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  1. Hello, How are you all ? After beating acne the biggest enemy will be the scars ! The scars will not pain you but it will give you a bad feeling I had done many lasers treatments more than 10 with different types of lasers I tried dermaroller , and subcision which i had with more than 4 doctors over 4 years but nothing fixed anything and my face still have alot of deep acne scars which many of them are rolling type and some are boxscars I went to doctor chu which was recommended from doctor davin lim and he told me he will do many seassions from me which will be prp+ tca+ derma pen and subcision I searched for reviews for this doctor but all opinions and reviews I find is from 5 years ago and more So I made this post so anyone who have tried to treat his acne scars with this doctors post his review and tell us his opinion please because he is the most famous one on the UK for these treatments
  2. Hey guys, I come to you just to warn you about tca cross, is not the best option due to its high risks. I dont get why doctors still perform this if the probability it gets worse is so high. Anyways I dont know if im being to pesimistic, i dont have many scars from acne i just had one that within two weeks for me got pretty bad so i decided to get tca cross done on it , its been 4 days and i already can tell how its going to turn out because it looks way worst than before, i dont see how its going to fill in. i whis i had never touched i would be more than happy if i was left with what it was before. And here is a story, i probably red all the information about the procedure before taking the decision, many comments are good many others are bad, but i decided i was going to do it, walkin towards the doctors office i was so affraid, if i was going for a little ice pick scar cause it got me depressed imagine if it gotten worse, i didnt follow my instincts .... too much risk, i even talked to the doctor again i told him i was affraid, he said dont worry believe me is the best option so it calmed me. now look guys we humans are so stubborn, i wish i had red a comment her warning me ... DONT DO IT, DONT DO IT. HOPEFULLLY this helps you .
  3. This was done by a dermatologist and it was supposed to be a small test spot(tca cross) to address some scars on my nose but for some reason it's effecting a huge part of my skin. I think what happened was when water was applied by q-tip, it must have bled out to the area around it? dunno. This is about day 3. The scab is starting to form. Looks horrendous and I am having anxiety over this. the white you see in the photo is lotion I just put on

    Forums Scar treatments 8 replies

    Just had TCA cross done on some icepicks and large pores by a reputable dermatologist. When I say just, I mean I did them around 8 hours ago. Is it normal that my open pores immediately look like icepick scars? They have frosted and then subsquently turned into deep pits. Is this normal? I know they are supposed to scab in a few days but they immediately look punctured and way worse then before.
  5. Hi, I have a small deep pitted ice picked scarred pore. Will several procures of TCA Cross really help improve this scar or is this acne scar procedure just a scam? I'm an older person so I might need more procedures than younger people. If it works, can anyone recommend someone in the NJ or NYC area? Thank you for your help.
  6. UPDATE: I will not continue with TCA cross or any type of peels. I feel like the improvement was minimal and some actually got worse. The very very long healing time only adds to my stress and i have accepted living with my icepicks.
  7. planning for filler

    Forums Scar treatments 15 replies

    Hello, I have posted here in the past, and i thought i would give an update and let you know my future plans and how i have been healing. The procedures listed below is what i have done: - subcison with TCA- July 2016 -subcision with TCA -November 2016 -3 or 4 microneedling with derminator My thoughts on my healing/treatments: -The TCA cross applied to box car scars take a long long time to heal, some are still not fully healed. I think my skin type is prone to hyperpigmentation, so with TCA i urge you to be really careful especially if you are ethnic. In general, I think some scars respond better than others, and it can actually cause damage if not applied correctly. -I will not stop the use of TCA cross or any type of peels as i feel the improvement was minimal and actually made some worse. -I feel my old Dr. was too aggressive. I had subcision on both sides of my face, cheeks,upper cheeks and temples. I feel like the subcision did help especially on my right cheek. However, i got nodules both times and a couple of them took almost one year to fully go away. Future plans (procedure will be in early June) Advise/opinions are welcomed! -HA filler, i specifically want to fill the ugly ugly scar on my right upper cheek, MY MAIN QUESTION IS: Should i do subcision in that area and wait a while then do a filler? I have done subcision on that scar twice and i feel like it has improved a little. I do not think it is tethred, and I am hoping my new Dr. will be able to use filler only and no subcision -what HA fillers do you guys think will work? I realize its the injector that matters the most and all the reviews on my new Dr. are good. - I try to microneedle every 3-5 months "aggressively" with the derminator. Please share your thoughts with me, pics below are from day one with zero procedures to today. Thanks!!!!
  8. I have come to realize I have a poor healing response. Any pimple, especially in my cheek area will leave a very shallow indent in its place. I always knew that my skin healed slowly, but now I am scared to start trying different treatments, specifically using the derminator and tca peel. Can anyone give me advice in what route I should take, especially those with the same issue. Can using the derminator cause further damage if my skin's healing ability is not the best? thanks so much!
  9. Hi All I finally get it no chemical peel or lasers can fix enlarged nose pores. I did all the extreme things to control or improve my large nose pores and scars. I had done more than 10 sessions of co2 with erbium which improved the scars and texture by 25%, atropic scars still there. These pores are crazy they are simply stubborn. They have affected my self esteem big time and have been a recluse for a while now. I don’t wish this to happen to anyone. Anybody who successfully cured enlarged pores, pitted and atrophy on nose. Please share information. I haven’t seen any successful real story.
  10. Help please!!

