TCA peel is a mid-grade chemical peel that penetrates deeper layers of skin providing deep cleansing and rejuvenation. The main ingredient of the formulation is trichloroacetic acid (also known as trichloroethanoic acid) which is an analogue of acetic acid as a highly toxic chemical absorbed through the skin with a strong bactericidal and anti-inflammatory effect used as a chemical cauterant.
The TCA peel’s action is based on coagulation of epidermal proteins, destruction and removal of damaged skin cells, stimulation of cell division in the basal layer of skin, formation of new cells and uniform distribution of natural skin pigment melanin. The effect of the TCA peel depends on the depth of penetration according to its concentration.
15% solution of TCA is used for a superficial peeling, 20-35% solution – for a medium grade peeling, while TCA concentration over 40% is never used for a skin peel treatment because of high risk of complications. Providing a strong caustic effect, high-concentrated TCA solutions can only be used locally for small (less than 1 cm in diameter) benign tumors removal.
The depth of TCA penetration into epidermis and its effectiveness depend on how many layers of solution are applied, on the type of the formulation (gel or hydroalcoholic), reaction with other chemical agents (such as resorcinol, acetone, glycolic and salicylic acids) during the procedure, mechanical skin damage on the treated skin areas, and also on the type of pre-peel skin preparation.
TCA peel is considered to be more painful than AHA peels. It is a serious medical treatment rather than just a cosmetological procedure requiring professional performance by a highly experienced beauty therapist.
Indications for TCA face peel:
• uneven skin texture
• photoaging-related fine lines and medium wrinkles
• acne scars and post-acne marks
• solar/senile lentigines (freckles)
• flat birthmarks
• acne prone oily skin
• post-acne stagnant spots
• dull uneven skin tone
• loose skin
• stretch marks (striae)
• enlarged pores
Absolute contraindications for TCA face peel:
• acute phase of chronic illness
• ARVI (acute respiratory viral infection)
• Roaccutane need
• recently suffered injuries and skin damage on the treated skin area
• need for radiotherapy
• fresh sun tan
• IV–VI skin phototype (Fitzpatrick skin type)
• age under 18
• acute skin inflammation, aggravation of dermatosis, herpes and acne
• hypertrophic and keloid scar formation
• recently (less than 8 weeks ago) performed cosmetological procedures that may cause skin injury (deep cleansing, mesotherapy, laser resurfacing)
• mental disorders
• recently (less than 6 months ago) taken aromatic retinoids
• papilloma and warts
Relative contraindications for TCA face peel:
• sensitive skin
• multiple nevuses
• hypertrichosis and hirsutism (as long as TCA is a strong hair growth stimulant)
Trichloroacetic acid (also known as trichloroethanoic acid) is an analogue of acetic acid in which the three hydrogen atoms of the methyl group have all been replaced by chlorine atoms. It is prepared by the reaction of chlorine with acetic acid in the presence of a suitable catalyst.
Properties of TCA:
• Keratolytic effect (more pronounced than by retinoic or glycolic acid) promoting removal of the upper layers of the epidermis
• Lifting effect by increasing collagen and elastin production
• Antioxidant effect by binding heavy metals and blocking free radicals providing skin protection against harmful environmental influences
• Comedolytic effect by unclogging sebaceous glands and smoothing pores
• Whitening effect achieved by dead skin cells exfoliation and skin texture improvement
• Antiseptic action providing bacteriostatic and bactericidal effect
• Dermal structures remodeling effect
Advantages of TCA face peel:
• Relative safety. As opposed to other chemical peeling agents such as phenol, TCA doesn’t possess acute toxicity.
• Adjusted penetration depth of the TCA determined by “frosting” when some skin areas turn white as the result of proteins denaturation.
• Uniform distribution of TCA over the skin surface
• Significant visible results
• No special skin preparations required
• The procedure doesn’t take long
• Reduced recovery time and no social restrictions required when using a 15% TCA solution.
Disadvantages of TCA face peel:
• Extensive list of contraindications
• TCA penetrates skin layers faster than other chemical peeling agents what can make it difficult to control the depth of its penetration.
• Discomfort and pain during the procedure
• Appearance of lamellar skin shedding during the post-peel period when using a 20-35% TCA solution requiring a longer recovery time.
