Chemical Reconstruction for Skin Scars (CROSS) is the name for a precise chemical technique to reduce atrophic scars, such as ice-pick acne scars, boxcar acne scars, and rolling acne scars. This method applies a concentrated acid to the scar tissue, inducing collagen remodeling and scar improvement. Our guide explains the science, benefits, and what to expect from the treatment process and recovery, offering a pathway toward clearer skin. You will also learn more about SHICROSS™ and its benefits over traditional TCA CROSS and phenol CROSS treatments for acne scars.
Icepick Scars
Boxcar Scars
Rolling Scars
Key Takeaways on CROSS Treatments
Understanding CROSS and its benefits
Chemical Reconstruction of Skin Scars (CROSS) is a technique that applies deep chemical peeling agents directly onto scars using fine applicator tools. CROSS aims to stimulate collagen remodeling beneath atrophic acne scars, thus raising the depth of scars and enhancing skin texture.
Importantly, CROSS chemical reconstruction has proven effective in treating various types of atrophic acne scars, including ice-pick, boxcar, and rolling scars. This makes it a highly versatile and effective treatment for individuals looking to improve the appearance of their skin.
Types of Skin Scars Treated with SHI CROSS
CROSS is specifically designed to treat atrophic scars, which include various types of scars such as boxcar acne scars, ice-pick acne scars, and rolling acne scars:
Icepick Scars
Ice pick scars are characterized as narrow indentations in the skin that usually result from severe cystic or papular acne burrowing deep in the skin. Among the three, ice pick scars are the most severe due to their tiny diameter and depth of penetration. They often appear on the forehead, cheekbones, and nose.
Among the three, ice pick scars are the most difficult acne scar treatment because of their narrowness and depth of penetration. In general, we have found that ice pick scars respond well to phenol CROSS, our frontline treatment method. However, patients with more severe ice pick scars may benefit more from punch excision, a process in which a small “cookie-cutter” tool is used to punch out the ice pick scar. In this manner, we ensure that the scar is removed in its entirety, as opposed to other treatments that merely treat the surface.
Boxcar Scars
Boxcar scars have sharp defined boundaries with more geometric indentations in the skin.Boxcar scars result from collagen depletion caused by acne breakouts, leaving a visible depression behind on the skin. Boxcars are typically shallower and wider than ice pick scars, and have vertical walls with an even, flat base.
Although boxcar scars can be treated with a variety of procedures, many of them, including laser, dermabrasion, and microneedling, work superficially and are ineffective for deeper scars.At our clinic, subcision, punch excision, and collagen stimulators are the most effective and long-lasting treatment options available. We will perform a thorough evaluation of each of your boxcar scars to customize your treatment plan.
Rolling Scars
Rolling scars develop when fibrous tissue tethers the epidermis to the underlying subcutaneous tissue, creating sloping and wave-like indentations in the skin. Rolling scars are shallow and soft depressions that become more noticeable when skin ages and loses its elasticity. Rolling scars can disappear over time but may require intervention depending on their severity.
Because rolling scars are the softest among the different scar types, they respond the best to subcision followed by collagen stimulation. We will perform a thorough evaluation of your rolling scars to assess their severity and depth to determine what layers will need to be subcised. It is important to manually sever the fibrotic tethers in multiple layers to completely remodel the skin. Any treatments that do not target these tethers will not solve the root cause of rolling scars.
The precision and effectiveness of CROSS make it an attractive option for individuals seeking to diminish these types of acne scars and regain smooth, clear skin.
The Science Behind CROSS
The CROSS technique involves:
- Applying a potent acid to the base of the acne scar
- Localized tissue damage
- Scar tissue breakdown
- Collagen denaturation
- Stimulation of tissue remodeling
- Protein precipitation and coagulative necrosis of cells in the epidermis
- Collagen necrosis in the papillary to upper reticular dermis
- Inflammation triggering a collagenization process
- Reduction in the appearance of scars
- Cosmetic improvement
The dermal collagen remodeling triggered by CROSS continues for several months after treatment, resulting in:
- Increased dermal volume
- Collagen production
- Glycosaminoglycan production
- Elastin fragmentation and reorganization
What is a Chemical Reaction?
