For non-icepick acne scars, the recommended Erbium:YAG approach is targeted shoulder ablation followed by broader resurfacing. Use a 3-mm focused spot handpiece in collimated/beam mode at 5–15 J/cm², delivering 2–4 passes over the raised scar borders or “shoulders.” Then treat the surrounding area with a scanning handpiece for 3 passes at 5–15 J/cm², using approximately 10–30% overlap to blend the scar into adjacent skin.
Core takeaway: The protocol is not simply full-field resurfacing. It first selectively flattens elevated scar margins with a small spot, then smooths the broader transition zone with scanning passes. Exact settings must be adjusted for scar depth, skin type, device characteristics, and healing response.
How the Erbium:YAG Protocol Works
Step 1: Flatten the raised scar shoulders
The clinician begins with a 3-mm focused spot handpiece in collimated or beam mode.
The treatment target is the elevated border of the non-icepick scar. Two to four passes at 5–15 J/cm² are used to ablate and level these raised shoulders.
Step 2: Blend the surrounding tissue
After targeted shoulder ablation, the broader scar area and adjacent skin are treated with a scanning handpiece.
A typical protocol is three scanning passes at 5–15 J/cm², with 10–30% overlap. This smooths the transition between the treated scar margin and the surrounding skin.
Why the sequence matters
Targeting the shoulder first addresses the structural edge that creates visible shadowing and unevenness.
The subsequent scanning treatment helps prevent a sharply demarcated treatment zone by blending the ablated margin into the surrounding tissue.
What Energy Density Should Be Used?
Ablative Erbium:YAG treatment
For the protocol described above, the relevant energy-density range is:
- Focused 3-mm handpiece: 5–15 J/cm²
- Scanning handpiece: 5–15 J/cm²
- Focused passes: 2–4
- Scanning passes: 3
- Scanning overlap: 10–30%
The appropriate point within the range depends on the scar’s elevation, tissue thickness, treatment area, skin phototype, and the specific laser system.
Do not confuse J/cm² with mJ settings
Some fractional, nonablative Erbium laser systems report energy as mJ per microbeam, rather than J/cm².
For example, nonablative fractional systems may use approximately 30–70 mJ with coverage levels that vary by skin type. Those values are not directly interchangeable with the 5–15 J/cm² ablative Erbium:YAG protocol.
Skin type and treatment density
For fractional nonablative treatment, darker phototypes generally require reduced coverage density to lower the risk of post-inflammatory hyperpigmentation.
That principle also applies clinically to ablative resurfacing: treatment density, overlap, passes, and fluence should be conservative when pigmentary risk is elevated.
Which Scars Are Appropriate for This Protocol?
Non-icepick and elevated-border scars
This approach is most relevant to boxcar-type or otherwise non-icepick scars with raised or sharply defined shoulders.
The laser is used to reduce the elevated border and create a smoother transition into the scar base and surrounding skin.
When combination treatment may help
Erbium:YAG resurfacing can be combined with subcision or autologous cell injections when tethering, volume loss, or broader dermal remodeling contributes to the scar.
These procedures address different components of acne scarring and should be selected based on the scar’s anatomy rather than applied automatically.
Deep ice-pick scars require a different strategy
Deep ice-pick scars are not the primary indication for this shoulder-smoothing protocol.
They may require procedures such as punch excision, elevation, grafting, chemical reconstruction, or another targeted technique before or alongside resurfacing.
Understanding the Trade-offs
More passes increase tissue removal
Increasing passes or fluence may improve flattening, but it also increases the risk of prolonged erythema, delayed healing, pigmentary alteration, and other complications.
The goal is controlled blending—not maximal ablation.
Higher overlap increases treatment density
Overlap improves coverage uniformity but increases the cumulative energy delivered to the same area.
Excessive overlap can create unnecessary thermal or ablative injury, particularly in darker skin types or when treating large anatomical units.
Laser cannot correct every scar component
Erbium:YAG can improve surface contour and scar edges, but it may not correct significant dermal tethering, deep volume loss, or active acne by itself.
Treating active inflammatory acne before resurfacing is generally important to reduce the risk of new lesions and impaired healing.
Remodeling is delayed
Visible improvement may continue for months as collagen remodeling develops.
Results should not be judged immediately after treatment, and staged treatment may be preferable to a single aggressive session.
How to Apply This to Your Project
The final settings should be selected by a qualified laser clinician after examining the scars, skin phototype, and device-specific calibration.
- If your primary focus is raised non-icepick scar borders: Use a 3-mm focused handpiece at 5–15 J/cm² for 2–4 passes, stopping when the shoulders are adequately flattened.
- If your primary focus is blending and overall texture: Follow targeted ablation with three scanning passes at 5–15 J/cm² and 10–30% overlap.
- If your primary focus is darker skin or pigment-risk reduction: Favor conservative treatment density, careful overlap, and staged treatment rather than automatically using the upper end of the energy range.
- If your primary focus is deep tethering or volume loss: Consider whether subcision, autologous cell injections, or another structural treatment should be combined with resurfacing.
A safe, effective protocol matches the energy density and treatment density to the scar’s anatomy rather than treating every acne scar with the same settings.
Summary Table:
| Parameter | Recommendation |
|---|---|
| Handpiece | 3-mm focused spot (collimated) for shoulders; scanning handpiece for blending |
| Fluence | 5–15 J/cm² (both modes) |
| Passes | 2–4 (shoulders); 3 (scanning) |
| Overlap | 10–30% (scanning) |
| Skin type consideration | Conservative settings for darker skin to minimize pigment risk |
| Additional treatments | Consider subcision or other procedures for deep tethering or volume loss |
At BELIS, we provide advanced Erbium:YAG laser systems designed for clinics and premium salons. Our devices offer precise control for optimal acne scar treatment. Contact us today to learn how our technology can elevate your practice and deliver exceptional patient outcomes. Get in touch
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