Combination of 80% Trichloroacetic Acid Cross and Platelet-rich

Fibrin Lysate for Improving Atrophic Acne Scar: A Case Series

Prima Meidiyanti

, Dwi Retno Adiwinarni

, Arief Budiyanto

,Yohanes Widodo Wirohadidjojo

Department of Dermatology and Venereology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah

Mada,Dr. Sardjito General Hospital, Yogyakarta, Indonesia

Keywords: Atrophic acne scar, CROSS,80% TCA, plateletlysate, PRFlysate

Abstract: Atrophy scar is a major complication of acne vulgaris. Therapy for atrophicacne scar is a challenge for

dermatologists. The technique of chemical reconstruction of skin scar (CROSS) by applying focal high

concentrations of trichloroacetic acid (TCA) on the basis of an atrophic scar can stimulate collagen

production. Platelet-Rich Fibrin (PRF) lysate is an immune concentrate and platelets that accumulate in one

fibrin membrane which may be useful for atrophic acne scarby stimulating collagen deposition.

Trichloroacetic acid and Lysate PRF work synergistically to improve atrophic acne scar. The purpose of this

case report was to determine the effectiveness of a combination of 80% TCA CROSS andPRFlysate for

atrophic acne scar to 2 patients of grade 3 and 4 in Goodman classification. Eighty percent TCAwas applied

on the basis of the atrophy scar using a wooden toothpick with a pointed tip and then PRFlysateapplied to

basis of scar every night. Digital photography analysis was performed in the next visit and found a

significant improvement from the basis of atrophy in both patients with only onceTCA CROSS application.

The combination of 80% TCA CROSS and PRF lysateare simple, easy to do, inexpensive procedures but

provide excellent results for atrophic acne scar.

1 INTRODUCTION

Permanent scar is the main complication of acne

vulgaris which can cause emotional and

psychological disorders. Acne scars can be grouped

into two types, that were hypertrophy and atrophy,

where atrophy is more common after acne. Atrophic

acne scaris divided into types of ice pick, boxcar and

rolling. Based on Goodman classification, there are

4 degrees of acne severity, namely macula, mild,

moderate and severe grade. Various therapeutic

modalities have been used to treat atrophic acne

scars such as laser resurfacing, chemical peeling,

subsidence, filler, dermabrasion, and excision punch.

Until now there has been no definitive and simple

therapy for atrophic acne scars. (Rajan et al.,

2017;Nofal et al., 2014)

The application of focal high levels of

trichloroacetic acid (TCA) on the basis of atrophy

scar is known as Chemical Reconstruction of Skin

Scar (CROSS). The therapeutic effect of TCA is

thickening of the dermis and collagen production.

Trichloroacetic acid CROSS is a promising therapy

for various types of atrophy scar, because it results

in rapid healing and lower complication rates

because the normal skin around it is not affected.

This therapy is still developing, so there are no

standard guidelines for its use.

Plateletlysateis a component of human blood that

contains many growth factors that can be obtained

from platelet-rich fibrin. Platelet-Rich Fibrin (PRF)

is an immune concentrate and platelets that

accumulate in one fibrin membrane. Beside

thatplatelets and their products, the wound response

naturally requires the fibrin matrix, which can

increase growth factors and play a role in wound

healing and the immune system. Therapy of PRF

resembles a natural healing process, is said to be

safe because of its autologous nature, and is a cost-

effective choice in the treatment of chronic skin

diseases that are not easily cured. (Acne et al.,

2015;Risya et al., 2017). There has never been a

reported topical use of PRF lysate for atrophic acne

scars.

This paper reports two cases of atrophic acne

scars that were treated with a combination of 80%

TCACROSSand PRFlysate. The discussion will

emphasize the response of the combination therapy

Combination of 80 .

DOI: 10.5220/0009988003290332

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 329-332

ISBN: 978-989-758-469-5

329

of 80% TCACROSS and PRFlysate on the healing

of atrophic acne scars so that it is expected to

become a new innovation in the management of

atrophic acne scars at a lower cost.

2 CASE

First case. A 20-year-old woman came for treatment

at the DermatovenereologypoliclinicRSUP Dr.

Sardjito with the chief complaint of acne scars on

her forehead, cheeks and chin to the upper neck

since 3 years ago. The patient has acne in face that

has lost and arising since 6 years ago. The patient

feels very disturbed and ashamed of his acne scars.

Patients do not have a history of keloids.

