What is TCA CROSS and how does it work?

TCA CROSS is the chemical reconstruction of skin scars (CROSS) using trichloroacetic acid (TCA). It is used as an inexpensive outpatient clinic procedure to treat atrophic acne scars. Acne is a common inflammatory skin condition and may result in atrophic, hypertrophic or keloid scars. Acne scars can cause significant psychological distress and social impact.

The TCA CROSS procedure involves depositing small amounts of TCA at high concentration (70–100%) onto the surface of the atrophic scar. This causes a local inflammatory reaction leading to the formation of new collagen fibres. The aim is to improve the appearance of the scar by increasing collagen reflectance and reducing shadows cast over scar depressions. Complete resolution is unlikely to be achieved with this treatment method alone.

What are the indications for TCA CROSS?

The decision to perform TCA CROSS depends on:

The type and severity of acne scarring

Patient preference and expectations

Clinician experience and expectations

TCA CROSS is useful in the following types of atrophic scar:

Boxcar acne scars

Rolling acne scars

Ice-pick acne scars

Boxcar acne scars

Boxcar scars Rolling acne scars

Rolling scars Ice-pick acne scars

Ice-pick scars

Acne scars

Assessment of acne scars

Acne scar severity can be graded using Goodman and Baron’s qualitative acne scar grading system to allow objective pre and post-treatment comparisons.

1. Macular scars

Macular scars can be erythematous, hyperpigmented (brown) or hypopigmented (pale) flat marks. They do not represent a problem of contour like other scar grades but of color.

2. Mild atrophic or hypertrophic scars

Mild atrophic (thin) or hypertrophic (thick) scars may not be obvious at social distances of 50 cm or greater and may be covered adequately by makeup or the normal shadow of shaved beard hair in men or normal body hair if extrafacial.

3. Moderate atrophic or hypertrophic scars

Moderate atrophic or hypertrophic scarring is obvious at social distances of 50 cm or greater and is not covered easily by makeup or the normal shadow of shaved beard hair in men or body hair if extrafacial, but is still able to be flattened by manual stretching of the skin (if atrophic).

4. Severe atrophic or hypertrophic scars

Severe atrophic or hypertrophic scarring is evident at social distances greater than 50 cm and is not covered easily by makeup or the normal shadow of shaved beard hair in men or body hair if extrafacial and is not able to be flattened by manual stretching of the skin.

How is TCA CROSS performed?

TCA CROSS is technically straightforward to perform and can be undertaken in a matter of minutes, depending on the number of scars to be treated.

The patient should be in a comfortable semi-recumbent position and remain still during the procedure.

The skin is cleansed with chlorhexidine/saline soaked gauze.

A fine blunt end-point instrument (such as a tooth-pick) is dipped into TCA and the excess is removed.

TCA is focally applied to the base of the atrophic scar.

The instrument is removed at the start of frosting of the skin surface (usually within 10 seconds).

The procedure is repeated for appropriate remaining scars.

The skin is intermittently cleansed using saline/chlorhexidine soaked gauze.

Great care should be taken to avoid sensitive surfaces (eyes, mucosal surfaces). Eye covers may be used. Emergency eye irrigation equipment should be at hand.

Trichloracetic acid for TCA CROSS procedures Applying trichloracetic acid for TCA CROSS procedures Frosting after applying trichloracetic acid in TCA CROSS procedure

TCA CROSS procedure for acne scars

After the procedure

The patient should be advised:

Frosting of the scar surface will last up to 12 hours

The skin around the treated sites will be red and sore for 24 to 48 hours

After 2 to 3 days a small scab will develop, which falls off after 3 to 7 days

He or she may wash as normal, and may apply make-up if desired

Sunscreen is recommended to reduce the chance of pigmentation

Most patients require 3 to 6 treatments with TCA CROSS for optimum improvement. Treatments may be repeated at 2 to 8 week intervals over 6 months.

Complications of TCA CROSS

TCA CROSS is generally well tolerated . Complications are rare when treatment is undertaken by an expert. They may include:

Prolonged local irritation and erythema

Damage to mucosal surfaces, ie lip, nostril, conjunctiva or cornea (eye) leading to painful ulceration and potential scarring, if TCA is inadvertently deposited on these sites

Post-inflammatory hyperpigmention (usually transient) or hypopigmentation (may be permanent)

Coalescence of adjacent scars to form larger scars

Sub-optimal response or lack of improvement in scarring

Treatments combined with TCA CROSS

Treatments that can be combined with TCA CROSS for acne scars include:

Topical retinoids

Microneedling — Dermaroller, Dermapen

Fractional laser treatment

Subcision

What is the outcome following TCA CROSS?

When used correctly, TCA CROSS is moderately effective for atrophic acne scars. Patients may expect a 1 to 2 grade improvement in their acne scars over a 6-month period.

Greater levels of patient satisfaction are associated with more severe pre-treatment scarring.