The CROSS technique utilizes a highly concentrated acid to denature proteins in the skin’s deeper layers. This process leads to protein precipitation, coagulative necrosis of the epidermis, and necrosis of collagen within the papillary and upper reticular dermis. A significant change during the process is the appearance of ‘frosting,’ which typically occurs within 10 to 15 seconds after application. This indicates that the peel has reached the correct depth and started the healing response.
Collagen Stimulation
Collagen stimulation is a critical process occurring during the CROSS method. The inflammatory reaction caused by the method leads to collagen remodeling, which reduces the severity of scars and enhances the skin’s appearance.
After the treatment, re-epithelization occurs from adnexal structures. This process plays a crucial role in the remodeling of dermal collagen and the regeneration of the skin.
Scar Improvement Process
Improvement processes begin to unfold following the CROSS treatment. Some things to expect during the healing process include:
- Scabs may form on the skin, and when these fall off, scars can initially appear larger.
- However, this is part of the healing process, and improvement is observed as the tissue heals and remodels.
- Notable improvement generally starts around four weeks post-treatment.
Patients can expect to see improvement after approximately one to four treatment sessions, with a gradual decrease in efficacy after three to six months. This emphasizes the potential need for multiple treatments over time.
CROSS Procedure: Step-by-Step
Patients are advised to pre-treat with a lightening agent like hydroquinone for two weeks prior to the CROSS procedure. Then, they should stop using such harsh chemicals and all retinols three days beforehand. Removal of makeup and shaving (if necessary) a day before the procedure also helps ensure clarity in the treatment areas. On the day of your appointment, professional photos will be taken to monitor your progress in the Phase System.
In the CROSS procedure:
- The face is cleaned with topical antiseptic agents before the application of the CROSS formula begins.
- The procedure requires the deposition of small amounts of acid specifically into the affected areas. This method is used to target and treat the problem areas directly.
- The CROSS treatment typically takes 30-60 minutes, which can vary depending on the number of scars being treated.
- A fume hood or other vacuum devices may be present to protect your eyes, nose, and sensitive areas from the chemical vapors.
Pre-Treatment Consultation
During the pre-treatment consultation, a thorough assessment of the patient’s medical history, current medications, and skin type is conducted. Priming the skin with a protocol of sunscreen and hydroquinone-containing cream prior to the CROSS helps minimize the risk of post-inflammatory hyperpigmentation, especially in patients with darker skin.
Before undergoing CROSS, patients should be screened for any allergies and sensitivities to the chemical peel components to avoid adverse reactions. A formal evaluation with a dermatologist is crucial to analyze the scars, develop a tailored treatment plan, and obtain informed consent prior to starting the CROSS procedure.
During the Procedure
During the procedure, coagulation of epidermal and dermal proteins is monitored through a frosty appearance on each treated atrophic scar. This indicates the proper application and start of the healing response. To preserve normal tissue, a precision applicator is recommended to prevent the spread of acid to adjacent healthy skin.
The procedure is usually comfortable for patients, and most do not require anesthesia as the sensation is similar to a tiny sting. The CROSS treatment typically takes 30-60 minutes, which can vary depending on the number of scars being treated.
Recovery Timeline After CROSS
The full healing process typically spans 10-14 days. During the healing process, patients may notice scabs forming on the skin. These scabs are a natural part of the healing process, and patients should not pick at them. Rather, they should let the scabs fall off naturally, which often occurs during showering.
Picking at scabs can lead to scarring or infection. Adhering strictly to the post-procedure care instructions is essential for minimizing risks and ensuring proper skin healing.
First Two Days (48 Hours)
In the first 48 hours post-treatment, the face is most sensitive. During this time, patients should avoid contact with water, sunscreen, makeup, hands, etc., to prevent any irritation to the skin. It is also important to avoid sun exposure, as UV exposure can inhibit the body’s natural healing processes and pigment the skin.
