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MEDIUM CHEMICAL PEEL

Medium chemical peels are an effective way to correct acne scars, address uneven pigmentation, improve the texture and tone of the skin, smooth out fine lines, and more. Medium chemical peels, also known as TCA (trichloroacetic acid) chemical peels, provide more dramatic results than light chemical peels, and they don’t require the extended recovery time of deep (phenol) peels. A medium chemical peel can be used to treat any area of the body and takes only minutes to complete.

WHAT IS A TCA MEDIUM CHEMICAL PEEL?

Medium chemical peels penetrate the skin more deeply than light chemical peels. In administering a medium chemical peel, the practitioner applies a solution containing trichloroacetic acid to the skin. This chemical solution, which is custom formulated for each patient, works by removing the dull, damaged outer layers of skin — those affected by acne, fine lines, sun exposure, and other factors. In the week or so after treatment, these dead layers of skin slough off, revealing a new, smooth layer of skin.

Medium depth TCA chemical peels work well for treating fine surface wrinkles, superficial blemishes, and pigmentation problems. Similar to the light chemical peel, medium chemical peels require less downtime than a deeper peel. TCA peels are the preferred choice for patients with darker skin.

TCA chemical peels are popular because they are an excellent “spot” treatment that can be used on any area of the body and can be completed in as little as 15 minutes. For best results, patients typically complete a prescribed series of treatments, with each treatment spaced two to three months apart.

This peel excels in providing correction for color irregularities of the skin, whether it’s age spots, sallow complexion, or the dark pigment deposited around the eyes. In addition to color irregularity, it also offers intermediate permanent wrinkle reduction.

A medium depth TCA peel is less aggressive than a deep chemical peel. Medium depth chemical peels present an attractive balance between beautiful skin restoration and tolerable post-op care that leaves patients’ skin vibrant and glowing.

WHAT ARE THE BENEFITS OF A TCA PEEL?

WHAT AREAS CAN BE TREATED WITH TCA PEELS?

The face, neck, chest, back, arms, and legs. TCA peels may be very cost effective on the body. However, the risks of problems may also be greater unless the practitioner is very experienced with TCA peels on the body.

When considering peels of non-facial areas, it’s important to realize that these areas do not heal as well as the face, and the desired results are not as predictable. It is important to note that you should never peel more than a small percentage of the body at one time in order to avoid any chance of potential toxicity.

CANDIDATES FOR MEDIUM CHEMICAL PEELS:

Medium (TCA) chemical peels are known for delivering long-lasting results after a brief healing process. TCA chemical peels are ideally suited to patients wishing to address wrinkles, superficial blemishes and scars, uneven pigmentation (including sunspots), and dark undereye circles. Because TCA peels deliver results beyond those achieved by a light chemical peel, and don’t have the long healing time of a deep (phenol) peel, they are an excellent middle-of-the-road approach to common skin conditions and imperfections.

TCA CHEMICAL PEEL PROCEDURE:

TCA peels are performed on an outpatient basis, usually in a doctor’s office. Depending on the concentration of trichloroacetic acid used and the patient’s preferences, light sedation might be utilized, though no general anesthesia is needed.
Medium chemical peels are applied in the same way as light chemical peels or deep (phenol) peels. The skin is first cleansed in preparation for treatment. Then the chemical solution is applied. As with any chemical peel, the specific chemical formulation depends on the patient. This chemical solution is left on the skin for an appropriate amount of time; then the physician washes it away with water and applies a soothing ointment.

HOW LONG DOES A TCA PEEL TAKE?

Depending on the size of the area being treated, a medium chemical peel may take 15 to 60 minutes to complete, though most treatments can be completed within 30 minutes.

TCA CHEMICAL PEEL SOLUTION

Trichloroacetic acid (TCA) is the active ingredient in a medium chemical peel. The degree and depth to which the TCA penetrates the skin can be adjusted for each patient, as can the concentration of TCA in the chemical peel solution. A 25% concentration may be suitable in some cases. For a slightly deeper penetration, the practitioner may use a concentration as high as 50%.

TCA CHEMICAL PEEL RECOVERY

After TCA chemical peels, a superficial crust forms over the treated area, then flakes off in three to seven days. The newly revealed skin may initially appear reddish, but the discoloration will fully fade within a week to reveal skin with dramatically improved texture, color, and overall appearance. Healing time takes approximately 1-2 weeks.
TCA chemical peel is not without possible side effects. Some mild swelling is common after this type of skin peel. Patients do not typically experience much pain, and any discomfort can be controlled by pain reliever. Though patients can return to their regular activities immediately after a chemical peel, redness takes about a week to fully fade. For this reason, many patients who undergo a TCA chemical peel choose to avoid public activities for about a week.
During recovery, it is important for the patient to follow the instructions given by the practitioner who applied the TCA peel. The practitioner will provide instructions for limiting sun exposure and taking other precautions after a medium chemical peel.

