60 Trichloroacetic Acid Peel

Rod J. Rohrich and Erez Dayan

Abstract

Trichloroacetic acid (TCA) is a versatile agent, efficacious in treating a spectrum of facial rhytides and dyschromias at varying concentrations. TCA is commonly used in a 30 to 35% concentration to achieve a medium-depth peel into the upper reticular dermis. The addition of Jessner’s solution before the TCA peel application leads to partial removal of epidermis, allowing for deeper penetration of the TCA. This combination is beneficial, as lower concentrations of TCA can be used for the same depth of peel, minimizing complications such as scarring.

Chemical peel – TCA – trichloroacetic acid – Jessner’s – skin resurfacing

60 Trichloroacetic Acid Peel

Key Points

Addition of Jessner’s solution to 35% trichloroacetic acid (TCA) improves quality and consistency of the peel while allowing for less TCA to be used for a given effect.
Preprocedure skin prep is important to avoid complications and optimize results.
Always ring out gauze or cotton-tip applicators with TCA on it to prevent adverse events.
Number of passes and pressure are both related to depth of peel.
Continuously assess color changes to determine depth and efficacy of peel.

60.1 Preoperative Steps

Consultation with the patient should be used to establish realistic goals and expectations as well as to educate the patient on important perioperative care instructions for optimal results. A careful history and physical examination allow the clinician to determine the patients’ candidacy (Table 60.1).

**Table 60.1** Indications and contraindications for the use of chemical peel
Indications for chemical peel	Contraindications
Superficial or deep rhytides/photoaging	Isotretinoin therapy within last 6 months
Preneoplastic or neoplastic lesions (i.e., actinic keratosis and lentigines)	Absence of pilosebaceous units on face
Underlying skin disease (i.e., acne)	Infection or open wounds (herpes and open acne cysts)
Pigmentary dyschromias	Medium or deep resurfacing procedure within 3 to 12 months
	Recent facial surgery involving undermining
	History of therapeutic radiation exposure
	Fitzpatrick skin types IV, V, and VI

Our preference is to pretreat all patients for 4 to 6 weeks before chemical peeling. This regimen includes topical tretinoin (0.05–0.1%), hydroquinone (2–4%), sunscreen, and alpha hydroxyl acid (4–10%). Pretreatment improves skin tolerance, regulates fibroblast and melanocyte function, improves dermal circulation, and allows for the treated skin to heal 3 to 4 days faster due to increased cellular division and new collagen formation. Modifications to this preprocedure regimen (dosages and application intervals) are made as needed based on tolerance and skin types. A week before peel, patients are started on a cleansing and toning protocol and are encouraged to maintain adequate hydration and moisture of the skin.
Acyclovir is initiated 2 days before chemical peel and continued 5 days after the peel in patients with prior history of herpetic lesions.
Setup is clearly labeled glasses ordered from left to right in the appropriate sequence of usage. The glasses are filled by the practitioner with: (1) 70% ethyl alcohol, (2) acetone, (3) Jessner’s solution, and (4) 35% TCA solution.
In our practice the Jessner’s solution is premixed by a pharmacist and contains 100 mg of 95% ethanol, 14 g of resorcinol, 14 g of salicylic acid, and 14 mL of lactic acid. Also, available on this table are 2 × 2 gauze and cotton-tip applicators.