Journal of General - Procedural Dermatology & Venereology

Indonesia

Volume 6 Article 6
Number 1 (June 2022 Edition)

6-30-2022

Combined use of CROSS TCA and modified subcision with PRP

administration for acne scars
Ahmad Fiqri
Dermatovenereology Department, Dr. Moewardi Hospital, Surakarta, Indonesia

Moerbono Mochtar
Dermatovenereology Department, Dr. Moewardi Hospital, Surakarta, Indonesia

Dendy Zulfikar
Dermatovenereology Department, Dr. Moewardi Hospital, Surakarta, Indonesia

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Recommended Citation
Fiqri, Ahmad; Mochtar, Moerbono; and Zulfikar, Dendy (2022) "Combined use of CROSS TCA and modified
subcision with PRP administration for acne scars," Journal of General - Procedural Dermatology &
Venereology Indonesia: Vol. 6: No. 1, Article 6.
DOI: 10.19100/jdvi.v6i1.293
Available at: https://scholarhub.ui.ac.id/jdvi/vol6/iss1/6

This Article is brought to you for free and open access by UI Scholars Hub. It has been accepted for inclusion in
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 Case Report

Combined use of CROSS TCA and modified subcision

with PRP administration for acne scars

Ahmad Fiqri, Moerbono Mochtar, Dendy Zulfikar

Dermatovenereology Department, Dr. Moewardi Hospital, Surakarta, Indonesia

Email: fiqridv@gmail.com

Abstract

Background: Acne vulgaris is a skin disease that can cause permanent scarring. Various therapeutic options
are available to treat atrophic scars, but combination therapy is still the best choice according to different types
of scars in a single patient. Chemical reconstruction of skin scars (CROSS) trichloroacetic acid (TCA), modified
subcutaneous incisionless (subcision), and platelet-rich plasma (PRP) can be used as a combination therapy
to treat acne scars.
Case Illustration: A 25-year-old man complained of acne scars on both sides of his face. Dermatologic
findings were blackheads, icepick, boxcar, and rolling scars. Clinically he had moderate to severe acne scores.
He was treated with a combination of CROSS TCA for icepick-type acne scars, modified subcision, and PRP
injection for rolling and boxcar-type acne scars on both sides of the face. During treatment, the patient was
given oral and topical antibiotics. The patient was followed-up after one month. It resulted in a good therapeutic
response, which showed 25%-49% of Goodman and Baron’s classification, and a visual analog scale of 6.
Discussion: CROSS TCA is a therapeutic choice for icepick-type acne scars with a simple, practical technique
and provides a significant effect. Modified subcision is modified therapies from the previous Khunger subcision
technique and a new alternative that can be applied to damaged tissue. This can maximally repair scarring,
facilitate surgeon, provide avenues, and increase maximum PRP penetration.
Conclusion: CROSS TCA with subcision and PRP are simple procedures that can be applied as an alternative
therapy to acne scars with good therapeutic response.

Keywords: CROSS TCA, PRP, scars, subcision

Background
Acne vulgaris (AV) is a chronic skin inflammation
as a result of a complex pathophysiology process.
AV has a prevalence of almost 95% in adolescents
and will be persistent in adults.1,2 The cause of AV
is multifactorial, related to genetics, race,
hormonal, stress, climate/temperature/humidity,
diet, and immune response.3
AV can result in a permanent scar.4 All types of
acne from papule, pustule, and nodulocystic
potentially generate scars during wound healing.5
A study reports an incidence rate of 16,7% of the
population can develop acne scars. There are two
basic types of scars, including hypertrophic and
atrophic scars, whereas 80-90% are
hypertrophic.6,7
The type of the scar depends on the
pathophysiology and lesion healing process. The
lesion healing process, affected by inflammation,
can lose collagen excessively, causing an atrophic
scar. Excessive collagen deposition can also
occur, thereby leading to a hypertrophic scar.
Atrophic scar prominently occurs on the face, while
hypertrophic one in the body and rarely occurs
spontaneously.8,9
A variety of therapeutic modalities can be used to
improve acne scars. Chemical reconstruction of
skin scars (CROSS) applies high-concentration
trichloroacetic acid (TCA) on acne scars with an
applicator, usually with a wooden-made pointed tip.
TCA is applied for a few seconds until the “white
frost” appears on the scar. Administering emollient

