Depths of chemexfoliation induced by various concentrations and application techniques of trichloroacetic acid in a porcine model

A 15% Trichloroacetic Acid + 3% Glycolic Acid Chemical Peel Series Improves Appearance of Hand Lentigines: An Evaluator-Blinded, Split-Hand Prospective Trial

BACKGROUND

Improving the appearance of lentigines on the hands is a key component to hand rejuvenation. Soft tissue fillers revolumize hands, but do not address pigmentary changes. OBJECTIVE: This study investigated the effiacy of a 15% trichloroacetic acid (TCA) + 3% glycolic acid (GA) combination peel in improvement of appearance of hand lentigines.

METHODS

A prospective evaluator-blinded, split-hand study was performed using a 15% TCA + 3% GA peel to treat patients with hand lentigines. Subjects received a total of 3 treatments at 4-week intervals on 1 hand, with the other hand serving as an untreated control. Final photographs were taken 12 weeks after the last treatment. Two blinded board-certified dermatologists graded improvement in hand lentigines using a 5-point scale.

RESULTS

Eighteen of 20 patients completed the study (90%). The mean age was 64.4 years (SE 1.6, range 51-71). The mean pain scores were 3.8 (SE 0.4) on a 10-point scale (1 = no pain, 10 = extremely painful). Blinded evaluators correctly identified the after-treatment photographs in 16 patients (88%). Physician and patient-graded mean improvement of lentigines was significant for treated versus control hands ( p < .01). No adverse events were noted.

CONCLUSION

A series of three 15% TCA + 3% GA peels are effective and safe in the treatment of hand lentigines.

Pilot Study on the Effect of a Single Topical Application of Trichloroacetic Acid 85% on Normal Cervical Tissue

Background: Early detection and treatment of cervical intraepithelial neoplasia (CIN) through a “see and treat” approach is a pillar of cervical cancer prevention programs in developing countries such as Indonesia. One of the major challenges faced is the limited N2O or CO2 gas supply for cryotherapy. Thus, an alternative therapeutic method such as trichloroacetic acid (TCA) topical application is needed as an alternative solution. The effectiveness of this therapy will depend on its destructive effect on eliminating the whole lesion in CIN.

Objective: To estimate the extent of damage in the normal cervical tissue after a single topical application of 85% TCA solution.

Design and Methods: This research was an intervention study carried out by applying ±5 ml of 85% TCA solution into the cervix of 40 patients scheduled for total hysterectomy for indications other than cervical pathology 24 h before surgery. The extent of tissue destruction was determined microscopically using histopathological specimens. The study protocol is registered at www.clinicaltrial.gov (ID NCT04911075).

Results: In the final analysis, 39 subjects were included. The necrotic area was detected at the superficial layer, accompanied by the full epithelial erosion thickness. In addition, there were also fibrotic areas resembling burned tissue in the stroma. The mean depth of destruction was 1.16 ± 0.01 mm in the anterior lip and 1.01 ± 0.06 mm in the posterior lip. There was no significant depth difference between the anterior and posterior lips (p ≥0.05). Moreover, the 85% TCA topical application was tolerable, as represented by the fact that the vast majority (82.1%) of participants experienced pain with a visual analog scale score of &lt;4.

Conclusion: Single dose of TCA 85% in topical solution was able to destroy the normal cervical tissue with a deeper mean depth than the mean depth of CIN III in squamous epithelium.

Trichloroacetic Acid Paint for Boxcar and Polymorphic Acne Scars

BACKGROUND

Scarring is a common complication of acne vulgaris with a significant impact on the psychological well-being of patients. Focal application of high concentration trichloroacetic acid (TCA) has been proven efficacious in treating ice-pick scars, but the utility in other scar types is understudied.

OBJECTIVE

The aim of this study is to evaluate the efficacy and safety of 90% TCA in boxcar and polymorphic acne scars using a novel brush applicator.

MATERIALS AND METHODS

Forty-one patients with acne scars were recruited for treatment of boxcar and polymorphic scar with 90% TCA applied with a cosmetic brush. Each patient received 3 treatment sessions spaced between 7 and 9 weeks apart.

RESULTS

All participants had good to excellent outcomes as per Jacob and colleagues grading. Patients with skin Type 3 to 6 had more excellent outcomes (13 patient, 59%) than patients of skin type 1 to 2 (9 patients, 41%). Two participants (5%) had postprocedural complications. Five participants (14%) were on concomitant isotretinoin with no appreciable increase in reepithelialization time or rate of complications.

CONCLUSION

Focal 90% TCA with a cosmetic brush applicator is safe and effective in treating boxcar and polymorphic scars. The clinical outcome is good to excellent with low rates of complication.

Use of 27-gauge Tuberculin Syringe for Trichloroacetic Acid Chemical Reconstruction of Skin Scars (TCA-CROSS)

Chemical Reconstruction of Skin Scars (CROSS) is a minimally invasive, safe, and cost effective technique for the management of ice pick acne scars that are otherwise generally resistant to treatment. 100% trichloro acetic acid (TCA) is usually applied using toothpicks and the end point is white discoloration of skin. The concentrated caustic agent quite often spills onto surrounding normal skin leading to superficial burns and post-inflammatory pigmentation. Use of 27-gauge tuberculin syringe gives a much more controlled access to apply TCA leading to better cosmetic outcome and fewer adverse effects.

