Acne Scar Program

A combination program designed by your doctor for your scar type, for rolling, boxcar and ice-pick acne scars.

 

Acne scarring affects 95 percent of people with acne vulgaris and can be challenging to treat. Severely inflamed spots may leave permanent scars, which can bring psychological pain, low self-esteem and a reduced quality of life. Picking or squeezing spots makes scarring more likely.

 

When it comes to acne scars, diversity is the norm: most people have a mix of scar types on the same face. That is why our program is tailor-made and multi-approach. Your doctor combines several techniques in each session, including TCA CROSS, subcision, PRP and resurfacing with fractional laser or microneedling, so that every type of scar you have is treated.

 

What it is and how it works

Why acne scars form

Scar formation is the skin's normal, natural response to healing after an injury deep enough to trigger it. Acne scars result from abnormal production and breakdown of collagen during that healing. In 80 to 90 percent of cases there is a net loss of collagen, which leaves an indented (atrophic) scar. Less often there is a net gain of collagen, which causes a raised (hypertrophic) scar or keloid.

 

The three types of indented acne scar

Indented scars are classified by the size and depth of the collagen loss. Different types are usually seen on the same person, which can make them hard to tell apart.

 

• Ice-pick scars (about 65% of indented scars): narrow, V-shaped indentations, generally smaller than 2 mm, with a sharp margin that reaches down into the deeper skin layer. Their depth makes them hard to fix with standard resurfacing.

• Boxcar scars (about 20%): wider, oval-to-round depressions of 1.5–4.0 mm with sharp, steep edges. Shallow boxcar scars (0.1–0.5 mm) respond to skin resurfacing; deep boxcar scars (0.5 mm or more) are more challenging.

• Rolling scars (about 15%): the widest, up to 5 mm across. Fibrous bands tether the skin to the structures beneath it, creating surface shadowing and an undulating, wavy appearance.

 

The techniques we combine

Resurfacing procedures are perhaps the most common interventions for acne scars. Resurfacing removes skin layers from the top down; dermabrasion was originally the main approach. We use both laser and non-laser resurfacing, together with targeted techniques for each scar type.

 

TCA CROSS for ice-pick scars. TCA CROSS stands for chemical reconstruction of skin scars using trichloroacetic acid (TCA). A high concentration of TCA is applied focally, pressing a toothpick-like applicator onto the whole indented area of each ice-pick scar until it turns frosted white. The frosting is a sign that proteins are denatured, the start of an inflammation that triggers new collagen production and reduces the depth of the scar. Because the surrounding skin is spared, healing is faster and the complication rate is low. TCA is an established peeling agent, mostly used for superficial and medium-depth peels; the higher the concentration, the deeper it reaches, so high concentrations can remodel deep scars. TCA is self-neutralizing and is not absorbed into the bloodstream, which is why concentrations as high as 100% can be used safely. Our 100% TCA is made to order.

 

Subcision for rolling scars. We specialize in classic subcision, a minimally invasive procedure that is increasingly popular for atrophic acne scars, especially rolling scars. Under local anesthetic, a small needle is moved beneath the skin to break up the fibrous bands of scar tissue that tether the skin and cause depressions. Releasing these adhesions lets the skin regain a smoother surface, and the controlled injury, including the small blood clot that forms, prompts new collagen that lifts the scar further. Subcision is especially suited to rolling scars, helps boxcar scars to a lesser degree, and is less effective for raised or hypertrophic scars. It works even better combined with other treatments such as fractional CO2 laser and PRP. Our approach is cautious: we avoid aggressive subcision techniques that carry a higher risk of complications such as further scarring, and aim for the best result with minimal risk.

 

PRP (self-extracted growth factors). Platelet-rich plasma (PRP) is a concentrate of platelets in plasma prepared from your own blood. Platelets release growth factors, including platelet-derived growth factor and transforming growth factor-beta, which speed up soft-tissue regeneration and collagen deposition. PRP improves the response of acne scars to resurfacing and reduces side effects after the procedure. It is often combined with subcision ("PRP subcision") and with resurfacing.

 

Microneedling. Skin needling, or collagen induction therapy, uses sterile micro-needles to puncture the skin superficially. This releases growth factors and activates a wound-healing process in which new collagen forms under the skin over 12 to 18 months. It is a simple, safe and effective way to treat indented scars: it does not damage the epidermis, has a short recovery time, also fades dark marks left by acne, and releases fibrous strands to improve indented scars and wrinkles. It also tightens and rejuvenates the skin.

 

CO2 fractional laser. Laser resurfacing removes the outer layer of the skin to boost regeneration, and its heat also improves elasticity. Our carbon dioxide fractional laser combines a CO2 laser with fractional technology: micro-ablative dots penetrate deep into the skin while severe damage and lateral heat damage are avoided, reducing downtime and side effects. It encourages wound renewal and new collagen and hyaluronic acid production. For darker skin tones, or if you prefer an alternative to laser, we can switch to microneedling as the resurfacing method.

