Combined treatment modalities in atrophic acne scars: a prospective study

Saravanan Narayanan, Kamalanathan Nallu, Sridhar Venu, Arul Raja Ganapathi


Background: Atrophic acne scars are one of the sequalae that follows acne vulgaris. These scars are big cosmetic concern presenting with varied morphology like ice-pick, rolling and boxcar scars and it needs multimodal approach to treat effectively rather than a single modality. Our main aim is to study the efficacy of combination therapy using subcision, micro-needling and trichloro acetic acid chemical reconstruction of skin scars (TCA CROSS) in a sequential manner for the management of atrophic acne scars.

Methods: Total 30 patients of either sex with grade 2, 3, and 4 atrophic acne scars were graded using Goodman and Baron qualitative grading and were enrolled in the study. After single sitting of subcision, micro-needling and 50% TCA CROSS were performed alternatively at 3 weeks interval for a total of 3 sessions of each. Grading of acne scars were done by taking photographs at pre-treatment, post treatment, 1st and 3rd month after last treatment session.

Results: Out of 14 patients with grade 4 acne scars, 9 (64.3%) patients improved to grade 2 and 5 (35.7%) patients improved to Grade 3. Out of 10 patients with Grade 3 scars, 6 (60%) patients improved to grade 1, and 4 (40%) patients were improved to grade 2 at the end of study. All 5 patients with Grade 2 scars showed significant improvement from baseline.

Conclusions: Subcision, micro-needling and TCA CROSS, if they are combined and adequately done in proper manner will have excellent response in all types of atrophic acne scars.


Subcision, Micro-needling, TCA CROSS, Goodman and Baron qualitative grading

Full Text:



Pandey SS. Epidemiology of acne vulgaris. Indian J Dermatol. 1983;3:109-10.

Rivera AE. Acne scarring: A review and current treatment modalities. J Am Acad Dermatol. 2008;59:659-76.

Khunger N. IADVL Task Force. Standard guidelines of care for acne surgery. Indian J Dermatol Venereol Leprol. 2008:74:28-36.

Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles. Dermatol Surg. 1995;21:543-9.

Alam M, Han S, Pongprutthipan M, Disphanurat M, Kakar R, Nodzenski M, et al. Efficacy of a needling device for the treatment of acne scars. A randomized clinical trial. JAMA Dermatol. 2014;150:844-9.

Aust MC, Fernandes D, Kolokythas P, Kaplan HM, Vogt PM. Percutaneous collagen induction therapy. An alternative treatment for scars, wrinkles, and skin laxity. Plast Reconstr Surg. 2008;121:1421-9.

Fabbrocini G, Cassiapouti S, Fardella N, Pastore F, Monfrecola G. CROSS technique: chemical reconstruction of skin scars method. Dermatol Ther. 2008;21(3):529-3213.

Khunger N, Bhardwaj D. Evaluation of CROSS technique with 100% TCA in the management of ice pick scars in darker skin types. J Cosmet Dermatol. 2010;10:51-5714.

Lee JB, Chung WG, Kwahck H, Lee KH. Foal treatment of acne scars with trichloroacetic acid: Chemical reconstruction of skin scars method. Dermatol Surg. 2002;28:1017-21.

Goodman GJ, Baron JA. The management of postacne scarring. Dermatol Surg. 2007;33:1175-88.

Goodman GJ, Baron JA. Postacne scarring: A Qualitative global scarring grading system. Dermatol Surg. 2006;32:1458-66.

Jacob CI, Dover JS, Kaminer MS. Acne scarring : A classification system and review of treatment options. J Am Acad Dermatol. 2001;45:109-17.

Garg S, Baveja S. Combination therapy in the Management of of Atrophic Acne Scars. J Cutan Aesthet Surg. 2014;7(1):18-23.

Badheka AD, Mansuri UU, Solanki RB, A study of efficacy of subcision, micro-needling and carbon dioxide fractional laser for treatment of acne scars. Int J Res Med Sci. 2016;4:2623-9.