Tca Peel Science

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The use of TCA as a peeling agent has a wide variety of applications depending on the concentration used (Fig. 7.2). The most important principal in determining response to a peeling agent is accurately assessing the depth of the condition for which treatment is intended. This principal applies to the depth of skin growths, pigmentation and degree of wrinkling. Superficial conditions such as epidermal melasma and actinic keratoses are readily treated with chem-

Table 1. Indications

Epidermal growths including actinic keratoses and thin seborrheic keratoses

Mild to moderate photoaging

Pigmentary dyschromias including melasma and post-inflammatory hyperpigmentation

Pigmented lesions including lentigines and ephelides

Acne

Acne scarring

Fig. 7.2a, b. Medium depth chemical peel for melasma. (a) Pre-operative, ^ (b) intraoperative - Level III frosting

Tca Peel Science

ical peeling and may only require a superficial peeling agent, whereas deeper conditions such as dermal melasma and severe wrinkling may prove difficult if not impossible to treat despite using a deeper peeling agent (Fig. 7.3). As a general rule a higher concentration TCA results in deeper penetration yielding a more thorough and longer-lasting treatment; this of course must be balanced with the lengthened downtime associated with a deeper peel. Multiple superficial chemical peels generally do not equal the efficacy of a single medium-depth peel. Still, not all conditions need to be treated with a deeper chemical peel as consideration must be given to what type of condition is being treated and most importantly what the patient's goals and tolerance are for the prescribed peel.

Epidermal growths such as actinic keratosis, lentigines or thin seborrheic keratoses can all be treated effectively with 25-35% TCA peels. Thicker epidermal growths or growths involving the dermis will be more resistant to treatment such as hypertrophic actinic keratoses and thicker seborrheic keratoses and may even be resistant to a medium-depth peel. Resistant lesions many times are best treated with a combination of a medium-depth chemical peel and other modalities such as manual dermasanding or CO, laser.

Table 2. Efficacy of Treatment

Excellent to Good Response Actinic keratoses Superficial melasma Superficial hyperpigmentation Ephelides Lentigines

Depressed scars (CROSS technique)

Variable Response

Seborrheic keratoses Hypertrophic keratoses Mixed melasma Mixed hyperpigmentation

Fig. 7.3a, b. Medium depth chemical peel for melasma. (a) Pre-operative, (b) Intraoperative - Level III frosting

Poor Response

Thick seborrheic keratoses

Deep melasma

Deep hyperpigmentation

Fig. 7.3a, b. Medium depth chemical peel for melasma. (a) Pre-operative, (b) Intraoperative - Level III frosting

Mild to moderate photoaging can be effectively treated with TCA peels. Mild photoaging as defined by the Glogau classification as type 1 include mild pigmentary alterations and minimal wrinkles. Often a superficial TCA peel 10-25% will be all that is necessary to make improvements with mild photoaging; this is especially true if multiple superficial peels are employed at regular intervals of 3-6 weeks. Moderate photoaging defined by Glogau as type II

improves minimally with a superficial chemical peel, but can be improved with a deeper peel such as a medium-depth peel. This is truer for the pigmentary changes versus the wrinkles. While some pigmentary improvements can be made with a medium-depth peel in the advanced aging seen in Glogau types III and IV, often these individuals require a deeper peel (phenol), laser resurfacing or a face lift to deal with the profound wrinkling encountered.

Pigmentary dyschromias can be effectively treated with chemical peeling. This can include ephelides, epidermal melasma, lentigines and epidermal hyperpigmentation. Many times repetitive superficial peels are sufficient to deal with these conditions; however, single medium-depth peels are an important tool to utilize, particularly if there is a deeper pigmentary component. Often times a Wood's lamp can prove invaluable in assessing pigmentary levels as epidermal pigmentation is accentuated. The deeper pigment extends into the dermis effectiveness of chemical peeling diminishes. Other treatment modalities including Q switched Nd:YAG or Alexandrite lasers might prove more useful in conditions where pigment is below the papillary dermis.

One caveat in treating post-inflammatory hyperpigmentation is taking care in not being too aggressive with a peeling regimen. A medium-depth peel may produce more inflammation and a resultant worsening of hyperpig-mentation in susceptible individuals. This is especially true in patients with Fitzpatrick skin types 3-6. It is better to start out with multiple superficial chemical peels in combination with bleaching agents before proceeding too soon to a medium-depth chemical peel.

The use of high-strength TCA (65-100%) for acne scarring has proven to be an exciting new application of TCA. In this technique chemical reconstruction of skin scars (CROSS technique) showed significant improvement. Specifically high-concentration TCA is focally applied to depressed or ice-pick scars and pressed hard with the wooden end of a cotton tip applicator. This induces a localized scar to occur, which over time effaces the depressed scar. Typically this requires five or six courses of treatment spread out over intervals of weeks to months.

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