Trichloroacetic Acid Peels

TCA is perhaps the best single agent for skin resurfacing. It exhibits unique properties that afford the cosmetic surgeon tremendous flexibility and versatility in treating a variety of clinical conditions. When properly used, TCA has an overall decreased morbidity as compared with other agents. It allows patients to achieve a predictable result with the benefit of disrupting their lives to a lesser degree.

Indications

Although TCA is the most popular and most widely used chemical peeling agent, proper usage is imperative to a successful outcome. Ideal candidates for TCA peeling include patients with pigmentation disorders and those who exhibit early facial rhytids. Patients with severe actinic damage and those with coarse facial rhytids are better served by other methods.

Pretreatment

To achieve the most consistent and reliable results, pretreatment of facial skin is mandatory. This improves the ability of TCA to penetrate beyond the stratum corneum and deep to the epidermal-dermal junction in a more predictable manner. We feel that almost all patients should undergo prepeel treatment with a combination of 8% hydroquinone, 1% hydrocortisone, and 0.05% retinoic acid. This bleaching formula is prepared for us by a pharmacist. Hydroquinone affects melanocytic metabolism by increasing the degradation of melanin, while decreasing melanin formation. It acts specifically by inhibition of tyrosinase, a hormone responsible for increasing the proliferation of melanocytes. Retin-A acts synergistically by increasing the penetration of hydro-quinone. An absolute indication for pretreatment is any patient with Fitzpatrick type III skin or greater. After this pretreatment regimen, TCA peeling is more predictable. This combination helps ensure a peel of consistent penetration with a lower risk of postinflammatory hyperpigmentation. Our patients use these products once daily for at least 4 weeks before undergoing their peel. Other cosmetic surgeons recommend treatment for a 6-week period. Alternative pretreatment regimens include the use of glycolic acid products ranging within 10 to 14% concentration. Glycolic acid acts to thin the stratum corneum and enhance TCA penetration. When glycolic acids are used for pretreating the skin, they are frequently used in combination with hydroquinones.

Technique

As with all chemical peeling, the skin should be degreased with an acetone-soaked sponge. The mechanical abrasion helps remove the stratum corneum, helping produce uniform penetration ofthe peeling agent. TCA may be applied as a 10 to 50% concentration, depending on the desired depth of penetration. We strongly discourage the use of TCA in concentrations higher than 35% because of a significantly higher risk of undesirable side effects such as scarring and hypopigmentation. We routinely use a 35% TCA concentration after the application of Jessner's solution. Jessner's solution is a keratolytic agent that acts by removing the stratum corneum to permit deeper penetration of the TCA. Unlike other peeling agents, the penetration of the TCA peel is affected by the number of layers applied. The goal is to achieve uniform frosting of the treated skin. Generally, the whiter the frost, the deeper the TCA has penetrated. It is important to note that a change in the color of the frost, from white to gray, represents penetration deep into the reticular layer and may result in hypertrophic scarring. Jessner's solution and 30% TCA can be used to treat actinic damage in the neck area.

Postpeel Care

Postpeel care may vary depending on the depth of the TCA peel. Patients undergoing superficial TCA peels are treated with occlusive agents such as bacitracin ointment, Eucerin cream, or

Elta. These are applied 4 to 5 times per day by the patient for 3 to 5 days until reepithelialization has occurred. At this point, the patient may resume wearing makeup and is instructed to use a skin moisturizer. Patients undergoing deeper TCA peels are instructed to follow the same directions but should expect reepithelialization to occur several days later, usually between 5 and 7 days. It is imperative that patients be instructed to avoid sun exposure for 6 weeks after their peel.

Complications

Hyperpigmentation The most common complication of TCA peeling is postinflammatory hyperpigmentation, which is generally the result of early sun exposure. It must be stressed that during the early stages of healing, sun exposure is prohibited. In most patients in whom this complication develops, failure to comply with this instruction is the most common cause. Patients may also exhibit this complication if pretreatment was inadequate. Birth control pill intake should also cease during this peripeel period, as their use can produce pigmentary changes.

Hyperpigmentation is usually easy to treat and will respond to 0.05% Retin-A cream in combination with 8% hydroquinone. We prefer to use our bleaching formula as described previously. This is usually applied once or twice daily for about 3 weeks, but it may be used longer if necessary. Some patients may experience moderate erythema secondary to Retin-A use. This problem is less common in those who were treated with Retin-A during the prepeel period. However, should this be of concern, topical hydrocortisone may be used for several weeks as required. These patients are also instructed to use a sunscreen with a sun protection factor (SPF) of 20 or greater.

Hypertrophic Scarring The risk of producing hypertrophic scarring from medium-depth TCA peels is rare. When it does occur, it appears most commonly along the mandibular border and in the perioral region. Thin-skinned patients are at greatest risk, as the TCA is more likely to penetrate deep into the reticular dermis. We consider the use of isotretinoin during the prior 12 months a contraindication to TCA peeling, as it has been shown that its use can lead to scarring. Most practitioners recommend waiting 18 to 24 months after the use of Accutane has been stopped before performing any skin resurfacing procedure. Clinically, it is probably safe to perform a peel on patients after they begin to produce normal oil in their skin. Patients who develop hypertrophic scarring are treated most successfully with injectable steroids, although some may require surgical revision after scar maturation.

Herpes Simplex Infection Herpes simplex infection may develop in any patient after undergoing any peel or laser procedure. Patients with or without a positive history are treated prophylactically with systemic antiviral agents daily, starting 2 days before the peel and continuing for a total of 7 days. Those patients who develop postpeel herpes infection are treated more aggressively with acyclovir or valacyclovir, 800 mg 4 times per day. Treatment is usually successful, and scarring does not result.

Summary

TCA peels represent the most common chemical peel performed. In our opinion, they are the most versatile agents available and may be used to treat a variety of dermatologic conditions. They are applicable to a diverse population and most commonly used to treat sun-damaged skin that shows pigmentary changes with mild to moderate rhytids. As with all skin resurfacing techniques, the key to successful TCA peeling is appropriate patient selection and the proper pretreatment regimen.

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