Are there alternatives to TCA for my ice pick, small boxcar scars and darkening of side burns (suspect melasma)? (Photos)

I have personally been using TCA CROSS for over twenty years (since it was first introduced into the U.S. following development by South Korean physicians to treat South Korean women with ice pick scars). This procedure, which can be used in all skin types, is best reserved for use in ice pick (pit) scars and very, very narrow based box car scars. It is ill-advised for use in wider based boxcar and rolling scars, where its inappropriate use may actually lead to the widening of the scars you are concerned about. Horror stories about this procedure abound, but all too often these are the results of home treatments in which the wrong kinds of scars were treated by the individual or when the highly potent acid (which is intended only to go down the shaft of the ice pick scar) has been intentionally applied or splashed unintentionally on surrounding normal skin and essentially burned it--a very tragic consequence of inappropriate use of the TCA.  The majority of the scars in the photos provided do appear to be of the ice pick variety and you might ask your physician to perform TCA CROSS on one or two test sites in unobtrusive locations so that you can see how you respond and how you heal. Be cautious when evaluating claims for relatively expensive "bells and whistles" devices, such as fraxels and radiofrequency machines, as these have been showing themselves to be far more backed by device manufacturer supported marketing hype and very little hard science. Some of your larger based scars may be more appropriately treated by simple subcision, another tried and true, relatively inexpensive approach to treating boxcar and rolling scars that I have personally been using to treat these for the past twenty-five years. Make sure that you consult with a board certified aesthetic physician with experience and expertise in performing TCA CROSS. And this segues to one final comment based upon a study published In the April, 2019 issue of Dermatologic Surgery entitled, "Nonphysician Practice of Cosmetic Dermatology: A Patient & Physician Perspective of Outcomes and Adverse Events".  The study concluded, "Both patients and physicians think more regulation should be in place on who can perform cosmetic procedures. More adverse events such as burns and discolorations occurred with patients seeing nonphysicians compared with those seeing physicians...More adverse events and encounters occurring outside traditional medical settings when nonphysicians performed these procedures call into question the required training and oversight needed for such procedures."  So, bottom line:  be very cautious in vetting who does the work on you, and best of luck. 

Although TCA cross is the treatment I recommend for ice picks and superficial pits, there are alternatives. Ice pick scars can be punched out and sutured provided there is adequate space between the scars.  This is followed by a laser or micro-needling. Pits can be treated with micro-needling or low-density ablative fractionated laser. Infini can be of some help if used at a superficial setting. Jeff Rapaport MD FAADRealself All-star

Agree with Dr Novick and Dr Rapaport - your primary treatment is with TCA CROSS. Will leave it up to you to entrust a specialist. If you do want alternatives, sure, punch it, excise it, or use a focal CO2 with angled delivery. Your type of scarring, even though its deep can be remodelled to obtain a 90-95% improvement over a period of 12-24 months- providing the correct methods are employed. Not a difficult job, however the rate limiting aspects include your skin type and background pigmentation. (More importantly the ABSOLUTE control of your acne)
Acne scar revision is a sub-specialised field. For the best results, one should target the acne scar type with ideal treatments and not just one device. 

For example deep ice pick scars, and narrow box car scars can be treated with TCA CROSS peels, mixed scars, rolling, and atrophic scars treated with fractional devices such as Fraxel, fractional lasers, PRP and INFINI radiofrequency. Atrophic scars (depressions) can be treated with either fat grafts, or dermal fillers. Tethered and anchored scars are best treated with surgical techniques such as subcision. Other surgical techniques that we use include punch elevation, surgical elevation, punch excision and traditional excision of focal scars. 

 

The majority of patients will have a collection of different scar types, and hence a tailored treatment METHOD will be best. Careful examination, especially under angled lighting with scar mapping will give you an understanding of what are the best options for your scars. In the majority of patients its finding the correct combination that give you best results, and everyone is unique! All the best, 

Dr Davin Lim. Acne scar dermatologist specialist. Brisbane, Australia.