fractional lasers offer a less aggressive approach with minimal downtime. Devices like Fraxel create microscopic columns of thermal injury deep within the dermis while leaving the surrounding tissue untouched. This fractional approach accelerates healing and stimulates collagen production without damaging the skin's surface. While multiple sessions are required, it may be considered as an option for potentially improving skin texture with less recovery time.

Chemical Peels for Superficial Improvement

Chemical peels involve applying a chemical solution to the skin to exfoliate the top layers and promote cell turnover. While superficial peels have little effect on rolling scars, medium-depth to deep peels using agents like Trichloroacetic Acid (TCA) may have an adjunctive role in improving overall skin texture. The TCA CROSS technique is one method that some clinicians use in selected cases. Peels are best viewed as a complementary treatment to improve overall skin tone and texture rather than a primary solution for deep, tethered scars.

Combining Treatments for Optimal Results

Achieving significant improvement in rolling scars rarely comes from a single treatment. Because these scars involve multiple issues—fibrous tethering, volume loss, and textural changes—a multi-modal approach that targets each problem is often the most effective strategy for comprehensive scar revision.

Why a Multi-Modal Approach Can Be Beneficial

A combination therapy plan may provide complementary benefits, where multiple treatments address different aspects of the scar. For instance, one procedure can release the scar tissue, while another can rebuild lost collagen and a third can refine the surface texture. This layered approach targets different aspects of scar structure from foundational to superficial levels. Treatment outcomes vary among individuals and results cannot be guaranteed.

Popular Treatment Pairings: Subcision with Fillers

The combination of subcision and dermal fillers is a cornerstone of rolling scar treatment. This pairing directly tackles the two primary characteristics of these scars: tethering and depression.

• Step 1: Subcision. A registered medical practitioner first performs subcision to cut and release the fibrous bands that pull the skin's surface downward.

• Step 2: Dermal Filler Injection. Immediately following subcision, a dermal filler is injected into the space created. This serves a dual purpose: it provides immediate volume to lift the depression and acts as a physical spacer to prevent the fibrous bands from re-forming and re-tethering the skin.

Treatment options may include temporary volume enhancement approaches or gradual collagen-stimulating treatments, with outcomes varying based on individual response and treatment selected.

Stacking Microneedling and Laser Treatments

For patients whose primary concern is texture and overall skin quality after addressing tethering, combining microneedling with laser resurfacing is a powerful strategy. Both treatments are centered on collagen induction but work in slightly different ways.

Microneedling, including Radiofrequency (RF) Microneedling, creates controlled micro-injuries deep within the dermis to trigger a robust healing response and new collagen formation. Fractional lasers, such as Fraxel or CO2 lasers, deliver targeted energy beams into the skin to remodel existing collagen and smooth the epidermal surface. When used together—either in alternating sessions or sometimes carefully stacked in a single appointment—these are treatment options for addressing skin texture concerns, with individual variation in treatment response and outcomes that cannot be guaranteed.

At-Home Skincare and Topical Treatments

While professional treatments are essential for addressing the structural nature of rolling scars, a dedicated at-home skincare regimen can support professional treatments and help maintain skin health.

The Role of Prescription Retinoids like Tretinoin

Tretinoin is a topical treatment option that may be prescribed for skin texture concerns. However, it cannot break the underlying fibrous bands that cause the depressions. It serves as an excellent long-term supportive therapy to improve skin quality and complement in-office treatments.

Over-the-Counter Ingredients to Support Skin Health

Several accessible ingredients can be incorporated into your daily routine to promote healthier, more resilient skin. These products help create a better canvas for professional treatments and can improve surface-level concerns.

• Retinols: As a gentler, over-the-counter version of retinoids, retinols also encourage cell renewal and collagen synthesis. They are a great starting point for those new to vitamin A derivatives.

• Alpha Hydroxy Acids (AHAs): Ingredients like glycolic acid and lactic acid exfoliate the top layer of the skin. This chemical exfoliation helps to smooth surface texture and can reduce the harsh shadows cast by scar indentations, making them appear less deep.

• Vitamin C: A potent antioxidant, Vitamin C is crucial for collagen synthesis. Applying it topically can help protect the skin from environmental damage and support the collagen-building effects of treatments like microneedling and laser therapy.