J Gen Proced Dermatol Venereol Indones. 2022:6(1);36-43 36

and avoiding sunlight exposure are recommended
following this technique implementation for 4
weeks. TCA leads to cells and collagen necrosis
pathways in the skin layer that prevent new scars
and hyperpigmentation from occurring.10
Subcision is a surgical technique for treating
atrophic scars, wrinkles, and contours using a 23-
26G gauge tri-beveled hypodermic needle inserted
through a puncture. The subcision corrects defect
using two mechanisms: sectioning subcutaneous
tissue and removing the bond on the location, and
forming new connective tissue. The subcision
technique is divided into lancing subcision,
horizontal fanning subcision, and vertical
subcision. Horizontal fanning subcision is often
used by inserting the needle into the middle-to-
deep dermis layer and wiping like a fan. The end
product of it is to avoid the connection between
papillary epidermis and deeper epidermis, creating
a controlled trauma that in turn, will lead to wound
healing and connective tissue formation.11
Platelet-rich plasma (PRP) is a high concentration
of autologous plasma solution obtained from the
patient’s own blood, containing platelets releasing
various growth factors (GF) necessary in the
wound healing process. PRP is a new therapeutic
option applied to dermatological conditions.12 Only
a few studies have been conducted on the
combination of modified techniques and PRP in
dealing with several acne scar types.12,13 The
objective of this case is to determine the advantage
of combined CROSS TCA and modified subcision
with PRP addition in acne scars and its
effectiveness as a combination therapy.
Case Illustration
A 25-year-old man came to the
Dermatovenereology Department of Dr. Moewardi
General Hospital Surakarta complaining of acne
scars on his face, which appeared when he was 15
years old, with blackhead (comedones) and small
acne on the face. Then the acne worsened and
suppurated. The patient treated it using the facial
wash and acne cream. When he was 20 years old,
the patient met a dermatovenereologist in
Yogyakarta, received topical medicine, and
underwent facial and chemical peeling treatment.
The acne improved, but the scars left deep scars.
He said that he had never taken treatment or cream
medicine anymore. He was exposed to sunlight
during work and when riding a motorcycle. His
parents also had acne when they were
adolescents. There is no history of diabetes or
allergy.
J Gen Proced Dermatol Venereol Indones. 2022:6(1);36-43
The physical examination showed that vital signs
were normal. Dermatological examination showed
that patient had Fitzpatrick IV-V skin type.
Blackheads were seen at a very close distance
with icepick, boxcar, and rolling types of scars at a
1-meter distance. Some acne scars would
disappear, but some were still visible during
stretching. Considering Goodman and Baron’s
criteria, such conditions belonged to moderate-
severe degree acne scars.
The treatment procedure commenced when the
patient’s face was free of active lesions. The
procedure of preparing PRP is explained below:
1. Whole blood was drawn from the patient
during treatment.
2. The specimen was then stored at 20-24° C
temperature before centrifugation.
3. High-speed whole blood centrifugation was
conducted (3000 rpm/3 minutes). Three
layers were created; the bottom layer
consisting of erythrocyte; the middle layer
consisting of PRP and erythrocyte; and the top
layer consisting of platelet-poor plasma
(PPP).
4. Supernatant plasma was taken from the upper
part of the tube.
5. The buffy-coat layer was transferred to other
sterile tubes.
6. Buffy coat tube was centrifuged at low speed
(1500 rpm/12 minutes) to separate
erythrocyte or using a leukocyte filtration
filter14.
The treatment procedure started with mapping the
acne scar area by dividing the icepick and rolling-
boxcar types according to therapy choices. Topical
anesthesia was applied to his entire face. CROSS-
TCA was administered to the face area with an
icepick scar using a sharp-pointed sterile toothpick
that had been cut and immersed into TCA 70%
solution until it appeared “frosting.” Subcision
followed with rolling and boxcar scar using a 23–
26-gauge needle. PRP subcutaneous injection was
conducted following subcision treatment. Then, an
ointment was applied to the entire face. The patient
was discharged and given oral antibiotic
Azithromicyn 500 mg once a day and topical
antibiotic ointment twice a day to the entire face for
three days as prophylaxis. He was advised not to
wash his face using tap water for three days and
avoid exposure to direct sunlight during treatment.
Monitoring was conducted one month following the
treatment.
Several side effects were observed during the
therapeutic process, i.e., minimal hematoma and
swelling in the treatment area 3 days post-
37
treatment. The evaluation was repeated by
referring to Goodman and Baron’s acne scar
criteria. Therapeutic response was considered
poor if there was no progress on acne scar
degrees/points (0%-24%), good if increased by 1
point (25%-49%), very good if increased by 2
points (50%-74%), and excellent if increased by 3
points (75%-100%) (Table 1).13 After one month of
treatment, the patient responded well to the
therapy on both sides. In addition, at the end of
therapy, an assessment was conducted as well on
the patient’s satisfaction level using a visual analog
scale (VAS), with a satisfaction score of more than
6 being excellent, 4-6 being good, and less than 4
being poor. The patient reported a VAS score of 6.