    Forums Scar treatments 1 reply

    I had a TCA 35% peel at home and after only 2 days my skin is peelin off and the new skin looks red and raw. I don't know if that is nornal or not. I don't know whether that can leave the area hypoigmentated or if I can even have keloids...I'm really frightened. I shouldn't have had the peeling on my own at such a high concentration. Have you ever had such raw skin? Does that heal normally? Shall I go to the hospital?
  11. I've taken the plunge! I've had my first TCA peel at 35% which is quite strong especially if it is your first experience with this acid. The procedure has been a basic one...I've cleaned my face with a soap free cleanser and then I've pat dried my skin until completely dry. Once my skin was dry, I put the gloves on and I've opened a pack of cotton gauzes. Then, I've put the acid on the gauze and I've applied very carefully the acid all over the face without making any pressure on the skin to avoid damage. The first 20 seconds were ok, right after this moment my skin has started to sting and in a minute or so all my skin became white (frosting). After 2 minutes (more or less.... I had no watch as TCA is not time-dependent) I've cleaned my skin with water and then I've used the soap free cleanser to remove any rests of the acid on my skin. After cleaning my face I've felt a lot of relief...that makes me feel that the peeling had not been fully neutralized. Then I've pat dried my skin until completely dry and that's it.... The procedure was over...I've not used any special neutralizer, nor have I used baking soda, repairing cream... Now, I feel my skin is tight and dry. This is more noticeable when I smile as I can "feel it". The frosting has gone away in 10 minutes and now my face is red. I'm gonna be at home the whole week studying, being relaxed, avoiding sun exposure. If I have to go out with friends that is gonna be from 20:30/21:00 to 07:30 haha. No sun. I want to thank veteran members who offer help and advice here... @UpliftingCat @beautifulambition @Quadboy and many others who offer help and support. I was warned not to start out at 35% but I've felt confident enough to do it. I feel ok, there have not been any problems during the peel and now I'm looking forward to seeing the results. I'd like to know whether I must follow any specific routine following the peeling. I've read moisturizer is not adviced until the skin is peeling off. I'm also a bit disappointed because I can see my scars and small moles through the redness...When I had dermapen sessions my skin was more swollen than today...I guess that is normal but I expected some swelling. Now the redness is lighter and it turned more like "brown". My plan is to heal properly and then I'll have derminator sessions from May to September (once a month) and then in October I'll start with TCA peels again. Below you have some pics I've taken 10-15 minutes after the peeling, when the frosting was about to completely disappear. I hope this thread can be useful to help other users who want to improve their acne scars.
  12. What would be better , a Q tip or toothpick for scars ? I read somewhere Q tip for the bigger ones and toothpick for the smaller ones (mainly ice pick scars)..... also does it matter if you get a little outside the scar ,like around the edges? I would think that would help even it out more? hmmm..
  13. I have a small 35% TCA bottle at home and a derminator device. That's all what I want to use. No filler, no subcision. For the moment, not TCA cross either. I always read threads in which people recommend subcision+filler as main treatments and then TCA peels for "texture issues". I wonder whether TCA on its own can improve mild acne scars. How much improvement could we have with microneedling+TCA peels over the months/years?
  14. Yesterday out of pure stupidity and negligence i put 100% TCA on my nose thinking this solution isnt that strong (i didnt do research unfortunately) . Now my nose is looking like this. These are the pics taken at around 40 hrs mark after the TCA peel. Within 15 seconds of applying TCA i washed my face with baking soda water after realizing it was a mistake and then applied triple antibiotic cream. Where will this peel wound be after a month or two and what can i expect. I live in a remote area there are no dermatologists nearby. I had ordered 100% TCA via Amazon. I am really depressed now and also angry at myself.

  15. Take vitamin D and K to begin with, that will help rebalance your retinoids. Anxiety is probably one of the main causes, as Accutane completely messes up your stress and sex hormones, so right now your body probably feels a tonne of stress. People who take such a limited dose recover much better, and one of my friends took 80mg for 15 months and he is good now, though it knocked him around for a fair bit.

