Title : A comparative study of microneedling alone versus microneedling combined with TCA CROSS in the treatment of acne scars
Abstract:
Acne is a chronic inflammatory skin condition that commonly affects adolescents and young adults and may result in permanent scarring if not treated adequately. The majority of acne scars are atrophic and develop due to collagen loss during the healing process. These depressed scars are classified into boxcar, rolling and ice-pick scars. Acne scarring not only causes cosmetic concerns but can also lead to significant psychological distress including reduced self-esteem and social anxiety. Various treatment modalities are available for acne scars; however, no single treatment is equally effective for all scar types. Microneedling is a safe, minimally invasive and cost-effective procedure that improves atrophic scars by stimulating collagen production though it shows limited effectiveness in deep ice-pick scars. Trichloroacetic acid (TCA) CROSS is a targeted and inexpensive technique that is particularly effective for treating deep ice-pick scars.This prospective study aimed to compare the effectiveness of microneedling alone with microneedling combined with TCA CROSS in the treatment of depressed acne scars. Young male and female patients presenting with boxcar, rolling and ice-pick scars were enrolled and divided into two treatment groups. A detailed clinical assessment was performed for all patients prior to treatment and all procedures were carried out under strict aseptic conditions. In the first group, patients were treated with microneedling combined with topical platelet-rich plasma (PRP). After the application of topical anaesthetic, microneedling was performed using a manual device along with topical PRP to enhance wound healing and collagen synthesis. Patients were advised post-procedure moisturisation, strict sun protection and avoidance of heat, makeup and active skincare products for two to four days, after which they could resume their regular skincare routine. In the second group, microneedling sessions were alternated with TCA CROSS using 70% TCA. During TCA sessions, the acid was carefully applied directly into deep scars using a toothpick until frosting appeared, after which the area was washed with normal saline. Patients were counselled regarding expected scab formation, the normal healing process, strict sun protection and the importance of avoiding scab manipulation. Both groups underwent six treatment sessions at four-week intervals, and maintenance sessions were advised every six to twelve months after completion of the initial treatment course. Treatment outcomes were evaluated at each visit using standardized photographs and patient feedback. Patients treated with microneedling and PRP showed significant improvement in overall skin texture and most depressed scars; however, deep icepick scars showed limited response. In contrast, the group receiving alternating microneedling and TCA CROSS showed improvement in all scar types, including deep ice-pick scars. Microneedling was associated with mild pain, transient redness and swelling lasting one to two days. TCA CROSS resulted in a longer healing time of two to three weeks and occasional post-inflammatory hyperpigmentation. Despite this, the combined treatment better overall results. In conclusion, microneedling with PRP is a safe and effective treatment for most atrophic acne scars. However, combining microneedling with alternating TCA CROSS sessions provides superior and longer-lasting results, particularly for deep icepick scars, within the same six months treatment period.