Table 1. The response of acne scar therapy based on the classification system by Goodman and Baron

Excellent Increase by 3 points 75 – 100 %

Very Good Increase by 2 points 50 – 74 %
Good Increase by 1 point 25 – 49 %
Poor No improvement in therapeutic response 0 – 24 %

Taken from Al-aajem et al. J Ideas Heal. 2019;2(2):118–22.13

Discussion the remodeling and tissue maturation remodeling

Four main factors causing acne incidence are
epidermal gland hyperproliferation, excessive
sebum production, inflammation, and
Propionibacterium acnes activity. The components
of sebum, triglyceride, and lipoperoxidase play an
important part in acne formation. Triglyceride is
broken down into free fatty acid by P. acnes, which
triggers P. acnes bacterial clumping and
colonization, local inflammation, and is
comedogenic. Lipoperoxidase also produces pro-
inflammation cytokine and activates peroxisome
proliferator-activated receptors) track, increasing
sebum production. The hormonal factor increasing
sebum production is the androgenic bond hormone
increasing sebaceous gland activities.15,16
All incidences will trigger the wound healing
process consisting of three main phases:
inflammation, proliferation, and remodeling.9
Inflammatory mediators are activated and released
on the lesion area to form tissue granulation. There
is a link between inflammation time and the acne
scar formation process. The pathogenesis process
of acne confirmed that inflammation phase
treatment prevents scarring. Thus, the acne lesion
treatment at the beginning of the inflammation
stage is recommended to be the best approach to
preventing acne scar formation.17
The damaged tissue is repaired in the proliferation
or the granulation tissue formation phase, creating
new blood vessels. Neutrophil replaced with
monocyte and changing into macrophage releases
some GFs: platelet-derived growth factors (PDGF),
fibroblast growth factors (FGF), transforming
growth factors α and ß (TGF- α and TGF-ß),
stimulating fibroblast migration and proliferation. In
phase, fibroblasts and keratinocytes produce
enzyme determining extracellular matrix (ECM),
which are matrix metalloproteinases (MMPs) and
tissue inhibitors MMPs (TIMPs). Matrix
metalloproteinases lower the enzyme interaction
level and form a lipid cascade for ECM remodeling.
The unequal ratio of MMPs to TIMPs contributes to
the development of atrophic and hypertrophic
scars. The excessive matrix degradation leads to
reduced collagen deposition, forming an atrophic
scar.8
Acne scars are formed due to the damage in three
stages of the lesion healing process above. The
scarred surface is open and wider than the
infundibulum (V-shape). Its orifice is small with a
sheer side. Boxcar scar is shallow (< 0.5 mm) and
deep (> 0.5 mm) with 1.5 - 4 mm diameter. The
shape of a boxcar scar ranges from round to oval
with a vertical edge, firm border, sheer tip, and wide
bed resembling a U-shape. The rolling type scar is
the widest one, “M”-shaped, with an irregular edge
and making the skin look wavy. The rolling scar is
commonly 4-5 mm broad and has dermal or
subdermal pulling characteristics.18 This acne scar
type can sometimes be found on a patient’s patient
and is difficult to distinguish. The qualitative
classification of acne scar atrophy often used is
Goodman and Baron’s classification system (Table
2).19
Before applying acne scar therapy, the patient
should be informed first that total repair is
impossible. The objective is to repair the acne
scar.20 A variety of non-invasive and minimally
invasive therapeutic modalities is available for
acne scars, including chemical peels, topical
retinoid, microdermabrasion, microneedling, and

