Focal Treatment of Acne Scars With Trichloroacetic Acid:

Chemical Reconstruction of Skin Scars Method

Jung Bock Lee, MD,* Woo Gil Chung, MD, † Ho Kwahck, MD,* and Kwang Hoon Lee, MD †
*Leejiham Skin Clinic and †Department of Dermatology, Yonsei University College of Medicine, Seoul, Korea

background. Acne scarring is a common complication of with 100% TCA CROSS. All patients had Fitzpatrick skin
acne and yet no appropriate and effective single treatment mo- types IV–V.
dality has been developed. We suggest a technique consisting of results. Patient treatment data indicated that 27 of 33 pa-
the focal application of higher trichloroacetic acid (TCA) con- tients (82%) (the 65% TCA group) and 30 of 32 patients
centrations by pressing hard on the entire depressed area of (94%) (the 100% TCA group) experienced a good clinical re-
atrophic acne scars. This technique is called chemical recon- sponse. All patients in the 100% TCA group who received five
struction of skin scars (CROSS) by the authors. or six courses of treatment showed excellent results. Good sat-
objective. To evaluate the clinical effects of CROSS on atro- isfaction rates in the 65% and 100% TCA groups were re-
phic acne scars in dark-complexioned patients. corded. There were no cases of significant complication.
methods. An analysis was conducted of 65 patients with atro- conclusion. CROSS is a safe and very effective single modal-
phic acne scars who were treated with CROSS in our hospitals ity for the treatment of atrophic acne scars with no significant
between July 1996 and July 2001. Thirty-three patients were complications.
treated with 65% TCA CROSS and 32 patients were treated

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 higher TCA concentrations is very risky and definitely
long history as an effective agent for rendering histo- not recommended.8 We also have limited experience
logic and clinical improvement to the skin and is par- and very little information regarding the effects of
ticularly safe when used as a superficial peel or in higher TCA concentrations for acne scars in dark-
“combination peels” of medium depth for acne scars.1–4 complexioned patients, including Koreans (types IV–
Application of TCA to the skin causes precipitation of VI), whose skin is known to develop postinflamma-
proteins and coagulative necrosis of cells in the epider- tory hyperpigmentation.9,10
mis and necrosis of collagen in the papillary to upper In order to maximize the effects of TCA and to
reticular dermis.1 Over several days the necrotic layers overcome complications such as scarring, hyperpig-
slough and the skin reepithelializes from the adnexal mentation, and hypopigmentation, we suggest a tech-
structures that were spared from chemical damage.3 nique consisting of the focal application of higher TCA
Dermal collagen remodeling after chemical peel may concentrations by pressing hard on the entire de-
continue for several months.4 Many investigators have pressed area of atrophic acne scars using a sharpened
observed that the clinical effects of TCA were due to wooden applicator (Figure 1).11 Eventually it produces
both a reorganization in dermal structural elements and multiple, frosted white spots on each acne scar (Figure
an increase in dermal volume as a result of an increase 2). This technique is called chemical reconstruction of
in collagen content, glycosaminoglycan, and elastin.5–7 skin scars (CROSS) by the authors; however, the tech-
Recent studies have shown that the reticular dermis nique itself has not been patented or restricted to pre-
heals with scarring. They offer an explanation for vent usage. The CROSS method, achieved with 65%
some of the increased risk associated with the use of or 100% TCA alone, has the advantage of reconstruct-
TCA for deeper peels, suggesting that peeling with ing 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
Address correspondence and reprint requests to: Kwang Hoon Lee, complication rate than conventional full-face medium
MD, Department of Dermatology, Yonsei University College of Medi- to deep chemical resurfacing, because the adjacent nor-
cine, 134 Shinchon-dong, Seodaemun-gu, Seoul 120-752, Korea, or e-mail: mal tissue and adnexal structures are spared. This tech-
[email protected]. nique does not involve the classic full-face chemical re-

