When a needle beats a laser for acne scars
Are we too reliant on energy-based devices for the treatment of acne scarring?
Laser and energy devices have transformed acne scar treatment, and they are not the answer to every scar. Some patterns — ice pick scars in particular — respond far better to precise manual techniques using instruments as simple as a needle, a tiny punch or a fine paint brush. This piece argues that the skill has been quietly displaced by the machine, and sets out which scars call for which.
Four numbers worth knowing
What we found
The useful first question is how deep the scar goes.
The Jacob classification is the most widely used system, but a simpler working algorithm sorts scars into superficial, deep, or a combination. Treatment should then follow from scar morphology, severity, skin type, acceptable downtime, age, timeframe, finances and insight — not from whichever device is in the room.
Ice pick scars remain stubbornly resistant to lasers.
They are among the most common atrophic scars and, despite advances in laser technology, are often refractory to it. The treatments of choice are manual: trichloroacetic acid or phenol CROSS delivered by wooden applicator, insulin syringe or fine paint brush. These deliberately low-tech techniques target the scar precisely, spare the surrounding tissue and cost the patient less.
A repurposed hair-transplant punch outlasts a biopsy punch many times over.
Punch excision is a faster alternative to CROSS for ice pick scars. Follicular unit extraction punches from 0.6 to 1.5 mm hold their edge past 100 excisions; biopsy punches blunt after three to eight. Finding the smallest diameter that will remove the scar reduces the risk of a spread scar in its place.
Focal peels beat whole-field peels for boxcar scarring.
Linear, broad and classic boxcar scars suit TCA or phenol croton oil, applied with undyed fine brushes. Painting the agent only where it is needed limits collateral damage, which means fewer side effects, faster recovery and lower procedural cost.
Subcision works by touch, and touch carries information a laser cannot read.
First described by the Orentreich brothers in 1995 with tri-bevelled needles, subcision now uses blunt cannulas, larger needles and cutting blades. The instrument passes through the deep dermis and hypodermis, dissecting fibrotic tissue and lifting depressed areas while stimulating new collagen.
That is the crux of the argument.
Lasers and radiofrequency microneedling deliver energy vertically and rely on what the paper calls 'chance events' to disrupt deep scar tissue. A clinician doing subcision feels fibrosis as the instrument passes through it, learns the resistance patterns of fibroseptal networks and retaining ligaments, and can triangulate entry points to release tethering with more predictability than a device firing blind.
Fillers are more predictable than energy devices for large rolling scars.
Soft tissue filler for atrophic scars was first reported in 1980. Studies report improvements from 33% to over 70%, with fewer adverse events, immediate results and virtually no downtime. Hyaluronic acid, calcium hydroxyapatite, polymethylmethacrylate and poly-L-lactic acid have all been used.
What this means for you
The answer is usually 'both'
The argument is not against energy devices — the author describes himself as an enthusiastic optimist about newer ones. In practice it is a combination of procedures that produces the best outcome, and the point is that the manual half should not be forgotten.
Let the scar choose the tool
Ice pick scars point towards CROSS or punch excision. Boxcar scars point towards focal peels. Rolling scars point towards subcision, often with filler. A device applied to every scar pattern will do well on some and poorly on others.
Simple instruments, properly used, are not primitive
A wooden applicator, an insulin syringe, a fine brush and a 0.8 mm punch cost almost nothing and, for the right scar, outperform equipment worth six figures. What they require instead is practice.
Why this matters
Over two decades acne scar revision has been reshaped by a stream of new energy devices, arriving faster than the evidence for them. The effect on practice has been subtle: the manual skills that used to define scar revision are less taught, less practised, and increasingly replaced by preset parameters on a screen.
This piece was written as a corrective, not a rejection. Energy devices earn their place, and newer ones are genuinely worth looking forward to. But there are scar patterns — ice pick scars above all — where a needle and a steady hand still do better than anything that plugs in, and it would be a poor outcome if that knowledge were lost simply because it cannot be bought.
Why it matters to you
If you have had repeated laser treatments for ice pick scars with little to show for it, the problem may not be the settings or the number of sessions. That scar pattern often needs a different kind of treatment altogether — and the question worth asking is what manual techniques the clinic actually offers.
What this study cannot tell you
Every study has a boundary, and it is fairer to state it than to leave you to guess.
- This is an opinion piece. It argues a position from the published literature and clinical experience, and does not report new controlled data.
- The improvement figures quoted for fillers come from separate studies with different techniques, products and follow-up, so they cannot be read as a head-to-head comparison.
- No trial has directly compared manual techniques against energy devices for any single scar pattern.
- Scar revision outcomes are strongly operator-dependent, which is the piece's own argument and also a limit on how far any of it generalises.
- The author has published previously on several of the manual techniques described, which is disclosed in the article's references.
Questions people actually ask
Are lasers the best treatment for acne scars?
For some scar patterns, yes. For others — ice pick scars most notably — they often are not, and those scars are described in the literature as frequently refractory to laser despite the advances in the technology.
The better framing is that the scar pattern should determine the treatment. Most people with mixed scarring need a combination of approaches rather than one device applied repeatedly.
What is TCA CROSS?
A technique where a strong chemical peeling agent — trichloroacetic acid, or phenol — is applied to the inside of a single scar and nowhere else, using a wooden applicator, an insulin syringe or a fine brush.
Because it is focal, the surrounding skin is spared. That means fewer side effects, quicker recovery and a lower cost than treating the whole face.
What is subcision?
A minimally invasive procedure in which an instrument is passed under a scar, parallel to the skin surface, to cut the fibrous bands tethering it down. Releasing those bands lifts the depression, and the process also stimulates new collagen.
It was first described in 1995 using needles; blunt cannulas and cutting blades are now also used. It suits rolling and atrophic scars.
Why do fillers get used for scars?
For larger rolling atrophic scars they are more predictable than energy devices, with results that are immediate, few adverse events and essentially no downtime. Published improvement figures range from 33% to over 70%.
One caution from the same author: if a scar is significantly tethered, it should be released first, otherwise the filler flows around the scar rather than lifting it.
Cite this paper
Lim D. Are we too reliant on energy-based devices for the treatment of acne scarring?. Opinions and Progress in Cosmetic Dermatology. 2022;2(3):72–74.
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Published 2022 · Summary written and reviewed by Dr Davin Lim, FACD · General information, not personal medical advice.
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