Comparison of efficacy and safety of 30% hydrogen peroxide with 50% trichloroacetic acid in seborrheic keratosis: a randomized controlled study

BACKGROUND

Seborrheic keratosis is a benign skin tumour. None of the common therapies is satisfactory. This study compared the efficacy of 30% hydrogen peroxide versus 50% trichloroacetic acid in treatment of seborrheic keratoses.

METHODS

This unblinded, comparative interventional study was conducted on 85 patients of seborrheic keratosis. Lesions were graded using physician's lesion assessment (PLA) scale (0, clear; 1, nearly clear; 2≤1 mm thick; 3≥1 mm thick). Patients were randomly assigned into two groups: A and B. Five target seborrheic keratosis lesions with PLA score of three were selected in each patient. Group A was treated with 30% hydrogen peroxide and group B with 50% trichloroacetic acid. Both groups received treatment every week up to 5 weeks or till complete resolution of lesions. Clinical photographs of all patients were taken every 2 weeks.

RESULTS

Both the groups were comparable in terms of age and sex. At the end of 6 weeks, lesions were cleared completely in 41.8% of patients in group A and in 23.8% in group B. Mean PLA score decreased significantly in group A from 3 to 1.79 (40.3%) at 2 weeks and to 0.63 (79%) at 6 weeks (P<0.001). The decrease in PLA score in group B was 2.41 (19.7%) and 1.13 (62.3%) at 2, and 6 weeks respectively (P<0.001). Hydrogen peroxide produced greater clearance of seborrheic keratosis (P=0.017) than trichloroacetic acid. Also, no major adverse effects were observed in the two groups.

CONCLUSIONS

Application of 30% hydrogen peroxide appears to be more efficacious as compared to trichloroacetic acid (50%) for treatment of seborrheic keratosis.

Chemical Regeneration of Wound Defects: Relevance to the Canine Palatal Mucosa and Cell Cycle Up-Regulation in Human Gingival Fibroblasts

Background

Trichloroacetic acid (TCA) is an agent widely applied in dermatology for skin regeneration. To test whether TCA can offer an advantage for the regeneration of oral soft tissue defects, the cellular events following TCA application were explored in vitro and its influence on the oral soft tissue wound healing was evaluated in a canine palate model.

Methods

The cytotoxicity and growth factor gene expression in human gingival fibroblasts were tested in vitro following the application of TCA at four concentrations (0.005%, 0.05%, 0.5% and 1%) with different time intervals (0, 3, 9 and 21 h). One concentration of TCA was selected to screen the genes differentially expressed using DNA microarray and the associated pathways were explored. TCA was injected in open wound defects of the palatal mucosa from beagle dogs (n = 3) to monitor their healing and regeneration up to day 16-post-administration.

Results

While the 0.5-1% concentration induced the cytoxicity, a significantly higher expression of growth factor genes was observed after 3 and 9 h following the 0.5% TCA application in comparison to other groups. DNA microarray analysis in 0.5% TCA group showed 417 genes with a significant 1.5-fold differential expression, involving pathways of cell cycle, FoxO signaling, p53 signaling, ubiquitin mediated proteolysis and cAMP signaling. In vivo results showed a faster reepithelialization of TCA-treated wounds as compared to spontaneous healing.

Conclusion

TCA promoted the healing and regeneration of oral soft tissue wound defects by up-regulating the cell cycle progression, cell growth, and cell viability, particularly at a concentration of 0.5%.

Comparison of efficacy of chemical peeling with 25% trichloroacetic acid and 0.1% retinoic acid for facial rejuvenation

INTRODUCTION

Skin aging is a problem which negatively affects the psyche of the person, social relations, as well as work life and health and which compels the patients to find appropriate treatment methods. Numerous treatment methods have been developed in order to delay aging and to reduce the aging effects in addition to having a younger, healthier and more beautiful facial appearance.

AIM

To compare the efficiency, cosmetic results and possible adverse effects of the peeling treatment with 25% trichloroacetic acid (TCA) and 0.1% retinoic acid for facial rejuvenation in patients presenting with skin aging.

MATERIAL AND METHODS

Fifty female patients in total presenting with medium and advanced degree skin aging were subject to this study. Two separate treatment groups were formed; the first group underwent chemical skin treatment with 25% TCA while the other group was applied with 0.1% retinoic acid treatment. Following the 4 months' treatment the patients were controlled three times in total for post lesional hypopigmentation, hyperpigmentation, scars, skin irritation and other possible changes per month. The pretreatment and first follow-up visit, and final control images were comparatively evaluated by three observers via specific software.

RESULTS

The healing rates of the group subject to retinoic acid were statistically higher (p < 0.05) compared to patients in the TCA group in the final follow-up visit following the treatment according to the first and second observers. On the other hand, according to the third observer, patients applied with retinoic acid presented with higher healing rates compared to those treated with TCA, however; this rate was not statistically significant (p > 0.05). The frequency of TCA- and retinoic acid-associated adverse effects was similar in both groups (p > 0.05). As a result of both treatments, a reduction in the quality of life scores as well as a pronounced recovery (p = 0.001) in the quality of life of those patients with skin aging was observed.

