1. No category

of Acne Scars With Trichloroacetic Acid:
Chemical Reconstruction of Skin Scars Method
Focal Treatment
JuNc Bocr Lnn, MD," \7oo GIr CnuNc, MDrt Ho KwencK, MD," eNo KweNc HooN Ler, MDt
oLeejiham Skin Clinic and IDePartment of Dermatology, Yonsei Uniuersity College of Medicine, Seoul, Korea
BACKGRouND. Acne scarring is a common complication of
acne and yet no appropriate and effective single treatment modality has been developed. We suggest a technique consisting of
the focal application of higher trichloroacetic acid (TCA) concentrations by pressing hard on the entire depressed area of
atrophic acne scars. This technique is called chemical reconstruction of skin scars (CROSS) by the authors.
oBJEcTIVE. To evaluate the clinical effects of CROSS on atrophic acne scars in dark-complexioned patients.
METHoDS. An analysis was conducted of 65 patients with atrophic acne scars who were treated with CROSS in our hospitals
between July 1996 and July 2001. Thirty-three patients were
treated with 65% TCA CROSS and 32 patients were treated
J. B. LEE,
types
CROSS.
All
patients had Fitzpatrick skin
IV-V.
Patient treatment data indicated that 27 of 33 patients (82Y") (the 65"/" TCA group) and 30 of 32 patients
(94%) (the 100% TCA group) experienced a good clinical response. All patients in the 100% TCA group who received five
or six courses of treatment showed excellent results. Good satisfaction rates in the 65Y" and 100"/" TCA groups were reRESULTs.
corded. There were no cases of significant complication.
coNCLUSIoN. CROSS is a safe and very effective single modality for the treatment of atrophic acne scars with no significant
complications.
MD, W. G. CHUNG, MD, H. KWAHCK, MD, AND K. H. LEE, MD HAVE INDICATED NO S/GNIF/CANT
/NTEREST
\Y{
ITH
CO
MMERCI AL S UPPORTERS.
TRICHLOROACETIC ACID (TCA) has a particularly
long history as an effective agent for rendering histologic and clinical improvement to the skin and is particularly safe when used as a superficial peel or in
"combination peels" of medium depth for acne scars.14
Application of TCA to the skin causes precipitation of
proteins and coagulative necrosis of cells in the epidermis and necrosis of collagen in the papillary to upper
reticular dermis.l Over several days the necrotic layers
slough and the skin reepithelializes from the adnexal
structures that were spared from chemical damage.3
Dermal collagen remodeling after chemical peel may
continue for several months.a Many investigators have
observed that the clinical effects of TCA were due to
both a reorganization in dermal structural elements and
an increase in dermal volume as a result of an increase
in collagen content, glycosaminoglycan, and elastin.s-7
Recent studies have shown that the reticular dermis
heals with scarring. They offer an explanation for
some of the increased risk associated with the use of
TCA for deeper peels, suggesting that peeling with
Address correspondence and reprint requests to: Kwang Hoon Lee,
MD, Department of Dermatology, Yonsei University College of Medicine, 134 Shinchon-dong, Seodaemun-gu, Seoul 120-752, Korea, or e-mail:
[email protected].
@
with 100% TCA
2002 by the American Society for Dermatologic Surgery, Inc.
1 5.00 /0 o D ermatol S ur g 2002 ;2 8 :1 0L7 -L
lS SN : 107 6-0 512 /02/$
.
