TCA CROSS

What is TCA?

TCA stands for trichloroacetic acid, a compound frequently employed at concentrations between 20-35% in chemical peels, designed to enhance facial skin by minimizing the visibility of scars and aging signs.

What is TCA CROSS and how does it work?

TCA CROSS refers to the method of chemically reconstructing skin scars (CROSS) utilizing trichloroacetic acid (TCA). This procedure is commonly administered in outpatient settings for the treatment of atrophic acne scars. It is cost-effective, generally safe, and often effective, though results can vary.

Acne, a prevalent skin disorder characterized by inflammation, can lead to various scar types like atrophic, hypertrophic, and keloid scars. These scars can potentially lead to emotional distress and social stigmatization.

The TCA CROSS method comprises the precise application of highly concentrated TCA (70-100%) onto the atrophic scar’s surface. This induces a localized inflammation that promotes the development of fresh collagen fibers. The primary goal is to enhance the scar’s look by augmenting collagen’s reflective properties and diminishing shadows that emphasize scar indentations. However, it’s important to note that achieving total scar removal with just this method is rare.

What are the indications for TCA CROSS?

The decision to undertake a TCA CROSS treatment is influenced by:

• The nature and extent of the acne scars.
• Patient’s desires and anticipated results.
• Expertise and expected outcomes from the clinician’s perspective.

TCA CROSS is beneficial for treating the following atrophic scars:

• Boxcar acne scars.
• Rolling acne scars.
• Ice-pick acne scars.

Assessment of acne scars

To facilitate objective comparisons before and after treatments, one can utilize the Goodman and Baron’s qualitative acne scar grading system:

1. Macular scars: These are flat marks that might appear erythematous, brown (hyperpigmented), or pale (hypopigmented). They reflect a color issue rather than a contour discrepancy.
2. Mild atrophic or hypertrophic scars: These are scarcely noticeable from a distance of 50 cm or more. Cosmetics or the natural shade from facial or body hair can conceal them effectively.
3. Moderate atrophic or hypertrophic scars: These scars are perceptible from 50 cm or more and cannot be easily hidden by cosmetics or natural facial hair shadows. However, manual stretching can still flatten atrophic versions of these scars.
4. Severe atrophic or hypertrophic scars: These scars are discernible even from distances exceeding 50 cm and resist concealment through cosmetics or hair shadow. They cannot be flattened by manually stretching the skin.

How is TCA CROSS performed?

TCA CROSS is relatively simple to administer and can be completed quickly, contingent on the number of scars being treated. Typically, the procedure is repeated at intervals of 2-4 weeks.

Steps:

• Position the patient semi-reclined and ensure they remain stationary.
• Cleanse the skin using chlorhexidine/saline-soaked gauze.
• Dip a fine-tipped tool (like a toothpick) into TCA, shaking off excess.
• Carefully apply the TCA directly to the scar’s base.
• Once skin frosting appears (usually within 10 seconds), remove the tool.
• Repeat for all relevant scars.
• Cleanse the skin periodically with saline/chlorhexidine gauze.
• Extra caution is essential near sensitive areas (eyes, mucous membranes). Eye protection might be necessary, and having emergency eye-wash equipment available is recommended. Refrain from treating patients who’ve undergone systemic retinoid therapy in the past year due to potential healing complications.

After the procedure

Post-procedure guidelines for patients include:

• Expect treated areas to frost for up to 12 hours.
• The surrounding skin may appear reddened and feel tender for 24-48 hours.
• A scab will likely form within 2-3 days and shed after 3-7 days.
• Regular washing and makeup application are permissible.
• Sunscreen application is advised to minimize pigmentation risk. Most patients witness optimal results after 3-6 TCA CROSS sessions, typically spaced 2-8 weeks apart over a 6-month duration.

Complications of TCA CROSS

While TCA CROSS is usually well received, potential complications, especially when not performed by specialists, include:

• Extended localized redness and irritation.
• Injury to mucous surfaces leading to ulcers and potential scars.
• Transient post-inflammatory hyperpigmentation or possibly permanent hypopigmentation.
• Merging of neighboring scars resulting in larger scars.
• Insufficient scar improvement.

Treatments combined with TCA CROSS

To enhance outcomes for acne scars, TCA CROSS can be complemented with:

• Topical retinoids.
• Microneedling techniques like Dermaroller or Dermapen.
• Fractional laser therapy.
• Subcision. Combined approaches often yield favorable results with minimal side effects.

What is the outcome following TCA CROSS?

When appropriately administered, TCA CROSS can provide moderate relief for atrophic acne scars. Over a span of 6 months, patients can generally anticipate a 1 to 2-grade enhancement in their scars. Satisfaction levels tend to be higher among patients who initially present with more pronounced scars.