ARE MULTIPLE TCA PEELS REQUIRED TO ACHIEVE DESIRED RESULTS?

One TCA peel is often sufficient to treat actinic keratosis and sun damage. Individual treatment plans vary, some patients will want multiple TCA chemical peel treatments to achieving optimal results. The number of treatments, as well as their spacing, depends on the patient’s goals, the condition of the patient’s skin, and other factors. For individualized advice, consult a practitioner experienced in administering TCA chemical peels.

RISKS AND BENEFITS:

Chemical peels rarely result in serious complications, but certain risks do exist. These risks include scarring, infection, swelling, changes in skin tone, and cold sore outbreaks. You can reduce the risks associated with facial peels by following all of the practitioner’s instructions completely and by providing a complete medical history.

CHEMICAL PEEL FAQs

Some aspects of the chemical peel procedure differ according to the type of peel (light, medium, or deep) being administered. However, all skin peel procedures follow the same basic protocols:
The chemical peel is administered in a doctor’s office, surgery center, or hospital by a trained cosmetic practitioner.
The patient is given a sedative to aid relaxation.
The practitioner cleanses the patient’s skin and applies a powerful prescription topical numbing cream to the treatment area.
A local numbing block may be administered to further numb the area.
The practitioner then applies the chemical peel solution. This solution is formulated according to each patient’s specific needs and goals. It is common for the patient to feel a tingling or stinging sensation as the chemical peel is applied.
After the skin peel solution has been on the skin for the prescribed amount of time, it is washed off with water. A soothing ointment is then applied; a thick coating of petroleum jelly is often used after TCA chemical peels.
The practitioner then instructs the patient on aftercare, and the practitioner may suggest use of a mild pain reliever for discomfort after the procedure.
Sun exposure is prohibited while the skin heals.

Though deep (phenol) peels are only appropriate for the face, the skin on any part of the body can be treated with mild and medium skin peels.
The chemical solution for body chemical peels is typically comprised of a combination of trichloroacetic acid (the main ingredient in a medium-depth skin peel) and glycolic acid (the main ingredient of a mild peel). The solution for body chemical peels is typically formulated to be slightly stronger than the chemical solution used for light or medium facial skin peels, though it is milder than the phenol solution used for deep skin peels.
As with facial chemical peels, body peels address the effects of sun damage, even out skin pigmentation, and improve skin texture. Chemical peels can also be used on the body to minimize stretch marks.

For light and medium skin peels, no general anesthetia or sedation is necessary. Patients are prepped with local prescription numbing cream and mild sedation medication to alleviate discomfort. Because of the use of sedation medication, patients are required to have a responsible driver to take them to and from our office the day of their procedure.

The area being treated is well numbed and patients are relaxed with a mild sedative medication. In general, patients only feel a mild stinging sensation during light or medium chemical peels. After the procedure, the practitioner may suggest a mild pain reliever to relieve any discomfort.

After a patient undergoes a TCA peel, the treated layers of skin gradually flake away, revealing a new layer of skin.

The recovery time after a chemical peel depends on the strength of peel administered, because each strength of peel affects the skin to a different degree.
With a Medium Depth TCA peel, a period of one week is needed for recovery. The new layer of skin appears three to seven days after treatment. After 7 days, you can resume using makeup and return to work and normal activities. About two weeks after treatment, the skin will be fully healed.
Typically, the stronger and deeper the peel, the longer the recovery will be, but also the results will be more significant.

As soon as you finish peeling you will see results. Your skin will continue to improve for 30-60 days provided you protect it from the sun.

TCA chemical peels are not a substitute for dermal fillers or cosmetic surgery. TCA peels can be performed in conjunction with other aesthetic treatments for replacing volume, tightening skin, and achieving optimal results.

Some of the results from a TCA peel lead to permanent improvements in the skin. Overall, the length of results will depend on the depth of the peel, your age and skin condition, and the extent of your continuing sun exposure. Your skin will continue to age, but you have a new starting point, with fresher, improved skin.