CONCLUSIONS

The photo aging treatment option with 0.1% retinoic acid is cheaper and more feasible for patients compared to 25% TCA, and it is also as reliable and effective as TCA.

Therapeutic response of 70% trichloroacetic acid CROSS in atrophic acne scars

BACKGROUND

Acne scarring is a common sequela of acne for which no single treatment method is uniformly effective. The chemical reconstruction of skin scars (CROSS) therapy using high-concentration trichloroacetic acid (TCA) has shown promise as a cheap, safe, and effective modality of treatment in acne scars.

OBJECTIVE

To assess the therapeutic response of 70% TCA CROSS on atrophic acne scars and to evaluate the adverse effects of this therapy.

MATERIALS AND METHODS

Fifty-three patients with postacne atrophic scars were treated with 70% of TCA focal application every 2 weeks by the CROSS technique and results evaluated on 3 parameters: physician assessment, patient assessment, and satisfaction level of patients, after a follow-up of 3 months.

RESULTS

Good or excellent improvement (>50%) was seen in 66% of patients on physician and patient assessments. The patients were either very satisfied or satisfied in 81.1% of cases. Patients with predominantly boxcar scars and higher pretreatment scar severity were associated with better treatment outcomes. Age, sex, duration of scars, or type of skin did not significantly influence the treatment outcome and adverse effects.

CONCLUSION

The study showed that 70% of TCA is a safe and effective treatment option in all types of atrophic acne scars, especially in severe boxcar scars.

Trichloroacetic acid application versus spray monopolar diathermy for treating benign cervical lesions: a randomized controlled clinical trial

OBJECTIVE

This study aimed to compare efficacy, tolerability, and safety of trichloroacetic acid (TCA) painting versus monopolar spray coagulation of the cervix for treating persistent benign cervical lesions.

MATERIALS AND METHODS

A prospective randomized controlled trial was done in a tertiary care referral facility and university hospital. A total of 246 cases with objective evidence of benign cervical lesions were divided into 2 groups according to the line of management. Group A was composed of 126 cases subjected to spray monopolar coagulation, whereas group B was composed of 120 cases subjected to TCA application. Cervical smearing and colposcopy with or without cervical biopsy were performed to exclude underlying malignant lesions. Trichloroacetic acid painting or spray monopolar coagulation of the benign cervical lesion(s) was also performed. Follow-up was performed to assess relief of symptoms and cervical morphology for 1 month. Main outcome measures include success of management tool, relief of symptoms, and normal cervical morphology after 1 month of therapy.

RESULTS

A statistically significant cure rate of cervical lesions after treatment in both groups without significant difference between both groups was reported. Failure rate was reported more in group B than group A mainly owing to hypertrophied ectopy and cervical polyp. Patient in group A reported low satisfaction (26.9%) and poor tolerability rate (44.5%) as compared with patients in group B, who reported high satisfaction (77.5%) and good tolerability rate (77.5%), this difference was statistically significant.

CONCLUSIONS

Both topical application of 70% TCA and monopolar spray coagulation offer considerable efficacy, acceptable success rates, and minimal complications. Spray coagulation is significantly superior in terms of less persistent or incompletely healed lesions. Nevertheless, topical application of 70% TCA has the advantages of simplicity, higher patient tolerability, and safety, which can be widely used by gynecologists who have limited experience with surgical procedures. It is highly recommended if the cervical lesion is ectopy or nonspecific cervicitis but not hypertrophic lesion such as hypertrophic ectopy or polyp.

Chemical reconstruction of skin scars therapy using 100% trichloroacetic Acid in the treatment of atrophic facial post varicella scars: a pilot study

Context:

Chickenpox (varicella) is a common viral disease caused by Varicella zoster virus. Facial atrophic scars after varicella infection are not uncommon and pose a cosmetic problem. Like atrophic scars of other aetiologies, they are a difficult condition to treat. There are not enough references in the literature regarding efficient treatment of post varicella scars. High strength Trichloroacetic acid (TCA), which is known to cause dermal collagen remodelling, was used to treat varicella scars in the present study.

Aims:

The study was undertaken to assess the efficiency of Chemical Reconstruction of Skin Scars (CROSS) technique using 100% TCA in the treatment of atrophic facial post varicella scars. Settings and Design: Open label, pilot study.

Materials and Methods:

A total of 16 patients with atrophic facial post varicella scars were treated by focal application of 100% TCA solution by pressing down upon the scar surface by a toothpick (CROSS technique). Total 4 sittings were given at 2 weekly intervals and the results evaluated after 3 months of follow-up. Statistical analysis was carried out using Fischer's exact t-test.

Results:

All of the 13 patients who completed the study showed good clinical improvement, with 69% patients grading the response as excellent (>75%) improvement, whereas the rest 31% patients reporting good (51-75%) improvement. No significant complications were seen in any patient.

Conclusions:

CROSS technique using 100% TCA is a safe, cheap and effective therapy for the treatment of post varicella scars.