    One of the ironic things about accutane is it makes your body react poorly to stress, then creates a fuckton of it.

    My full recovery advise is:
    "Buy creatine, fish oil, coq10, zinc, multivitamins and a decent protein powder, take the recommended dosages for all of these, and try to meditate for 20 minutes a day"(if its early days take some k2 and vitD as well, that will get your retinoids in check post tane)

    Anyway, even if you are a random healthy male the things I've recommended would only improve your health, all would probs be available if you went to your local discount chemist 
  16. Hello, Newbie here Sorry if this has been answered as nauseum, I tried searching and couldn’t find anything definitive. I’ m trying to find out what type of peel to order to do either weekly or biweekly maintenance. I just completed a TCA full face peel (1 layer at 30%, for about 4 mins) I know it’s high, but I have worked my way up to that strength and my skin is very resistant to peeling. I’m pretty much done peeling now on day 7. I’ve done 20% a few times in the past. I want to maintain my results but will obviously wait until my skin is healed for a few weeks. I was thinking about glycolic but not sure what strength to use?My main concerns are textural/hyperpigmentation and some shallow indented mostly rolling scarring on cheeks. any info is helpful and alternative recs are appreciated.
  17. Starting A Self Diary

    Forums Scar treatments 15 replies

    I'm making this post to track my future progress with my acne scars. I've posted here a few years ago and eventually just stopped trying altogether, but recently felt a few kicks in my self-confidence so I am back and going to try a few things. This will likely be a post that I come back to update on over a long period of time since results never come instantly. In high school I had terrible cystic acne resulting in many different types of scars on my cheeks, and some on forehead but I am not too worried about those. Since I have many types of scars I am looking into doing a few things, reading this article I grew a little hope that I could see some improvement. Any input would be awesome, but I have purchased a derminator to begin dermaneedling, as well as some tca 20% for a few peels like the article. Will also be looking into subcision because I think that was a major part of the study that shouldn't be ignored. When i receive my derminator I will probably be posting the intial day I do it, then post a follow-up a few weeks out after micro-swelling has gone down. I would like to try what they did in the study and do the TCA peel 2 weeks later (not sure what % I will do it at). I may actually spread it out to 3 weeks after because I don't want to add more harm and impact collagen production.
  18. Would TCA 30% do any good? Pics