Tca peels article

https://aestheticsjournal.com/feature/medium-depth-peels

Medium Depth Peels
BY DR RAUL CETTO / 19 MAR 2018
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Dr Raul Cetto discusses the mechanisms of action and antiageing benefits of chemical peels

Chemical peeling is the application of a chemical agent of a defined strength, resulting in predictable accelerated exfoliation and skin damage. The release of cytokines and inflammatory mediators following this damage results in thickening of the epidermis, and an increase in dermal volume through deposition of collagen, producing the appearance of rejuvenated skin.1

There are generally three depths of chemical peels: superficial, medium and deep (Figure 1). This article will focus on medium as a discussion on superficial and deep will each warrant an entirely separate article. A medium-depth peel aims to reach the papillary and upper reticular dermis at a depth of approximately 0.45mm. In general terms, medium depth peels use a trichloroacetic acid (TCA) concentration of 35-50%. TCA is an analogue of acetic acid, which was first used by German dermatologist Dr Paul Gerson Unna as a chemical peel – this was documented in 1882.2 Its medical and cosmetic applications continued to be studied throughout the early 20th century and was found to improve the appearance of scars, blemishes and wrinkles in a 50% solution. However, complications such as hyperpigmentation and scarring were high at this concentration. By the 1950s, dermatologists had found several new ingredients to produce mixtures with a lower solution of TCA to reduce the risk and produce a more predictable outcome.3

Medium-depth peel agents and mechanisms of action

Several chemical agents are commonly used in medium-depth peels to produce a predictable and controlled exfoliation of the skin –discussed below.

35-50% TCA

TCA at 35-50% can be used in the treatment of photoageing, particularly actinic keratosis, pigmentation, fine facial rhytides and moderate perioral wrinkles.3 It is not appropriate for the treatment of lax skin or deep rhytides caused by movement of the muscles of facial expression, which would be better treated using a deeper acting peel.5 TCA causes protein to denature leading to keratocoagulation and keratinocyte death. As the skin then re-epithelialises, collagenesis is observed and the previously present abnormal keratinocytes are replaced by healthy new cells.6 The concentration of TCA will also determine the depth of action. For example, a 15-20% TCA concentration will only reach the epidermis, whereas a 45% TCA solution will likely penetrate to the upper reticular dermis.7 Multiple applications should be considered as an alternative to a higher concentration, for example several applications of 20% TCA in six week intervals can produce the same effects as one application at 45%. Higher concentrations or multiples applications of TCA are better tolerated by patients with thick, seborrheic skin, rather than those with smooth thin skin. A period of pre-treatment of the skin with retinoid or hydroquinone (available on prescription only) will improve the penetration, as will proper skin degreasing with an alcohol preparation solution.3 Augmentation of the TCA should also be considered, for example an application of 0.025-0.05% retinoic acid just before TCA application enhances penetration and may provide better results.3 The best results for patients with photoageing are obtained in patients with phototype II, although it is also effective in type III and IV phototype patients. TCA is not systemically absorbed and therefore can be used safely in patients with cardiac, hepatic and renal morbidities.

35% TCA augmented with Jessner’s solution

Jessner’s solution consists of resorcinol, salicylic acid, lactic acid at 85%, and ethanol at 95%. This was first described by American dermatologist Dr Gary Monheit in 1989.8 Jessner’s solution destroys the epidermal barrier function by breaking the intercellular bridges between keratinocytes allowing a TCA solution (35% is typically used) to better penetrate the epidermis.8 This combination clinically improves the appearance of photoaeing skin, actinic keratoses, and rhytides.8

35% TCA augmented with solid CO2

In 1986, Brody and Hailey reported positive results to treat actinic degeneration, acne scarring, rhytids, and pigmentary aberrations with the application of solid carbon dioxide to ‘ice’ the skin, to enhance the penetration of a 35% TCA solution used.9

The histological specimens studied by Brody and Hailey showed an expanded papillary dermis with neocollagen formation in the sub-epidermal region of the dermis and a mid-reticular dermal band consisting of elastic fibres and collagen. This technique was reported to penetrate to the upper reticular dermis and to be more effective than Jessner’s solution plus 35% TCA in the treatment of acne scarring;9 however, it has been reported that it can destroy melanocytes not confined to the epidermis and therefore result in hypopigmentation, particularly in darker skins.10 It was also noted that the depth of penetration is difficult to control and somewhat unpredictable, yielding variable results and complication, because the depth of action of the solid CO2 is dependent on how hard the operator applied the block to the skin, which is a difficult measure to standardise.9,10

35% TCA augmented with 30-70% glycolic acid

Glycolic acid peels penetrate the skin easily and have anti-inflammatory, keratolytic, and antioxidant effects.11 The glycolic acid peel is applied prior to the TCA. Different concentrations of glycolic acid can be used (30%-70%) to adjust the intensity of the peel.11 Glycolic peels are usually better tolerated by patients compared to Jessner’s solution because it produces less visible exfoliation post procedure.12

Complications

Chemical peels can potentially cause several complications, some of which can be treated easily. In general, medium-depth peels produce fewer complications, and with less frequency than deep peels as their penetration is more superficial, so the damage to the skin is more limited. There is no risk of systemic complication when using a medium-depth peel.

