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
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
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.
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.
