The Comparison of Dentist Drill with Chemical Reconstruction of

Skin Scars (CROSS) Trichloracetic Acid (TCA)

on Icepick Acne Scars

Moerbono Mochtar

, Leonardo Trisnarizki

, and Indah Julianto

Department of Dermato - Venereology

Medical faculty of Sebelas Maret University. Dr.Moewardi general Hospital - Surakarta

Keywords: Acne scars, Dentist drill CROSS TCA.

Abstract: Acne scar is the most common complication of acne with high incidence rate. There are 3 types of acne scars

ie. boxscar, icepick and rolling. Icepick scar is the most frequent in upto 60-70% cases. Dentist drill is small

high speed drill used to remove decayed teeth in dental caries treatments. The drill can also be used to treat

icepick acne scars. Chemical reconstructions of skin scars (CROSS) using Trichloracetic Acid (TCA) is also

an effective treatment for icepick scars. Objective: To compare the effectiveness of dental drill with CROSS

TCA for treating icepick scars. The total of 10 patients aged 20-40 year old, Fitzpatrick skin type III-IV, with

moderate to severe acne scars more than 3 months were included. Dentist drill was performed on the right

cheek, while CROSS TCA was performed on the left cheek. Comparison of the effectiveness were based on

clinical improvement by photograph, wound healing time, and patients comfort. The patients were evaluated

on days 3, 7, 14 and 30. At the end of the study 6 patients showed excellent clinical improvement, while 4

others showed moderate improvement. Both method were effective for icepick scars treatment. Dentist drill

provided faster wound recovery (3 days) than CROSS did (7 days). However CROSS TCA is more practical

because no special tools requirement, no anesthesia, and more comfortable for the patients.

1 INTRODUCTION

Acne scars are the most common complication of acne. This

scar can be found in 95% of acne patients resulting in

psychological effects such as low self-esteem, impaired

social interactions, and may influence the successful in

searching a job (Hession and Graber, 2015). Acne scars

classified into three i.e atrophic, hypertrophic and keloid

(Gozali et al., 2015). Atrophic scar is the most frequently

found acne scars in about 80-90% case (Fabbrocini et al.,

2010). By morphology atrophic scars are divided into

boxscar, icepick and rolling (Hession and Graber, 2015).

The icepick scars found in 60-70% of cases (Fabbrocini et

al., 2010).

Chemical reconstructions of skin scars (CROSS) using

high concentrations of Trichloracetic Acid (TCA) 70-100%

is an effective therapy for the management of icepick scars

(Agarwal et al., 2015; Khunger et al., 2011). This method

is effective and safe on dark skin or Fitzpatrick IV- V skin

type (Khunger et al., 2011). The principle of this procedure

is to make a new wound with chemical liquid which will

increase the volume of the dermis due to the formation of

new collagen, glicoseaminoglycans and elastin so that the

scars flatten (Weber et al., 2011; Ramadan et al., 2011).

Dentist drill, is a small high-speed drill, used by

dentists to remove decayed teeth in caries dentist

treatment (Bor gigi, 2017). This tool can also be used

in dermatology the treatment of acne icepick scars

with the same principle mechanism as CROSS TCA

by making a new wound on the scar that will stimulate

wound healing with the formation of the new tissue.

The purpose of this study is to compare the

effectiveness of CROSS TCA with dental drill in

clinical improvement of acne icepick scars.

2 CASES

The total of 10 patients aged between 20-40 years

with acne scars were recruited in this study. The

inclusions criteria were patients with Fitzpatrick 3-4

skin types and acne scars more than 3 months willing

to follow the study. Exclusion criteria were patients

with active inflammatory acne, history of keloids,

history of herpes simplex or herpes zoster in the facial

region. All study subjects had normal vital signs.

Acne scars in the facial region were visible from

50cm distance and when it was stretched the scar did

not disappear. Photograph were taken before and after

the procedure to evaluate clinical improvement.

Mochtar, M., Trisnarizki, L. and Julianto, I.

