Would TCA Cross be a good solution for my grade 2 acne scars? (Photos)

Question

I have mod grade 2 acne scars that really bother me. I have done microneedling with PRP, subsicion and microneedling RF, but I'm looking for another modality to help me. I came across TCA Cross. I'm wondering if tca cross would be effective for me? What concentration is recommended for my skin, I'm middle eastern. How far apart should I do each treatment? Is every two weeks safe? I'd also like a ballpark figure on how much improvement you've seen in your patients.

Jason Emer, MD · Answer

light TCA would be good but you ned a long term plan I would start with stronger device like co2 and then go into halo or moxi long term with microneedling and PRP or fractora.

at home peels like cosmelan, enlighten and aerify along with dermarolling (emerageage roller with anteage MD ampules weekly) should be started now at home (see link).

if you have post inflammatory hyperpigmentation/melasma/discoloration that needs cosmelan or enlighten peels at home which we can do virtually and send to your home along with aerify peels regularly, vivatia foam, restorsea 10x, faith essence serum, and cosmelan 2 cream.

Acne scar treatment needs a combination approach for improvement.  For the best results, one should target the acne scar type.  As everyone has a unique pattern of acne scarring, the best solution is a tailored one.  Typically you need fillers like bellafill and sculptra for atrophic indented type scars with or without subcision.  Subcision for depressed tethered scars.  Vascular lasers like yellow laser, aerolase, excel V or IPL for redness or thick scars. And lasers such as fraxel, erbium, co2 or fractional radiofrequency like venus viva, skinfinity, intensif or fractora microneedling RF for textural issues and superficial scarring.  Deep ice pick scars and narrow box car scars are best treated with TCA CROSS and punch excision.  All lasers are combined with microneedling and PRP to get even better results and improve healing times.   The majority of patients will have a collection of different scar types, and hence a tailored treatment plan is needed by an expert physician.  It is never about the laser or product that gives the results, its about the expert behind the equipment that gets you the outcome.  Scars cannot be cured and will need life-long treatments to maintain and build on the results.  For those at high risk for hyperpigmentation (darker skin types or asian or hispanic or mixed ethnicities) we already pre-treat the skin with cosmelan or enlighten lightening peels to prevent complications from energy-based or chemical-based treatments.  Best, Dr. Emer.

Raffy Karamanoukian, MD, FACS · Answer

Acne scars are usually characterized within the subtypes of atrophic, hypertrophic, pigmented, or inflammatory. These subtypes of acne scars can be visually discerning in ambient light and can cause significant cosmetic concerns. Indented and atrophic scars require a combination approach to stimulate collagen and elastin, thereby smoothing contour and uneven skin. These are usually combined with lasers and depigmentation protocols to reduce inflammatory hyperpigmentation (Melarase AM and Melarase PM). Our Hidef protocols for acne scars include fillers such as Sculptra, Juvederm, Radiesse, and Restylane to improve deep acne scars; Vascular lasers to reduce inflammation and post-inflammatory redness and erythema; Fractional lasers to smooth contour and collagen; and Fractional RF to stimulate production of collagen within atrophic scars. Textural improvement and superficial scarring can be improved with Cosmelan peels, TCA Cross for ice-pick scars, deep chemical peels, and fractional CO2. We offer a personalized approach to your combination of scars and a formal evaluation with consultation is recommended to help you achieve your final results. Our plastic surgery office offers subcision and combination TCA Cross to help reduce deeply pitted scars. In terms of pigmentation and skin resonance, we recommend daily use of Melarase AM and Melarase PM coupled with Retinoid creams to achieve brilliant skin.

Best,
Dr. Raffy Karamanoukian
Realself100 Surgeon

Best, 
Dr. Raffy Karamanoukian
Realself100 Surgeon

Davin Lim, MBBS, FACD - Account Suspended · Answer

Really hard to see. I suspect there are significant rolling scars - I find it difficult to see any sharp demarcated scars with the pictures. You also have really active acne on your right cheek- ideally your acne should be in absolute remission before any invasive treatments.

The ideal treatment for acne scars will depend on the morphology of individual scars. For example, rolling scars are best treated with subcision, atrophic scars with fillers, pick-ice pick scars with TCA or Phenol CROSS/ Paint, box-scar scars with fractional laser/ modified TCA/ phenol chemical peels, hypertrophic scars with steroid injections/modulated fractional delivery.

Energy devices such as lasers, microneedling RF and bipolar radiofrequency are other methods to treat ‘general’ scar types. For example devices can improve rolling-tethered scars as well as ‘deep - superficial scars’ such as broad ice-pick scars and broad box-car scars. Devices should be viewed as a method of scar revision, and rarely as a sole modality. Exceptions do apply- for example in patients with predominantly shallow/broad box-car scars and or superficial pits.

Another factor that will determine the ideal combination of treatment is the skin type of patients. Skin typing used to determine the ‘skin colour’ of patients. Darker skin patients will require modifications to treatment parameters. This includes a lower percentage of chemical peels, conservative protocols for lasers and energy devices and in some cases pre and post treatment of skin to reduce but not eliminate the chances of PIH- post inflammatory hyperpigmentation- skin darkening.

The very first step in scar revision is to accurately determine the subset of scars you have. This is best done with a real time examination. Factors such as animation (rather than static photographs) are frequently used to determine the amount of ‘deep scarring’ /anchored scars or tethering. Palpation or touch is also extremely important to determine the presence of dermal and subdermal fibrosis. Scars that have altered ‘texture’ either hard or soft (atrophy) are more challenging to treat compared to scars with ‘normal’ texture. In some cases the use of angled lighting can be employed to accurately map scar types.

My answers given in the context of this question is a general plan given the limited information. For an accurate guide, one has to take into consideration factors such as animation, touch, feel, real time examination and most importantly subjective measures, namely patient expectations. A real time consult with a procedural dermatologist or plastic surgeon is required for the best accuracy- diagnosis.

All the best, Dr Davin S. Lim, Dermatologist. Brisbane. Australia.

Robert T. Buchanan, MD (retired) · Answer

First, TCA Cross is not an answer for this problem. I personally think it should be restricted as anything that actually uses TCA can be quite dangerous.  I am also not a fan of using any peel for your problem.  What you really wished to do is to remove the elevated dermis around the depressed scars without lowering the scar any.  This smooths the skin. When a peel is applied, the liquid can actually pool in the scars and make the area deeper.  The ideal method of dealing with this is to use an ablative laser taking down the skin around the depressed scars to the level of the scar.  This requires more work than simply running a laser across the skin as is frequently done.  Another thing that works well is use of tretinoin to stimulate the bodies production of collagen to fill in the scars.  The micro-needling you had can also help this.

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