Dermatological examination of the forehead, left

and right cheeks, upper chin and neck are atrophic

scar, multiple, varied forms (rolling scars, scar

boxes, icepick scar), sizes varying from 1 mm to 3

mm. Based on the history and physical examination,

the diagnosis of this case is the atrophic acne scars

of grade 3 (moderate).

The management given to patients was a

combination of 80% TCACROSS and

PRFlysatewhich was applied at night to a CROSS

spot location. Taking blood for PRF is done on the

14th day after the first day of menstruation. Before

the treatment, patients were informed informed

about the risk of transient or permanent

hyperpigmentation. Patients were asked to come in 2

weeks to do the second TCACROSS. The patient is

planned to do TCACROSS up to 3-4 times at

intervals of 2 weeks. At the time of application of

TCA, the patient feels like a mild burning sensation

and lost within a few minutes later. The scars then

turn to erythem and in a few days a crust appears on

top of it and releases itself within 6-7 days. When

patient control in 2 weeks later, the base of the scar

is very up and parallel to the healthy skin around it

but the base of the scar becomes reddish. Patients

were not treated with TCA CROSS anymore and

only plateletlysate were given at night, and were

asked to avoid sunlight. At 4 weeks later, the redness

in the area on CROSS has been greatly reduced. The

severity of acne decreases to grade 2 (mild).

Second case. A 21-year-old man came to the

DermatovenereologypoliclinicRSUP Dr. Sardjito

with the chief complaint of acne scars on his

forehead, cheeks and chin since 1,5 years ago. The

patient has acne that has lost and arising since 5

years ago. The patient feels very disturbed and

ashamed of his acne scars. Patients do not have a

history of keloids

Dermatological examination of the forehead, left

and right cheeks, and chin is obtained erythematous

atrophic scar, multiple, varied forms (rolling scar,

scar box, icepick scar), size varies from 1-5 mm.

Based on the history and physical examination, the

diagnosis of this case is the atrophic acne scars of

grade 4 (severe).

The management given to patients was a

combination of 80% TCACROSS and PRFlysate

which was applied at night to a CROSS spot

location. Before the treatment, patients were

informed informed about the risk of transient or

permanent hyperpigmentation. Patients were asked

to come in 2 weeks to do the second TCACROSS.

At the time of application of TCA, the patient feels

like a mild burning sensation and lost within a few

minutes later. The scars then turn to erythem and in

a few days a crust appears on top of it and releases

itself within 10 days.Because of thefull activity, the

patients were only able to get control in the third

month, and the results of the scar test showed

significant improvement. The degree of severity of

acne decreases to degree 2 (mild).

Figure 1. Female patient with atrophic acne scargrade 3. A) Before therapy B) Good treatment response after 1 month from

the first therapy

330



Figure 2. Male patient with atrophic acne scargrade 4. A) Before therapy B) Excellent treatment response after 3 months

from the first therapy

In the CROSS technique, the face is cleaned first

with the cleanser face and eye were closed, then the

TCA is applied to the base of the scar using a

wooden toothpick which is pointed for several

seconds until the "white frost" appears on the scar.

After that, the patient is given gentamicin

creamtwice a day until crusts are formed and the

patient is asked to avoid sun exposure.

Platelet-rich fibrinlysate was isolated from about

20 ml of healthy subjects venous blood, then 20 ml

of venous blood was put in 2 sterile test tubes10 ml.

Blood is taken on day 14 after the first day of

menstruation in female patients. Centrifugation of

2000 RPM for 10 minutes. The fibrin matrix formed

is separated from erythrocyte deposits using sterile

scissors or tweezers. The fibrin matrix is then

incubated for 24 hours at 4◦C until a supernatant is

formed which is the PRF lysate. After ensuring that

the remaining fibrin is attached to the bottom of the

tube, the supernatant is sucked and transferred into 2

ml ependorf tube and stored at -20◦C until used.

3 DISCUSSION

Acne is an inflammatory disease that can form an

atrophic scar, if the response to repair and healing is

poor. The occurrence of atropicacne scars is

associated with loss of collagen which causes the

formation of atrophy. Atrophic acne scars has a

significant psychosocial impact especially for

adolescents. Various therapeutic modalities are

available to treatatrophic acne scars such as surgical

revision, chemical resurfacing, laser resurfacing,

with mixed results and quite expensive

costs.(Abbrocini et al., 2008;Zaleski-larsen et al.,

2016)

