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TCA Cross: The Best Treatment For Deep, Ice-Pick Acne Scars?

TCA Cross: The Best Treatment For Deep, Ice-Pick Acne Scars?

Today, there are a plethora of in-clinic, acne scar treatments available to patients from chemical peels, micro-needling radiofrequency, subcision, dermal fillers and laser-based resurfacing.

It’s no wonder many patients find themselves overwhelmed and confused at which treatment option is the best for their specific acne scar.

Acne scars are a common complication that those suffering from acne vulgaris experience after a breakout. The most common type of acne scars are atrophic acne scars, i.e., 80-90% of people have scars that are associated with a loss of collagen.

For a quick recap, these are the three types of atrophic acne scars:

Boxcar: Oval depressions with sharply demarcated vertical edges that tend to be wider at the surface than ice-pick scars.

Ice-pick: Narrow (<2mm) and deep scars that extend vertically into the dermis or subcutaneous tissue and tapers to a point at the base.

Rolling: Scars that can reach up >5mm in diameter that have a rolling or undulating appearance.

Despite the prominence of acne scars in patients, acne scars remain surprisingly difficult to treat with no easy and definitive solution.

And despite the popularity of laser treatments, there are certain instances where laser techniques may not be the best option due to its inability to reach deep into the dermis.

This is in the case of deep, ice-pick scars—the most common type of atrophic acne scar that is also the hardest type to treat due to its depth that does not make it respond well to lasers or chemical peels alone.

The best solution for deep, ice-pick scars: TCA Cross

TCA Cross stands for the chemical reconstruction of skin scars using trichloroacetic acid. It is a manual technique that involves the manual application of a high concentration of trichloroacetic acid (70-100%) onto each scar using a sharp-tipped wooden applicator or needle.

As compared to chemical peels which are lower in concentration (20-35%), TCA Cross is more aggressive and is better able to reach the deeper layers of the dermis to cause cell death to the skin cells; essentially creating a local inflammatory reaction that leads to the formation of new collagen and elastin fibers and sloughing off the top layer to reveal new, healthy tissues.

The results are cumulative, whereby the scar is gradually elevated due to collagen stimulation, By destroying the outer damaged layers, it accelerates the normal process of exfoliation and leads to tissue remodeling, thereby decreasing scar appearance.

With each treatment, patients can expect a 20-30% improvement in their acne scar, and it is recommended that patients undergo 3-6 sessions spaced about 4-6 weeks apart for best results. The majority of patients can expect to see a 1-2 grade improvement in their acne scars over the next 6-9 months.

In fact, multiple studies have shown that it works best in treating deep, ice-pick or small boxcar acne scars and can also effectively treat enlarged pores. Studies have shown the safety and efficacy of using TCA Cross including darker-skin patients and can be performed on the same day with other procedures such as subcision, as well as ablative and non-ablative fractional resurfacing.

In one particular study assessing the efficacy of 100% TCA Cross on 30 patients with predominantly ice-pick scars, all patients saw an excellent improvement, with 73.3% achieving excellent improvement in their scars. Even when used as a single-modality treatment, TCA Cross is found to be just as effective!

While traditional laser resurfacing techniques can be too aggressive for some patients, the beauty of TCA Cross is that your doctor can choose to use a lower concentration to minimize any side effects such as scar formation, post-inflammatory hyperpigmentation (PIH) and hypopigmentation which is associated with chemical peels and ablative laser treatments.

Most importantly, it can reach deep within the dermis to target and treat deep acne scars and provide predictable and consistent results!

The best treatment for acne scars: a combination approach

Yes, TCA Cross is a highly successful treatment for improving deep, ice-pick scars; however, it should NOT be used as a replacement for acne scar laser and other manual techniques.

A 2019 study done with 30 patients showed that using a combination of subcision, micro-needling and 50% TCA Cross showed an improvement in acne scar grade after several sessions.

Another recent 2019 study that conducted a review of a series of combination therapies that included manual techniques such as TCA Cross and subcision concluded that all patients experienced an improvement in their acne scarring and were satisfied with their results.

In fact, those who have had previously done ablative fractional CO2 laser procedures as a single-modality treatment noticed less improvement!

At the end of the day, the biggest takeaway here is not to underestimate the power of incorporating manual techniques into your acne scar removal treatment plan.

How we treat acne scars @ The Clifford Clinic

At our clinic, our doctors focus on using a combination approach to customize and design a treatment program that maximizes results in fewer treatment sessions and minimizes discomfort and undesirable side effects!

Your treatment should depend on several factors including your acne scar type, skin condition and expectations.

Each solution comes with its pros and cons, for example, subcision works best for depressed and tethered boxcar and rolling scars, while fractional lasers are extremely effective in treating skin texture irregularities.

Dermal fillers are recommended to help volumize atrophic, indented scars, while vascular lasers such as Vbeam is used to treat facial redness. Deep atrophic scars can also be treated with INFINI RF for faster and better results.

Our doctors have decades of experience treating all types of acne scars, and combined with the arsenal of acne treatment solutions available at our clinic—we are confident that we can dramatically improve your acne scars and help you achieve clearer, more healthy-looking skin!

The best acne scar treatment is EARLY treatment. Especially if you aren’t seeing results using a single modality—contact us to learn more about our acne laser treatment and acne scar removal cost and book your appointment today!


  • What is the procedure like?

After cleansing and priming your skin, our doctor will proceed to apply the peeling agent using a wooden applicator within the base of the scar tissues.

You might feel a slight heating sensation while the doctor continues to add additional layers and your skin may appear yellowish or whitish during the treatment.

Once all the scars have been treated, the doctor will proceed to remove the agent from the skin and apply a cold compress and antibiotic ointment to protect the skin and help with the healing process. The entire procedure should take roughly 5-15 minutes.

This procedure is conducted without the use of local anesthesia, and the majority of patients describe this procedure as highly tolerable.

  • What is the downtime like?

The downtime for TCA Cross will be about 5-7 days, and patients can expect the frosting (white areas on the scars) to remain for up to 12 hours, with some redness and swelling in the first 1-2 days. It is also normal for scabs to form which will eventually fall off on its own in 3-7 days.

Not to worry, the frosting simply signals that the proteins in the skin are being denatured and that the treatment is working its magic!

Those with darker skin may also develop a brown discoloration which can take several weeks to months to resolve.

During the healing process, it is important for you to avoid excessive sun exposure for at least 2 weeks following your treatment.