TCA Peels

A TCA peel, also known as a trichloroacetic acid peel or a chemical peel, can improve the look of skin damaged by the sun or skin that is aged by eliminating fine lines and wrinkles. The chemical solution applied to the treatment area causes it to exfoliate and eventually peel off. The newly regenerated skin is typically smoother and less wrinkled. Depending on the strength of the acid that is used, a TCA peel is a superficial peel or medium peel but it is rarely a deep peel. TCA peels that use between 10%-35% solution are superficial peels while 40%-50% is a medium-depth peel. When lighter peel strength is used, the patient gets less of an overall peel. The higher the strength, the deeper the peel will be.

Am I a Good Candidate for a TCA Peel?

A GOOD CANDIDATE for a TCA peel is anyone looking to rejuvenate skin on the:

• Face
• Neck
• Chest
• Arms
• Legs
• Hands

Skin conditions and skin types determine candidates. Skin types range from one to six with “a one” being a very light person and “a six” being a patient with very dark skin. Normally, the best candidate for a chemical peel is a person with light hair and fair skin.

Skin Conditions Treated By TCA:

TCA peels can be used to treat numerous skin conditions including:

• Age spots
• Leathery skin
• Scars
• Sagging skin
• Hyperpigmentation (darkening of skin)
• Crow’s feet
• Melasma

Patients who are NOT GOOD CANDIDATES suffer from:

• Eczema
• Sunburn
• Cuts or broken skin
• Dermatitis
• Psoriasis
• Rosacea
• An active skin disease
• Active Herpes simplex sores (cold sores, fever blisters)

In addition, patients who have used prescription skin care products, Retin-A, skin-lightening or bleaching agents and products that contain ascorbic acid within the last 48 hours should not undergo TCA peels. Pregnant or lactating women are not suitable for this type of treatment.

How is a TCA Peel Performed?

Prior to a TCA peel, patients need to start preparing their skin approximately 2 to 3 weeks in advance. The skin will need to be cleansed two times daily and a special moisturizer or cream will be applied once or twice a day. The use of a daily sunscreen is a requirement since the patient cannot have a TCA peel if they already have sunburn. This skin care regimen helps the skin peel more evenly, reduces the chance of infection and promotes a faster healing time.

All TCA peels work by removing the top layer of dry and damaged skin. Superficial peels only remove the outermost layer of skin called the stratum corneum. This layer is made of keratin, wax and dead skin cells. As the concentration of the acid increases, or, as additional layers of TCA are applied, the chemical penetrates further down and permits the deeper layers of skin to shed. TCA “self neutralizes” so it does not depend on the time it is allowed to stay on the skin like other types of acids.  For example, glycolic acid is neutralized in order to control the depth of the peel. This is the basis for the peel to progress from a superficial peel to a medium or deep peel. The deeper the peel, the more it reveals healthy underlying skin while also having a larger risk for complications.

Different Types of Peels

• Superficial Peels – These are generally safe and effective for all skin types. The ideal patient for a superficial peel is a person in their 20’s through their 40’s with minimal sun damage or minor skin irregularities. Patients with fine lines and wrinkles, black heads and white heads are generally good candidate for a superficial peel. Patients with surface scarring, mild discoloration and rough skin may also benefit from a superficial peel.
• Medium Peels – This type of peel is more aggressive and treats skin conditions that are a little more profound. A good candidate for a medium peel is a patient between the ages of 40 to 60 with moderate wrinkling, sun damage and a reasonable amount of discoloration. Any patient with age spots, freckles or rough skin may also benefit from this type of peel.
• Deep Peel – This type of peel is very aggressive since the chemical penetrates deeply into the middle layers of skin. The ideal candidate for a deep peel is someone with a skin type of “one or two” and has moderate to more severe skin conditions such as wrinkles, age spots, freckles and shallow scars.

Differences between the Peels:

1. A superficial peel is called a lunchtime peel since it is the mildest form of a chemical peel and gently exfoliates the outer layer of skin. Alpha-hydroxy acid and salicylic acid are the most common peeling agents in a superficial peel but the mildest ones are peels based with simple fruit enzymes. The peeling agents are mixed with other mild solutions to create a liquid or paste which is applied to the skin. The peel is left on the skin for 15 minutes or less in order to penetrate the epidermis. No anesthesia or pain medication is needed for a superficial peel.
2. Medium peels are generally comprised of glycolic acid or trichloroacetic acid and involve two different peel layers: A Jessner’s peel solution (a medium depth chemical solution) is applied first. The depth to which this peel can penetrate depends on how many layers are applied. A TCA 35% peel is applied next. During a medium peel, the chemical is applied to the area so it can penetrate the outer and middle layers of the skin. This treatment takes longer and is a little more painful since the chemical soaks into the deeper layers. Pain medication and an oral sedative might be given prior to this treatment.
3. Deep peels consist mainly of phenol but they may also contain trichloroacetic acid. Deep peels are the most painful type of peel since they penetrate deep into the middle layer of the skin. Deep peels take 60 to 90 minutes. Patients are generally given an oral sedative, pain relievers or general anesthesia during the peel process. Deep peels are performed in highlighted areas and are done with 15-minute breaks between treatments to avoid patients getting too much phenol at once.  