Trichloroacetic acid has long been used and safe

for superficial chemical peel or deep chemical peel

in the atrophic acne scars.The therapeutic effect of

TCA is thickening of the dermis and collagen

production. This effect is more visible on deep

chemical peel, but deep peel with higher

concentrations of TCA is very risky and definitely

not recommended. To maximize the effect of TCA

therapy and reduce complications, such as scarring,

hyperpigmentation, and hypopigmentation, a

technique was found, namely the application of high

focal TCA concentrations on the basis of the

atrophic acne scars using sharp wood applicators,

known as CROSS, popularized by Lee et al. This

technique results in faster healing and fewer

complications than full face chemical peels because

normal tissue and adjacent adnexal structures are not

exposed.(Acne A et al., 2015)

Several studies have examined the effects of

TCA concentrations on CROSS. The application of

TCA to the skin can cause cellular necrosis in the

epidermis and necrosis of collagen in the papilla and

reticular dermis.(Abbrocini et al., 2008). Therapy for

atrophic acne scars with a very high 65%TCA

CROSS concentration of has shown high efficacy

with minimal side effects after 3-6 times therapy.

Seventy percent of TCA CROSS is effective for all

types, especially boxes scar after fourth therapies.

CROSS TCA 100% is a cost-effective modality for

icepick scar in individuals with darker skin but there

is a hypopigmentation transient effect.(Bhargava S

et al., 2018; Lee JB et al., 2002)

Platelets have a major role in hemostasis, but

their function in regulating immune response, wound

healing, osteogenesis, and angiogenesis has recently

become a broad research topic. Some proteins

released from platelets activated by platelets are

specifically involved in the occurrence of wound

healing, including tumor growth factor β (TGF-β),

platelet-derived growth factor (PDGF), insulinlike

growth factor-1 (IGF-1). ), basic fibroblast growth

factor (bFGF), vascular endothelial growth factor

(VEGF), and connective tissue growth factor

Combination of 80

331

(CTGF). Platelets also release coagulation factors,

serotonin, histamine, endostatin, and hydrolytic

enzymes. If platelets meet with fibroblasts,

interactions will occur between cells. Platelet lysates

isolated from blood have been shown to stimulate

fibroblasts, this is because platelet-generated PDGF

can stimulate resting fibroblasts to migrate

fibroblasts and proliferate through activation of

PCNA and synthesis of TGF-β through the JAK-

STAT signaling pathway. In addition to platelets and

their products, the wound response naturally requires

the fibrin matrix, which can increase growth factors.

(Sclafani, 2009;Wirohadidjojo YW et al., 2016)

Platelet lysatecan be obtained from PRF.

Platelet-Rich Fibrin (PRF) is an immune concentrate

and platelets that accumulate in one fibrin

membrane, which contains all blood-forming

components and plays a role in wound healing and

the immune system.(Chirag B Desai et al., 2013)

Platelet-rich fibrin (PRF) is referred to as platelet-

rich plasma (PRP) second generation with a simpler

manufacturing process without requiring additional

anticoagulants. Platelet-rich Fibrin (PRF) has a

natural fibrin structure that can protect growth

factors from proteolysis. Platelet-rich Fibrin (PRF)

releases periodically and maintains its activity for a

long time. This happens because platelets on PRF

are trapped in the matrix. TGF-β1 and PDGF AB

levels reached the highest number on day

14.Platelet-rich fibrin lysateuntil day 14 can still

optimally trigger osteoblast proliferation and

differentiation whilePRP lysatedoes not. The growth

factor level in thePRF lysateis higher than that in

thePRPlysate. Growth factor can increase the repair

time of damaged skin and accelerate tissue

remodeling with increased collagen synthesis.

(Rajan et al., 2017; Wirohadidjojo YW et al., 2016).

Both patients in this case had an icepick, rolling,

boxcar atrophic acne type and were given 80% TCA

CROSS therapy and PRFlysate. Significant results

were obtained in the form of a base increase from

the atrophy scar with only 1 time the TCA CROSS

application. In the first case, the base of the scar is

parallel to the normal skin around it, but the base of

the scar becomes reddish. After 4 weeks of follow-

up, the redness of the scar was reduced. In the

second case, the base of the scar has risen and most

of it has aligned with the normal skin around after

the third month's follow-up. Permanent side effects

were not found in the second case. Longer follow-up

is still needed for the first case to find out the

permanent side effects of this combination therapy.

4 CONCLUSION

This case report shows that a combination of 80%

TCA CROSS and PRFlysateis a simple, easy-to-do,

inexpensive procedure but provides excellent results

for atrophic acne scar. Larger studies and longer

follow-up time are still needed to assess the

effectiveness of this combination therapy.

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