higher TCA concentrations is very risky and definitely
not recommended.s \7e also have limited experience
and very little information regarding the effects of
higher TCA concentrations for acne scars in darkcomplexioned patients, including Koreans (types IVVI), whose skin is known to develop postinflammatory hyperpigmentation.e'10
In order to maximize the effects of TCA and to
overcome complications such as scarring, hyperpigmentation, and hypopigmentation, we suggest a technique consisting of the focal application of higher TCA
concentrations by pressing hard on the entire depressed area of atrophic acne scars using a sharpened
wooden applicator (Figure 1).11 Eventually it produces
multiple, frosted white spots on each acne scar (Figure
2). This technique is called chemical reconstruction of
skin scars (CROSS) by the authors; however, the technique itself has not been patented or restricted to prevent usage. The CROSS method, achieved with 65"/"
or 1.007o TCA alone, has the advantage of reconstructing acne scars by focusing on the dermal thickening
and collagen production that increase with high TCA
concentrations.T Healing is more rapid and has a lower
complication rate than conventional full-face medium
to deep chemical resurfacing, because the adjacent normal tissue and adnexal structures are spared. This technique does not involve the classic full-face chemical re-
Published by Blackwell Publishing, Inc
021-
1018
Dermatol
LEE ET AL.: TREATMENT OF ACNE SCARS.W,ITH TCA
Surg
28:1 1:November 2002
Figure 2. CROSS method: A) before and B) shortly after the procedure.
Figure 1. A) Sharpened wooden applicator and B) sharpened tip.
fection. Before CROSS, pretreatments such as tretinoin
surfacing, but rather it can be used on focal chemical
scar reconstruction. \7e have used this technique successfully for treating facial acne scars and dilated pores
for the past 10 years. The purpose of this study was to
evaluate the clinical effects of the CROSS method on
atrophic acne scars in dark-complexioned patients.
Materials and Methods
An analysis was conducted of 65 patients with atrophic acne
scars who were treated with the CROSS method in our hospitals between July 1996 and July 2001. The CROSS
method consists of the focal application of higher TCA concentrations by pressing hard on the entire depressed area o(
atrophic acne scars using a sharpened wooden applicator
(Figure 1). TCA, 65-100% weight/volume, unbuffered, was
made to order by a local pharmacy.
The patients' ages ranged from 25 to 45 years (mean
32.5 years). Fifty-five patients were women and 10 were
men. All patients had Fitzpatrick skin types IV-V. Thirtythree patients were treated with 65"/" TCA CROSS and 32
with 100% TCA CROSS.
For independent clinical assessment, two blinded physicians evaluated the photographs taken before treatment and
6 months after completion of the treatment. Physicians cate-
gorized the improvement as follows: excellent, improvement
greater thanTO"/"; good, improvement of 50-70%; fair, improvement of 30-50%; poor, improvement less than 30"/".
The patient satisfaction rates were recorded from the interviews conducted 6 months after the last treatment. The physicians evaluated complications such as persistent erythema'
permanent hyperpigmentation, hypopigmentation, herpes
simplex flare-up, scarring, or keloids.
Patients were evaluated carefully before treatment about
the factors considered important, including the patients'
current and past medications and active acne lesion. Relevant history was obtained, including any history of prior hypertrophic scarring, keloids, allergies, or herpes simplex in-
cream were not applied because of the risk of unpredictable
and excessive TCA penetration.
Local anesthetics or sedation were not needed for CROSS.
Patients were comfortable during the procedure' After facial
washing with soap, the skin was c-h,eJlAf.d-with algbgl. And
then either 65% TCA or 1.00"/" TCA was focally applied by
pressing hard on the entire depressed area of atrophic acne
scars using a sharpened wooden applicator (Figure 1). The
apskin was monitored carefully @"
pearance afier asfgglc applkatigg. The frosted appearance is
'---"- of coagulation of epidermal and dermal proteins
iEeEilli
and is used mainly to monitor the peel depth. Focal application of TCA produced even frosted spots on each acne scar
wlth!!-10-jse9!d! (Figure 2). Lfter CROSS, an ointmentbased antibiotic instead of an occlusive dressing was applied
for moisturizing effect, but this application was discontinued
after crust formation in order to avoid the risk of detaching
the crust. Oral prophylaxis consisting of antibiotics and antiviral medications were not needed after CROSS. One to 2
weeks after CROSS, a moisturizer sunscreen cream consisting
of 0.05% tretinoin, 5% hydroquinone, and a hydrobase was
used in some patients for a minimum of 4 weeks. The application of makeup was allowed after CROSS. CROSS was reto allow dermal thickening and collagen p
Results
The patient treatment data indicated that 27 of 33 patients (827") (the 65% TCA group) and 30 of 32 patients (94o/o) (the 100% TCA group) experienced a
good clinical response (Table 1). In the 65% TCA
group, 1,5 of 15 patients (100%) who received more
than six courses of treatment demonstrated good or
excellent results, as did 2 of 5 patients (40%) who received treatment three times (Table 1 and Figure 3).
