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The Art of the TCA Chemical Peel
The process is part art, part chemistry
The Art of the TCA Chemical Peel

The process is part art, part chemistry

We live in an interesting time in terms of skin resurfacing. Tried and true methods, such as chemical peels, have been superceded by newer but relatively untried technologies, including fractional laser, plasma resurfacing, and other nonablative modalities.

No doubt about it: These are exciting technologies, but at the same time they disappoint. The industry and media hype surrounding the use of some devices produces a situation in which expectationsof both surgeon and patientexceed the results. Due to this rapidly changing environment, I have seen more than one person spend over $100,000 on a laser or similar device only to be disappointed with the outcomes. The device becomes little more than an expensive door stop.

I believe I can achieve better results with $1.50 worth of trichloroacetic acid (TCA) chemical peel than thousands of dollars in laser treatments.

Chemical peeling was the first skin resurfacing procedure, with reports of early civilizations using fruit acids to treat the facial skin. Aggressive chemical peeling was pervasive in Europe and was performed by lay peelers. Ethnic communities brought this art to the West Coast of the United States in the early 20th century as secret recipes with a continuation of lay treatments.

As the medical community began to observe and control chemical face peeling, the procedure was studied in numerous fashions. Aggressive phenol face peels reigned supreme for years, but these were fraught with problems, such as severe porcelain hypopigmentation, caustic burns, organ system toxicity, and death.

Over the ensuing years, phenol peeling became more controlled, but largely was displaced by TCA as the peeling agent of choice. TCA is much safer, predictable, and more easily controlled than phenol and croton oil. It is commonly used from concentrations of 15% to 70% and, although predictable, can nonetheless cause severe burns and hypopigmentation when used incorrectly.

TCA exerts its action by the almost immediate coagulation of dermal proteins, which in part through severe vasoconstriction produces a white "frost" as the coagulation proceeds. The color and intensity of the frost and skin serve as end points for various chemical peel depths, which directly correlate to healing time and clinical result.

As with all skin resurfacing procedures regardless of mechanism, chemical peeling is part art and part science, similar to dermabrasion, and less controlled than lasers. Each patient presents a unique set of circumstances that affect how the acid reacts to the skin. Skin hydration, sebum content, thickness, and actinic damage and acid concentration can all affect the penetration of acid into the dermis. Due to this, each patient may require different treatment.

Pigmented skin always presents resurfacing challenges, and chemical peeling is no exception. Although all skin types can be safely peeled with TCA, many nuances exist with pigmented skin.

The treatment of Fitzpatrick skin types 4-6 should be reserved for experienced peelers only. These patients are much more difficult to manage in terms of treatment depths, pigmentation abnormalities, and reactive skin states postpeel.

Most adult patients can be classified as having mild, moderate, or severe actinic damage, which corresponds with the same classification of dyschromias and rhytids. The novice peeler should begin with light-skinned patients with moderate dyschromias and rhytids. Although very aggressive, high-concentration TCA peels can produce dramatic laser-like results, the safety margin decreases. With like-laser skin resurfacing, it is better to seek safe moderate improvement than riskier "home runs." The key term in any resurfacing is to be conservative.

I feel the best way to teach or learn chemical peeling is to begin with ultra-light peels on conscious patients.

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