- Email: [email protected]
Trichloroacetic acid application in chemical peeling
TRICHLOROACETIC ACID APPLICATION IN CHEMICAL PEELING HAROLD J. BRODY, MD
In chemical peeling of the skin for photoaging, the absorption of trichloroactic acid (TCA) after contact with the epidermis depends on the photoaged status of the skin in concert with the actual method of application. Protein coagulation and increasing penetration are reflected in the frost, but only an approximate inexact definition of depth estimation can be ascertained from the color. Although 35% TCA has an excellent record of safety and clinical results, 50% TCA is frought with more complications owing to the inherent unpredictability of the agent, and the addition of additives to slow penetration does not alter its increased capability for scarring. Either 35% TCA as a single agent or techniques to admit 35% TCA to deeper depths in the dermis by altering the epidermis immediately preceeding application have enabled excellent clinical results to be obtained with a minimum of complications. KEY WORDS: chemical peeling, chemexfoliation, trichloroacetic acid
Application dynamics of 35% trichloroacetic acid (TCA) to the face depend on the preexisting photodamaged status of the skin. If the skin is treated first with retinoic acid, glycolic acid, lactic acid, or similar compounds alone or in combination, or if the corneal layer is stripped with acetone or alcohol, the frosting and uniformity of application will be faster. If not, the frosting or penetration will be slower and variable. Either way, absorption will occur because photodamage is not a barrier to TCA. ~ Inherently, a concentration of 35% TCA has been shown histologically to penetrate through the epidermis to the papillary dermis, and a concentration of 50% TCA has been shown to penetrate through the papillary dermis to the upper reticular dermis. In the traditional approach, TCA is applied with a 4 x 4 or 2 x 2 gauze pad as the chief wounding agent applicator. After make-up and stratum corneum debris are removed with povidone iodine surgical scrub, a 3 to 5 minute acetone and alcohol scrub will loosen or remove the stratum corneum. TCA can be aplvlied rapidly, beginning with a cotton-tipped applicator under the eyes while the patient is looking up and then continuing with the gauze pad through each cosmetic unit: right cheek, perioral area, left cheek, forehead and eyebrows, and nose, rubbing in the solution liberally and rapidly (Fig 1). Ice packs are applied as the skin turns white. 2 The degree of protein coagulation and evenness of penetration is reflected as the skin turns light white, white, and very white. The author does not believe that a predictable estimation of depth can be approximated from the color, though the progression to stronger colors may certainly indicate increasing penetration. If several colors of white remain in the facial skin 'after 5 to 10 minutes, the decision to return to the light From the Department of Dermatology, Emory University School of
Medicine, Atlanta, GA. Address reprint requests to Harold J. Brody, MD, 478 Peachtree St, Suite 71 l-A, Atlanta, GA 30308. Copyright 9 1995 by W. B. Saunders Company 1071-0949/95/0202-0006505.00/0
white areas and reapply TCA there results in increased protein coagulation and wounding. 3 If the assumption is made that initial solution application actually did occur adequately in these lighter areas, reapplication is usually not necessary, and the clinical result will be typically even and excellent as expected for the wounding agent. One can repeat TCA application in these areas or on the entire face if deemed necessary for desired greater wounding. Forcing uptake in an area of increased photodamage is acceptable in the treatment of actinic keratoses, for example, but for photopigmentation or rhytides, this may engender greater risk. As a general rule, the production of the typical very white frost of 35% TCA is not associated with complications (Fig 2). The technique of application of 50% TCA is the same as for 35% except that, because TCA is concentrationdependent, the stronger agent will cause more rapid coagulation and penetration. The light white color rarely occurs and the rapidity of frost development is greater. The margin of error is much less, and the risk of complication is higher. The dermatology literature suggests greater risk of scarring with high strength TCA than with phenol. 4 Therefore, for the treatment of significant rhytides, the author still uses the Baker-Gordon formula, which has a 30-year record of excellent safety and predictable results. If 50% TCA is forced into the deep dermis to remove rhagades and the whitest frost is produced, the result is more unpredictable, as is inherent with the agent. Some wrinkles may disappear, whereas others may not. Texture changes may result, and scarfing may occur. Unpredictable scarring has been produced with plain 50% TCA in spite of the appearance of the frost, the preexisting status of the skin, the method of application, and other factors. Dermatologic surgeons have devised methods to achieve penetration of 35% TCA to a similar level as 50% TCA: to the upper level of the reticular dermis. These methods include pretreatment of the skin w i t h solid carbon dioxide, J e s s n e r ' s salicylic acid/ resorcinol/lactic acid combination, or 70% glycolic acid
Operative Techniques in Plastic and Reconstructive Surgery, Vol 2, No 2 (May), 1995:127-128
127
Fig 1. Preoperative photo showing application of TCA with single 4 in x 4 in gauze square.