J Gen Proced Dermatol Venereol Indones. 2022:6(1);36-43 38

radio frequency. The invasive therapy includes the
acne scar section and ablative laser for acne scars.
Research is developed continuously to find another
safer, more comfortable, and effective therapy for
the patient. The latest therapeutic option is
phototherapy or intradermal stem cell injection for
patients with moderate-severe degree atrophy
scar.21
In this case, the patient’s face has several acne
scar types: icepick, boxcar, and rolling in some
areas, so a combined CROSS TCA and modified
subcision technique treatment are given to icepick
type of acne scar, with PRP addition for boxcar and
rolling types (Figure 1).

A B

C D

E F

Figure 1. (A, C, E) The patient’s face from the front, right, and left before the treatment using CROSS TCA
and modified subcision therapy with PRP addition.
(B, D, F) The patient’s face 1 month after the treatment.

J Gen Proced Dermatol Venereol Indones. 2022:6(1);36-43 39

CROSS using high-concentration TCA (70%-
100%) is an effective therapy in managing icepick
acne scars.22 This CROSS-TCA method is
effective and safe in the dark or Fitzpatrick IV-V
type skin. This method’s principle is to make
lesions with chemical liquid that will increase
dermis volume due to the formation of collagen
tissue, glucose-aminoglycans, and elastin, and
thereby the scar seems to be shallower. CROSS-
TCA technique manages acne scars effectively as
it is more practical and does not require specific
tools and anesthesia first so that the patient will be
more comfortable.23
In this case, the modified subcision technique is
used for rolling and boxcar types of acne scars.11
PRP is a new alternative therapy that has been
evaluated and is advantageous to acne scar
patients. PRP is a plasma fraction element of
autologous blood over-baseline concentration.12
The principle is to take the patient’s blood to be
centrifuged at varying speeds until it is divided into
three layers: PPP, PRP, and erythrocyte. The
material with the highest-specific gravitation will
pile up on the bottom of the tube. PRP contains
some growth factors: PDGF, high-level TGF-beta
1, and vascular endothelial growth factor (VEGF).14

Subcision is a term representing an undermining A previous study conducted by Deshmukh and

local subcutaneous form without an incision to
remove the skin from the skin tissue adhesion
below it and create a controlled new wound to
initiate the new wound healing with an expectation
that collagen tissue will be formed and deal with
atrophic/concave area. Subcision also contributes
to the removal of atrophic scar and results in
trauma at the macroscopic level of scar tissue to
create a new collagen matrix and tissue,
responsible for the permanent clinical improvement
of an atrophic scar. Subcision is a simple and safe
procedure that can be combined with other
treatment.24
Many modifications have been made to skin
surgical techniques, including subcision technique.
Belgaumkar25 found that 40 patients treated with a
single subcision method compared with combined
subcision and PRP injection with split-face
reported that the area of face getting combined
treatment provides an outcome PRP and subcision
showed greater improvement (32.08%) in post-
acne scars as compared to subcision alone
(8.33%). A study by Abou Khedr et al.26 also
compared the atrophic scar repairing method with
subcision and modified subcision with the PRP
method on 15 patients with respective treatments,
finding that the patients treated using combined
therapy had better outcomes than those treated
using the single subcision method.

Table 2. A qualitative classification system by Goodman and Baron

Classification Degree Clinical manifestation

1 Macula The scar can be erythematous and flat hyper-or hypopigmentation. No
problem with skin contour such as other level acne scar classification but
merely color change
2 Mild Mild atrophy or hypertrophy scar is less visible from 50-cm or more
distance and can be covered well with makeup
3 Moderate Moderate atrophy or hypertrophy scar is visible from 50-cm or more
distance and cannot be covered well with makeup, but it seems to be flat
or to disappear when the skin is stretched manually.
4 Severe Severe atrophic or hypertrophic scar is visible from 50 cm or more
distance, cannot be covered with makeup, and does not disappear if the
skin is stretched manually.

