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TCA CROSS - A Snapshot

- TCA (Trichloroacetic Acid) is used as a chemical peel with its penetration and action dependent on the concentration of the peel.

- TCA is found in Jessner’s peel at a concentration of 14% combined with resorcinol and salicylic acid at equal concentrations.

- TCA is a versatile peeling agent which can peel and penetrate different levels of the skin based on the concentration used, with less than 35% causing a superficial peel, 35-50% causing a medium depth peel and greater than 50% causing a deep peel (when used as a single-agent).

- In concentrations of 50% and above, it is used in scar revision as a focal deep peeling agent.

- The technique is known as TCA CROSS (Chemical Reconstruction of Skin Scars) and is used predominantly to improve chicken pox, ice pick and boxcar scars.

- Choice of TCA concentration is guided by personal experience and preference.

- The original study by Lee et al in 2002 used a concentration of 65%, however concentrations of up to 100% concentrations has been used in the TCA CROSS technique.

- TCA solution is typically applied using a tooth-pick or a fine paint brush. - Frosting occurs within minutes and may last for up to 12 hours. A scab forms within a few days and resolves usually by day 7. Treatment is usually repeated every 2-4 weeks until desired outcome is achieved (usually a few sessions only).

- Possible complications of TCA peels include persistent erythema, dyspigmentation, and other forms of scarring.

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REFERENECES
• Lee JB, Chung WG, Kwahck H, Lee KH. Focal treatment of acne scars with trichloroacetic acid: chemical reconstruction of skin scars method. Dermatol Surg. 2002 Nov;28(11):1017-21; discussion 1021. doi: 10.1046/j.1524-4725.2002.02095.x. PMID: 12460296.

• Fabbrocini G, Cacciapuoti S, Fardella N, Pastore F, Monfrecola G. CROSS technique: chemical reconstruction of skin scars method. Dermatol Ther. 2008 Nov-Dec;21 Suppl 3:S29-32. doi: 10.1111/j.1529-8019.2008.00239.x. PMID: 19076629.

• Khunger N, Bhardwaj D, Khunger M. Evaluation of CROSS technique with 100% TCA in the management of ice pick acne scars in darker skin types. J Cosmet Dermatol. 2011 Mar;10(1):51-7. doi: 10.1111/j.1473-2165.2010.00526.x. PMID: 21332915.

• Agarwal N, Gupta LK, Khare AK, Kuldeep CM, Mittal A. Therapeutic response of 70% trichloroacetic acid CROSS in atrophic acne scars. Dermatol Surg. 2015 May;41(5):597-604. doi: 10.1097/DSS.0000000000000355. PMID: 25899884.

• Nofal E, Helmy A, Nofal A, Alakad R, Nasr M. Platelet-rich plasma versus CROSS technique with 100% trichloroacetic acid versus combined skin needling and platelet rich plasma in the treatment of atrophic acne scars: a comparative study. Dermatol Surg. 2014 Aug;40(8):864-73. doi: 10.1111/dsu.0000000000000091. PMID: 25006854.

• Vishwanath T, Barve A, Farande P, Ghate S, Shinde G, Nagpal A. Use of blunted needle of insulin syringe as a simple method for precise delivery of drug during chemical reconstruction of skin scars (CROSS). J Am Acad Dermatol. 2020 Sep;83(3):e177-e178. doi: 10.1016/j.jaad.2019.08.065. Epub 2019 Aug 30. PMID: 31476340. .