Of interest is that all patients in the 100% TCA group
who received five or six courses of treatment showed
Dermatol Suig
-
LEE ET AL.: TREATMENT oF ACNE scARS wrTH
2B:1 1 :November 2002
excellent results (Table 1 and Figure 4). Table 1 shows
that the clinical effects of 100"/" TCA CROSS were
better than those of 65"/" TCA CROSS.
Good satisfaction rates inthe 65o/" and 100% TCA
groups were recorded in 27 of 33 patients (82"/") and
30 of 32 patients (94%), respectively (Table 2). In the
65% TCA group, L6 of 33 patients (49%) and 11 of
33 patients (33%) were satisfied with this therapy absolutely and moderately, respectively (Table 2). In the
1,00% TCA group , 1.9 of 32 patients (59%l and 11 of
34 patients (34%) were satisfied absolutely and moderately, respectively (Table 2).
There were no cases of significant complication at
the treatment sites such as persistent erythema, perma-
nent hyperpigmentation, hypopigmentation, herpes
simplex flare-up, scarring, or keloids. Relative to the
65%TCA CROSS treatment, 100% TCA CROSS did
not increase the frequency of complications. Only
mild erythema, which faded over 2-8 weeks, and transient postinflammatory hyperpigmentation, which disappeared over 6 weeks, occurred. Mild pustular eruptions occurred in only four patients and cleared within
1 week with the use of cefadroxil 500 mg three times a
day. The two patients who received isotretinoin for 3
months before treatment showed good results without
excessive scarring, although it should be noted that
full-face medium to deep chemical resurfacing is relatively contraindicated in patients who have taken
isotretinoin within the previous 6 months because of
the increased risk of hypertrophic scarring.
The results indicated that higher treatment frequency of CROSS application on acne scars improved
the therapeutic effect, and there were no significant
complications. Furthermore, application of a higher
Table 1. Effectiveness of the cRoss Method on the Treatment of
Acne Scars according to the Number of Courses
Number of Courses
Effects
of
No.
CROSS
65%rCA
Excellent
Good
Fair
Poor
Total
1
(20) 1 (13)
(20) 4 (s0)
2(40) 1 (13)
1 (20) 2 (25)
1
1
58
2 (40)
3 (60)
5
B
t
(s3)
(47)
(41)
s
(63)
Excellent
7
Good
8 (41) 3 (38)
2 (12)
Fair
Poor
Total
1l
2 (100)
s
(1
12 (36)
1s (46)
3 (e)
3 (e)
15
00% TcA
of patients
33
00)
1
e (se)
11(34)
532
2 (6)
0 (0)
Percentages are in parentheses.
Excellent, more than 70% of the lesions disappeared; good, 50-70% of the lesions
disappeared; fair, 30-50o/o of the lesions disappeared; poor, less than 30% of the
lesions disappeared.
TCA
1019
TCA concentration was more effective in the treatment of atrophic acne scars.
Discussion
Acne is a chronic inflammatory disease of the pilosebaceous unit'and a condition commonly experGnced in
adolescents, but recent data indicate that the prevalence of clinical acne does not show a significant decrease in women between the ages of 25 and 44 years.r2
Acne scars are more common in this persistent acne
group, because acne scars correlate with the duration
of acne. Minor acne scarring may occur in up to 95"/o
of patients, but to a significant degree in only 220/0.13'14
Recently acne scars have been classified into three
types: icepick, rolling, and boxcar.15 Various treatment
modalities are used for reconstructing and improving
the appeannce of acne scars, including punch excision,
punch elevation, subcutaneous incision (subcision), chemical skin resurfacing, and laser skin resurfacing.l6'17 By
combining these multiple modalities, it is possible to produce dramatic improvement in acne scars.18 However,
procedures that include chemical skin resurfacing have
generally been limited to skin types IV-VI.e So far, no
appropriate and effective single treatment modality has
been developed for reconstructing and ameliorating the
appearance of acne scars.