Evaluation of CROSS technique with 100% TCA in the management of ice pick acne scars in darker skin types

BACKGROUND

Acne scars are difficult to treat. Chemical reconstruction of skin scars (CROSS) is a technique using high strength trichloroacetic acid (TCA) focally on the atrophic acne scars to induce collagenization and cosmetic improvement.

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of CROSS technique using 100% TCA in ice pick scars in dark skin types IV and V.

METHODS

Thirty patients with ice pick acne scars were initially primed for 2 weeks before the procedure. The priming agents used were hydroquinone 4% applied in the morning and tretinoin 0.025% in the night. Sunscreens were advised to prevent postinflammatory hyperpigmentation. Subsequently, they underwent focal application of 100% TCA with a wooden toothpick in each individual scar, at 2 weekly intervals, for four sessions. Improvement was assessed by the physician, photographic assessment by an independent investigator, and patient feedback by visual analogue scale after the fourth treatment.

RESULTS

Excellent improvement (more than 70%) was observed in the majority of patients (73.3%), while 20% patients showed good improvement (50-70%) and 6.7% patients had fair results (30-49%) at the end of four sessions. Transient hypopigmentation was observed in one patient and hyperpigmentation in two patients. However, no significant adverse effects such as prolonged pigmentary changes or scarring were noted.

CONCLUSION

Treatment of ice pick acne scars with the CROSS technique using high strength 100% TCA is a safe, minimally invasive, efficacious, and cost-effective technique in darker skin. Adequate priming and continued use of hydroquinone and tretinoin reduces complications and promotes healing.

An Assessment of the Efficacy and Safety of CROSS Technique with 100% TCA in the Management of Ice Pick Acne Scars

Background:

Chemical reconstruction of skin scars (CROSS) is a technique using high concentrations of trichloroacetic acid (TCA) focally on atrophic acne scars to induce inflammation followed by collagenisation. This can lead to reduction in the appearance of scars and cosmetic improvement.

Aims:

The aim of this pilot study is to investigate the safety of the CROSS technique, using 100% TCA, for atrophic ice pick acne scars.

Settings and Design:

Open prospective study.

Material and Methods:

Twelve patients with predominant atrophic ice pick post acne scars were treated with the CROSS technique, using 100% TCA, applied with a wooden toothpick, at two weekly intervals for four sittings. Efficacy was assessed on the basis of the physician’s clinical assessment, photographic evaluation at each sitting and patient’s feedback after the fourth treatment, and at the three-month and six-month follow-up period, after the last treatment.

Results:

More than 70% improvement was seen in eight out of ten patients evaluated and good results (50 – 70% improvement) were observed in the remaining two patients. No significant side effects were noted. Transient hypopigmentation and hyperpigmentation was observed in one patient each. Physician’s findings were in conformity with the patient’s assessment. Three months after the last treatment, one patient noted a decrease in improvement with no further improvement even at the six-month follow-up period.

Conclusion:

The CROSS technique with 100% TCA is a safe, efficacious, cost-effective and minimally invasive technique for the management of ice pick acne scars that are otherwise generally difficult to treat. In few patients the improvement may not be sustained, probably due to inadequate or delayed collagenisation.

Induction of PDGF-B in TCA-treated epidermal keratinocytes

Trichloroacetic acid (TCA) is one of the most widely used peeling agents, and induces full necrosis of the whole epidermis, followed by reconstitution of the epidermis and the matrix of the papillary dermis. The cytotoxic effects of TCA, such as suppressing proliferation of keratinocytes and fibroblasts and protein synthesis by fibroblasts, have already been reported. However, the entire biological mechanism responsible for TCA peeling has yet to be determined. Hypothetical activation effects of TCA treatment on epidermal cells to induce production of growth factors and cytokines are examined, and are compared with its cytotoxic effects in terms of time course and applied TCA concentrations. After various periods of incubation with TCA, viability of Pam212 murine keratinocytes was investigated with MTT assay and dye exclusion assay, and production of growth factors and cytokines with reverse transcription-polymerase chain reaction (RT-PCR). Changes in platelet-derived growth factor (PDGF)-B mRNA expression and protein production in the human skin specimens after TCA application were then examined by RT-PCR and immunohistochemistry, respectively. Incubation with TCA showed cytotoxicity and induced death of Pam212 cells, depending on the incubation period and the TCA concentration. In addition, expressions of PDGF-B, tumor growth factor (TGF)-alpha, TGF- beta1 and vascular endothelial growth factor, which are the growth factors reportedly secreted from keratinocytes during wound healing, were all detected in Pam212 cells after short-term treatment with TCA. Expressions of inflammatory cytokines such as interleukin (IL)-1 and IL-10 were also induced. In TCA-treated NIH-3T3 fibroblasts, in contrast, observed was upregulation of only keratinocyte growth factor, which is reportedly secreted from fibroblasts, as well as the similar cytotoxic effect. In human skin, PDGF-B mRNA expression became significantly upregulated after TCA application, and then immediately downregulated. Immunoreactive PDGF-B in the cytoplasm of keratinocytes became detectable throughout the epidermis after TCA application, reached maximum after the peak of mRNA expression, and then declined significantly over 24 h when the epidermis became completely necrotic. The TCA-treated epidermis acts as a major source of growth factors, including PDGF-B, before undergoing full necrosis. This effect might contribute to a promotion of re-epithelialization and dermal regeneration without wound contraction and scarring.