© 2002 by the American Society for Dermatologic Surgery, Inc. • Published by Blackwell Publishing, Inc.
ISSN: 1076-0512/02/$15.00/0 • Dermatol Surg 2002;28:1017–1021
1018 lee et al.: treatment of acne scars with tca Dermatol Surg 28:11: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 cream were not applied because of the risk of unpredictable
scar reconstruction. We have used this technique suc- and excessive TCA penetration.
cessfully for treating facial acne scars and dilated pores Local anesthetics or sedation were not needed for CROSS.
for the past 10 years. The purpose of this study was to Patients were comfortable during the procedure. After facial
evaluate the clinical effects of the CROSS method on washing with soap, the skin was cleansed with alcohol. And
then either 65% TCA or 100% TCA was focally applied by
atrophic acne scars in dark-complexioned patients.
pressing hard on the entire depressed area of atrophic acne
scars using a sharpened wooden applicator (Figure 1). The
Materials and Methods skin was monitored carefully until it reached a “frosted” ap-
pearance after a single application. The frosted appearance is
An analysis was conducted of 65 patients with atrophic acne
the result of coagulation of epidermal and dermal proteins
scars who were treated with the CROSS method in our hos-
and is used mainly to monitor the peel depth. Focal applica-
pitals between July 1996 and July 2001. The CROSS
tion of TCA produced even frosted spots on each acne scar
method consists of the focal application of higher TCA con-
within 10 seconds (Figure 2). After CROSS, an ointment-
centrations by pressing hard on the entire depressed area of
based antibiotic instead of an occlusive dressing was applied
atrophic acne scars using a sharpened wooden applicator
for moisturizing effect, but this application was discontinued
(Figure 1). TCA, 65–100% weight/volume, unbuffered, was
after crust formation in order to avoid the risk of detaching
made to order by a local pharmacy.
the crust. Oral prophylaxis consisting of antibiotics and anti-
The patients’ ages ranged from 25 to 45 years (mean
viral medications were not needed after CROSS. One to 2
32.5 years). Fifty-five patients were women and 10 were
weeks after CROSS, a moisturizer sunscreen cream consisting
men. All patients had Fitzpatrick skin types IV–V. Thirty-
of 0.05% tretinoin, 5% hydroquinone, and a hydrobase was
three patients were treated with 65% TCA CROSS and 32
used in some patients for a minimum of 4 weeks. The appli-
with 100% TCA CROSS.
cation of makeup was allowed after CROSS. CROSS was re-
For independent clinical assessment, two blinded physi-
peatedly performed every 1–3 months to allow dermal thick-
cians evaluated the photographs taken before treatment and
ening and collagen production.
6 months after completion of the treatment. Physicians cate-
gorized the improvement as follows: excellent, improvement
greater than 70%; good, improvement of 50–70%; fair, im- Results
provement of 30–50%; poor, improvement less than 30%.
The patient satisfaction rates were recorded from the inter- The patient treatment data indicated that 27 of 33 pa-
views conducted 6 months after the last treatment. The phy- tients (82%) (the 65% TCA group) and 30 of 32 pa-
sicians evaluated complications such as persistent erythema, tients (94%) (the 100% TCA group) experienced a
permanent hyperpigmentation, hypopigmentation, herpes good clinical response (Table 1). In the 65% TCA
simplex flare-up, scarring, or keloids. group, 15 of 15 patients (100%) who received more
Patients were evaluated carefully before treatment about than six courses of treatment demonstrated good or
the factors considered important, including the patients’ excellent results, as did 2 of 5 patients (40%) who re-
current and past medications and active acne lesion. Rele- ceived treatment three times (Table 1 and Figure 3).
vant history was obtained, including any history of prior hy- Of interest is that all patients in the 100% TCA group
pertrophic scarring, keloids, allergies, or herpes simplex in- who received five or six courses of treatment showed
Dermatol Surg 28:11:November 2002 lee et al.: treatment of acne scars with tca 1019