TCA peel stages:
1. Pre-peel preparation
2. Make-up removal and skin cleansing
3. Application of TCA
5. Application of a calming mask
6. Post-peel home skin care
Ideally TCA peel should be performed during the period from October to March to avoid excessive sun exposure. Superficial glycolic peel is used as a pre-peel skin preparation. The patient should use special skin care containing fruit acids and moisturizers with sunscreen for 14-20 days after the prep-procedure.
At this stage experts recommend taking medications that help strengthening blood vessels to improve tissue regeneration. Moreover, scrubs, bast wisps and sponges, as well as epilation, shaving, eyebrow correction, sauna and solarium should be avoided one month before the treatment. It is highly recommended to take herpes prevention medications for 3-4 days before the treatment.
Make-up removal and skin cleansing
A gel cleanser is preferable due to the ability of lipids containing cleansing milk to reduce the penetrating ability of TCA.
Application of TCA
A uniform layer of TCA should be applied quickly all over the treated skin area with a special brush. During the application process some burning sensations on skin are possible. A fan is used to relieve pain. As long as TCA peel causes severe pain, it is usually performed under local anesthesia when the concentration of the solution exceeds 30%. The exposure time takes a few minutes. The key point of a proper procedure performance is to provide and control a uniform penetration of the active ingredient into epidermis. The depth of the penetration can be determined by skin frosting appearing as whitening of some skin areas. Light pink tone of affected skin areas indicates shallow penetration of the TCA into outer skin layers only, while milky white and pale white tone indicate deeper penetration of the active ingredient into deeper layers of skin through to the basement membrane.
There is also a post-peel skin damage evaluation system designed by an American dermatologist and skin care expert, Dr. Zein Obagi MD. He created a modified 30% TCA peel (Blue Peel) compounding regular ingredients with a special blue-colored base and some substances that slow down the penetration of TCA into skin turning the formulation into 15% solution. The beauty therapist should apply a thin uniform layer of the peel formulation over the skin surface controlling the coloring of skin. If the skin turns blue uneven and spotty, that means TCA penetrates skin not as uniform as it was supposed causing undesirable skin reaction and complications. Depending on the thickness of the epidermis, 1 to 4 layers of preparation are required to achieve necessary penetration depth.
Degrees of skin damage
1. Epidermolysis – mobility of the epidermis that can be clearly defined by palpation (the skin feels like a soft cheese).
2. Pink spots indicate that TCA has reached the epidermal and dermal layers of skin (the skin is colored pink).
3. Even blue tone indicates dermal penetration of the active ingredient (the skin is colored light-blue).
4. Frosting or pale white skin tone indicates the penetration of TCA into reticular layer of the dermis (the skin looks frosted).
Some manufacturers suggest special alkaline neutralizers, but TCA peel can also be simply neutralized with pure water relieving the burning sensation on skin.
Application of a calming mask
It is very important to apply a moisturizing mask with anti-inflammatory effect after the procedure to calm down the skin and reduce the risk of complications.
Post-peel home skin care
A proper post-peel skin care is considered to be one of the most important acid peel stages that determines the final results of the treatment and assures complications prevention. The goal of the post-peel skin care is to provide strong skin protection from different damaging factors such as dehydrating, UV-radiance, bacterial skin infections, and to promote skin regeneration.
Following products are used for these purposes:
• Preparations that form a semipermeable membrane (protein hydrolysates, aloe extract, hyaluronic acid) retaining moisture and creating favorable conditions for natural regeneration.
• SPF 50+ sunscreens and melanogenesis inhibitors that help to prevent hyperpigmentation.
• Skin care products containing antioxidants such as green tea and similar antioxidant agents.
• Preparations possessing vasoprotective and anti-inflammatory effects (hamamelis extract, calendula extract) that help to reduce inflammation, swelling and hyperemia.
• Regeneration stimulating preparations such as zinc and vitamin complexes that promote skin renewal and provide scarring prevention.
• ceramides that promote epidermal barrier recovery and reduce skin sensitivity.
• Antiviral drugs which are recommended to use within 3-4 days after the procedure for herpes prevention.
• Mesotherapeutic biorevitalization with hyaluronic acid providing skin moisturizing and elasticity recivery.
The post-peel skin treatment using these skin care products should be performed during 14 days after TCA face peel.
Potential complications after TCA peel
Most patients suffer complications after chemical peel to some degree. The complications usually occur in the first few days after the procedure as a normal skin reaction to TCA.
Following skin reactions are expected:
• Erythema (excessive redness of treated skin areas). The degree of the symptom depends on the TCA concentration used for the peel. In contrast with AHA peel which causes skin redness for 4 hours after the procedure, TCA peel causes a more severe form of erythema for the next 5 days.
