CROSS Technique with Full Strength TCA in the Management of Ice Pick Acne Scars

Sir,

I read with interest the manuscript on treatment of ice pick acne scars by Bhardwaj and Khunger, May- August issue of JCAS.[1]

CROSS technique is no doubt a very easy, economical and efficient technique for treatment of atrophic ice pitted acne scars.[2] The article misses some vital information. In the methods section, it is mentioned that the scars were counted in each patient which means an objective evaluation of scars was also done in the study besides subjective evaluation by the investigator. However, which scoring system for scars was used is not mentioned.[34] It would be worthwhile to mention how the objective assessment in the improvement of scarring was noted. If not, then what is the purpose of counting scars? It should be recorded.

In the observation table, where 80 percent patients have been shown to have excellent improvement, it should have been mentioned that how much reduction in number of scars (count) defined excellent improvement as scars were initially counted. Secondly, the assessment in table is a representation of results seen at end of four sessions only. The tables including assessment at end of 3 and 6 months would have given a better idea of how persistent the results were in the study as it is not the immediate but long term results which matter. Thirdly, it is mentioned that a statistical package of SPSSIO version was used for analysis. It is however not mentioned how the analysis was interpreted through SPSSIO version in the study.

In the figures, there is no pre and post treatment picture to show excellent improvement. The figures start with the frosting step. The initial picture of the patient before application of TCA should have been included which is very vital for comparison. It is difficult to appreciate if Figure 2 and 3 are of same patient, as Figure 2 is a close picture while Figure 3, a far distance picture with complete side view of face. There is significant difference in photographic angle and color of picture for comparison. Another fallacy is in the abstract which mentions that transient hyperpigmentation was noted in one patient but in results it is not mentioned which patient developed transient hyperpigmentation. Did it belong to 80 percent group showing excellent improvement? It would be interesting to know if the patient was Fitzpatrick IV or V, as darker skin types run more risk of transient hyperpigmentation. CROSS technique would be very useful in Indian setup if long term results are equally impressive.