Pigmentary changes

Reactive hyperpigmentation can occur after any depth of chemical peel. Usually, lighter complexions have lower risk of hyperpigmentation.1 Priming the skin by using a combination of hydroquinone and retinol creams for several weeks before a medium-depth peel, can reduce the rate of hyperpigmentation.1 Demarcation lines, a harsh line between treated and untreated areas, can be softened if the boundary of the peeling area is hidden under the mandibular line and feathered gradually to the normal skin.13

Hypopigmentation is associated with darker skin types and increased post-peel sun exposure.6

Infection

Bacterial and fungal complications in chemical peels are rare.1,14 Patients with positive history of herpes simplex infection should be treated prophylactically with antiviral medications acyclovir or valacyclovir during peeling, until full re-epithelisation is achieved, as all peels can reactivate the virus. Toxic shock syndrome has also been reported after chemical peels, and patients should be warned of the symptoms for this reason.3,14

Scarring

The contributing factors to the likelihood of post-peel scarring are not well understood yet. However, delayed healing and persistent redness may precede scarring. A topical steroid should be used to treat such scarring as soon as a diagnosis is made, but this may still not prevent unsightly scars from forming.1 The most common location of post-peel scars is in the lower part of the face, and this may be due to more aggressive treatment in this area or possibly due to eating and speaking during the healing process, which moves these tissues.3,7

Milia

These are inclusion cysts, which appear as a part of the healing process in up to 20% of patients after chemical peels, usually eight to 16 weeks’ post procedure and can be long-lasting or even permanent. They are more likely to occur in patients who have had a deep peel rather than a medium. If they do not resolve spontaneously, patients can be treated with mild epidermabrasion following re-epithelialisation, gentle extraction or electrodissection.1

Acneiform dermatitis

Acneiform eruption after chemical peels can appear immediately after re-epithelialisation and is not a rare complication. It can be related to exacerbation of previously existing acne or may be due to overuse of oily preparations on the new skin. Short-term systemic antibiotics, together with discontinuation of any oily products will usually provide relief.1

Discussion

In the patient’s consultation, various contraindications should be discussed to ascertain whether the patient is a good candidate for the proposed intervention. Absolute contraindications are active and recent bacterial, viral, fungal or herpetic infection, open wounds, a history of the use of medication with photosensitising potential, such as exogenous oestrogen, an oral contraceptive pill or isotretinoin use in the preceding 12 months, inflammatory dermatoses (psoriasis, atopic dermatitis, pemphigus) and facial skin melanoma. In addition, most would call a non-compliant patient an absolute contraindication to this treatment as pre-peel treatments and post-peel sun exposure limitation relies entirely on patient compliance, and non-compliance will likely produce an undesirable outcome. The patient must be motivated enough to adhere to a daily regimen for a few weeks before and after the procedure. If a patient has a history of abnormal scarring, then a medium depth or deep peel would not be recommended. Sun-damaged skin shows epidermal changes, elastosis, and collagen distortion in the mid-reticular dermis and, to eradicate this, a deep peel would be required. More superficial peels, even when performed in repetition, do not reach the affected histological level and therefore have a minimal effect on photodamaged skin.10 Practitioners should advise patients to stop smoking. The dynamic action of puffing can create or worsen perioral rhytides. The smoke can cause squinting, increasing wrinkling around the eyes and nose, and furthermore, the chemicals in the smoke can cause enzymatic reactions that can cause wrinkling around the mouth and eyes.10 Patients should be carefully counselled about the downtime of five to 10 days following a medium depth peel.4 Patients who are overly self-conscious may not be prepared for their aesthetic appearance immediately following the peel. Particularly, patients with unrealistic expectations or suspected body dysmorphic disorder should be excluded from these treatments, and counselled in line with General Medical Council (GMC) guidance on these matters.15 All discussion and steps in the counselling process should ideally be fully documented, as recommended by the GMC.16

Conclusion

The type of peel that will be best for any patient will be dependent on their skin type, their medical history, their cosmetic concerns and their expectations. Thorough counselling is absolutely necessary to ensure that the best possible results are achieved. Patient selection is key with regards to medium depth peel application.