immediately before 35% TCA application. These specific techniques have b e e n described in the literature, 6"7"8 and their" records of safety in treating t h o u s a n d s of cases have s h o w n generally comparable clinical results to plain 50% TCA w i t h o u t the p r o d u c t i o n of contractile scarring and with a scarring complication rate of less t h a n 1%. 9 Because of these combination techniques, this a u t h o r n o longer uses 50% TCA alone, except for local application or selected portions of cosmetic units. It is the o p i n i o n of the a u t h o r that the addition of emulsifiers, additives, and surfactants to TCA in the h o p e of slowing penetration m a y change the ability of the chemical to p e n e t r a t e but does not alter the capability of 50% TCA to p r o d u c e scarring because t h e y d o n ' t significantly alter the final concentration of the TCA. 1~ Additives m a y e v e n increase the penetration of TCA to the lower dermis b y giving a false sense of security to the physician and leading to overcoating and the p r o d u c t i o n of contractile scarring. The frequency rate by c o m p a r i s o n to 35% TCA c o m b i n a t i o n s is u n d e t e r m i n e d . H o w e v e r , 35% T C A does not seem to i n h e r e n t l y possess as great of a risk of scarring. G o o d clinical results with a n d w i t h o u t additives seem to be similar. 11 The a u t h o r prefers either 35% TCA alone as described or the TCA combination peels, w h i c h m a y s p e e d the coagulation of proteins o n application because of the usage of adjunctive preliminary agents. The combinations use the safe 35% concentration while ameliorating the defects of p h o t o a g i n g or specifically selected d e p r e s s e d scarring. M a n y t h o u s a n d s of TCA peels have b e e n p e r f o r m e d in this fashion with safe a n d predictable results.
REFERENCES
Fig 2. Frosting after application of 35% TCA showing minor variations in shades of white frosting, which are not discernable on healing postoperative photo.
128
1. Stegman SJ: A comparative histologic study "of the effects of three peeling agents and dermabrasion on normal and sundamaged skin. Aesth Plast Surg 6:123-135, 1982 2. Brody HJ: General peeling concepts, in Chemical Peeling, St Louis, Mosby, 1992, pp 44-45 3. Brody HJ: Variations and comparisons in medium depth chemical peeling. J Dermatol Surg Oncol 15:953-963, 1989 4. Ayres S: Dermal changes following application of chemical cauterants to aging skin. Arch Dermatol 82:578, 1960 5. Baker TJ, Gordon HL: Chemical face peeling, in Surgical Rejuvenation of the Face. St Louis, Mosby, 1986, pp 37-100 6. Brody HJ: Medium depth chemical peeling of the skin: A variation of superfical chemosurgery. J Dermatol Surg Oncol 12:1268-1275, 1986 7. Monheit GD: The Jessner's + TCA peel: A medium depth chemical peel. J Dermatol Surg Oncol 15:945-950, 1989 8. Coleman WP, Futrell JM: The glycolicacid trichlor0acetic acid peel. J Dermatol Surg Oncol 20:76-80, 1994 9. Brody HJ: Complications of chemical peeling. J Dermatol Surg Oncol 15:1010-1019, 1989 10. Dinner MI, Artz JS: Chemical peel What's in the formula? Plast Reconstr Surg 94:406-407, 1994 11. Clinical Discussions, Joint Meeting of Florida Society of Dermatologic Surgery and Florida Society of Plastic and Reconstructive Surgery, Miami, FL, Sept. 15, 1990 and American Academy of Facial Plastic and Reconstructive Surgery, Indianapolis, IN, March 3-4, 1993
HAROLD J. BRODY
In chemical peeling of the skin for photoaging, the absorption of trichloroactic acid (TCA) after contact with the epidermis depends on the photoaged status of the skin in concert with the actual method of application. Protein coagulation and increasing penetration are reflected in the frost, but only an approximate inexact definition of depth estimation can be ascertained from the color. Although 35% TCA has an excellent record of safety and clinical results, 50% TCA is frought with more complications owing to the inherent unpredictability of the agent, and the addition of additives to slow penetration does not alter its increased capability for scarring. Either 35% TCA as a single agent or techniques to admit 35% TCA to deeper depths in the dermis by altering the epidermis immediately preceeding application have enabled excellent clinical results to be obtained with a minimum of complications. KEY WORDS: chemical peeling, chemexfoliation, trichloroacetic acid