The Comparison of Dentist Drill with Chemical Reconstruction of Skin Scars (CROSS) Trichloracetic Acid (TCA) on Icepick Acne Scars.

DOI: 10.5220/0008155202570261

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 257-261

ISBN: 978-989-758-494-7

257

Figure 1. A. Frosting appearance after aplication of CROSS TCA with wooden tip applicator B. Dentist drill application with

perpendicular angle. C. Post dentist drill procedure.

Based on Goodman and Baron criteria, this acne scar

belongs to a moderate to severe acne scar (Goodman

and Baron, 2006).

First we cleaned the facial region with milk

cleaser and cleansing solution, then the icepick acne

scars were marked with permanent marker. The

CROSS TCA were performed without anesthesia on

the left cheek by aplying TCA 80-100% to the base

of the scars by stretching the skin. The TCA applied

with wooden applicator (toothpicks) until whittish or

“frosting” appeared. The tip of wooden applicator

was adjusted to the size of the scars. Dentist drill

applied to the right cheek by 1 mm round tip brace

drill with 90

angle or perpendicularly until

superficial dermis using. This procedure were

perfomed under local lidocain anesthetic (Figure 1).

Topical antibiotic was applied to the skin and the

patients were advised not to wash the face for three

days after the procedured, avoid direct sunlight

during the treatment, and not to manipulate the crust

because it healed within 7 days. The patients were

evaluated and photographed on days 3, 7, 14 and 30

after the procedure (Table 1).

3 RESULT

The clinical improvement by photograph, the wound

healing time, and the patient comfort were compared

between the two procedures. Clinical evaluation of

scars improvement was based on Goodman and

Baron acne scars criteria (Goodman and Baron,

2006). The scars improvement was considered poor if

there was no progress on the degree of acne (0-24%),

moderate if there was 1 point increase (25-49%),

good if there was 2 points increase (50-74%), and

excelent if there was 3 points increase (75-100%)

(Bhadwaj and Khunger, 2010).

Both procedures gave moderate to excellent

clinical improvement in all subject after 30 days

(Figure 2). Based on the wound healing time, dentist

drill procedure healed faster within 3 days, whereas

the CROSS TCA the wound in the form of blackish

crusts still appeared more than 7 days (Figure 2).

However all of patients felt that the CROSS TCA was

more convenient than dentist drill. There was no

serious side effect during the treatment in both

procedures except mild side effect such as erythema,

crust and edema. Post inflammatory

hyperpigmentation (HPI) was also not present in all

patients.

4 DISCUSSION

The icepick scar is the most common acne scar in 60-

70% of cases. This scar has wider surface than the

base. It is like V shape. The rolling acne scars are

usually larger than 4mm in size with wavy surfaces

forming the letter "M". While the boxscar has a round

to oval shape and has a firm vertical boundary to form

the letter "U"(Fabbrocini et al., 2010).

The pathogenesis of acne scarring is not fully

understood. The risk of acne scarring is associated

with the severity of acne and the time to start the

treatment. Acne scar is thought to be derived from the

non inflammatory process into inflammatory acne

that results in follicular wall rupture. The rupture will

lead to the release of irritating materials such as hair,

fat, keratin, bacteria to the dermis so that there is an

inflammation in the dermis that will activate the

complement with classical and alternative pathways

(Maharani and Kusumawardhani, 2016).

There are various modalities of acne scar

treatment such as dermabrasion, subcision, chemical

peels, punch excision, microneedling, soft tissue

augmentation, and laser (Hession and Graber, 2015;

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

258

Figure 2. A.E. Before dentist drill procedure B.F excellent clinical improvement 30 days after dentis drill procedure. C.G

before CROSS TCA D.H Excellent clinical improvement 30 days after CROSS TCA. I. 3 days after dentist drill the wound

healed faster J. Wound 3 days after CROSS TCA.

Table 1. Comparison of CROSS TCA and dentist drill.

