|Year : 2013 | Volume
| Issue : 2 | Page : 37-41
Chemical reconstruction of skin scars (CROSS) technique using trichloroacetic acid 50% in different types of atrophic acne scars
Yehia Farouk El Garem1, Eren Emil Habib Ghabrial2, Mohammed Hami Embaby1
1 Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Alexandria, Egypt
2 University of Alexandria, Alexandria, Egypt
|Date of Submission||17-Oct-2013|
|Date of Acceptance||17-Nov-2013|
|Date of Web Publication||31-Dec-2013|
Yehia Farouk El Garem
Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Alexandria
Source of Support: None, Conflict of Interest: None
Acne scarring is a common complication of acne, and no appropriate and effective single treatment modality has been developed yet. A new technique of focal application of high strength trichloroacetic acid (TCA) (65-100%) has been suggested.
The aim of the study was to evaluate the efficacy and safety of 50% TCA in three different types of atrophic acne scars using the chemical reconstruction of skin scars technique in three sessions, each at an interval of 1 month.
Materials and methods
Thirty adults with a clinical diagnosis of atrophic acne scars were selected.
Statistically significant difference was found in the total Goodman score between the atrophic acne scars before and after treatment (P < 0.0001), especially between the icepick and boxcar scars before and after treatment (P < 0.05). In addition, statistically significant difference was observed in the percentage of improvement between the three types of atrophic acne scars (P < 0.05). The best improved were the icepick type followed by the boxcar scars and then the rolling scars.
Chemical reconstruction of skin scars technique using 50% TCA is nonsurgical and safe in the treatment of atrophic acne scars, especially the icepick type followed by the boxcar scars, with minimal side effects and a short downtime.
Keywords: chemical peeling, icepick, scarring
|How to cite this article:|
Garem YF, Ghabrial EE, Embaby MH. Chemical reconstruction of skin scars (CROSS) technique using trichloroacetic acid 50% in different types of atrophic acne scars. Egypt J Dermatol Venerol 2013;33:37-41
|How to cite this URL:|
Garem YF, Ghabrial EE, Embaby MH. Chemical reconstruction of skin scars (CROSS) technique using trichloroacetic acid 50% in different types of atrophic acne scars. Egypt J Dermatol Venerol [serial online] 2013 [cited 2017 Dec 18];33:37-41. Available from: http://www.ejdv.eg.net/text.asp?2013/33/2/37/123911
| Introduction|| |
Acne is a common condition observed in up to 80% of individuals between 11 and 30 years of age and in up to 5% of older individuals , . Acne scarring is an unfortunate and permanent complication of acne vulgaris, which may be associated with significant psychological distress  .
All types of acne, from papulopustular to nodulocystic disease, can cause scarring; hence, adequate treatment must be started early. A time delay up to 3 years between acne onset and adequate treatment is related to ultimate degree of scarring in both sexes  .
It was found that 80-90% of individuals with acne scars have scars associated with a loss of collagen (atrophic scars) compared with a minority who show hypertrophic scars and keloids  . Atrophic scars have been subclassified into icepick, boxcar, and rolling scars  .
Several modalities have been suggested to treat acne scar, including surgical techniques (punch graft, punch excision, and subcision), resurfacing techniques (dermabrasion, ablative laser treatment, and chemical peels), nonablative laser treatment, autologous fat transfer, and injection of dermal fillers.
A high concentration of trichloroacetic acid (TCA; 95-100%) applied focally to atrophic acne scars has been histologically shown to increase collagen fibers in the dermis resulting in shallower depth of the acne scars. This is called the chemical reconstruction of skin scars (CROSS) method  .
High concentration of TCA is often associated with complications such as hyperpigmentation; hence, the aim of this study was to evaluate the efficacy and safety of low TCA concentration (50%) using the CROSS technique in different types of atrophic acne scars.
| Materials and Methods|| |
Thirty adults with a clinical diagnosis of atrophic acne scars were selected from the Dermatology outpatient clinic of Main University Hospital, Faculty of Medicine, Alexandria University. The University ethical committee approved the study, and informed consent was obtained from every patient after explaining the nature of the research.
Exclusion criteria included patients with a history of isotretinoin therapy within 6 months before the study, recurrent herpes virus eruption, allergic reactions, and keloids or hypertrophic scars and patients with cutaneous infection.