Application dynamics of 35% trichloroacetic acid (TCA) to the face depend on the preexisting photodamaged status of the skin. If the skin is treated first with retinoic acid, glycolic acid, lactic acid, or similar compounds alone or in combination, or if the corneal layer is stripped with acetone or alcohol, the frosting and uniformity of application will be faster. If not, the frosting or penetration will be slower and variable. Either way, absorption will occur because photodamage is not a barrier to TCA. ~ Inherently, a concentration of 35% TCA has been shown histologically to penetrate through the epidermis to the papillary dermis, and a concentration of 50% TCA has been shown to penetrate through the papillary dermis to the upper reticular dermis. In the traditional approach, TCA is applied with a 4 x 4 or 2 x 2 gauze pad as the chief wounding agent applicator. After make-up and stratum corneum debris are removed with povidone iodine surgical scrub, a 3 to 5 minute acetone and alcohol scrub will loosen or remove the stratum corneum. TCA can be aplvlied rapidly, beginning with a cotton-tipped applicator under the eyes while the patient is looking up and then continuing with the gauze pad through each cosmetic unit: right cheek, perioral area, left cheek, forehead and eyebrows, and nose, rubbing in the solution liberally and rapidly (Fig 1). Ice packs are applied as the skin turns white. 2 The degree of protein coagulation and evenness of penetration is reflected as the skin turns light white, white, and very white. The author does not believe that a predictable estimation of depth can be approximated from the color, though the progression to stronger colors may certainly indicate increasing penetration. If several colors of white remain in the facial skin 'after 5 to 10 minutes, the decision to return to the light From the Department of Dermatology, Emory University School of
Medicine, Atlanta, GA. Address reprint requests to Harold J. Brody, MD, 478 Peachtree St, Suite 71 l-A, Atlanta, GA 30308. Copyright 9 1995 by W. B. Saunders Company 1071-0949/95/0202-0006505.00/0
white areas and reapply TCA there results in increased protein coagulation and wounding. 3 If the assumption is made that initial solution application actually did occur adequately in these lighter areas, reapplication is usually not necessary, and the clinical result will be typically even and excellent as expected for the wounding agent. One can repeat TCA application in these areas or on the entire face if deemed necessary for desired greater wounding. Forcing uptake in an area of increased photodamage is acceptable in the treatment of actinic keratoses, for example, but for photopigmentation or rhytides, this may engender greater risk. As a general rule, the production of the typical very white frost of 35% TCA is not associated with complications (Fig 2). The technique of application of 50% TCA is the same as for 35% except that, because TCA is concentrationdependent, the stronger agent will cause more rapid coagulation and penetration. The light white color rarely occurs and the rapidity of frost development is greater. The margin of error is much less, and the risk of complication is higher. The dermatology literature suggests greater risk of scarring with high strength TCA than with phenol. 4 Therefore, for the treatment of significant rhytides, the author still uses the Baker-Gordon formula, which has a 30-year record of excellent safety and predictable results. If 50% TCA is forced into the deep dermis to remove rhagades and the whitest frost is produced, the result is more unpredictable, as is inherent with the agent. Some wrinkles may disappear, whereas others may not. Texture changes may result, and scarfing may occur. Unpredictable scarring has been produced with plain 50% TCA in spite of the appearance of the frost, the preexisting status of the skin, the method of application, and other factors. Dermatologic surgeons have devised methods to achieve penetration of 35% TCA to a similar level as 50% TCA: to the upper level of the reticular dermis. These methods include pretreatment of the skin w i t h solid carbon dioxide, J e s s n e r ' s salicylic acid/ resorcinol/lactic acid combination, or 70% glycolic acid
Operative Techniques in Plastic and Reconstructive Surgery, Vol 2, No 2 (May), 1995:127-128
127
Fig 1. Preoperative photo showing application of TCA with single 4 in x 4 in gauze square.