• Sunscreen: Daily application of a broad-spectrum sunscreen (SPF 30 or higher) is non-negotiable. It protects the skin from UV damage that can degrade collagen and worsen the appearance of scars. It is also essential for preventing hyperpigmentation after any professional procedure.

Managing Expectations for Topical Solutions

It is critical to understand the limitations of at-home skincare for rolling scars. These scars are caused by deep, subcutaneous tethers that pull the skin's surface downward. Topical products mainly affect the epidermis and upper dermis and have limited effect on deeper fibrous bands.

Therefore, topical creams, serums, or lotions alone are unlikely to significantly reduce rolling scars [source unknown]. The primary role of at-home care is to improve overall skin health, smooth surface texture, and support the regenerative processes initiated by professional treatments. Think of topical solutions as a vital maintenance and preparation tool, not a standalone cure.

Choosing the Right Treatment Plan

Navigating the various treatments for rolling scars can be overwhelming. An individualized approach, discussed with a qualified medical professional, may help guide treatment discussions with your healthcare provider. This section outlines the key steps and considerations for creating a successful treatment plan.

Considering a Doctor Consultation

The first and most critical step in addressing rolling scars is to schedule a consultation with a registered medical practitioner or plastic surgeon. Self-diagnosis can be misleading, and professional assessment is essential for an accurate diagnosis and effective treatment. During the consultation, your healthcare provider will physically examine the scars, often using dynamic animation (asking you to smile or pucker) to assess the degree of tethering. They will also evaluate your skin type, discuss your medical history, and understand your aesthetic goals to recommend a customized and realistic treatment protocol.

Factors to Consider: Skin Type and Scar Severity

Your unique skin characteristics and the nature of your scars will heavily influence the recommended procedures. A healthcare provider will consider the following:

• Skin Type: Using a system like the Fitzpatrick scale, your doctor will determine your skin's sensitivity and risk of pigmentation changes. Darker skin tones (Fitzpatrick types IV-VI) have a higher risk of post-inflammatory hyperpigmentation (PIH) from aggressive treatments like ablative lasers or deep chemical peels. For these skin types, procedures like RF microneedling or subcision are often preferred as safer starting points.

• Scar Severity: The depth, width, and degree of fibrous tethering are crucial factors. Deeply anchored rolling scars may be assessed for subcision as part of a comprehensive treatment approach. Milder, more superficial rolling scars may be candidates for collagen-stimulating treatments such as microneedling or non-ablative fractional lasers. The number and distribution of scars also impact the overall plan.

Understanding Treatment Costs and Recovery Time

Practical considerations like budget and lifestyle play a significant role in choosing a treatment plan. It's important to have a transparent discussion with your provider about these factors.

• Treatment Costs: Procedures such as subcision, dermal fillers, microneedling, and chemical peels have varying costs depending on the procedure, the practitioner's expertise, and your location. Some treatments may involve multiple sessions. Be sure to discuss the total estimated cost with your healthcare provider. These procedures are considered cosmetic and are not typically covered by insurance.

• Recovery Time (Downtime): Each treatment comes with a different recovery period, which can vary by individual. Subcision may cause bruising and swelling. Ablative laser resurfacing may involve a period of recovery that requires aftercare and social downtime. Understanding the expected recovery for each option allows you to plan treatments around your work and social commitments.

How to Prevent Future Rolling Scars

Prevention plays an important role in reducing the risk of developing new rolling scars. Since these scars result from damage to the skin's underlying structure, controlling the initial cause—most often inflammatory or cystic acne—is important.

Acne Management and Control Tips

Effectively managing acne can help minimize scarring. Deep, inflamed lesions like cysts and nodules can cause significant damage to collagen and subcutaneous fat. Key strategies include:

• Seek Early Dermatological Care: Early consultation with a healthcare provider may allow for timely treatment approaches that may be considered for acne management.

• Adopt a Consistent Skincare Routine: Use a gentle cleanser, a non-comedogenic moisturizer, and daily sun protection. Sunscreen is important as UV exposure can worsen inflammation and post-inflammatory hyperpigmentation.