Atrophic scars were subdivided into icepick, boxcar, and rolling scars according to the classification by Jacob et al.  . By asking the patients about their response to sun exposure, skin types were classified according to the Fitzpatrick skin type classification. Grading of scars was carried out according to the Goodman and Baron's qualitative global scarring grading system  . Goodman's quantitative global scarring score  was used to calculate the total score of all atrophic scars in the patient and as an individual score for each type of atrophic scars alone. This scoring system depends on the grade of severity, the type, size, and morphology of scar, and the number of lesions. The score was calculated for each patient at baseline before the first session and in a month following the three sessions of CROSS using 50% TCA. Photographs were taken at baseline and after a month of completing the three sessions.
The skin was carefully cleansed with 70% alcohol and acetone-soaked gauze to remove the cutaneous oil. After stretching the skin, 50% TCA was applied to the atrophic scars using a wooden toothpick. TCA was dropped within the base of the scar by applying some pressure. The emergence of white frosting in the treated sites was monitored closely. The areas showing insignificant frosting were recoated, and special attention was given to the stinging pain and erythema.
Patients were instructed to wash their face with water immediately after peeling to minimize pain and erythema. Topical antibiotic cream and sunscreen were applied immediately after the procedure. Patients were instructed to use a steroid or antibiotic cream twice daily for the first week, to avoid irritating soaps and crust picking, to minimize sun exposure, trauma, and tension at the scar site, to apply sunscreen daily with a sun protection factor of 50 or more, and to use a mixture of hydroquinone (4%) and tretinoin (0.025%) after the detachment of the crust until the next session. The sessions were given three times (at an interval of 1 month).
Clinical evaluation and recording the side effects
Post-treatment improvement was using a four-scaled grading reported by Jacob et al.  . The improvement was graded excellent if more than 70% of lesions had disappeared, good if 50-70% of scars had disappeared, fair if 30-49% of scars had disappeared, and poor if less than 30% of scars had disappeared.
The satisfaction to the patients was classified as absolutely satisfied if the satisfaction rate was more than 70%, moderately satisfied if the satisfaction rate was 50-70%, and not at all satisfied if the satisfaction rate was less than 50%  . The side effects and downtime days due to post-treatment crust formation were also reported.
The clinical and laboratory results obtained were statistically analyzed using statistical package for social science for personal computers. Data were summarized as mean (SD), and range for quantitative variables and percentage for qualitative variables. Comparison between groups was carried out using the χ2 -test for qualitative variables and the Student t-test and analysis of variance for qualitative variables. P values less than 0.05 were considered statistically significant.
| Results|| |
The study was conducted on six (20%) male patients and 24 (80%) female patients. The age of the patients ranged between 23 and 36 years, with a mean of 27.2 ± 3.59 years. Eight patients (26.7%) were of skin type III, 10 patients (33.3%) were of type IV, and 12 patients (40%) of skin type V.
Nineteen patients (63.3%) had both icepick and boxcar scars, six patients (20%) had icepick scars, one patient had (3.3%) rolling scars, and four (13.3%) patients had all three types of scars.
With respect to the severity, 29 (96.7%) patients had severe grade of acne scars and one (3.3%) patient had moderate grade of scars, according to Goodman's qualitative global scarring grading system  .
Comparison between Goodman score before and after treatment
The Goodman score before treatment ranged from 9 to 27, which was decreased after treatment to 3-17. The mean average of the score before treatment was 16 ± 5.32 and decreased to 8.1 ± 3.34 following treatment. The average of the percentage of improvement was 49.3 ± 11.15. Improvement in acne scars following three sessions of 50% TCA was statistically significant (P < 0.0001) [Figure 1], [Figure 2], [Figure 3] and [Figure 4].
Relation between the type of scar and the reduction in Goodman's score
Before treatment, the mean Goodman scores in the icepick and boxcar scars were 8.96 ± 1.40 and 9.22 ± 3.36 respectively and they were significantly reduced to 4.00 ± 1.52 and 5.09 ± 2.48 respectively after 3 sessions (P < 0.05). Meanwhile, there was no significant change in rolling scars mean score before and after treatment (P > 0.05). The mean percentage of improvement between the three types was statically significant (P < 0.05) [Table 1].
|Table 1: Relationship between the type of scar and the reduction in Goodman's score|
Click here to view
Grade of improvement after treatment
In the present study, 19 (63.3%) patients showed good improvement and 11 (36.7%) patients showed fair improvement. None showed excellent or poor improvement.