After 48 Hours: Getting Face Wet
After 48 hours, patients can return to a face washing routine that includes washing with water and a gentle soap. Do not rub at any scabs, so let the water run down your face.
Patients are advised to:
- Use sunscreen continuously following CROSS treatment
- Limit sun exposure
- Use a broad-spectrum sunscreen SPF of 30 or higher to protect the treated areas, especially to prevent hyperpigmentation in darker skin types.
Three Day Mark (72 Hours)
If prescribed to you, you can start to apply a lightening agent such as hydroquinone cream to your skin three days after the procedure. The type of agent, frequency of use, and duration of use can vary based on your provider.
1 Week (7 Days)
Throughout the first week, it is common to have scabbing that may resemble brown or red dots. These scabs are a natural part of the healing process. Do NOT pick at them. Let them fall off naturally, which often occurs during showering.
Picking at scabs can lead to skin scars or infection.
2 Weeks (14 Days)
By the 14-day mark, the scabs should fall off. If you still notice some dead skin on your face, take a warm shower and gently rub your face with a damp cloth. By this point, you may also be asked to stop using lightening creams or other aftercare products.
Pre-Treatment Consultation
During the pre-treatment consultation, a thorough assessment of the patient’s medical history, current medications, and skin type is conducted. Priming the skin with a protocol of sunscreen and hydroquinone-containing cream prior to the CROSS helps minimize the risk of post-inflammatory hyperpigmentation, especially in patients with darker skin.
Before undergoing CROSS, patients should be screened for any allergies and sensitivities to the chemical peel components to avoid adverse reactions. A formal evaluation with a dermatologist is crucial to analyze the scars, develop a tailored treatment plan, and obtain informed consent prior to starting the CROSS procedure.
During the Procedure
During the procedure, coagulation of epidermal and dermal proteins is monitored through a frosty appearance on each treated atrophic scar. This indicates the proper application and start of the healing response. To preserve normal tissue, a precision applicator is recommended to prevent the spread of acid to adjacent healthy skin.
The procedure is usually comfortable for patients, and most do not require anesthesia as the sensation is similar to a tiny sting. The CROSS treatment typically takes 30-60 minutes, which can vary depending on the number of scars being treated.
Tips for Healing
During the healing process, patients should:
- Avoid using any home exfoliators to prevent irritation and damage to the healing skin
- Expect peeling and flakiness as common reactions of the skin as it heals and regenerates post-treatment
- Be aware that temporary changes in skin texture, including roughness or dryness, are typical after undergoing CROSS treatments.
In case scabs form, they should be allowed to naturally separate without picking at them to avoid potential scarring.
Potential Complications
Potential complications of CROSS treatment include:
- Healing complications for patients who have undergone systemic retinoid therapy within the prior 12 months
- Necrosis of healthy surrounding tissue and exacerbation of scarring if phenol CROSS, TCA CROSS, or other chemicals are not precisely applied
- Increased risk of scar worsening if larger volumes of TCA CROSS are applied
A potential complication of TCA CROSS specifically is the coalescence of neighboring scars, which may result in the development of larger scars. Rare complications following CROSS include prolonged local irritation and erythema. It is essential to have a ROSS performed by a skilled professional to minimize these risks.
Benefits of Combining CROSS with Other Treatments
While CROSS is a potent procedure by itself, combining it with other treatments can significantly boost its effectiveness. This synergy can lead to higher rates of improvement in the appearance of atrophic post-acne scars, higher patient satisfaction, and improved scar appearance.
Subcision
One of the treatments that can be combined with CROSS is subcision. When CROSS is combined with subcision, patients have reported higher satisfaction rates compared to those who underwent subcision alone. These treatments can be performed on the same day as the CROSS procedure or within a certain timeframe.
Biostimulators and Fillers
Hyaluronic acid fillers or poly-L-lactic acid biostimulators are other treatments that can be used in conjunction with CROSS. These injectable treatments can enhance skin plumpness and reduce superficial scarring. Patient testimonials highlight that integrating CROSS with these treatments leads to improved skin texture and shallower scars.
In particular, combining CROSS with biostimulator treatment has been found to be beneficial for patients with darker skin types, potentially reducing the number of treatment sessions needed, saving time and cost for the patient.
