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Is TCA CROSS The Best Ice Pick Scar Removal Treatment?

by Dr Wan Chee Kwang
October 2, 2022

Ice pick scars, like the name suggests, look like the skin has been subjected to an ice pick attack. These deep gouges are often very noticeable and unsightly leading many patients to seek to get rid of the scarring.

Ice pick scar removal is distinct from other types of atrophic acne scar removal. Scar removal treatments that may work very well for other types of atrophic acne scars may barely make a dent in ice-pick scars. This is due to the unique configuration of ice pick scars. The deep narrow pits of ice pick scars form after intense and deep-seated skin inflammation. Typically they result from severe acne, especially of the nodulocystic type.

Typical energy-based acne scarring treatments such as fractional infrared lasers, and fractional radiofrequency microneedling (e.g. Infini, Secret RF, etc.) may struggle to produce significant effects. This is because ice pick scars have a very deep base and a small surface area. The deep base may be beyond the penetration depth of the energy devices. Furthermore, the tiny size of ice pick scars exposes only a small surface area to the energy deposited by the machines. This is not to say that energy-based treatments will not have any effects on ice picks scars but that they may have limited effects and require a disproportionately high number of treatments. As a result, attempting to treat ice-pick scars with energy devices may not be the most efficient or cost-effective approach.

Instead of spamming numerous sessions of energy-based treatments and hoping for indirect improvements, more aggressive yet targeted treatments may work better for ice-pick scars.

TCA CROSS For Ice Pick Scar Removal

tca cross with a toothpick for ice pick scars
TCA CROSS being done with a toothpick for ice-pick scars

A common treatment often recommended by medical aesthetics, dermatology, or plastic surgery clinics for specifically treating ice-pick scars is TCA CROSS. Short for trichloroacetic acid chemical reconstruction of skin scars, it delivers a bead of concentrated acid to the deepest part of the ice pick scar.

Epithelium, the protective surface layer of the skin, lines ice pick scars. The epithelial lining prevents the surfaces within the ice pick scar from sticking and growing together. TCA CROSS destroys the base of the ice pick scar including the epithelial lining. This stimulates collagen deposition and allows new epithelium to 'bridge' across the base of the scar. Repeated over a few treatment sessions, the end result is a gradually shallower scar.

TCA CROSS has been studied for ice-pick scars, producing a 50-70% improvement in scar depth on average.

Risks of TCA CROSS

However, like all acne scar treatments TCA CROSS is not without its problems:

  • Prolonged redness as the skin reacts to the controlled injury. This can be quite obvious especially if treating multiple ice pick scars concurrently
  • Post-inflammatory hyperpigmentation or hypopigmentation, especially in darker skin types
  • Takes multiple sessions to show results and may not work for very deep or wider scars
  • A small but significant chance of worsening or widening the ice pick scar. It is difficult to control where the TCA liquid flows. Inadequate healing can result in more collagen destruction than production.

Multiple technical modifications can reduce the risk and increase the effectiveness of TCA CROSS for ice pick scar removal. For example, instead of using a coarse toothpick, many doctors are now using very fine needles to deliver smaller amounts of TCA more precisely. Growth factors which boost the healing process and increase the amount of collagen deposition can also be very helpful.

Pinpoint Laser Ablation

Ablative lasers have been studied for ice-pick scar treatment. They are used very carefully to produce controlled destruction of the base of ice pick scars. This precise pinpoint vaporization minimizes the damage to the surroundings and thus lowers the risk of widening the ice pick scar. The ablated columns then heal over from the surrounding skin, hopefully at a shallower depth than the original scar. Studies have shown that pinpoint laser ablation can be more effective than TCA CROSS in treating ice-pick scars.

In my experience, however, pinpoint laser ablation may sometimes fail to stimulate enough of a healing response to produce adequate collagen. In patients with tendencies towards atrophic scarring, the holes left by ablative lasers may not fill up properly.