    Forums Scar treatments 3 replies

    I have been struggling with these acne scars for years and I'm strongly considering trying a TCA peel, My question is how effective would it be? I would be using it strictly on my nose and any advice would be deeply appreciated.
  19. I posted this 2- years ago when I was asked for proof of successful treatments "pics", or has anyone had success. This is now included in my DIY Guide to Acid peels (Linked off the FAQ - top of the acne scar sub - first post - Under Peels). This post was made so you can see the treatments we offer do successfully work even if people do not post "pics". Acid peels are very successful as a alternative to laser at resurfacing the skin (without the side effects). If your doing DIY it takes many treatments over time ) 3 months it takes collagen to develop, or your Dr can do a "deep" sedated TCA or Penol peel to get under the scars. Microneedling without TCA is not effective they work synergistically together over time. This may be subsituated with RF Microneedling (Infini) if you have the proper scars and $$$$. Also be aware the above study exact method might not work for you or your individual case, this is why the FAQ was made (many studies like this hide secrets Dr's do for treatment or do things unsafe for home DIY. Do not attempt this without reading the FAQ and Acid Peel Guide. AS always a doctor can treat with much better results and quicker outcomes for your personalized scar types. Point anyone who wants proof to this post ("Pics" below). ______________________________ TCA, Microneedling, Subcision w/ Filler give the best results for Acne Scars! Combination Therapy in the Management of Atrophic Acne Scars Shilpa Garg and Sukriti Baveja J Cutan Aesthet Surg. 2014 Jan-Mar; 7(1): 18–23. doi: 10.4103/0974-2077.129964 INTRODUCTION Acne is prevalent in over 90% adolescents and it persists into adulthood in approximately 12%-14% of cases with psychological and social implications.[1,2,3] In some patients with acne, the inflammatory response results in permanent, disfiguring scars from either increased tissue formation or due to loss or damage of tissue. Hypertrophic scars and keloids are examples of scars that result from increased tissue formation. Scars with loss or damage of tissue can be classified into icepick, rolling and boxcar scars.[4] There is no standard treatment option for the treatment of acne scars. Medical management of atrophic scars can be done by using topical retinoids. Surgical management can be done using punch excision, elliptical excision, punch elevation, skin grafting and subcision depending on the type of scar. Procedural management includes microdermabrasion, chemical peels, percutaneous collagen induction by microneedling and dermabrasion. Tissue augmentation can be done using xenografts, autografts and homografts. Various ablative and non-ablative lasers and light energies are also available for treatment of atrophic acne scars.[5] Out of these multiple treatment options, treatment has to be tailored to patient's needs, tolerance, and goals along with the physician's assessment, skills and expectation. Patient should be counselled that the ultimate goal of any intervention is to improve the scars and no currently available treatment will attain total cure or perfection. In 1995, Orentreich and Orentreich described subcision as a method of subcuticular undermining of scars using a tri-beveled hypodermic needle. This results in lifting the scar by releasing the papillary dermis from the binding connections of the deeper tissues and by the formation of connective tissue that results from the course of normal wound healing.[6] It is mainly used for the treatment of rolling type of atrophic scars.[4] The mechanism hypothesised for action of percutaneous collagen induction using dermaroller is that it creates thousands of microclefts through the epidermis into the papillary dermis. These wounds create a confluent zone of superficial injury which initiates the normal process of wound healing[7] with release of several growth factors. This stimulates the migration and proliferation of fibroblasts resulting in collagen deposition[8] which continues for months after the injury.[9] Another hypotheses states that on penetration of skin with the microneedles, the cells react with a demarcation current which in addition to the needles own electrical potential results in release of various growth factors. This cuts short the healing process and stimulates the healing phase.[10] Dermaroller also opens pores in upper layers of epidermis and allows creams to be absorbed more effectively by the skin. Fifteen percent tricholoroacetic acid (TCA) peel is superficial peeling agent. It causes exfoliation, improves the skin texture and induces collagen synthesis.[11] The aim of our study was assessment of combination therapy using subcision, dermaroller and 15% TCA peel for the management of atrophic acne scars. The rationale for combining these three minimally invasive procedures was their additive action on acne scars. Subcision releases the scars from the underlying adhesions which should be the first step for any treatment for acne scars. Microneedling with dermaroller causes collagen induction along with enhancing absorption of tretinoin cream. Fifteen percent TCA peel causes improvement in skin texture as well as collagen induction. Hence by combining these three minimally invasive modalities one can release the scars, enhance collagen induction, increased penetration of topical agents and resurface the skin. MATERIALS AND METHODS Fifty patients with atrophic acne scars were enrolled in this study. Exclusion criteria were patients with active acne, active herpes labialis, patients on systemic retinoids, evidence or history of keloid scars, pregnancy or lactation, history of any facial surgery or procedure for scars and patients with unrealistic expectations. All the patients were counselled for surgical intervention and written informed consent was taken. The atrophic acne scars were graded by a single non-treating physician using Goodman and Baron Qualitative scar grading system [Table 1].