Acne scar classification
Acne scars are the result of inflammation within the dermis brought on by acne.
Acne scar is created by the wound trying to heal itself resulting in too much collagen in one spot.
Scarring can occur as a result of damage to the skin during the healing of active acne. There are two basic types of scar depending on whether there is a net loss or gain of collagen (Atrophic and Hypertrophic scars). Eighty to ninety percent of people with acne scars have scars associated with a loss of collagen (atrophic scars) compared to a minority who show hypertrophic scars and keloids.
Atrophic Scars
Icepick scar：narrow（2 mm）, punctiform, and deep scars are known as icepick scars. With this type of scar, the opening is typically wider than the deeper infundibulum forming a ‘‘V’’ shape.
Rolling scar：dermal tethering of the dermis to the subcutis characterizes rolling scars, which are usually wider than 4 to 5 mm. These scars give a rolling or undulating appearance to the skin（‘‘M’’ shape）.
Boxcar scar：round or oval scars with well-established vertical edges are known as boxcar scars. These scars tend to be wider at the surface than an icepick scar and do not have the tapering V shape. Instead, they can be visualized as a ‘‘U’’ shape with a wide base. Boxcar scars can be shallow or deep.
The qualitative scarring grading system proposed by Goodman and Baron
Grades of Post Acne Scarring Level of disease Clinical features
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Macular：These scars can be erythematous, hyper- or hypopigmented flat marks. They do not represent a problem of contour like other scar grades but of color.
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Mild：Mild atrophy or hypertrophy scars that may not be obvious at social distances of 50 cm or greater and may be covered adequately by makeup or the normal shadow of shaved beard hair in men or normal body hair if extrafacial.
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Moderate：Moderate atrophic or hypertrophic scarring that is obvious at social distances of 50 cm or greater and is not covered easily by makeup or the normal shadow of shaved beard hair in men or body hair if extrafacial, but is still able to be flattened by manual stretching of the skin if atrophic.
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Severe：Severe atrophic or hypertrophic scarring that is evident at social distances greater than 50 cm and is not covered easily by makeup or the normal shadow of shaved beard hair in men or body hair if extrafacial and is not able to be flattened by manual stretching of the skin.
Acne scar morphological classification
Acne Scars Subtype Clinical Features
Icepick scar：Icepick scars are narrow（2 mm）, deep, sharply marginated epithelial tracts that extend vertically to the deep dermis or subcutaneous tissue.
Rolling scar：Rolling scars occur from dermal tethering of otherwise relatively normal-appearing skin and are usually wider than 4 to 5 mm. Abnormal fibrous anchoring of the dermis to the subcutis leads to superficial shadowing and a rolling or undulating appearance to the overlying skin.
Boxcar scar：
Shallow
Diameter <3 mm diameter
Diameter >3 mm diameter
Boxcar scars are round to oval depressions with sharply demarcated vertical edges, similar to varicella scars. They are clinically wider at the surface than icepick scars and do not taper to a point at the base.
Deep
Diameter <3 mm diameter
Diameter >3 mm diameter
They may be shallow（0.1～0.5 mm）or deep（0.5 mm）and are most often 1.5 to 4.0 mm in diameter.
Ice pick scars：Deep pits, that are the most common and a classic sign of acne scarring.
Box car scars：Angular scars that usually occur on the temple and cheeks, and can be either superficial or deep, these are similar to chickenpox scars.
Rolling scars：Scars that give the skin a wave-like appearance.
Hypertrophic and Keloidal Scars
Hypertrophic scars：Thickened, or keloid scars.
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