Laser Scar Treatments
CROSS can also be effectively combined with energy-based treatments such as laser resurfacing for treating atrophic acne scars. By combining these treatment modalities, dermatologists can provide a comprehensive acne scar treatment that addresses individual scar characteristics.
This comprehensive approach not only leads to improved scar appearance but also higher patient satisfaction.
Pre-Treatment Consultation
During the pre-treatment consultation, a thorough assessment of the patient’s medical history, current medications, and skin type is conducted. Priming the skin with a protocol of sunscreen and hydroquinone-containing cream prior to the CROSS helps minimize the risk of post-inflammatory hyperpigmentation, especially in patients with darker skin.
Before undergoing CROSS, patients should be screened for any allergies and sensitivities to the chemical peel components to avoid adverse reactions. A formal evaluation with a dermatologist is crucial to analyze the scars, develop a tailored treatment plan, and obtain informed consent prior to starting the CROSS procedure.
During the Procedure
During the procedure, coagulation of epidermal and dermal proteins is monitored through a frosty appearance on each treated atrophic scar. This indicates the proper application and start of the healing response. To preserve normal tissue, a precision applicator is recommended to prevent the spread of acid to adjacent healthy skin.
The procedure is usually comfortable for patients, and most do not require anesthesia as the sensation is similar to a tiny sting. The CROSS treatment typically takes 30-60 minutes, which can vary depending on the number of scars being treated.
Number of Treatments Needed
To achieve the best cosmetic results, the total number of CROSS treatments typically varies from one to five sessions. However, the number of treatments needed can vary based on several factors, including the cosmetic location of the scars, their severity, and the individual’s healing response.
These factors can influence the number of CROSS treatments that are required.
Cosmetic Location of Scars
The cosmetic location of the scars can influence the number of CROSS treatments needed. For instance, areas such as the nose, forehead, and chin may require more sessions of CROSS treatment because the scarring in these regions tends to be more resistant and the skin topography is much different than the cheeks or temples.
Scar Severity
The severity of acne scars also directly affects the number of CROSS sessions required. For instance, more severe acne scars, which can be identified by grading systems like the Goodman and Baron scale, may require more sessions for optimal results.
Individual Healing Response
Another consideration is the individual’s healing response. As some patients may form collagen differently, the technique used during CROSS can significantly influence the number of treatments needed.
For instance, patients who form collagen more slowly may require additional sessions.
Pre-Treatment Consultation
During the pre-treatment consultation, a thorough assessment of the patient’s medical history, current medications, and skin type is conducted. Priming the skin with a protocol of sunscreen and hydroquinone-containing cream prior to the CROSS helps minimize the risk of post-inflammatory hyperpigmentation, especially in patients with darker skin.
Before undergoing CROSS, patients should be screened for any allergies and sensitivities to the chemical peel components to avoid adverse reactions. A formal evaluation with a dermatologist is crucial to analyze the scars, develop a tailored treatment plan, and obtain informed consent prior to starting the CROSS procedure.
During the Procedure
During the procedure, coagulation of epidermal and dermal proteins is monitored through a frosty appearance on each treated atrophic scar. This indicates the proper application and start of the healing response. To preserve normal tissue, a precision applicator is recommended to prevent the spread of acid to adjacent healthy skin.
The procedure is usually comfortable for patients, and most do not require anesthesia as the sensation is similar to a tiny sting. The CROSS treatment typically takes 30-60 minutes, which can vary depending on the number of scars being treated.
Long Term Results
Improvements in acne scars from CROSS, TCA CROSS, or phenol CROSS are typically seen within 2-9 months, with peak collagen stimulation and subsequent scar improvement usually observed about 6 to 9 months after each treatment session. Patients are typically followed up at intervals of two months after the last treatment to assess the long-term results and any delayed side effects.
It’s important to note that individual outcomes may vary and not all patients will experience progressive improvement.