 

What it is for

• Ice-pick acne scars

• Boxcar acne scars

• Rolling acne scars

• A mix of scar types on the same face

• Dark marks left after acne (with microneedling)

 

Who it is for

Anyone with indented (atrophic) acne scars, from mild to severe and resistant scarring. The program is especially useful when you have more than one type of scar, because each technique targets a different type.

 

Who should not have it

Subcision is less effective for raised or hypertrophic scars. If you have a history of cold sores, please tell your doctor before treatment.

 

The treatment

Each session takes 45–60 minutes. Your doctor first examines your skin and designs the combination for your scar types; the exact details of your treatment depend on that examination. Every case and every step is carried out by a medical doctor.

 

What happens in a session

Generally we use several techniques in each session (TCA CROSS, PRP, subcision, fractional laser and microneedling). For resistant scarring, a typical plan alternates two kinds of session once a month until the result you want is reached:

 

First session

 

• TCA CROSS, to correct pitted (ice-pick) scars

• PRP subcision, where your own growth factors help stimulate new collagen

• A chemical peel, to improve shallow acne scars

• A calming "Miracle mask", to reduce inflammation and downtime

 

Second session

 

• Microneedling, to resurface the whole area and make the skin even and smooth

• Fractional laser, for deep pitted scars

• PRP subcision

• A calming "Miracle mask"

 

TCA CROSS step by step

Your face is cleansed with soap and water to remove oil, and every ice-pick scar is marked. TCA is applied to the base of each scar and your doctor watches until a frosted appearance develops. The discomfort is so slight that no numbing cream or local anesthetic is needed; you may feel mild burning, which is well tolerated. Frosting, redness and swelling settle within 4–6 hours. A crust forms the next day and gradually falls off, within 3–4 days in most patients, depending on skin type. People with very oily skin, or who use a lot of moisturizer, may heal differently and skip the crust phase.

 

During the scab phase the scar can sometimes look deeper than before. This is because the scar tissue is shrinking and preparing to peel off, which temporarily exposes a deeper-looking base. It is a passing effect: the scar gradually refills with new collagen after the scab phase, which typically lasts about 10 days depending on skin type.

 

Subcision

Subcision is done under local anesthetic. Recovery is brief and you can return to normal activities quickly. Results build gradually as collagen production continues, and multiple sessions may be needed.

 

Number of sessions

The number of sessions is always set by your doctor after an in-person assessment, depending on your scar type, severity and skin. Several treatments can be combined on the same day, as your doctor advises.

 

Before and aftercare

After-care is a crucial factor in the success of the treatment. Once the procedure is done, it is your body that produces the new cells and collagen, so give it the best conditions.

 

Before treatment

• Read the labels of your skin-care products. If they contain glycolic acid or retinoic acid, stop using them two weeks before the procedure (and for two weeks after).

• If you have a history of cold sores, please inform your doctor.

 

After treatment

• Do not pick at crusts while they heal.

• Use at least 2 grams of SPF 30 PA+++ sunscreen, reapplied several times a day, and strictly until all crusts have fallen off, to prevent post-inflammatory hyperpigmentation (dark marks).

• Avoid strong sunlight, especially in the first two weeks, because UV light disrupts new collagen production. Avoid intense sun such as sunbathing for at least one month where possible; if sun exposure is necessary, wear clothing that covers the treated area.

• Apply a generous amount of sensitive-skin moisturizer (no whitening, no perfume, no AHA or BHA) several times a day for a week. Your own stem cells and fibroblasts work best on moist rather than dry skin, and this also minimizes scabbing after resurfacing.

• Cleanse and moisturize daily with light, mild products.

• Do not use abrasive scrubs or toners for about a week after the last treatment, and avoid alcohol-based toners and whitening products for the first week. Let the skin heal fully before returning to your normal routine.

• Do not go swimming for at least 5 days.

• No exercise for 24 hours.

• Makeup: after TCA CROSS alone, makeup can be applied as usual; after resurfacing, regular makeup can be applied from the next day.

• Pay attention to nutrition: avoid high-sugar foods and make sure you get enough protein and vitamin C, the building blocks of new collagen.

• Do not smoke, and limit passive smoking, for the next 6 months, the period of most intense new collagen production.

 

If you have any questions about aftercare, please ask us; we are always happy to help you get the best result.

 

Quality and safety

• A tailor-made plan for every case, based on your doctor's examination of your scar types and skin.

• Every case and every step is performed by a medical doctor. The doctors and staff speak fluent English and specialize in caring for international patients.