• Skin peeling is a common post-peel skin reaction and is usually hardly noticeable when using fruit acid peels. However, TCA peel causes lamellar skin shedding of the treated skin areas for at least a week.
• Swelling as manifestation of a local skin inflammatory response to an aggressive skin treatment. TCA peel increases capillary permeability causing capillary liquid accumulation in tissue which leads to skin swelling. Fruit acid peels do not show such side effects, while TCA peel with concentration less than 15% may easily cause this type of complication. Skin swelling usually occurs on 1-2 day after the procedure and lasts for a few days.
• Skin darkening on the treated areas disappearing in about 10 days after the skin has completely peeled off.
• Skin sensitivity consisting in hypersensitive reaction of treated skin areas to external irritants such as sunlight, mechanical/physical action and temperature exposure. The symptoms usually clear up within 10 days.
Unexpected complications of TCA peel
Unexpected complications may occur immediately after the procedure, as well as after a long period of time. This type of complications is not a normal skin reaction to acid peel having an extremely negative impact on the skin health and esthetic consequences.
These are following skin reactions:
• Herpes infection usually occurring by using 20-35% TCA. Patients with low immune system suffering from recurrent herpes are in high-risk group. It is recommended to take Acyclovir as a preventive medication, however a full course of complex therapy may be required for an intensive treatment.
• Infectious complications which result from violating hygiene standards by the beauty therapist or by the patient himself during the recovery time after the procedure. The most frequently occurring infection is streptostaphylodermia which needs to be treated with antibiotics.
• Allergy is a rarely occurring skin reaction by TCA peel. However a hypersensitive skin reaction to other external irritants may occur during the post-peel period. It is recommended to make skin sensitivity test before the procedure to avoid undesirable skin reactions to the peel ingredients. It is also important to completely eliminate or avoid potential allergens as much as possible during the recovery time after the procedure.
• Marbling effect on the skin caused by death of a large number of melanocytes by excessively deep chemical exposure. This effect is irreversible, a course of superficial acid peels can only help to slightly reduce uneven skin tone.
• Persistent erythema occurring by the patients suffering from enlarged superficial blood vessels. The symptoms persist for about 12 months and clear up without treatment. To speed up the recovery process, sun exposure, sauna, physical activity, alcohol and spicy food should be avoided.
• Hyperpigmentation is one of the most frequently appearing skin reactions by TCA peel. It is actually a direct consequence of an improperly made pre-peel skin diagnostic. Possible causes of hyperpigmentation include skin cells dysfunction, however the patient should first be examined to determine predisposition to hyperpigmentation and to treat existing break-outs if necessary. A course of phenol or retinoic peels and mesotherapy with 15% ascorbic acid are recommended to reduce the symptoms.
• Aggravation of seborrheic dermatitis and acne induced by excessive activity of sebocytes caused by inflammations. Patients with oily acne-prone skin are in high-risk group. Complex of vitamins A and E is considered to be an effective prevention measure.
• Demarcation line between the treated skin area and the skin area that wasn’t treated. Such reaction is typical for dark skin with enlarged pores. This problem can be eliminated by using Jessner’s peel as an additional treatment.
• Keloid or hypertrophic scars occurring by using elevated concentration of TCA (over 50%) or by the violation of technology using 30% TCA.
Please note that lamellar skin shedding during the post-peel period by using 20-35% TCA peel is a normal skin reaction requiring a longer recovery time (up to 2 weeks) and restriction of social life until the skin restores completely.
The procedure can be repeated no sooner than 2 months after the first treatment using 15% TCA. A mid-grade chemical peel can be performed several times, but not more often than once a year.
Remember that the reduction potential of the skin reduces with aging, thereby TCA peel is not always the best solution for mature skin. Complications such as persistent erythema and post-inflammatory hyperpigmentation occur more often by mature aged patients. Before prescribing chemical peel, the beauty therapist should first assess general skin condition and its ability to recover after an aggressive treatment. Only high-qualified and experienced beauty expert can make the right decision for you.
10-15% TCA peels run about $150-$200 each and need 3-5 peels. 20-25% TCA peels run about $250-350 each and most need 2-3 peels. 30-35% TCA peels run about $400-450 each and 1-2 peels do great for most clients. You also will need a good cortisone lotion, bleaching cream and sunscreen with each peel.
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