[12] Table 1 Goodman and Baron Qualitative scar grading system Patient's skin was primed using topical tretinoin cream 0.05% at night along with sunscreen with a minimum SPF of 30 during the day for 2 weeks prior to starting the treatment. At the start of treatment, subcision was performed only once using a 24G needle. One day after the subcision, patient was called for the first sitting of microneedling with dermaroller containing 192 needles of needle size 1.5 mm. Eutectic mixture of lignocaine 2% and prilocaine 2% cream was applied under occlusion for 1 hour to the affected areas which was removed using gauze. Thereafter topical tretinoin cream 0.05% was applied to the affected area. Treatment was performed by rolling the dermaroller in vertical, horizontal and diagonal directions in the affected area until appearance of uniform fine pinpoint bleeding. Then the area was wiped with saline soaked gauze and tretinoin cream 0.05% was applied and washed off after 30 minutes. Two weeks after dermaroller, patient was called for 15% TCA peel. Whole face was cleansed using spirit and degreased using acetone. Fifteen percent TCA peel was applied with cotton tipped applicator on full face. Appearance of speckled white frosting was the end point of treatment with peel. After using dermaroller and 15% TCA peel, patient was instructed to apply sunscreen in the morning and mometasone furoate cream 0.1% twice daily for 5 days after which sunscreen was continued in the morning with tretinoin cream 0.05% applied at night time. Patient was asked to discontinue topical tretinoin cream application 2 days prior to TCA peel. Thereafter, dermaroller and 15% TCA peel were repeated alternately after every 2 weeks for six sessions of each and this was taken as the end point of our study. In some patients who developed inflammatory lesions of acne during treatment, capsule doxycycline or topical clindamycin cream 1% was given as and when required. Any adverse effects and interference in daily activities post-treatment were noted. Patients were evaluated for results 1 month after the last procedure was performed. Post-treatment scars were graded again by the same physician using Goodman and Baron Scale. Patient graded their response to treatment as poor, good, very good or excellent with 0-24%, 25-49%, 50-74% and 75-100% improvement, respectively, in their acne scars. The patients were followed up for 1 year at two monthly intervals to observe the sustenance of improvement in scars. Digital colour facial photographs were taken before treatment, during each visit of treatment, at 1 month after the last procedure and at 2 monthly intervals for 1 year after the last procedure. Patients were instructed to continue application of topical tretinoin cream 0.05% for 1 year after the last procedure. Statistical analysis Descriptive statistics such as mean and standard deviation are calculated. Data is presented in frequencies and their respective percentages. Data was entered and analysed using SPSS version 18. RESULTS Out of 50 patients, 49 patients completed the treatment. Out of 49 patients 2 patients were treated with capsule doxycycline during the treatment protocol due to active acne eruptions. Out of 49 patients there were 30 females and 19 males with age group between 18-39 years with mean age of 25.6 ± 5.2 yrs. 9 patients (18.4%) had Type III Fitzpatrick skin type, 32 (65.3%) type IV and 8 (16.3%) patients had type V Fitzpatrick skin type. Pre treatment melasma was present in 3 (6%) patients. Out of 49 patients who completed the treatment, 16 patients had Grade 4, 22 patients had Grade 3 and 11 patients had Grade 2 scars before treatment. The physician's assessment of response to treatment based on Goodman and Baron Qualitative scar grading system is summarised in Table 2. In patients with Grade 4 scars, 10 patients (62.5%) showed improvement by 2 grades i.e., their scars improved from Grade 4 to Grade 2 of Goodman Baron Scale [Figure [Figure1a1a and andb].b]. Six patients (37.5%) with Grade 4 scars showed improvement by 1 grade [Figure [Figure2a2a and andb]b] with scars being obvious at social distances of 50 cm or greater. In 22 patients with Grade 3 scars, 5 patients (22.7%) showed improvement by 3 grades i.e., they were left with no scars at all [Figure [Figure3a3a and andb],b], Two patients (9.1%) improved by 2 grades and as per Grade 1 they were left with only hyper-pigmented flat marks [Figure [Figure4a4a and andb]b] and 15 patients (68.2%) showed improvement by 1 grade by moving to Grade 2 [Figure [Figure5a5a and andb]b] as per Grade 2 their scars were not obvious at social distances of 50cm or greater. All 11 patients (100%) who had Grade 2 scars before treatment showed improvement by 2 grades in their scars and were left with no scars [Figures [Figures6a6a–b and and7a7a–b]. Hence all 49 patients (100%) had improvement in their scars by some grade with no failure rate. In patients with Grade 4 scars [Table 3], 12 patients (75%) graded their response to treatment as very good with 50-74% improvement in their acne scars after treatment and 4 patients (25%) had good improvement in their scars with 25-29% improvement. In patients with Grade 3 scars, 8 patients (36.4%) graded their response to treatment as excellent with 75-100% improvement in their scars and 14 patients (63.6%) reported the response as very good with improvement between 50 and 74%. All 11 patients (100%) with Grade 2 scars graded their response after treatment as excellent with improvement between 75 and 100%. Poor response with 0-24% improvement in scars was reported by none of the patients. Improvement in scars was first noted in majority of the patients after completing two sitting of dermaroller and peel. At the end of 1-year of follow-up, it was observed that all the 49 patients sustained the level of improvement in their grade of scars which was attained at the end of the last procedure [Figure [Figure8a8a–c]. Although improvement in the scars as noticed by the patient and the physician continued in the follow up period of 1 year, there was no further shift in the grade of scars. Table 2 Physician's assessment of response to treatment based on Goodman and Baron Qualitative scar grading system Figure 1 (a) Grade 4 acne scars; (b) Improvement in acne scars from Grade 4 to Grade 2 after treatment Figure 2 (a) Grade 4 acne scars; (b): Improvement in acne scars from Grade 4 to Grade 3 after treatment Figure 3 (a) Grade 3 acne scars; (b) Post-treatment patient had no scars Figure 4 (a) Grade 3 acne scars; (b) Improvement in acne scars from Grade 3 to Grade 1 after treatment Figure 5 (a) Grade 3 acne scars; (b) Improvement in acne scars from Grade 3 to Grade 2 after treatment Figure 6 (a) Grade 2 acne scars; (b) Post-treatment patient had no scars Figure 7 (a) Grade 2 acne scars; (b) Post-treatment patient had no scars Table 3 Patient's assessment of response to treatment Figure 8 (a) Grade 4 acne scars; (b) Improvement