excellent results (Table 1 and Figure 4). Table 1 shows TCA concentration was more effective in the treat-
that the clinical effects of 100% TCA CROSS were ment of atrophic acne scars.
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
Discussion
30 of 32 patients (94%), respectively (Table 2). In the
65% TCA group, 16 of 33 patients (49%) and 11 of Acne is a chronic inflammatory disease of the piloseba-
33 patients (33%) were satisfied with this therapy ab- ceous unit and a condition commonly experienced in
solutely and moderately, respectively (Table 2). In the adolescents, but recent data indicate that the preva-
100% TCA group, 19 of 32 patients (59%) and 11 of lence of clinical acne does not show a significant de-
34 patients (34%) were satisfied absolutely and mod- crease in women between the ages of 25 and 44 years.12
erately, respectively (Table 2). Acne scars are more common in this persistent acne
There were no cases of significant complication at group, because acne scars correlate with the duration
the treatment sites such as persistent erythema, perma- of acne. Minor acne scarring may occur in up to 95%
nent hyperpigmentation, hypopigmentation, herpes of patients, but to a significant degree in only 22%.13,14
simplex flare-up, scarring, or keloids. Relative to the Recently acne scars have been classified into three
65% TCA CROSS treatment, 100% TCA CROSS did types: icepick, rolling, and boxcar.15 Various treatment
not increase the frequency of complications. Only modalities are used for reconstructing and improving
mild erythema, which faded over 2–8 weeks, and tran- the appearance of acne scars, including punch excision,
sient postinflammatory hyperpigmentation, which dis- punch elevation, subcutaneous incision (subcision), chem-
appeared over 6 weeks, occurred. Mild pustular erup- ical skin resurfacing, and laser skin resurfacing.16,17 By
tions occurred in only four patients and cleared within combining these multiple modalities, it is possible to pro-
1 week with the use of cefadroxil 500 mg three times a duce dramatic improvement in acne scars.18 However,
day. The two patients who received isotretinoin for 3 procedures that include chemical skin resurfacing have
months before treatment showed good results without generally been limited to skin types IV–VI.9 So far, no
excessive scarring, although it should be noted that appropriate and effective single treatment modality has
full-face medium to deep chemical resurfacing is rela- been developed for reconstructing and ameliorating the
tively contraindicated in patients who have taken appearance of acne scars.
isotretinoin within the previous 6 months because of Most surgeons want to use higher TCA concentra-
the increased risk of hypertrophic scarring. tions because they produce increased dermal thicken-
The results indicated that higher treatment fre- ing and collagen volume.7 However, such use results
quency of CROSS application on acne scars improved in resurfacing difficulties and can produce severe scar-
the therapeutic effect, and there were no significant ring because of damage to the adjacent normal skin,
complications. Furthermore, application of a higher although severe scarring usually does not occur in re-
surfacing with lower TCA concentrations because of
reepithelialization from hair follicles and adjacent nor-
Table 1. Effectiveness of the CROSS Method on the Treatment of
Acne Scars according to the Number of Courses
mal tissue that were spared from chemical damage. So
peeling with higher TCA concentrations is very risky
Number of Courses and definitely not recommended.19
Effects of CROSS 3 4 5 6 No. of patients We suggest the CROSS method, which consists of
the focal application of higher TCA concentrations,
65% TCA
even up to 100%, by pressing hard on the entire de-
Excellent 1 (20) 1 (13) 2 (40) 8 (53) 12 (36)
Good 1 (20) 4 (50) 3 (60) 7 (47) 15 (46)
pressed area of atrophic acne scars using a sharpened
Fair 2 (40) 1 (13) 3 (9) wooden applicator. This technique, achieved with higher
Poor 1 (20) 2 (25) 3 (9) TCA concentrations of 65% or 100% TCA alone, has
Total 5 8 5 15 33 the great advantage of reconstructing the acne scars by
100% TCA focusing on the dermal thickening and collagen pro-
Excellent 7 (41) 5 (63) 2 (100) 5 (100) 19 (59) duction that increases with high TCA concentrations.
Good 8 (47) 3 (38) 11 (34) Of interest is that rather than being equivalent to the
Fair 2 (12) 2 (6) classic full-face chemical resurfacing, this technique
Poor 0 (0) can be used on focal chemical scar reconstruction.
Total 17 8 2 5 32
Moreover, this technique can avoid scarring and re-
Percentages are in parentheses. duce the risk of developing hypopigmentation by spar-
Excellent, more than 70% of the lesions disappeared; good, 50–70% of the lesions
disappeared; fair, 30–50% of the lesions disappeared; poor, less than 30% of the
ing the adjacent normal skin and adnexal structures.
lesions disappeared. We found that in using the CROSS method, applica-
1020 lee et al.: treatment of acne scars with tca Dermatol Surg 28:11:November 2002

Figure 4. CROSS of the cheek with 100% TCA A) before and B) af-
ter six courses of treatment.

100% TCA CROSS did not increase the frequency of

Figure 3. CROSS of the cheek with 65% TCA A) before and B) after complications compared with 65% TCA CROSS. All
three courses of treatment. cases of mild erythema and transient postinflammatory
hyperpigmentation faded over 1–2 months and focal skin
tion with 100% TCA was more effective in treating infections were cleared by oral antibiotics. No herpes
atrophic acne scars than with 65% TCA. simplex flare-up occurred in the nine patients with a pos-
Repeated CROSS application can normalize deep itive history of herpes without oral antiviral prophylaxis.
rolling and boxcar scars, and a similar result can be A history of drugs that depress adnexal glands,
achieved for deep icepick scars with higher TCA con- such as isotretinoin, is a relative contraindication to
centrations of up to 100%. Because clinical improve-
ment is proportional to the number of courses of
Table 2. Satisfaction Rates With the CROSS Method for the
CROSS treatment, this method is effective for the Treatment of Acne Scars
treatment of all deep acne scar types. Furthermore, it
can also be utilized for autologous soft tissue augmen- TCA Concentration
Grade of
tation prior to performing the classic full-face resur- satisfaction 65% TCA 100% TCA No. of patients
facing modalities for deeply pitted areas.20 Also, we
Absolutely 16 (49) 19 (59) 35 (54)
have used this technique successfully for treating di-
Moderately 11 (33) 11 (34) 22 (34)
lated pores. Recently we used the CROSS method for Not at all 6 (18) 2 (6) 8 (12)
reconstructing depressed surgical scars. Total 33 32 65
No patient developed any significant complication
Percentages in parentheses.
such as persistent erythema, permanent hyperpigmenta- Absolutely, satisfaction rate more than 70%; moderately, satisfaction rate 50–
tion, hypopigmentation, scarring, or keloids. The use of 70%; not at all, satisfaction rate less than 50%.
Dermatol Surg 28:11:November 2002 lee et al.: treatment of acne scars with tca 1021