Scar Excision Or Grafting

punch grafts in place for ice pick acne scar treatment
Punch grafts being placed after punch excision of ice-pick acne scarring

More surgically gifted doctors such as plastic surgeons may be more inclined to simply cut out the entire scar and close the resultant wound through stitching or with a skin graft. Problem solved? In many cases, yes, but in patients with atrophic acne scarring, we have to bear in mind that they do not heal well. Simple scar excision may instead give rise to worse complications.

Removing the piece of scar-containing skin produces a full-thickness wound. The surrounding skin is then pulled inwards and stitched together to close the wound. The natural tendency is for the surrounding skin to pull back outwards, placing tension on the wound and the stitches holding the wound together. In patients with poor healing, this may result in even more scarring in the form of stitch marks or an even bigger sunken scar.

In skin grafting, a separate piece of skin from elsewhere on the body is used to replace the scarred skin that was excised. Sometimes the graft fails to survive, contracts, or becomes sunken instead resulting in an even bigger scar.

Microsurgical Excision For Ice Pick Scar Removal

syris polarized loupes during laser treatment
Polarized loupes like the Syris are very useful for microsurgical ice pick scar excision

Microsurgical excision is a calibrated form of excision done under magnification with fine instruments and precision ultrapulse lasers. The amount of tissue removed is restricted to the bare minimum to preserve as much structural skin integrity as possible and reduce wound tension. Extremely fine sutures are placed invisibly to provide long-lasting wound support while avoiding visible stitch marks that may produce new scars. Given that it takes much longer and requires a high level of finesse, microsurgical excision can cost much more than other ice-pick scar treatments. However, when done right it can produce excellent results.

Is TCA CROSS Best For Your Ice Pick Scars?

Are you suffering from ice-pick scars, perhaps after acne? Most clinics would offer TCA CROSS by default.

TCA CROSS can work very well for some ice-pick scars, particularly narrow ones. However, like all treatments, TCA CROSS is not perfect. No matter how we try to minimize the risks of a bad outcome with TCA CROSS, the fact remains that it is inherently dependent on the configuration of the scar. For wider or deeper scars, I personally prefer microsurgical excision to minimize the risks of surgery. However, it is important to analyze your ice pick scar carefully instead of making a blanket recommendation for TCA CROSS treatment.

Feel free to consult if you are considering treatment for your ice-pick scars!

References

  1. Bhardwaj, D., & Khunger, N. (2010). An Assessment of the Efficacy and Safety of CROSS Technique with 100% TCA in the Management of Ice Pick Acne Scars. Journal of cutaneous and aesthetic surgery3(2), 93–96. https://doi.org/10.4103/0974-2077.69020
  2. Vishwanath, T., Barve, A., Farande, P., Ghate, S., Shinde, G., & Nagpal, A. (2020). Use of blunted needle of insulin syringe as a simple method for precise delivery of drug during chemical reconstruction of skin scars (CROSS). Journal of the American Academy of Dermatology83(3), e177–e178. https://doi.org/10.1016/j.jaad.2019.08.065
  3. Mitra, D., Singh, G. K., Singh, T., & Mitra, B. (2021). Use of 27-gauge Tuberculin Syringe for Trichloroacetic Acid Chemical Reconstruction of Skin Scars (TCA-CROSS). Journal of cutaneous and aesthetic surgery14(3), 357–358. https://doi.org/10.4103/JCAS.JCAS_147_20
  4. Ahmed, R., Mohammed, G., Ismail, N., & Elakhras, A. (2014). Randomized clinical trial of CO₂ LASER pinpoint irradiation technique versus chemical reconstruction of skin scars (CROSS) in treating ice pick acne scars. Journal of cosmetic and laser therapy : official publication of the European Society for Laser Dermatology16(1), 8–13. https://doi.org/10.3109/14764172.2013.854633
  5. de Almeida, A. R., de Oliveira, N. I., Kadunc, B. V., & de Almeida Prado Sampaio, S. (1998). Surgical pearl: lubricating jelly as a dressing in punch grafts for pitted acne scars. Journal of the American Academy of Dermatology38(4), 613–615. https://doi.org/10.1016/s0190-9622(98)70126-4

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