in acne scars from Grade 4 to Grade 2 after treatment; (c): Sustenance of improvement in acne scars from Grade 4 to Grade 2 at 1 year of follow-up There was improvement in rolling, boxcar and linear tunnel type of scars with little or no improvement in ice pick scars. All patients tolerated the procedure well. Side effects were mild and transient. Post-dermaroller transient erythema and oedema lasted for 1-4 days with a mean of 2.4 ± 0.7 days. Post-peel exfoliation of skin was present from 2 to 7 days with a mean of 4.4 ± 1 day. Only three patients (6%) developed post-inflammatory hyper-pigmentation (PIH) which was treated with sunscreen in the morning and triple combination of tretinoin, hydroquinone and mometasone at night time. The PIH subsided after 5 months of topical treatment. One patient (2%) developed mildly tender cervical lymphadenopathy each time after dermaroller which lasted for around 3 weeks and subsided on its own. There was no interference in daily activity with no loss of days at work. DISCUSSION This study has shown good results in patients with severe Grade 4 and 3 acne scars with 10 (62.5%) patients with Grade 4 scars moving to Grade 2 and 5 (22.7%) patients with Grade 3 scars improving to have no scars at the end of treatment. In Grade 2 scars all the 11 patients (100%) showed improvement by 2 grades and were left with no scars. Hence, all 49 (100%) patients showed improvement in their scars by some grade with no failure rate. The physician's analysis also correlated with the patient's assessment of improvement in scars with 12 (75%) patients with Grade 4 scars reporting improvement as very good, 8 (36.4%) patients with Grade 3 scars as excellent and 11 (100%) patients with Grade 2 scars as excellent with poor response reported by none of the patients. The procedure was well tolerated by all the patients. Post-procedure there was no loss of work days and side effects were mild and transient. In spite of patients being of Type III, IV and V Fitzpatrick skin type, only three patients (6%) developed PIH during the treatment, which subsided within 5 months of topical therapy. It has the advantage of being an office procedure and in being cost-effective. Topical tretinoin 0.05% favours the development of a regenerative lattice-patterned collagen network rather than the parallel deposition of scar collagen found with cicatrisation. Since dermaroller opens pores in the upper layer of epidermis and allows creams to be absorbed more effectively, it is for this reason that topical tretinoin was applied during dermaroller and kept for 30 minutes post-procedure to maximise its absorption in skin. Also the improvement in the grade of scars was sustained in the follow-up period of 1 year. Although ablative laser resurfacing is generally considered to be the most effective option for scar resurfacing, it is associated with significant damage to the epidermis and basal membrane with associated inflammation which causes erythema, scarring and pigmentation problems.[13,14,15] It also has a long downtime. In comparison, percutaneous collagen induction does not induce post-operative dyspigmentation as the epidermis and basal membrane are left intact.[16] CONCLUSIONS As the demand for less invasive, highly effective cosmetic procedures is growing, this combination of treatment for acne scars has shown good results not only in Grade 2 but also in severe Grade 4 and 3 acne scars. The treatment is well tolerated in Fitzpatrick skin types III, IV and V with no failure rates or loss of days at work. There is a high level of patient satisfaction, minimal downtime and the treatment is cost-effective to the patient. To our knowledge, this is the first study using this combination of therapy in the management of atrophic acne scars and the first in which topical tretinoin cream was applied both during and immediately after doing dermaroller. __________________________________________________________________________________________________________________ Indian Dermatol Online J. 2014 Jan-Mar; 5(1): 95–97. doi: 10.4103/2229-5178.126053 PMCID: PMC3937506 Subcision plus 50% trichloroacetic acid chemical reconstruction of skin scars in the management of atrophic acne scars: A cost-effective therapy Jasleen Kaur and Jyotika Kalsy1 Treatment of acne scars is a dilemma both for the treating physician and the patient as no oral or topical medicine works and it is associated with emotional and psychological stress. Acne scars are classified into three different types: Atrophic, hypertrophic, or keloidal. Atrophic scars are the most common type of acne scars. They have been further classified into three types as described by Jacob et al.[1] into ice-pick scars, rolling scars, and boxcar scars. Most of the patients with atrophic acne scars have more than one type of scars. Various treatment modalities like punch excision and elevation, subcision, chemical peeling using various strengths of TCA, micro-needling, ablative, non-ablative lasers and fillers either singly or in combinations have been described in literature with varying results. Most of these procedures require costly equipment and materials and not affordable by many people. Subcision or subcutaneous incision-less surgery is a term coined by Orentreich and Orentreich[2] in 1995 as the treatment option for atrophic acne scars. Here hypodermic 18 no. needle is used to break the fibrotic strands that tethered the scars to the underlying tissues leading to uplifting of scars. Combining subcision with other scar revision techniques or repeated subcisions may be beneficial to the patients.[3] TCA chemical reconstruction of skin scars (CROSS)[4] is another useful method for treatment of atrophic acne scars. It involves focal application of 50-100% of TCA with a wooden applicator on the base of an atrophic scar, which causes precipitation of proteins and coagulative necrosis of cells in the epidermis. There is necrosis of collagen in the papillary and upper reticular dermis. Healing is rapid because of sparing of adjacent normal tissues and adnexal structures. So there is reorganization of dermal structural elements and increase in collagen content that leads to filling of the atrophic scar. While going through the literature, we found that different studies have used subcision and CROSS TCA alone or in combination with other techniques as well as their comparative studies but we did not find any study combining these two techniques together to the best of our knowledge. Encouraged by that, we combined subcision and TCA cross in all types of scars as subsicion breaks the dermal tethering of the scar tissue and TCA will remodel the collagen underneath the scar which treats the basic pathology of the scar to some extent. In our study, 10 female patients between the age group of 20-35 years of skin type 4 and 5 with atrophic acne scars on the face were randomly selected. Most of the patients had more than one type of atrophic scars of grade 4 severity as described by Goodman.