The Suitability of Phenol CROSS, TCA CROSS, and SHICROSS™ for Different Skin Types
CROSS is generally suitable for all skin types and works by promoting collagen production which aids in improving and elevating acne scars over time. While safe for Fitzpatrick skin types IV and V, certain patients, such as those with oily skin, may need a more frequent CROSS treatment schedule to achieve significant improvement.
TCA CROSS and Phenol CROSS are very effective tools to induce collagen remodeling in atrophic scars, but they each have their drawbacks. For instance, patients with more pigmented skin have a higher risk of experiencing post-inflammatory hyperpigmentation with TCA CROSS. Conversely, individuals with pigmented skin who do phenol CROSS also have a higher risk of experiencing post-inflammatory hypopigmentation. Therefore, our carefully crafted and expertly honed SHICROSS™ procedure, on the other hand, has been designed to minimize these risks and provide superior results. See the link below for more information about the differences between TCA CROSS, phenol CROSS and SHICROSS™
Read About How our SHICROSS™ improves on TCA CROSS and traditional phenol CROSS.
Special Considerations for Darker Skin
Darker skin types are more prone to post-inflammatory hyperpigmentation (PIH) after CROSS, which may persist for several months. To help minimize the risk of pigmentation changes, darker skin patients are advised to use a bleaching cream nightly for two weeks before the procedure and avoid tanning.
Managing Hyperpigmentation
The CROSS technique is proven safe and effective for ice pick acne scarring on darker skin types, but vigilance for post-inflammatory hyperpigmentation is vital. Hydroquinone creams are commonly prescribed to prevent and treat resulting hyperpigmentation in darker-skinned patients following CROSS treatment. They may be applied nightly.
Patients are advised to avoid tanning and utilize sun protection for 2 weeks before and up to 2 months after treatment to minimize pigmentation risks.
Customized Treatment Plans
Customized treatment plans are imperative as they consider each patient’s unique skin type and acne scarring, thus optimizing the outcomes of CROSS treatments. An experienced dermatologist may incorporate CROSS with ancillary treatments such as:
- chemical peels
- laser procedures
- dermal fillers
- specialized skincare products
To comprehensively treat acne scars, target acne scars and enlarged pores.
Proper evaluation during a comprehensive consultation to assess the variety of acne scars is pivotal in creating an individualized treatment plan to meet the specific needs of the patient.
CROSS Safety and Potential Side Effects
Patients with a keloid scar history should avoid SHICROSS, phenol CROSS, and TCA CROSS as it could potentially deteriorate their skin’s texture. Transient hypopigmentation and hyperpigmentation have been observed side effects in individual patients after CROSS treatment. However, complications from CROSS are rare when performed by experts.
General Safety
CROSS should only be performed by a qualified healthcare provider to ensure safety and effectiveness. The procedure is known for its minimal downtime and safety profile when conducted by experienced dermatologists, with a specific technique that spares adjacent normal tissue. Patients with certain conditions such as active inflammatory lesions or a keloidal tendency are excluded from treatment, and clinicians should be aware of potential adverse effects to manage them effectively.
Common Side Effects
Common side effects of CROSS include redness, soreness, and mild to moderate pain during application, which resolves shortly after the procedure, along with swelling and temporary darkening of the treated area. Side effects such as local burning, erythema, stinging, and pigmentation changes, including hyperpigmentation and hypopigmentation, are possible and should be carefully monitored, especially in sensitive skin.
Risks during CROSS can be mitigated by:
- Monitoring for adverse reactions like excessive frosting during the procedure
- Employing experts for safe management
- Following proper aseptic techniques to prevent infections.
Rare Complications
Although rare, complications can occur with CROSS treatment. These could include:
- Neurological complications such as confusion or dizziness when CROSS is absorbed systemically
- Systemic toxicity
- Cardiac arrhythmias
- Accidental deposition of phenol CROSS, TCA CROSS, or our proprietary formula on mucosal surfaces
- Coalescence of adjacent scars into larger scars
- Scarring, including keloid formation
Anaphylaxis is a very rare but serious allergic reaction that can happen with phenol CROSS or TCA CROSS in the event of an allergy to its components.
