Treatment of Acne Scars with Microneedling and Chemical Reconstruction of Scarred Skin Therapy (CROSS) Using Penol/Croton Oil Combination

June 2024 | Volume 23 | Issue 6 | 418 | Copyright © June 2024


Published online May 27, 2024

doi:10.36849/JDD.7657

Quita Lopez MD

Private Practice, Lake Oswego, OR

Abstract
Background: Microneedling has been shown to release growth factors, which improves the appearance of acne scars by itself and in combination with different therapy modalities. Combining microneedling with Chemical Reconstruction of Scarred Skin (CROSS) therapy using a 60% phenol and 0.2% croton oil combination results in a significant improvement of acne scarring.
Objective: To assess the safety and efficacy of combination treatments using microneedling in combination with CROSS therapy that contains 60% phenol and 0.2% croton preparation in patients with Fitzpatrick skin types III to V. 
Materials and Methods: Patients were treated over a 5-year period for atrophic acne scars using microneedling combined with CROSS. Most of the patients had combination atrophic scarring. High-quality before and after photographs were taken of the patients to assess the improvement in the scars. 
Results: Most of the patients (89.5%) had Fitzpatrick skin types IV through V.  Analysis was done on a maximum of 3 microneedling sessions with 1 to 3 CROSS sessions. Photographic evaluation using the Global Aesthetic Improvement Scale showed an 18% grade-1 improvement and 81% grade-2 improvement. The Goodman and Baron Qualitative scar grading system showed a 62% grade-1 improvement and 38% grade-2 improvement.
Conclusion: Combination treatments work best for atrophic scars. This is the first published report of using microneedling with a 60% phenol/0.2% croton oil combination. It proved to be very effective and safe in treating atrophic acne scars in Fitzpatrick skin types III to V, with minimal side effects and a quick recovery.

J Drugs Dermatol. 2024;23(6):418-422.     doi:10.36849/JDD.7657

INTRODUCTION

Acne scarring is a common problem that results in adverse psychological symptoms including depression, low self-esteem, and embarrassment about appearance. In the past, various therapeutic options have been described with variable clinical outcomes. These include medical topical treatments, subcision, surgical excision, fractional lasers, CO2 resurfacing, radiofrequency, dermabrasion, and deep chemical peels. Microneedling has become more popular recently compared to 15 years ago. Studies in the literature show that combination therapies are the most effective for treating acne scars.1-5

Phenol formulas with croton oil in the range of 0.1% to 0.7% were popular from the 1920s to the 1960s. Baker and Litton were early plastic surgeons who used these formulas. The Baker-Gordon formulas had 2.1% croton oil concentrations. 

Hetter and Stone were plastic surgeons who clarified that the croton oil is a vesicant, allowing the phenol to penetrate more deeply. When less than 1% croton oil is used, there is minimal abnormal pigmentation or delayed healing.6-9 

Rullan noted that in his first 20-plus years of peeling experience that phenol peels liquefied both the epidermis and upper dermis, whereas trichloroacetic acid (TCA) caused protein denaturation without liquefaction.10 He performed a 2-day phenol/croton oil peel consisting of 60% phenol and 0.2% croton oil. On the second day he performed an abrasion of the scar with curettes or sandpaper, the goal being to achieve punctate bleeding in the shoulders (or edges) and deepest defects of the scars. The croton oil/phenol solution was then applied again with pencil-tip applicators. He concluded that the 2-day peel with chemabrasion was superior to peeling alone, and he obtained an 80% improvement in acne scars. He published his study in 2004.

In 2002, Lee coined the term CROSS (Chemical Reconstruction of Scarred Skin).11 His study described the application of 65% and 100% TCA to atrophic scars by pressing a wooden applicator to the entire scar to help break down the shoulders of the scars. The 100% TCA concentration had a better result after 4 to 6 treatments; and after 6 treatments there was a greater than 70% improvement.