[5] In all the patients, there were no active acne lesions and none of them were on oral isotretinoin 3 months prior to inclusion in our study. Patients with keloidal tendencies, bleeding diathesis, and history of recurrent herpes simplex were excluded. Complete hemogram, random blood sugar levels, and viral markers were done in all the patients. Written consent after explaining the risks and benefits of treatment was taken from all the patients along with pre-/post-procedure photographs. Subcision followed by 50% TCA CROSS was done at 4 weeks interval for three sessions. Patients were followed-up monthly for improvement in scars up to 6 months. Priming was done 2 weeks prior to the treatment with 2% hydroquinone and tretinoin 0.025% cream at night and sunscreen more than 30 sun protection factor (SPF) was given in the morning. Procedure was carried out after application of topical anesthetic cream for 45 min followed by infiltration of 2% Xylocaine with normal saline under aseptic conditions. A no. 18 hypodermic needle attached to a syringe was introduced horizontally underneath each scar and was moved back and forth till the snapping sound was heard. We used no. 18 hypodermic needle because it is cheap and easily available. Homeostasis was maintained by pressure. We cleaned the entire area with normal saline which was followed immediately by 50% TCA with the tip of a toothpick by pressing hard on the entire area of depressed atrophic acne scars irrespective of the type of scar and frosting was taken as the end point, antibiotic cream was applied, and patient was sent home. Patient was advised to apply antibiotic cream twice daily followed by sunscreen in the morning. Erythema, edema, and crusting lasted for 7-10 days in all the patients to varying severity. After 10 days, the patient was advised to apply azelaic acid 20% cream at night. Results were evaluated on the basis of global scar grading system, visual improvement by photographs and patient satisfaction. The global acne scarring classification is a four-category qualitative system by Goodman[5] based on scar morphology and ease of masking by makeup or normal hair patterns. Grade 1 means macular scarring only, Grade 2 is mild atrophy, which is not visible beyond 50 cm and can be easily masked by makeup, Grade 3 is moderate atrophy obvious at social distance not easily masked by makeup while Grade 4 is severe atrophy. Percentages in improvement were calculated as a combination of the three parameters, i.e. global scar grading system by Goodman, visual improvement by photographs showing the change in the grade and patient satisfaction, which was assessed by giving a questionnaire to the patient where they had to rate their improvement on 0-10 point scale. Excellent >70% Good 50-70% Fair 30-50% Poor <30% We labeled results as excellent when there was a two-grade change in the scars observed by the dermatologist both by grading system, photographs, and patient rated his improvement as more than 7 [Figures [Figures11 and and33]. Figure 1 Sites involved right cheek. (a) Post-acne scars mostly ice pick, boxcars and few roller scars. (b) Decrease in number and depth of scars Figure 3 Site involved is left cheek and left temple. (a) Many ice pick scars and a few boxcars and very few rolling scars. (b) Decrease in depth and size of scars Results were taken as good when there was one-grade improvement in acne scars observed by the dermatologist both by grading system, photographs, and patient rated his improvement as 5, 6, or 7 [Figure 2]. Figure 2 Sited involved right cheek. (a) Multiple post-acne ice pick and roller scars. (b) Decrease in size and depth of all the scars Results were taken as fair when there was improvement in acne scars observed by the dermatologist by photographs only and patient rated his improvement as 3, 4, or 5. Results were taken as poor when there was no improvement in acne scars observed by the dermatologist either by photographs or by grading system but it was only subjective improvement as told by the patient when they rated it between 1 and 3. In all the patients, scar grading improved from grade 4 to grade 2 and results were graded excellent, good, and fair in 6, 3, and 1 patients respectively [Table 1]. Although in various studies best results with CROSS TCA are seen in ice-pick scars but since in our study we combined it with subcision, results were equally good even in rolling scars and boxcars scars. Post-inflammatory hyperpigmentation was transient in three patients, which persisted for 15-20 days post-procedure, which further decreased over the time period with 20% azelaic acid and in one case, the mild hyperpigmentation persisted even at the end of 6 months in spite of the best efforts for reasons not known. The patients were also happy with the results except for the one where hyperpigmentation persisted. Although the procedure has a downtime in the form of erythema, edema, and crusting, it is comparable to all other resurfacing procedures and the problem of post-inflammatory hyperpigmentation can be judiciously tackled with the proper and repeated use of sunscreens and lightening agents. Each procedure when done individually has downtime of few days. So, we tried to reduce it by combining the two procedures. Hence, it can be concluded that subcision combined with TCA CROSS is a simple, safe, and cost-effective procedure, which does not require any specialized or costly equipments or materials or any special training and can be performed as an out-patient-department procedure by any budding dermatologist.
  20. Hi, I was wondering if it was possible to use both AHA and BHA together. I use glycolic acid at night and I was wondering if I could use salicylic acid 2% gel in the morning or if it would be too much? Also, I'm a woc (black) and I have ice pick scarring, is there any other procedure except TCA peels that is suitable for my skin? I don't want to experience hyper or hypopigmentation. (I do not have any existing pimples right now, just a little hyperpigmentation and ice pick scarring)
  21. Your advice vs derms advice