• 100% TCA is made to order, and applied only to the scars themselves so the surrounding skin is spared.

• A cautious approach to subcision: we avoid aggressive techniques that carry a higher risk of complications, balancing risks and benefits in every case.

• PRP from your own blood reduces side effects after resurfacing, and a calming mask ends the session to reduce inflammation and downtime.

• No severe side effects have ever been seen with our TCA CROSS treatment.

 

The science

TCA CROSS

The CROSS technique was first reported by Lee and colleagues. High-concentration TCA (70–100%) causes a local inflammatory reaction that leads to new collagen fibers and remodeling of the dermal collagen, a process that continues for several months after treatment. As collagen, glycosaminoglycans and elastin increase and reorganize, the dermal volume grows, improving the scar by increasing light reflection and reducing the shadows cast over depressions.

 

• In a study of 53 adults with atrophic acne scars, 70% TCA applied focally every two weeks (CROSS therapy) gave good or excellent improvement (more than 50%) in 66 percent of patients, according to patient and physician assessments; 81 percent of patients were satisfied or very satisfied.

• In a study of 16 patients treated with 100% TCA, 69 percent reported excellent results (more than 75% improvement) and the rest reported good results.

• In another series, 8 patients (80%) showed considerable improvement, more than 70%, after four sessions. The CROSS technique with 100% TCA was found to be safe, minimally invasive and effective for ice-pick scars, and can be used safely on all skin types.

 

In our own patients, 80 percent show excellent improvement after four sessions, and ice-pick scars continue to improve at the three-month follow-up. For optimal improvement most patients need 3 to 6 TCA CROSS treatments at 2- to 8-week intervals.

 

Microneedling

Six months after microneedling resurfacing, collagen and elastin production improved by 400% up to 1,000%. One year after therapy, epidermal thickness improved by 40%. Facial skin analysis showed improved skin roughness one month after treatment.

 

Fractional laser

Laser resurfacing has been used since the mid-1990s. In acne scars, fractional laser results are fast and practical: in about 35% of patients the scarring was completely removed and in another 40% it improved significantly, with nearly all showing a reduction of the lesions. Dotted ice-pick and indented scars responded best. Fractional photothermolysis with a CO2 fractional laser is a safe and effective method for treating acne scars.

 

Subcision

Wider, deeper and more noticeable rolling scars look dramatically better after subcision; boxcar scars improve much less but still benefit to some degree. Subcision is more effective when combined with fractional CO2 laser and PRP. In the clinic, patients with severe acne scars (grades 3 and 4) showed impressive results: more than 90 percent improved by at least one grade, and 70 percent had an excellent response. Side effects were minimal, such as slight redness, swelling and pain lasting 1–2 weeks, and the procedure was well tolerated by all patients.

 

PRP

PRP is beneficial in atrophic acne scars by promoting collagen deposition. Several mechanisms explain its added benefit in combination treatments:

 

• Activated platelets release secretory proteins, such as platelet-derived growth factor and transforming growth factor, that attract stem cells and stimulate them to divide, and support new blood vessel formation and collagen production.

• PRP enhances the production of hyaluronic acid, which absorbs water, increases skin volume and elasticity, and supports cell regeneration, the extracellular matrix and collagen production.

 

Raised scars and keloids

Fractional lasers can also reduce hypertrophic scars and keloids by inducing heat-shock proteins and generating new collagen.

 

Frequently asked questions

My scars are quite severe. What procedures would you recommend?

Generally we use several techniques in each session (TCA CROSS, PRP, subcision, fractional laser and microneedling). This works best because the different treatments take care of all types of scarring. The details of your treatment depend on your skin examination, which we go through with you at a face-to-face consultation.

 

I have resistant acne scarring. What is the best plan?

A typical plan alternates two sessions once a month. The first combines TCA CROSS for pitted scars, PRP subcision, a chemical peel for shallow scars and a calming mask. The second combines microneedling to resurface the whole area, fractional laser for deep pitted scars, PRP subcision and a calming mask. These are alternated until you reach the result you want.

 

Why does my scar look deeper after TCA CROSS?

During the scab phase the scar tissue shrinks and prepares to peel off, which can make the base look deeper for a while. It is temporary: the scar gradually refills with new collagen after the scab phase, which lasts about 10 days depending on skin type.

 

Does TCA CROSS hurt?

The discomfort is minimal, so no numbing cream or local anesthetic is needed. Most people feel only a mild, well-tolerated burning.

 

Can I wear makeup after treatment?

After TCA CROSS, makeup can be applied as usual. After resurfacing, regular makeup can be applied from the next day.

 

I have darker skin. Can I still have resurfacing?

Yes. For darker skin tones, or if you prefer to avoid laser, we can use microneedling as the resurfacing method instead of fractional laser.

 

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