Choosing the Right Provider for CROSS
Choosing a provider who has a solid track record of successful CROSS treatments guarantees that the provider has the requisite experience and skills for this specific procedure. Choosing a provider who is recognized for their expertise in treating acne scars can instill confidence in patients that they are receiving care from a specialist in the field.
Questions to Ask
When selecting a provider for CROSS treatment, it’s vital to inquire about the provider’s experience with CROSS, particularly related to cases similar to their own skin type and acne scars. It’s also crucial to discuss any medical history or skin conditions that might influence the appropriateness and safeness of CROSS treatment.
Finding a Trusted Provider
Finding a trusted provider for CROSS treatment is crucial. Look for a provider who:
- is a board-certified dermatologist
- has a specialization in treating acne and acne scarring
- is consistently recognized by reputable sources as a leading expert for treating acne scars
Seeking recommendations from previous patients who have had positive experiences and outcomes with their acne scar treatments can guide one to a trusted acne scar specialist.
Our Proprietary Acne Scar Treatments
Meet The Acne Scar Phase-Out System
Our proprietary phase system is specifically designed to attack acne scars from all angles: chemical reconstruction from the top-down and physical reconstruction from the bottom-up and from the side. We pride ourselves in our meticulous, personalized, and longitudinal approach to treating your scars.
Skin Acne Treatments & Procedures
While our proprietary phase system is highly customizable and flexible for patients, we recognize that patients may benefit from other procedures as well. Explore these treatment options below and see if they may be right for you!
How Can I Prevent Future Scarring from Happening?
Scarring is more common with poorly resolved cystic or nodular acne. In addition, it has an even greater likelihood of occurring when irritated or squeezed. Therefore, the first step to prevent scarring is to simply leave your acne lesions alone. It is difficult at first, but is worth the patience at the end.
At the same time, it is also important to ensure that your acne lesions do not become over-inflamed. The prolonged inflammation of your active acne will also increase scarring. Steroid injections, notably kenalog injections, are highly effective in quelling inflammation of your acne and thereby limit scarring.
How Do I Know What Type of Acne Scar I Have?
Our specialists at Scar Healing Institute can help identify your acne scar or scarring. We will work with you to create a plan that will help you achieve both mental and physical healing. Find out more!
If you are concerned that you may have acne scars, it is important to consult with a dermatologist or other skin care professional. Our dermatologists will be able to assess your skin and determine if you have any scarring.
Summary
In conclusion, CROSS is a potent, effective, and versatile treatment for various types of atrophic acne scars. By promoting collagen production and remodeling, it improves the appearance and texture of the skin. With its minimal downtime and side effects, CROSS is a promising treatment for those seeking to improve their skin and boost their confidence. As always, it’s crucial to consult with a qualified healthcare provider to discuss your skin conditions, potential benefits, and risks to make an informed decision about the treatment.
Summary
In conclusion, CROSS is a potent, effective, and versatile treatment for various types of atrophic acne scars. By promoting collagen production and remodeling, it improves the appearance and texture of the skin. With its minimal downtime and side effects, CROSS is a promising treatment for those seeking to improve their skin and boost their confidence. As always, it’s crucial to consult with a qualified healthcare provider to discuss your skin conditions, potential benefits, and risks to make an informed decision about the treatment.
SHICROSS is intended to be done once, as the treatment causes the body to grow new skin in the affected areas, closing deep indentations or scars. The results are relatively fast and cost-effective as well.
Yes, CROSS treatment can be worth it for atrophic acne scars, especially for those with darker skin types.
The key difference between CROSS and a chemical peel is that CROSS targets individual acne scars using a high concentration of acid, while a chemical peel treats broader areas of the skin with lower concentrations of the acid.
TCA CROSS is a treatment for improving acne scars by using trichloroacetic acid (TCA) to make individual scars less shallow. It is used as treatment for ice pick scars, boxcar scars, and may work for other types of acne scars and dilated pores. We do not offer TCA CROSS at SHI.
We do not use TCA CROSS as part of our acne scar treatment. Instead, we use SHICROSS, our chemical reconstruction formula suited for your acne scars.
