ANAIS skin care

TCA cross method used by plastic surgeons & dermatologists worldwide

-Pitted scars

-Scars

-Acne scars

-Rolling scars

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 with 100% TCA CROSS. All patients had Fitzpatrick skin types N-V.

RESULTS: Patient treatment data indicated that 27 of 33 pa­tients (82%) (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 65% and 100% TCA groups were re_ 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.
J. B. LEE, MD, W. G. CHUNG, MD, H. KWAHCK, MD, AND K. H. LEE, MD HAVE INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS.

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.l-4 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.1 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.4 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.

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 higher TCA concentrations is very risky and definitely not recommended.8 We 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 postin£lamma­tory hyperpigmentation.

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 100% TCA alone, has the advantage of reconstruct­ing acne scars by focusing on the dermal thickening and collagen production that increase with high TCA concentrations.7 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 resurfacing, but rather it can be used on focal chemical scar reconstruction. We 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 of 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 cate­gorized the improvement as follows: excellent, improvement greater than 70%; 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 in­fection. Before CROSS, pretreatments such as tretinoin 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 cleansed with alcohol. And then either 65% TCA or 100% TCA was focally applied by pressing hard on the entire depressed area of atrophic acne scars using a sharpened wooden applicator (Figure 1). The skin was monitored carefully until it reached a "frosted" appearance after a single application. The frosted appearance is the result of coagulation of epidermal and dermal proteins and is used mainly to monitor the peel depth. Focal applica­tion of TCA produced even frosted spots on each acne scar within 10 seconds (Figure 2). After CROSS, an ointment­ based 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 hydro base was used in some patients for a minimum of 4 weeks. The appli­cation of makeup was allowed after CROSS. CROSS was re­peatedly performed every 1-3 months to allow dermal thick­ening and collagen production.

Results:
The patient treatment data indicated that 27 of 33 pa­tients (82%) (the 65% TCA group) and 30 of 32 pa­tients (94%) (the 100% TCA group) experienced a good clinical response (Table 1). In the 65% TCA group, 15 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 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 in the 65% 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, 16 of 33 patients (49%) and 11 of 33 patients (33 %) were satisfied with this therapy ab­solutely and moderately, respectively (Table 2). In the 100% TCA group, 19 of 32 patients (59%) 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, perma­nent 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 cefadroxil500 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 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 experienced 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.12 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% of patients, but to a significant degree in only 22 %.

Recently acne scars have been classified into three types: icepick, rolling, and boxcar. Various treatment modalities are used for reconstructing and improving the appearance of acne scars, including punch excision, punch elevation, subcutaneous incision (subcision), chem­ical skin resurfacing, and laser skin resurfacing. By combining these multiple modalities, it is possible to pro­duce dramatic improvement in acne scars.lS However, procedures that include chemical skin resurfacing have generally been limited to skin types N-VJ.9 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.7 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.

We suggest the CROSS method, which consists of the focal application of higher TCA concentrations, even up to 100%, 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 100% 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, applica­tion with 100% TCA was more effective in treating atrophic acne scars than with 65% TCA.

Repeated 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 100%. Because clinical improve­ment is proportional to the number of courses of CROSS treatment, 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 hyperpigmenta­tion, hypopigmentation, scarring, or keloids. The use of 100% TCA CROSS did not increase the frequency of complications compared with 65% TCA CROSS. All cases of mild erythema and transient postinflammatory hyperpigmentation faded over 1-2 months and focal skin infections 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 tomedium to deep chemical resurfacing because of the increased risk of developing hypertrophic scars.3 We 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 94% 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.