Histometric and histochemical analysis of the effect of trichloroacetic acid concentration in the chemical reconstruction of skin scars method

BACKGROUND

Atrophic scars can be induced by various causes, including severely inflamed acne, chicken pox, and trauma. Many treatment modalities are used for reconstructing and improving the appearance of scars with various treatment results.

OBJECTIVE

A recent report shows the clinical efficacy of the chemical reconstruction of skin scars (CROSS) method, which consists of the focal application of trichloroacetic acid (TCA) in a higher concentration. Histometric analysis of the CROSS method, however, has not yet been established.

METHODS

In this study, five hairless mice were used to evaluate the effect of the CROSS method and to analyze the difference between the CROSS method and simple TCA application.

RESULTS

Similar histologic changes were observed in the two methods, including epidermal and dermal rejuvenation with new collagen deposition. These changes, however, were more prominent in the CROSS method-treated areas, particularly when 100% TCA was used.

CONCLUSION

The results of this study suggest that treatment of atrophic scars using the CROSS method is more effective than simple application of TCA in activating fibroblasts in the dermis and increasing the amount of collagen.

Histologic Study of Depressed Acne Scars Treated with Serial High-Concentration (95%) Trichloroacetic Acid

BACKGROUND

Acne scarring is a common manifestation that remains a therapeutic challenge to dermatologists, dermatologic surgeons, and plastic surgeons. Although multiple therapeutic modalities exist, treatment often remains inadequate. The use of high-concentration (95%) trichloroacetic acid (TCA) applied focally to atrophic acne scars has been described.

OBJECTIVE

The current study confirms the utility of focal application of 95% TCA to acne scars in addition to a histologic examination of this technique.

METHODS

Acne scars in three patients were treated with focal 95% TCA by serial application. Wooden applicators were used to apply TCA focally and repeated at 6-week intervals for a total of six treatments. Punch biopsies were performed at baseline and at 1 year postoperatively. Histologic examination was performed with routine hematoxylin/eosin, Masson trichrome, and Verhoeff-van Gieson staining.

RESULTS

Clinical examination revealed apparent cosmetic improvement in both depth and appearance of acne scars. Patient satisfaction was high. Histologic examination demonstrated a decrease in the depth of acne scars. In addition, increased collagen fibers and fragmentation of elastic fibers were noted. There were no complications from the procedure.

CONCLUSION

Focal application of high-concentration TCA to atrophic and "ice-pick" acne scars appears to produce clinical improvement. Histologic changes of this technique are described.

Therapeutic Effect of Topical Applications of Trichloroacetic Acid for Vaginal Intraepithelial Neoplasia after Hysterectomy

OBJECTIVE

We attempted to evaluate the therapeutic effect of trichloroacetic acid (TCA) for vaginal intraepithelial neoplasia (VaIN) after hysterectomy and to identify factors affecting persistence/recurrence.

METHODS

Twenty-eight post-hysterectomy patients with various grades of VaIN were enrolled in this study between January 2001 and December 2003. They were managed with intravaginal 50% TCA once weekly for 1-4 weeks, and all patients were followed up every 3 months for at least 1 year. Assessments by Papanicolaou smear and colposcopy were performed, as was biopsy when indicated during the follow-up period. Cox regression analysis was used to identify independent factors predicting persistence/recurrence.

RESULTS

In 20 of 28 patients (71.4%) VaIN went into remission. Treatment success was observed in all 11 patients with VaIN I, whereas only 9 out of 17 patients (53%) with VaIN II/III went into remission (P = 0.009). Severity of VaIN was the only significant independent predictor of persistence/recurrence (odds ratio = 3.5; 95% confidence interval = 1.1, 11.6; P = 0.038). The treatment was well tolerated with no major side effects.

CONCLUSIONS

Based on our findings, 50% TCA was a potential agent with minimal side effects for low-grade VaIN. Further prospective controlled study is warranted to verify our statements. However, as for high-grade lesions, further investigation with different TCA concentration is compelling.

Focal Trichloroacetic Acid Peel Method for Benign Pigmented Lesions in Dark-Skinned Patients

BACKGROUND

Benign pigmented lesions, including seborrheic keratosis, solar lentigines, melasma, and freckles, are common disorders, and various treatment modalities have been tried. We suggest a technique consisting of focal trichloroacetic acid (TCA) peel applied by pressing firmly onto the focal lesions.

OBJECTIVE

To evaluate the clinical effects of focal TCA peel on pigmented lesions in dark-skinned patients.

METHODS

An analysis was conducted of 106 patients with benign pigmented lesions who were treated using focal TCA peel. Seborrheic keratosis was treated with 65% focal TCA peel, solar lentigines, and freckles with 50% to 65% focal TCA peel, and melasmas with 10% to 50% focal TCA peel. Patients had Fitzpatrick skin types IV-V.