Taken from Goodman GJ, Baron JA. J Cosmet Dermatol. 2006;5(1):48–52.19

J Gen Proced Dermatol Venereol Indones. 2022:6(1);36-43 40

 A B

C D

E F

Figure 2. (A) Identification of rolling, boxcar, and icepick scar areas, (B) Administration of CROSS TCA to
icepick type of acne scars, (C) Drawing PRP using a different gauge (D) Modifying the gauge tip for
subcision, (E) Subcision treatment, and (F) PRP injection for rolling and boxcar type of acne scars.

J Gen Proced Dermatol Venereol Indones. 2022:6(1);36-43 41

In this case, two different techniques were used for
different acne scar types. CROSS TCA technique
is an option to repair icepick type of acne scar. The
modified subcision technique with PRP injection is
an option to improve the rolling and boxcar types of
acne scars, but only very few studies have reported
its use concomitantly (Figure 2). Considering the
result of one-month monitoring, a good therapeutic
response was achieved in this case according to
Goodman and Baron’s criteria, and patient
satisfaction with a VAS score of 6.
Conclusion
The CROSS TCA technique was chosen in this
case because it is the first-line therapy for icepick
acne scars. The modified subcision technique with
PRP addition was selected to improve the boxcar
and rolling types of acne scars effectively. The
outcome indicated that the two sides of the face
treated had an acne scar improvement score of
25%-49%, referring to the good category based on
Goodman and Baron’s qualitative classification, at
one-month monitoring. Monitoring and further
study are still needed with the larger sample size
concerning the combined CROSS TCA and
modified subcision with PRP in managing acne
scar patients with a similar issue.
References
1. Common JEA, Barker JN, Steensel MAM.
What does acne genetics teach us about
disease pathogenesis? Br J Dermatol
[Internet]. 2019 Oct 10;181(4):665–76.
Available from:
https://onlinelibrary.wiley.com/doi/10.1111/bj
d.17721
2. Skroza N, Tolino E, Mambrin A, et al. Adult
acne versus adolescent acne: A retrospective
study of 1,167 Patients. J Clin Aesthet
Dermatol. 2018;11(1):21–5.
3. Naveed M, Bashir S, Khalid S, Qamar S,
Shahid M, Raheela HW. Risk Factors of acne
vulgaris among young females. J Humanit
Cult Stud. 2020;0958(3):116–21.
4. Clark AK, Saric S, Sivamani RK. Acne scars:
how do we grade them? Am J Clin Dermatol
[Internet]. 2018 Apr 11;19(2):139–44.
Available from:
http://link.springer.com/10.1007/s40257-017-
0321-x
5. Heng AHS, Say YH, Sio YY, Ng YT, Chew FT.
Epidemiological risk factors associated with
acne vulgaris presentation, severity, and
scarring in a Singapore Chinese population: A
cross-sectional study. Dermatology.
J Gen Proced Dermatol Venereol Indones. 2022:6(1);36-43
2022;238(2):226–35.
6. Awaloei YM, Prastowo NA, Regina R. The
correlation between skin type and acne scar
severity in young adults. J Kedokt dan
Kesehat Indones. 2021;12(1):52–7.
7. Kurokawa I, Layton AM, Ogawa R. Updated
treatment for acne: Targeted therapy based
on pathogenesis. Dermatol Ther (Heidelb)
[Internet]. 2021;11(4):1129–39. Available
from: https://doi.org/10.1007/s13555-021-
00552-6
8. Moon J, Yoon JY, Yang JH, Kwon HH, Min S,
Suh DH. Atrophic acne scar: A process from
altered metabolism of elastic fibres and
collagen fibres based on transforming growth
factor-β1 signalling. Br J Dermatol.
2019;181(6):1226–37.
9. Mathew-Steiner SS, Roy S, Sen CK. Collagen