    Forums Scar treatments 5 replies

    Hi guys Sorry for posting a bit in recent times, I just need a last word of advice now before I go ahead with procedures for my scarring, so this will hopefully be my last post until skin updates in the coming months. I recently posted on here asking for advice on what I should do for my scars. Two of you experienced members suggested I look into TCA peels and the derminator to help with my scarring, also suggesting fillers would NOT be worth it, as my scars are too shallow. I then went to see a derm a few days later, who seemed reasonably knowledgable. He suggested that I have fillers put in, followed by 2-4 sessions of TCA cross, then followed by 1-2 TCA peels to finish it off. Now, you can see why I'm in a tough head space here, do I listen to the derm, or to the people that have bucketloads of experience with scarring on this website? Ive attached 2 photos below, I guess I just want to know - do you guys believe your suggestions would work better for my scarring than the derms suggestion? If so, I will change my treatment plan with him asap. Thanks
  22. TCA Cross AFTER Fillers

    Forums Scar treatments 3 replies

    Hi guys I went and saw a derm for my skin yesterday. He seemed very knowledgeable and keen to help me without ripping me off with lasers like some other derms/doctors. He suggested we start off by doing filler followed by 3-4 sessions of TCA cross, as I have quite a range of boxscars and a few ice picks and rolling. I happily obliged to doing this and have the fillers booked in for the 28th of July. However, after getting home and thinking about it overnight, I'm wondering about the logic behind doing the fillers before the TCA cross. Wouldn't getting the fillers prevent the best possible results I could get with TCA cross, seeing as the scars will be pushed up and not as shallow as they would be without the fillers in? Would I be correct in saying this? Or will I still get the same results from the TCA cross regardless of whether I get fillers or not? I know it's not an interesting topic for most of you, but I'd really appreciate a reply from anyone knowledgeable on this area so I can rearrange fillers to do post the TCA cross sessions before it's too late! Cheers Hotdog
  23. Raised scar after TCA Cross?

    Forums Scar treatments 1 reply

    I had two TCA Cross treatments a while ago - both times it took about 6 month to get rid of all redness, but the overall results were satisfiying. So my 3rd time was 4 months ago and last week this red bump popped up near the location where I had the TCA done. At first I thought it's just a pimple, but upon closer inspection I'm worried it might be a keloid scar. It's quite soft and there's a whitish part in the middle. Would be great if someone with similar experience could help me out.
  24. Hi All, I have went thru two subcision treatments and two TCA cross treatments. The second treatments was 4 months after the first and it has been about 6 months since my last treatment. While i have noticed some results, the scarring on left temple which are mostly icepicks have not seen too much improvement imo. I have micro needled three times with the derminatior. Do you guys think if i keep microneedling, the ice picks will improve? I really dont want to do any more TCA or subcision cause the side effects last way too long for me. I had bumps that took months (about 5 months) to go completely down and the redness from the TCA has lasted well over 8 months (still a lot of redness) . What can i do to improve my ice picks? will constant needling work? (once every 6-8 weeks) ?

    Forums Scar treatments 1 reply

    Help!!! I did TCA cross on some of my acne scars and they are super dark right now that not even makeup will cover them. Can yall recommend what to put on after doing TCA cross to help heal faster???