RESULTS

Patient treatment data indicated that 19 of 23 (83%) patients with seborrheic keratosis, 42 of 49 (86%) patients with solar lentigines, 8 of 14 (58%) patients with freckles, and 11 of 20 (55%) patients with melasma experienced a good clinical response. Good satisfaction rates in the seborrheic keratosis, solar lentigines, freckles, and melasma groups were recorded. No significant complications were observed.

CONCLUSION

The focal TCA peel method presented in this study is a safe and effective modality for the treatment of benign pigmented lesions with no significant complications.

Microabrasion versus microabrasion followed by 15% trichloroacetic acid for treatment of cutaneous hyperpigmentations in adult females

BACKGROUND

Cutaneous hyperpigmentations are common skin disorders that are often refractory to currently available treatments.

OBJECTIVE

To evaluate the efficacy of microabrasion alone or microabrasion with 15% trichloroacetic acid (TCA) for treatment of cutaneous hyperpigmentations.

METHODS

Twenty female patients were treated with microabrasion alone every 2 weeks (group 1), and 20 female patients were treated with microabrasion and application of 15% TCA every 3 weeks (group 2). All patients underwent up to eight treatments. The overall duration of treatment ranged from 2 to 4 months.

RESULTS

In group 1, a complete remission was observed in 8 of 20 cases (40%), partial remission in 10 of 20 cases (50%), and no remission in 2 of 20 cases (10%). In group 2, a complete remission was observed in 10 of 20 cases (50%), a partial remission in 8 of 20 cases (40%), and no remission in 2 of 20 cases (10%). No unexpected or serious side effects were observed in either group.

CONCLUSIONS

Microabrasion alone or microabrasion with 15% TCA is an effective, well-tolerated treatment for cutaneous hyperpigmentations.

Skin rejuvenation regimens: a profilometry and histopathologic study

OBJECTIVE

To quantitatively examine the effects of skin rejuvenation regimens in treating photodamaged skin.

METHODS

Fourteen patients with photodamaged skin were considered for analysis. Skin rejuvenation regimens were as follows: (1) 10 weeks of treatment with topical 0.05% tretinoin emollient cream, (2) 10 weeks of treatment with 0.05% tretinoin emollient cream and topical ascorbic acid lotion, (3) 6 superficial trichloroacetic acid peels, and (4) a combination of the topical treatments and superficial peels. Comparisons of the treatments were analyzed using profilometry and histologic findings.

RESULTS

Profilometry analysis provided quantification of the changes from each treatment group and among the treatment programs. Each group showed improvements from baseline. Trichloroacetic acid peels combined with application of the topical products improved skin topography to a greater extent than the less aggressive regimens. Histologic changes correlated well with the skin replica findings.

CONCLUSIONS

A 10-week skin rejuvenation regimen objectively improved photodamaged facial skin. Significant changes are noted when combining topical treatments with superficial peels. Hence, use of a combination of trichloroacetic acid peels, 0.05% tretinoin emollient cream, and ascorbic acid lotions is well tolerated and superior to either component alone as part of a comprehensive skin care and sun protection program.

Focal treatment of acne scars with trichloroacetic acid: chemical reconstruction of skin scars method

BACKGROUND

Acne scarring is a common complication of acne and yet no appropriate and effective single treatment modality has been developed. We suggest a technique consisting of the focal application of higher trichloroacetic acid (TCA) concentrations by pressing hard on the entire depressed area of atrophic acne scars. This technique is called chemical reconstruction of skin scars (CROSS) by the authors.

OBJECTIVE

To evaluate the clinical effects of CROSS on atrophic acne scars in dark-complexioned patients.

METHODS

An analysis was conducted of 65 patients with atrophic acne scars who were treated with CROSS in our hospitals between July 1996 and July 2001. Thirty-three patients were treated with 65% TCA CROSS and 32 patients were treated with 100% TCA CROSS. All patients had Fitzpatrick skin types IV-V.

RESULTS

Patient treatment data indicated that 27 of 33 patients (82%) (the 65% TCA group) and 30 of 32 patients (94%) (the 100% TCA group) experienced a good clinical response. All patients in the 100% TCA group who received five or six courses of treatment showed excellent results. Good satisfaction rates in the 65% and 100% TCA groups were recorded. There were no cases of significant complication.

CONCLUSION

CROSS is a safe and very effective single modality for the treatment of atrophic acne scars with no significant complications.

Dermal peels

Dermal chemical peeling is a very satisfying procedure for patients and physicians alike. Although not providing the ablation of deep wrinkles and scars that dermabrasion and laser procedures may accomplish, trichloroacetic acid peels usually result in few complications and rapid recovery. Patients can usually expect photographic improvement in their skin. The results are usually long lasting, and most patients do not need to repeat dermal peels for at least 2 years. Of all resurfacing procedures, dermal peeling provides the best benefit-to-risk ratio.

