Ice pick acne scars: why we aim the CO2 laser at one point at a time

Hello, I'm Dr. Yong-Heon Ha (Dr. Jay) at Repic Clinic in Gangnam, Seoul.

Lean in close to the mirror. Do you see a few tiny holes on your cheeks or temples that look like large pores, except they stay exactly the same when you stretch the skin? Those are usually ice pick scars. Patients who fly in to see us often tell me the same story: "I had laser treatments at home. My skin got better overall, but these little holes didn't budge."

There is a reason for that. An ice pick scar typically has an opening less than 2 mm wide, but it runs deep. A laser that spreads its energy across the whole cheek tends to graze the rim and move on. So at Repic we don't spread the CO2 laser over ice pick scars. We focus it on each hole, one at a time, and deliver the energy into a single point. This is called the CO2 pinpoint irradiation technique.

What makes an ice pick scar different

We sort acne scars by their cross-section. Rolling scars are soft, wave-like dips. Boxcar scars have sharp edges and a flat floor. Ice pick scars are narrow and deep, like a puncture. Most faces have a mix, so the first job at a consultation is mapping which type sits where.

The walls of an ice pick scar are lined with hardened, fibrous tissue left behind by old inflammation. That tissue is what holds the hole open. Filling the floor alone rarely makes the opening smaller, so the hole itself needs its own treatment.

Why one point instead of a wide pattern

Fractional lasers scatter tiny columns of energy evenly across the skin. That is a sensible way to refine texture over a large area. A hole less than 2 mm across, though, only catches the few columns that happen to land on it.

Pinpoint turns that logic around. We find each hole and send the beam straight down into it. The heat vaporizes the hardened fibrous tissue inside the scar on the spot, and the thermal effect around the rim encourages collagen to tighten and rebuild. You could call it "CROSS done with light": one laser shot placed into each hole.

The depth is set on the device, so the energy can reach the dermis where it is needed. And because the beam stays in one spot, there is less spread into the normal skin around the scar.

How it compares with TCA CROSS

If you have researched ice pick scars, you have probably come across TCA CROSS. A high-strength TCA solution is dabbed into the floor of the scar to coagulate the tissue, and collagen fills in over the following weeks. It is a long-established method, and because it is a liquid it reaches the floor of the scar evenly.

Neither approach is simply right or wrong; they work in different ways. Repic does not perform TCA CROSS or punch excision, and we treat ice pick scars with CO2 pinpoint instead. Here is how the two compare.

The last row deserves a second look. Because this is a laser, short-term darkening of the treated spots (post-inflammatory hyperpigmentation) can be a little more likely than with TCA. That is why sun protection and aftercare matter as much as the treatment itself.

What the research shows, and what it doesn't

The technique was first reported in 2008 by a team at the Armed Forces Daegu Hospital in Korea. They used a conventional CO2 laser in pinpoint fashion on 35 people with atrophic acne scars. All 35 showed clinical improvement, with few side effects. The aim was to get a fractional-like result from a standard CO2 laser.

Later, a group in Egypt compared the two methods directly in ice pick scars. In one randomized trial of 28 people, 14 received CO2 pinpoint and 14 received TCA CROSS, four sessions three weeks apart, with three months of follow-up. Improvement in scar severity scores was reported to be greater in the pinpoint group, and all 14 pinpoint patients improved without major side effects.

Keep the limits in mind, though. The trial was small, it was open-label (everyone knew which treatment was being given), and it took place at a single center. That is not enough to say pinpoint is definitely better. In a separate trial of 60 people with ice pick scars, one of the same researchers compared pinpoint alone with pinpoint plus needling. Both groups improved clearly, and there was no difference between them.

I share these studies so you can see the reasoning behind what we do. Your result will be your own, and no number in a paper can promise it.

How we use it at Repic

Having ice pick scars does not mean pinpoint is the only step. If the floor and the dermis around the holes have sunk, treating the holes alone will still leave a dip. So we split the work:

• The base: subcisional injection releases the bands pulling the floor down, and needle-free Curejet with Juvelook Volume builds up the floor and the surrounding dermis.
• The holes: CO2 pinpoint works on the walls and the hardened fibrous tissue.
• The edges: where sharp boxcar edges sit alongside, the same CO2 step uses shouldering to soften the rim.

That CO2 step is part of the VIP (full face) option of REPIC Scar Care on our price list. The Signature and Premium (full face) options do not include CO2. So when ice pick scars are in the mix, we usually suggest VIP, and the final combination is decided by the doctor after diagnosis, based on depth, number and the skin around the scars. You can see how each scar type is handled in our acne scar guide, and full prices are on our price list.

What to say at your consultation "Some of these look like pores to me. Could you show me which ones are ice pick scars before we plan anything?"

Recovery, and planning it around your trip

Right after treatment, each treated spot has a tiny opening and a crust, and the area looks flushed. Some people get small pustules over the next few days. The most common mistake is picking at the crusts. They protect the new skin forming underneath, so let them come off on their own.

Then there is the sun. Laser-treated skin picks up pigment easily for a while. Wear sunscreen every time you go out, and add a hat or a mask on top. Keep your routine gentle and moisturizing, and pause exfoliating acids and retinoids until we tell you it is fine to restart.

If you are visiting Seoul, do not book this for the day before your flight home. How long the crusts and redness last depends on how many scars are treated and how your skin heals, so we pick the date with you at the consultation, around your stay.

How many sessions will I need?

Honestly, I can't give you a fixed number. Repic has no set protocol for the number of sessions or the gap between them. We decide from the depth and number of scars and how quickly your skin recovers. For reference, the trials above used four sessions three weeks apart.

It helps to agree on a realistic goal, too. Deep ice pick scars do not vanish in one go. Over several sessions the holes usually become shallower and the openings less visible. "Noticeably less visible" is a realistic aim. "Completely gone" usually is not.

Please note After CO2 pinpoint you may have redness, crusting, small pustules and temporary darkening (post-inflammatory hyperpigmentation). Rarely, infection or worsening of the scar can occur. Do not pick the crusts, protect the area from the sun and follow your aftercare plan. Tell us at the consultation if you tend to form keloids or hypertrophic scars, if you currently have inflamed acne, or if you are taking or have recently taken oral isotretinoin. These call for extra caution about whether and when to treat. Results and recovery vary from person to person, and treatment goes ahead only after a diagnosis and a consultation with the doctor.

Each hole takes time, so the first step is knowing exactly which scars you have. If you would like to know the right order for your skin, start with a diagnosis.

References

1. Ahmed R, Mohammed G, Ismail N, Elakhras A. Randomized clinical trial of CO2 laser pinpoint irradiation technique versus chemical reconstruction of skin scars (CROSS) in treating ice pick acne scars. J Cosmet Laser Ther. 2014;16(1):8-13. PMID 24131091
2. Kim S. Clinical trial of a pinpoint irradiation technique with the CO2 laser for the treatment of atrophic acne scars. J Cosmet Laser Ther. 2008;10(3):177-80. PMID 18608703
3. Mohammed G. Randomized clinical trial of CO2 laser pinpoint irradiation technique with/without needling for ice pick acne scars. J Cosmet Laser Ther. 2013;15(3):177-82. PMID 23581798