During a TCA peel, the doctor will start by cleansing the skin using liquid cleansers, alcohol or acetone to remove the natural oils from the skin. A cotton tip applicator, small brush or gauze sponge evenly applies the TCA solution onto the skin. The chemical begins to break down the binding elements of the skin’s top layer. If the patient is awake, they may feel a temporary burning sensation, or a mild numbness or stinging, once the acid is applied. This temporary discomfort can be managed with a cold compress or a hand-held fan. Once the desired amount of “frost” is obtained, cool compresses are applied for comfort. Any remaining discomfort dissipates shortly after the acid neutralizes and post-procedure ointment is massaged into the skin.

Alternative Procedures

• Dermabrasion is an exfoliating technique that utilizes a rotating instrument to remove the outer layers of skin and it is usually performed on the face. Some of the conditions it can treat include fine lines, acne scars, damage from the sun and uneven skin texture
• Laser resurfacing is a treatment that reduces skin irregularities and facial wrinkles. It is performed using concentrated, short pulsating beams of light on the areas of skin to be treated in order to accurately remove the skin layers

What is the Cost of a TCA Peel?

The cost of a TCA peel depends on the depth of the peel, the region of the body treated and the location of the country where it is performed. The average chemical peel can cost anywhere from $150-$900 depending on the depth of the peel. Patients also need to be aware of the fact that superficial and medium peels are performed in a doctor's office at a substantially lower cost to the patient. On the other hand, deep peels are normally performed in a surgical facility and have a higher cost.

Recovery and Downtime

The length of the RECOVERY time depends on the type of TCA peel:

• A superficial peel has less recovery and downtime. Most patients can resume all normal activities directly after a superficial peel. The skin usually turns pink, heals quickly and can be covered by makeup. Furthermore, there is only a small amount of peeling which occurs after a superficial peel.
• A medium peel causes a controlled burn on the skin so the patient will need to take some time off work to recover. A medium peel will have little to no discomfort after the procedure but over-the-counter pain medication can be used if needed. With a medium peel, the patient can expect swelling around the eyes and redness which takes 5-7 days to heal. The skin on the treated area will turn a reddish-brown color in 2 to 3 days and become crusty. Over the following days, the skin will become flakey and peel off. As the old skin peels off, a new layer of skin is revealed with less wrinkles and a smoother texture.
• A deep peel causes a deeper controlled burn that can be uncomfortable for a few days. The doctor will usually prescribe some pain medication and the patient should take them as directed. Since a deep peel will cause a deeper burn, it will take about 10-14 days for the skin to grow back. Most patients take about 2 weeks off work since the skin will be swollen and very red for 2 weeks all the way to 2 months. The complete healing time for a deep peel can be several months.

Healing Tips:

For a quicker recovery, and the best results, patients should maintain proper care of the skin during the recovery period. The care is much like the pre-procedure skin care regimen of cleansing the skin often with water, or a special washcloth, as directed by the doctor. For a medium and deep peel, the treatment area may be covered with an ointment and bandages. The doctor will instruct the patient on how to wash off the ointment 24 hours after the procedure. If necessary, the ointment is reapplied. The bandages should remain in place, except when cleansing the area, for 2 days post-op. It is important to keep the skin moisturized and avoid sun exposure until the peeling has completed.

Results

The results for TCA peels vary according to the patient’s skin condition, the area of the body that is treated and the type of peel used by the doctor. Non-facial areas do not heal as well as the face so the results are less predictable.

• With a superficial peel, patients can see the results once the treatment area has finished peeling in approximately one week
• The results of a medium peel may take 7-14 days
• The results of a deep peel can take 4-6 weeks

For all types of peels, sunscreen should be used daily since the new skin is more sensitive and can burn easily. Patients that allow the skin to tan or burn will have poorer lasting results.

Although the results are considered durable, and essentially permanent, they are subject to change over time. For the best results, superficial peels should be repeated in a series of two or three since the severity of sun damage and the age of the patient may not be able to treat everything in one procedure. Medium peels can be repeated one or two times a year to maintain the results. Deep peels are usually not repeated due to the depth of the peel.

Limitations and Risks of TCA Peels

When it comes to LIMITATIONS concerning parts of the body treated by TCA peels, medium peels are limited to only treating certain areas of the body while superficial peels can treat the face, chest, arms, legs and other parts of the body.

Deep peels are normally limited to being used on the face and to only treating patients with skin types 1 and 2. Darker skin types are generally not safe for a deep peel because there is a high chance of dyspigmentation or scarring. Deep peels in darker toned individuals give patients a higher chance of hyperpigmentation (darker spots) or hypopigmentation (lighter spots) which may be permanent. Even patients with lighter skin tones might have bleached skin from the effects of a deep peel sometimes referred to as “porcelain skin.”

Risks

There are a number of RISKS when having a TCA peel. Some risks are common to all three peels while others are specific to a certain type of peel. They include:

• A risk of toxicity with deep peels
• Increased sensitivity to the sun
• Prolonged redness
• Crusting
• Allergic reactions
• Acne
• Bacterial infections
• Viral infections (herpes flare)
• Fungal infections
• Scarring
• Uneven absorption
• Burns with medium and deep peels
• Blistering

Choose an Experienced Doctor

When considering a TCA peel, it is important to choose the right doctor for the procedure. Ideally, a board-certified dermatologist should perform the treatment or a plastic surgeon specifically trained in chemical peels. Patients should ask to see “before and after photos” of the doctor’s real patients. Choosing an experienced doctor decreases the risk of side effects and increases the chances of a successfully performed TCA peel.

Written by Cosmetic Town Editorial Team- SP

Based on an exclusive interview with Jennifer Krejci, MD in San Antonio, TX