Formulation of trichloroacetic acid peeling solution: a bibliometric analysis

Since the beginning of this century, trichloroacetic acid solutions of various concentrations have been used for chemical exfoliation. These solutions have been prepared by using four different formulas. To prepare a 50% solution, for instance, water may be added to 50 g of trichloroacetic acid crystals until 100 ml of solution is obtained (weight-to-volume solution). Alternatively, 50 g of water may be added to 50 g of trichloroacetic acid crystals (weight-to-weight solution), or 50 g of trichloroacetic acid crystals may be solved in 100 ml of water (weight-plus-volume solution). Finally, a saturated trichloroacetic acid solution (or "100% solution") may be diluted by an equal volume of water (dilution). Depending on the method used, these so-called 50% solutions contain 40 to 71 weight-to-volume percentages of trichloroacetic acid. From a review of 120 publications on trichloroacetic acid peeling that have appeared since 1926, it was concluded that the authors of 87 of these publications (73 percent) did not report their formula for the trichloroacetic acid solution. Any one of the four methods was reported to have been used by the 33 authors who did report their formula. Eight of 10 internationally reputed pharmacopeias were found not to include the formula of a trichloroacetic acid solution. Proper evaluation of results and prevention of complications of trichloroacetic acid chemexfoliation is only feasible if both the concentration and the formula of trichloroacetic acid solution are reported by the author. Practitioners who use a trichloroacetic acid solution need to establish that the concentration of the solution they apply corresponds with that of the solution reported in the literature.

TCA-based blue peel: a standardized procedure with depth control

BACKGROUND

Trichloroacetic acid (TCA) peels are popular, well known, and widely utilized to correct a variety of skin problems. Different methods exist, ranging from the use of plain TCA to augmented or modified TCA at concentrations ranging from 30% to 50%. However, peel results vary depending upon the physician skill level, patient selection, and patient management.

OBJECTIVES

The purpose of this article is to fill the gap for a peel that is deeper than superficial exfoliative procedures yet lighter than a medium-depth peel, to simplify and standardize the TCA peel, to define depth properly based on intraoperative clinical signs, to implement a color guide that facilitates even application of TCA and avoids skip areas, and to identify and minimize variables that may contribute to inconsistent outcomes.

METHODS

A coating system for TCA application is created by selecting a specific TCA concentration (15% or 20%), TCA volume (4 or 6 ml, respectively), and a standardized body surface area to be peeled (5%), taking into consideration skin thickness and fragility. Multiple coats of TCA are applied to reach the desired endpoints: papillary dermis (light Blue Peel) or the immediate upper reticular dermis (light/medium Blue Peel). Clinical signs guide the depth achieved (frost quality, even blue, pink sign, epidermal sliding) and correlate retrospectively with healing time (7-10 days).

RESULTS

The TCA Blue Peel was found to be a simple and consistent treatment approach for problems related to the epidermis, papillary dermis, and immediate upper reticular dermis. An unexpected benefit was the appearance of skin tightening and a reduction of skin laxity in many cases. This suggests that the papillary dermis and the immediate upper reticular dermis play a significant role in skin tightness.

CONCLUSION

A simple coating system for achieving depth-controlled TCA peels is presented with correlation to intraoperative clinical signs. This method makes it easier to peel skin of all racial backgrounds, including nonfacial skin. This is especially useful for many patients previously excluded from having procedures that penetrate beneath the papillary dermis. Commonly encountered variables in chemical peels are presented which may affect outcome.

Preoperative and postoperative topical tretinoin on high-tension excisional wounds and full-thickness skin grafts in a porcine model: A pilot study

BACKGROUND

Tretinoin induces neovascularization and the formation of collagen when applied topically.

OBJECTIVE

The goal was to determine whether preoperative and postoperative treatment with tretinoin enhances the healing of high-tension, full-thickness excisional wounds and the survival of full-thickness skin grafts.

METHODS

A blinded, randomized, placebo-controlled pilot study involved high-tension excisional wounds and full-thickness skin grafts treated perioperatively with tretinoin in a porcine model.

RESULTS

Perioperative treatment of high-tension excisional surgery sites with tretinoin appeared to have no consistent beneficial or adverse effects on wound healing or scar spreading. In the full-thickness skin graft model, a trend toward impaired wound healing was noted.

CONCLUSION

The collagen-inducing effects of topical tretinoin do not appear to enhance the healing of high-tension excisional surgery wounds in a porcine model. Tretinoin does not appear to improve the survival of full-thickness skin grafts and, in fact, a detrimental effect was apparent in our model.

The use of chemical peelings in the treatment of different cutaneous hyperpigmentations

BACKGROUND

Several chemical agents including hydroquinone, retinoic acid, and azelaic acid are currently used in the treatment of cutaneous hyperpigmentations. Recently chemical peelings with kojic acid, glycolic acid, and trichloroacetic acid, either alone or in combination, have been introduced for treatment of hyperpigmentations.

OBJECTIVE

The purpose of our study was to evaluate the efficacy of trichloroacetic acid as well as glycolic acid associated with kojic acid in the treatment of cutaneous hyperpigmentations.

METHODS

Twenty patients with diffuse melasma were treated with a solution composed of 50% glycolic acid and 10% kojic acid whereas 20 patients with localized hyperpigmentations (lentigo) were treated with 15%-25% trichloroacetic acid.