Most surgeons want to use higher TCA concentrations because they produce increased dermal thickening and collagen volume.T However, such use results
in resurfacing difficulties and can produce severe scarring because of damage to the adjacent normal skin,
although severe scarring usually does not occur in resurfacing with lower TCA concentrations because of
reepithelialization from hair follicles and adjacent normal tissue that were spared from chemical damage. So
peeling with higher TCA concentrations is very risky
and definitely not recommended.le
\7e suggest the CROSS method, which consists of
the focal application of higher TCA concentrations,
even up to L00"/", by pressing hard on the entire depressed area of atrophic acne scars using a sharpened
wooden applicator. This technique, achieved with higher
TCA concentrations of 65%" or I00%" TCA alone, has
the great advantage of reconstructing the acne scars by
focusing on the dermal thickening and collagen production that increases with high TCA concentrations.
Of interest is that rather than being equivalent to the
classic full-face chemical resurfacing, this technique
can be used on focal chemical scar reconstruction.
Moreover, this technique can avoid scarring and reduce the risk of developing hypopigmentation by sparing the adjacent normal skin and adnexal structures.
We found that in using the CROSS method, applica-
IO2O
LEE ET
AL.: TREATMENT OF ACNE
SCARS
.WITH TCA
Dermatol
Surg
28:1 1 :November 2t102
Figure 4. CROSS of the cheek with 100% TCA A) before and B) after six courses of treatment.
TCA CROSS did not increase the frequency of
complications compared with 65'/" TCA CROSS. All
casei of mild erlthema and transient postinflammatory
1,00%
Figure 3. CROSS of the cheek with 65% TCA A) before and B) after
three courses of treatment.
tion with I00% TCA was more effective in treating
atrophic acne scars than with 65% TCARepeated CROSS application can normalize deep
rolling and boxcar scars, and a similar result can be
achieved for deep icepick scars with higher TCA concentrations of up to 1,00%. Because clinical improve-,
ment is ptopottio.tul to the number of courses of
CROSS treaiment, this method is effective for the
treatment of all deep acne scar types. Furthermore, it
can also be utilized for autologous soft tissue augmentation prior to performing the classic full-face resurfacing modalities for deeply pitted areas.20 Also' we
have used this technique successfully for treating dilated pores. Recently we used the CROSS method for
reconstructing depressed surgical scars.
No patient developed any significant complication
such as persistent erythema, permanent hyperpigmenta-tion, hypopigmentation, scarring, or keloids. The use of
hyperpigmentation faded over IJ months and focal skin
infictions were cleared by oral antibiotics. No herpes
simplex flare-up occurred in the nine patients with a positive history of herpes without oral antiviral prophylaxis.
A history of drugs that depress adnexal glands,
such as isotretinoin, is a relative contraindication to
Table 2. Satisfaction Rates With the CROSS Method for the
Treatment of Acne Scars
Grade
of
satisfaction
Absolutely
Moderately
Not at all
Total
TCA Concentratrcn
65%TCA
16 (4e)
1 1 (33)
6(18)
11
1OO%TCA
1e (5e)
11(34)
2 (6)
32
No.
of patients
35 (s4)
22 (34)
B (12)
65
Percentages in parentheses.
Absoluie-ly. satisfaction rate more than 70%; moderately, satisfaction rate 507\yo: not at all. satisfaction rate less than 50%
Derhatol Surg 28:11:November 2002
medium to deep chemical resurfacing because of the
increased risk of developing hypertrophic scars.3 \J7e
believe that a drug history of isotretinoin is not a relative contraindication and does not influence the clinical results because CROSS may spare the adjacent
normal skin. But further study is required to determine the effect of isotretinoin in CROSS.