• Incorporate Active Ingredients: Some over-the-counter products containing ingredients like salicylic acid or benzoyl peroxide may support acne management, but results vary between individuals. For more stubborn cases, a doctor can recommend prescription-strength options.

• Consider Diet and Lifestyle: Although these measures are not a cure, managing stress, ensuring adequate sleep, and considering diet may support overall skin health.

Why You Should Avoid Picking or Squeezing Lesions

It can be tempting to pick at or squeeze a pimple, but this habit is one of the leading causes of preventable scarring. Here’s why you should adopt a hands-off approach:

• Increases Inflammation and Trauma: Squeezing a deep lesion creates intense, localized trauma. This physical pressure can damage the delicate collagen and elastin fibers in the dermis. The body's healing response to this injury may result in the formation of fibrous bands that tether the skin down, creating a rolling scar.

• Pushes Bacteria Deeper: Attempting to pop a pimple can push bacteria, oil, and dead skin cells further into the skin, potentially worsening the infection and leading to a larger, more inflamed lesion with a higher risk of scarring.

• Interrupts the Natural Healing Process: Your skin has a natural process for healing blemishes. Picking creates an open wound, prolonging healing time and increasing the likelihood of both textural scarring and discoloration.

Instead of picking, apply a spot treatment or cover the blemish with a hydrocolloid patch. For large or painful cysts, consulting a healthcare provider is recommended, as they can advise on appropriate treatments to manage inflammation and reduce the risk of scarring.

Frequently Asked Questions

Can Rolling Scars Be Significantly Improved?

Professional treatments are available for rolling scars. Treatment outcomes vary significantly based on individual skin characteristics and scar severity. Complete scar removal is not typical, and treatment aims to address texture and contour concerns with varying degrees of individual response. Treatment aims to address the fibrous bands in the skin and stimulate collagen production. A personalized, multi-modal approach may provide visible improvement, though results vary among individuals.

How Many Treatment Sessions Will I Need?

The number of treatment sessions varies depending on individual skin type, scar severity, and chosen method. Your healthcare provider will provide a tailored assessment and explain the likely treatment schedule.

Is Treatment for Rolling Scars Painful?

Discomfort during treatment varies among individuals. For many procedures, topical numbing agents or local anesthesia are used to reduce sensation. Patients may experience pressure, warmth, or mild tenderness, which typically resolves over time.

What Are Common Single Treatment Options?

While combination therapy is often used in practice, certain standalone treatments may provide benefits in some cases. For tethered rolling scars, subcision is often considered an important treatment as it targets the fibrous bands that contribute to the scar. For shallower, non-tethered scars, RF microneedling or fractional CO2 laser may help stimulate collagen and improve texture in some patients. Dermal fillers may provide temporary improvement in skin contour.

Summary

Rolling scars are a form of atrophic scarring characterized by wide, shallow depressions with sloping edges, creating a wavy, uneven texture on the skin. Their underlying cause involves fibrous bands that tether the epidermis to deeper subcutaneous tissue, pulling it downward. Consequently, effective treatment generally focuses on releasing these tethers and stimulating collagen production to restore lost volume.

For optimal outcomes, a combination of professional treatments is commonly recommended. Subcision is often used to release the fibrous bands causing the indentation, and it may be combined with dermal fillers to support volume restoration. Collagen-inducing therapies, including microneedling, RF microneedling, and laser resurfacing, may contribute to skin texture improvement in some cases, depending on individual response.

While at-home skincare, including prescription retinoids, may support skin health and cell turnover, it is generally not expected to fully address the deeper structural nature of rolling scars. Consulting a board-certified doctor is the most important step to assess scar severity and skin type, and to develop a tailored treatment plan. Preventing new scars through diligent acne control and avoiding picking at lesions remains the best long-term strategy for maintaining smooth skin.

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Note: This article is for educational purposes only and does not constitute medical advice. Individual treatment plans should be developed in consultation with qualified healthcare professionals. Treatment outcomes vary from person to person, and no guarantee of results is intended or implied. All professional treatments mentioned should be performed by licensed medical practitioners in Singapore, using HSA-approved products, devices, and techniques, as applicable.