medium to deep chemical resurfacing because of the peeling agents and dermabrasion on normal and sundamaged skin.
Aesthetic Plast Surg 1982;6:123–35.
increased risk of developing hypertrophic scars.3 We 6. Brodland DG, Roenigk RK, Cullimore KC, Gibson LE. Depths of
believe that a drug history of isotretinoin is not a rela- chemexfoliation induced by various concentrations and application
tive contraindication and does not influence the clini- techniques of trichloroacetic acid in a porcine model. J Dermatol
Surg Oncol 1989;15:967–71.
cal results because CROSS may spare the adjacent 7. Butler PE, Gonzalez S, Randolph MA, Kim J, Kollias N, Yarem-
normal skin. But further study is required to deter- chuk MJ. Quantitative and qualitative effects of chemical peeling
mine the effect of isotretinoin in CROSS. on photo-aged skin: an experimental study. Plast Reconstr Surg
2001;107:222–8.
We conclude that the CROSS method presented in 8. Hayes DK, Berkland ME, Stambough KI. Dermal healing after lo-
this study is a safe and very effective single modality cal skin flaps and chemical peels. Arch Otolaryngol Head Neck
for the treatment of atrophic acne scars with no signif- Surg 1990;116:794.
9. Yoon ES, Ahn DS. Report of phenol peel for Asians. Plast Reconstr
icant complications. The degree of clinical improve- Surg 1999;103:207–17.
ment was proportional to the number of courses of 10. Ragland HP, McBurney EI. Complications of resurfacing. Semin
CROSS treatment, with good improvement after three Cutan Med Surg 1996;15:200–7.
11. Goodman GJ. Management of post-acne scarring: what are the op-
to six courses being recorded in more than 90% of tions for treatment? Am J Clin Dermatol 2000;1:3–17.
cases. Most patients, 82% in the 65% TCA group and 12. Goulden V, Stables GI, Cunliffe WJ. Prevalence of facial acne in
94% in the 100% TCA group, were satisfied with the adults. J Am Acad Dermatol 1999;41:577–80.
13. Layton AM, Henderson CA, Cunliffe WJ. A clinical evaluation of
CROSS method. Furthermore, the CROSS method acne scarring and its incidence. Clin Exp Dermatol 1994;19:303–8.
with 100% TCA was more effective in treating atro- 14. Goodman GJ. Post-acne scarring: a short review of its pathophysi-
phic acne scars than with 65% TCA. ology. 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
2001;45:109–17.
References 16. Harmon CB, Yarborough JM. Surgical management of acne scar-
ring. Dermatol Ther 1998;6:57–67.
1. Brody HJ. Variations and comparisons in medium-depth chemical 17. Mackee GM, Karp FL. The treatment of post acne scars with phe-
peeling. J Dermatol Surg Oncol 1989;15:953–63. nol. Br J Dermatol 1952;64:456–9.
2. Collins PS. Trichloroacetic acid peels revisited. J Dermatol Surg 18. Whang KK, Lee M. The principle of a three-staged operation in the
Oncol 1989;15:933–40. surgery of acne scars. J Am Acad Dermatol 1999;40:95–7.
3. Coleman WP, Brody HJ. Advances in chemical peeling. Dermatol 19. Dinner MI, Artz JS. The art of the trichloroacetic acid chemical
Clin 1997;15:19–26. peel. Clin Plast Surg 1998;25:53–62.
4. Otley CC, Roenigk RK. Medium-depth chemical peeling. Semin 20. Watson D, Keller GS, Lacombe V, Fodor PB, Rawnsley J, Lask GP.
Cutan Med Surg 1996;15:145–54. Autologous fibroblasts for treatment of facial rhytids and dermal
5. Stegman SJ. A comparative histologic study of the effects of three depressions. A pilot study. Arch Facial Plast Surg 1999;1:165–70.

Commentary
This is a novel technique not yet reported in North America. hope that others will now try this technique so that more expe-
The simplicity of this procedure makes this an easier procedure rience can be reported in our literature.
for the clinician and more patient friendly than more conven-
tional dermabrasion or CO2 laser resurfacing. It also requires Gary Monheit, MD
less equipment than nonablative laser treatments of scars. I Birmingham, AL