'We
conclude that the CROSS method presented in
this study is a safe and very effective single modality
for the treatment of atrophic acne scars with no significant complications. The degree of clinical improvement was proportional to the number of courses of
CROSS treatment, with good improvement after three
to six courses being recorded in more than 90"/" of
cases. Most patients, 82"/" in the 65"/" TCA group and
94o/" in the 100% TCA group, were satisfied with the
CROSS method. Furthermore, the CROSS method
with 100% TCA was more effective in treating atrophic acne scars than with 65% TCA.
LEE ET AL.: TREATMENT OF ACNE SCARS WITH
TCA IO2I
peeling agents and dermabrasion on normal and sundamaged skin.
Aesthetic Plast Surg 1.982;6:1.23-3 5.
6. Brodland DG, Roenigk RK, Cullimore KC, Gibson LE. Depths of
chemexfoliation induced by various concentrations and application
techniques of trichloroacetic acid in a porcine model. J Dermatol
Surg Oncol 1.9 89 ;1 5 :9 67 -7 1.
7. Butler PE, Gonzalez S, Randolph MA, Kim J, Kollias N, Yaremchuk MJ. Quantitative and qualitative effects of chemical peeling
on photo-aged skin: an experimental study. Plast Reconstr Surg
200I;1,07:222-8.
8. Hayes DK, Berkland ME, Stambough KI. Dermal healing after 1ocal skin flaps and chemical peels. Arch Otolaryngol Head Neck
Svg 1990;7t6:794.
9. Yoon ES, Ahn DS. Report of phenol peel for Asians. Plast Reconstr
Surg
1
999; 1 03 :207 -1,7.
10. Ragland HP, McBurney EI. Complications of resurfacing. Semin
Cutan Med Surg 1.996;1.5:200-7.
11. Goodman GJ. Management of post-acne scarring: what are the options for treatment? Am J Clin Dermatol 2000;1.:3-17.
12. Goulden V, Stables GI, Cunliffe S(/J. Prevalence of facial acne in
adults. J Am Acad Dermatol 1999;41:577-80.
13. Layton AM, Henderson CA, Cunlif{e WJ. A clinical evaluation of
acne scarring and its incidence. Clin Exp Dermatol 1.994;'1.9:303-8.
14. Goodman GJ. Post-acne scarring: a short review of its pathophysiology. Australas J Dermatol 2001.;42:84-90.
15. Jacob CI, Dover JS, Kaminer MS. Acne scarring: a classification
system and review of treatment options. J Am Acad Dermatol
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References
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2. Collins PS. Trichloroacetic acid peels revisited. J Dermatol Surg
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3. Coleman IfP, Brody HJ. Advances in chemical peeling. Dermatol
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Cutan Med Surg 1996;15:1.45-54.
5. Stegman SJ. A comparative histologic study of the effects of three
16. Harmon CB, Yarborough JM. Surgical management of acne scar-
ring. Dermatol Thet 1998;6:57-67.
17. Mackee GM, Karp FL. The treatment of post acne scars with phe-
nol. Br.f Dermatol 1952;64:456-9.
18. Whang KK, Lee M. The principle of a three-staged operation in the
surgery of acne scars. J Am Acad Dermatol 1999;40:95-7.
19. Dinner MI, Artz fS. The art of the trichloroacetic acid chemical
peel. Clin Plast Surg 1998;25:53-52.
20. 'Watson D, Keller GS, Lacombe V, Fodor PB, Rawnsley J, Lask GP.
Autologous fibroblasts for treatment ol facial rhltids and dermal
depressions. A pilot study. Arch Facial Plast Surg 1999;1.:165-70.
Commentary
This is a novel technique not yet reported in North America.
The simplicity of this procedure makes this an easier procedure
for the clinician and more patient friendly than more conventional dermabrasion or CO2 laser resurfacing. It also requires
less equipment than nonablative laser treatments of scars. I
hope that others will now try this technique so that more experience can be reported in our literature.
Ganv MounEIT, MD
Birmingbam, AL