Can dermal fillers, such as hyaluronic acid (HA) fillers like Juvederm (hyaluronic acid) or Restylane (hyaluronic acid), help lift and improve the appearance of atrophic acne scars in a patient with a history of acne?

Dermal Fillers for Acne Scars: Evidence-Based Recommendation

Yes, dermal fillers—particularly hyaluronic acid fillers like Juvederm and Restylane—can effectively lift and improve the appearance of atrophic acne scars, but they work best as part of a combined treatment approach with microneedling and platelet-rich plasma (PRP) or platelet-rich fibrin (PRF). 1, 2, 3

How Dermal Fillers Work for Acne Scars

Acne scarring is fundamentally a three-dimensional problem requiring volumetric correction, not just surface treatment. 1 Fillers address this by:

• Providing immediate structural lift to depressed atrophic scars through direct injection into the scar base 1, 2
• Stimulating delayed collagen remodeling when using combined high and low molecular weight HA formulations 4
• Reducing visible scar count from an average of 48.8 scars to 15.4 visible scars after two treatment sessions 1

Evidence for Filler Efficacy

Hyaluronic Acid Fillers (Strongest Evidence)

• Low-viscosity HA (20 mg/mL) injected in microdoses into the mid-to-superficial dermis shows immediate visual improvement in all treated lesions 2
• Standard cross-linked HA fillers demonstrate statistically significant reductions in acne scar volume with early impact, though effects plateau over time 4
• Combined high/low molecular weight HA produces delayed but more pronounced improvements in scar elasticity and stretch compared to traditional fillers, with maximal benefit at 6 months 4
• Treatment series of 3 sessions spaced 4 weeks apart, using up to 2 mL per side of face, improves overall facial appearance, scar severity, and patient self-esteem through 36 weeks follow-up 3

Permanent Fillers

• Polymethylmethacrylate (PMMA) fillers are FDA-approved for acne scarring and supported by randomized controlled trial evidence 5
• Poly-L-lactic acid has initial supporting evidence but requires further study 5

Critical Limitation: Fillers Alone Are Suboptimal

The American Academy of Periodontology guidelines and recent evidence clearly demonstrate that fillers as monotherapy are inferior to combination approaches: 6, 7

• Microneedling + PRP shows 70.43% mean improvement 6, 7
• PRP alone shows 48.82% improvement 6, 7
• Microneedling alone shows only 39.71% improvement 6, 7

Optimal Treatment Algorithm

First-Line Approach

1. Microneedling combined with PRF or PRP (3 sessions, 1 month apart) 6, 7
   • PRF shows 3-fold higher "excellent" outcome rates compared to PRP 7, 8
   • Apply platelet concentrates before microneedling (not after) to allow needle penetration to push biologics deeper 6
   • Needle depth: 1.5 mm 8, 9
   • Maintenance every 6 months 6, 7

Adjunctive Filler Use

1. Add HA fillers for residual deep scars after completing microneedling series 1, 2, 3
   • Use modified vertical tower technique for selective elevation of persistent atrophic scars 1
   • Low-viscosity HA (20 mg/mL) for discrete depressed scars 2
   • 3 treatment sessions, 4 weeks apart 3

Scar Type Response Hierarchy

Best to worst response with combination treatment: 7, 8

1. Rolling scars: Best clinical response 7, 8
2. Boxcar scars: Good response 7, 8
3. Ice pick scars: Most resistant to treatment 7, 8

Expected Outcomes

With Combination Microneedling + PRP/PRF:

• Goodman and Baron scar grade reduction from 3.45 to 1.47 (vs. 3.33 with control treatments) 7, 8
• Patient satisfaction scores: 5.95 vs. 5.35 with microneedling alone 7
• 36% of patients report >75% satisfaction vs. only 3% with microneedling alone 7
• Significantly shorter downtime and faster healing compared to single modality 7, 9

With HA Fillers Alone:

• Immediate visual improvement in treated lesions 2
• Gradual improvement over time with highest benefit at study end (36 weeks) 3
• Mean volume required decreases from 1.144 mL to 0.525 mL from first to second session 1

Safety Profile

• HA fillers: Adverse events typically mild to moderate, expected, and procedure-related (transient pinpoint bleeding at injection sites) 2, 3
• PMMA permanent fillers: FDA-approved but carry risk of granuloma formation with permanent placement 5
• Combination treatments: No significant increase in adverse events when adding PRP/PRF to microneedling 6

Common Pitfalls to Avoid

• Do not use fillers as monotherapy when combination approaches are available and superior 6, 7
• Do not apply PRP after microneedling—apply before to allow needle penetration to drive biologics into tissue 6
• Do not use Q-switch lasers for atrophic acne scars—they fragment pigment but don't stimulate collagen remodeling needed for scar improvement 8
• Avoid treating too early after scar revision surgery—wait 4-6 weeks after suture removal, ideally 3 months, before starting laser or microneedling treatments 9

Important Caveats

• Patient age and scar duration negatively correlate with treatment improvement—younger patients with newer scars respond better 7
• The American Academy of Dermatology guidelines do not specifically recommend fillers as first-line treatment for acne scars, focusing instead on chemical peels, lasers, and intralesional steroids for active nodular lesions 6
• Maintenance is required—effects are not permanent with temporary HA fillers, requiring repeat treatments 3