Clinical improvement

30 da

s after

rocedure

Wound Healing Time Patient

Comfortness

CROSS

Dentist drill

3 DAYS 7 Days 14 Days 30 Days

CROSS

Dentist

drill

CROSS Dentist

drill

CROSS Dentist

Drill

CROSS Dentist

Drill

CROSS Dentist

Drill

Patient 1

Moderate Moderate

- + + + + + + + + -

Patient 2

Very good Very good

- + - + + + + + + -

Patient 3

Moderate Moderate

- + + + + + + + + -

Patient 4

Very good Very good

- + - + + + + + + -

Patient 5

Moderate Moderate

- + - + + + + + + -

Patient 6

Excellent Excellent

- + + + + + + + + -

Patient 7

Very good Very good

- + - + + + + + + -

Patient 8

Moderate Moderate

- + + + + + + + + -

Patient 9

Excellent Excellent

- + - + + + + + + -

Patient 10

Excellent Excellent

- + + + + + + + + -

The Comparison of Dentist Drill with Chemical Reconstruction of Skin Scars (CROSS) Trichloracetic Acid (TCA) on Icepick Acne Scars

259

Zaleski-Larsen et al., 2016;Simmons et al., 2014) The

other treatment option is chemical reconstructions of

skin scars (CROSS) using Trichloracetic Acid (TCA)

high concentration 70-100% which effective on

icepick scars and it is safe for skin colour (Khunger et

al., 2011; Bhardwaj and Khunger, 2010). This

procedure can also be used in rolling scars and

varicella scars (Ramadan et al., 2011; Sardana et al.,

2014). Kim et al reported the use of 100% CROSS

TCA on icepick scars with similar results to the

erbium laser therapy (Agarwal et al., 2013).

Dentist drill in dermatology can also be used for

the management of acne icepick scar. The mechanism

of this drill is almost similar to CROSS TCA by

making a new wound around the scars so that it will

stimulate wound healing with the formation of a new

collagen tissue. Even various therapeutic modalities

are available with varying effectiveness, but some of

the outcome is still less than optimal (Sardana et al.,

2014). No single therapy is universally effective in all

types of scars (Gozali et al., 2015). Therefore some

clinician use combination therapy to improve the

effectiveness (Agarwal., 2013).

In the 10 patients we studied, the acne scars was

clearly visible in 50 centimeters and when they were

stretched several acne scars flattened but some did

not. Such conditions were categorized in moderate-

severe acne scars (Goodman and Baron, 2006). Six

study subject who had more predominant icepick

acne scars showed significant clinical improvement.

Four patients experienced less significant clinical

improvement. The possible causes of this condition

was mixed type of the acne scars, while only the acne

scars being treated was icepick scars, and not others

(rolling and box scar). Therefore the clinical

improvement by photopgraph appeared less

significant. However if we looked closer, the icepick

scars looked flattened by both procedure. The other

reason is the the size of icepick scars is less than 2mm,

smaller than box scars and rolling scars, so that

despite there were flattened scars, the clinical

improvements is not significant. Another possible

cause is that the procedures for acre scars should be

performed in multiple replications depending on the

patient's clinical response, while in all the above

patients we only treat the patient once.

The dental drill provided faster recovery than

CROSS TCA. On the 3rd day the wound has already

closed. Whereas in CROSS TCA group multiple

blackish crusts (Table 1) still persisted. In the 7th day

the entire crust disappeared in dentis drill group but

in CROSS TCA some were still observed.

The patients complained of burning sensation for

5 minutes with CROSS TCA. This occured because

CROSS TCA was performed without anesthesia,

whereas a dental drill was given a local anesthetic

injection. However, injection of pehacaine also

caused pain at the time of injection, especially if the

location of the scars scattered. It was done several

times in some areas caused greater pain. Another

complaint of patients was the sound of drill which

made the patient feel uncomfort. Based on patient

comfort, CROSS TCA is preferred compared to the

dentist drill.

5 CONCLUSION

The CROSS TCA and dental drill were effective in

treating icepick scars acne. Each of these procedure

has its own advantages and disadvantages. The use of

a dental drill has a faster wound healing time.

However CROSS TCA is more practical because no

special tools requirement, no anesthesia, and it gives

more comfortable feeling.

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