RESULTS

Complete regression of diffuse melasma was observed in 6 of 20 patients (30%), a partial regression in 12 of 20 patients (60%), and no regression in 2 of 20 patients (10%) treated with 50% glycolic acid and 10% kojic acid. Complete regression of localized hyperpigmentations was observed in 8 of 20 patients (40%), a partial regression in 10 of 20 patients (50%), and no regression in 2 of 20 patients (10%) treated with 15-25% trichloroacetic acid.

CONCLUSIONS

Based on our findings, both peelings can be considered effective in the treatment of cutaneous hyperpigmentations.

Comparison of the frequency-doubled Q-switched Nd:YAG laser and 35% trichloroacetic acid for the treatment of face lentigines

BACKGROUND

Face lentigines are one of the manifestations of photodamaged skin and often put people in socially embarrassing situations. Several lasers have been used to remove lentigines at vast expense. However, trichloroacetic acid (TCA) is an alternative for treating lentigines that costs much less.

OBJECTIVE

To compare the efficacy of the frequency-doubled Q-Switched Nd:YAG laser (532 nm) and 35% TCA for the treatment of face lentigines.

METHODS

Twenty patients (Fitzpatrick skin Types III-IV) with a total of 37 lentigines on faces were randomly collected; each lentigo was divided into medial and lateral halves. Frequency-doubled Q-switched Nd:YAG laser (532 nm) and 35% TCA were applied to the medial and lateral halves of each lentigo respectively. The efficacy after 1 treatment was compared after 6 months.

RESULTS

The frequency-doubled Q-switched Nd:YAG laser (532 nm) had a better result than that of 35% TCA for the treatment of facial lentigines.

CONCLUSION

In order to get a better result after one treatment, the authors suggest the frequency-doubled Q-switched Nd:YAG laser (532 nm) rather than 35% TCA for treating lentigines even though the cost of frequency-doubled Q-switched Nd:YAG laser (532 nm) is greater than that of 35% TCA for both physician and patient.

Periorbital rejuvenation: a review of dermatologic treatments

BACKGROUND

The periorbital region serves as a barometer of chronologic and environmental age and, as such, patients often seek its cosmetic rejuvenation.

OBJECTIVE

The purpose of this article was to review the dermatologic treatments available for periorbital skin rejuvenation.

METHODS

Topical retinoic and glycolic acid preparations, chemical peels, botulinum and collagen injections, dermabrasion, and laser resurfacing procedures for periorbital skin rejuvenation were reviewed. The relative benefits and risks of each treatment were detailed.

RESULTS

Minimal photodamage with mild rhytides should be responsible to topical acid therapy and superficial peels, whereas moderate wrinkling and photodamage generally require medium-depth peels, collagen injections, or erbium:YAG laser resurfacing. Deeper rhytides and more extensive cutaneous photo-damage usually necessitate CO2 laser resurfacing and botulinum injections.

CONCLUSIONS

Proper patient selection and assessment of aging severity are critical to determine the best therapeutic option.

Deep chemical peeling

Facial skin wrinkling and sagging are concerns that often compel patients to seek counsel on rejuvenative procedures. Facial plasty procedures will alleviate many of these concerns. However, deep chemical peels, in conjunction with surgery or alone, can often significantly improve both the ravages of excess sun exposure and the stigmata of aging.

Medium-depth chemical peeling

Trichloroacetic acid (TCA) alone or in combination with other agents is the mainstay of medium-depth chemical peels. Indications for medium-depth chemical peels include both medical conditions, such as diffuse photodamage with contiguous actinic keratoses, and cosmetic conditions, such as the aging face and solar lentiginosis. Medium-depth chemical peeling with TCA is relatively simple and is associated with a favorable risk/benefit ratio. However, proper patient selection, with attention to both medical and psychological factors, requires significant experience. The histological basis of the rejuvenating effects of TCA peels is well established, with a consistent correlation between wound depth and TCA concentration. The clinical effects of medium-depth chemical peels are generally gratifying for both patient and physician.

Treatment of photodamaged skin with trichloroacetic acid and topical tretinoin

BACKGROUND

Photodamaged skin typically displays lentigines, actinic keratoses, wrinkles, and textural alteration. Chemical peeling has been used to treat these, but few controlled studies have been performed to determine its efficacy.

OBJECTIVE

Our purpose was to compare the efficacy of a medium-depth chemical peel with and without tretinoin before and after treatment.

METHODS

Sixteen men with actinic damage including actinic keratoses were treated with a 40% trichloroacetic acid(TCA) chemical peel. Half were pretreated for 6 weeks with topical tretinoin; they also used tretinoin after the peel. Photographs were obtained at baseline and at 6 weeks and 6 months after treatment. Changes in specific features were rated by a panel of three examiners.

RESULTS

Some improvement was noted in all patients. More rapid and even frosting was observed in the patients pretreated with tretinoin. Solar lentigines, actinic keratoses, and skin texture were the features of photoaging most affected; wrinkles were least affected. No statistically significant difference was found between patients treated with TCA and tretinoin (before and after peel) and those with TCA alone.

CONCLUSION

A medium-depth chemical peel with 40% TCA alone produced moderate improvement in some manifestations of actinic damage but had little effect on wrinkles. Treatment with tretinoin before and after TCA did not significantly enhance the efficacy of the peel.