In the present study, seven (23.3%) patients were absolutely satisfied and 23 patients (76.7%) were moderately satisfied after completing their sessions. The downtime in patients due to post-treatment crust formation ranged from 3 to 10 days with a mean of 6.5 ± 1.9. It ranged from 5 to 7 days in 15 (50%) patients, was less than 5 days in two (6.7%) patients, and greater than 7 days in 13 (43.3%) patients.
Distribution of the studied patients with respect to their self-assessment
In the present study, 10 (33.3%) patients had a score of 2 (moderate improvement) and 20 (66.7%) patients had a score of 3 (significant improvement).
The side effects that were observed during the treatment in different skin types are shown in [Figure 5].
| Discussion|| |
Peeling with high TCA concentrations is very risky and definitely not recommended, as it may result in scarring when penetrating reticular dermis  .
In the present study, there was statistically significant reduction in the scar score after three sessions of 50% TCA, which was in agreement with the study by Leheta et al.  and Khunger and Bhardwaj  .
Lee et al.  using a concentration of 65% TCA for atrophic acne scars on five patients, found that 20% of patients showed excellent improvement after three sessions and 50% showed excellent improvement after six sessions. These results showed that there was a significant correlation between the percentage of acne scar improvement and both the number of sessions performed and the TCA concentration used.
This indicated that using 50% TCA for more than three sessions can increase the degree of improvement until it reaches excellent results. There was a significant increase in the percentage of improvement in icepick type followed by boxcar scars and then rolling scars with the lowest percentage of improvement. It was found that icepick scars showed a significantly greater percentage of improvement when treated with CROSS using 100% TCA than with percutaneous induction (PCI)  . However, there was a statistically significant improvement in rolling scars when treated with PCI than with CROSS using 100% TCA.
The better improvement in icepick and boxcar types with CROSS using TCA can be explained by the fact that the focal applications of TCA can reach deeply pitted areas. The depth of the icepick or boxcar scars, which cannot be fully reached using PCI, could be treated using a focally concentrated treatment option such as CROSS.
Kim et al.  conducted a split-face trial comparing between a 1550 nm Er : Glass fractional laser and the CROSS technique. In patients with rolling scar type, the objective and subjective improvement rates were significantly higher in the sides treated with a 1550 nm Er : Glass fractional laser than with the CROSS method. However, in patients with icepick scar, there were no statistically significant differences between the two treatment sides.
Ramadan et al.  conducted a split-face study comparing between subcision and the CROSS technique, using 100% TCA for three sessions, on 20 patients with rolling scars. They reported a significant difference between the two sides in terms of decrease in the scar depth and size. Although 100% TCA CROSS resulted in a reduction in the depth and size of the rolling scars, there was a significant reduction in the subcision side.
The nonsignificant improvement of rolling scars using TCA can be explained by the fact that these scars result from dermal tethering of the skin. Abnormal fibrous anchoring of the dermis to the subcutis leads to superficial shadowing and a rolling or undulating appearance. Although they tend to be shallow, the subdermal tether precludes treatment from the surface above. Correction of the subdermal component is essential for treatment success  .
In the present study, postprocedure downtime ranged from 3 to 10 days due to post-treatment crust formation. In the study by Leheta et al.  the downtime was 9.6 ± 3.1 days. This longer downtime study can be explained by the higher concentration of TCA used. It is suggested that application of TCA 50% instead of 100% using the CROSS technique has the advantage of shortening the downtime while having a good to fair reduction in acne scars.
In the present study, some side effects were observed. Eighteen (60%) patients had mild discomfort and 12 (40%) patients had moderate discomfort. Two patients with Fitzpatrick skin type IV had prolonged erythema post-treatment, which lasted for 4 weeks. Erythema responded well to topical steroids. Two patients with skin type V had post-treatment hyperpigmentation. They responded well to hydroquinone 4% once daily for 6 weeks. There was a significant relationship between the skin type and the side effects.
Pigmentary problems can occur, despite a reasonable avoidance of solar radiation. It is because of the melanocytic sensitivity caused by the irritating effect of the peel  .
On comparing the previous studies by Leheta et al.  , Khunger and Bhardwaj  , Kim et al.  , and Ramadan et al.  with the present study, it was found that the higher the TCA concentration used, the more the incidence of pigmentary alteration.
Application of 50% TCA using CROSS technique is safe and economic, with minimal side effects and a short downtime. Increasing the number of sessions above three will probably increase the improvement in scar reduction. It is effective in the treatment of the icepick type followed by the boxcar scars. Rolling scars need an alternative treatment to detach subdermal tethering.
| Acknowledgements|| |
Conflicts of interest
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]