in wound healing. Bioengineering. 2021;8(5).
10. Meidiyanti P, Adiwinarni DR, Budiyanto A,
Wirohadidjojo YW. Combination of 80%
trichloroacetic acid cross and platelet-rich
fibrin lysate for improving atrophic acne scar:
A case series. 2020;(Ictromi 2019):329–32.
11. Zayed A, Abelghafar R, Hehazy A, Orabi S,
El-Mesidy M. Novel subcision technique
combined with either microneedling or
trichloroacetic acid 35% peeling for acne
scars: A comparative study. J Egypt Women’s
Dermatologic Soc. 2021;18(2):109–18.
12. Rohmah RN. Microneedling dengan platelet-
rich plasma (PRP) untuk skar akne atrofi.
Cermin Dunia Kedokt [Internet].
2021;48(9):380–5. Available from:
http://www.cdkjournal.com/index.php/CDK/art
icle/view/1500
13. Al-aajem BMR, Alkayally KK, Alkayally AKK.
Evaluation of efficacy and safety of platelet-
rich plasma (PRP) and microneedling
(radiofrequency) in the treatment of atrophic
acne scars. J Ideas Heal. 2019;2(2):118–22.
14. Miranda S, Costa MFM, Rebouças N, Ramos
MT, Lessa DAB, Alencar NX. Protocols for
preparation of platelet rich plasma (PRP) in
quarter horses. Pesqui Vet Bras.
2019;39(8):614–21.
15. Sutaria AH, Masood S, Schlessinger J. Acne
vulgaris [Internet]. Vol. 379, StatPearls. 2022.
p. 1343–52. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/290836
70
16. Mohiuddin AK. A Comprehensive Review of
acne vulgaris. Inno J Clin Pharm [Internet].
2019;1(1):1–17. Available from:
www.innovationinfo.org
17. Dréno B, Stein GL. Acne scarring: Why we
should act sooner rather than later. Dermatol
Ther (Heidelb). 2021;11(4):1075–8.
42
18. Callaghan DJ. Review on the treatment of
scars. Plast Aesthetic Res. 2020;2020.
19. Goodman GJ, Baron JA. Post-acne scarring -
a quantitative global scarring grading system.
J Cosmet Dermatol [Internet]. 2006;5(1):48–
52. Available from:
https://onlinelibrary.wiley.com/doi/10.1111/j.1
473-2165.2006.00222.x
20. Behrangi E, Goodarzi A, Roohaninasab M,
Sadeghzadeh-Bazargan A, Nobari NN,
Ghassemi M. A review of scar treatment
related to acne and burn. J Crit Rev.
2020;7(4):714–22.
21. Dastagir K, Obed D, Bucher F, Hofmann T,
Koyro KI, Vogt PM. Non-invasive and surgical
modalities for scar management: A clinical
algorithm. J Pers Med. 2021;11(12).
22. Amin S, Rashid T, Shehzad A, Arshad A,
Younas S. Outcome of CROSS technique with
100 % trichloroacetic acid in the management
of atrophic icepick acne scars. J Pakistan
Assoc Dermatologists. 2018;28(4):485–8.
23. Abrusci V, Benzecry V. Acne Scar: CROSS
J Gen Proced Dermatol Venereol Indones. 2022:6(1);36-43
(Chemical Reconstruction of Skin Scar). In:
Minimally Invasive Aesthetic Procedures
[Internet]. Cham: Springer International
Publishing; 2020. p. 649–58. Available from:
http://link.springer.com/10.1007/978-3-319-
78265-2_90
24. Dadkhahfar S, Robati RM, Gheisari M,
Moravvej H. Subcision: Indications, adverse
reactions, and pearls. J Cosmet Dermatol.
2020;19(5):1029–38.
25. Deshmukh NS, Belgaumkar VA. Platelet-rich
plasma augments subcision in atrophic acne
scars: A split-face comparative study.
Dermatologic Surg [Internet]. 2019;45(1):90–
8. Available from:
https://journals.lww.com/00042728-
201901000-00012
26. Abou Khedr NAE-A, Hussein TM, Abd El-
Fatah AME-S. Comparing the role of
subcision suction method with and without the
injection of platelet-rich plasma in the
treatment of depressed scars. J Surg
Dermatology. 2017;2(2):88–97.
43