immediately before 35% TCA application. These specific techniques have b e e n described in the literature, 6"7"8 and their" records of safety in treating t h o u s a n d s of cases have s h o w n generally comparable clinical results to plain 50% TCA w i t h o u t the p r o d u c t i o n of contractile scarring and with a scarring complication rate of less t h a n 1%. 9 Because of these combination techniques, this a u t h o r n o longer uses 50% TCA alone, except for local application or selected portions of cosmetic units. It is the o p i n i o n of the a u t h o r that the addition of emulsifiers, additives, and surfactants to TCA in the h o p e of slowing penetration m a y change the ability of the chemical to p e n e t r a t e but does not alter the capability of 50% TCA to p r o d u c e scarring because t h e y d o n ' t significantly alter the final concentration of the TCA. 1~ Additives m a y e v e n increase the penetration of TCA to the lower dermis b y giving a false sense of security to the physician and leading to overcoating and the p r o d u c t i o n of contractile scarring. The frequency rate by c o m p a r i s o n to 35% TCA c o m b i n a t i o n s is u n d e t e r m i n e d . H o w e v e r , 35% T C A does not seem to i n h e r e n t l y possess as great of a risk of scarring. G o o d clinical results with a n d w i t h o u t additives seem to be similar. 11 The a u t h o r prefers either 35% TCA alone as described or the TCA combination peels, w h i c h m a y s p e e d the coagulation of proteins o n application because of the usage of adjunctive preliminary agents. The combinations use the safe 35% concentration while ameliorating the defects of p h o t o a g i n g or specifically selected d e p r e s s e d scarring. M a n y t h o u s a n d s of TCA peels have b e e n p e r f o r m e d in this fashion with safe a n d predictable results.
REFERENCES
Fig 2. Frosting after application of 35% TCA showing minor variations in shades of white frosting, which are not discernable on healing postoperative photo.
128
1. Stegman SJ: A comparative histologic study "of the effects of three peeling agents and dermabrasion on normal and sundamaged skin. Aesth Plast Surg 6:123-135, 1982 2. Brody HJ: General peeling concepts, in Chemical Peeling, St Louis, Mosby, 1992, pp 44-45 3. Brody HJ: Variations and comparisons in medium depth chemical peeling. J Dermatol Surg Oncol 15:953-963, 1989 4. Ayres S: Dermal changes following application of chemical cauterants to aging skin. Arch Dermatol 82:578, 1960 5. Baker TJ, Gordon HL: Chemical face peeling, in Surgical Rejuvenation of the Face. St Louis, Mosby, 1986, pp 37-100 6. Brody HJ: Medium depth chemical peeling of the skin: A variation of superfical chemosurgery. J Dermatol Surg Oncol 12:1268-1275, 1986 7. Monheit GD: The Jessner's + TCA peel: A medium depth chemical peel. J Dermatol Surg Oncol 15:945-950, 1989 8. Coleman WP, Futrell JM: The glycolicacid trichlor0acetic acid peel. J Dermatol Surg Oncol 20:76-80, 1994 9. Brody HJ: Complications of chemical peeling. J Dermatol Surg Oncol 15:1010-1019, 1989 10. Dinner MI, Artz JS: Chemical peel What's in the formula? Plast Reconstr Surg 94:406-407, 1994 11. Clinical Discussions, Joint Meeting of Florida Society of Dermatologic Surgery and Florida Society of Plastic and Reconstructive Surgery, Miami, FL, Sept. 15, 1990 and American Academy of Facial Plastic and Reconstructive Surgery, Indianapolis, IN, March 3-4, 1993
HAROLD J. BRODY