Trichloroacetic acid chemexfoliation (chemical peel) for extensive premalignant actinic damage of the face and scalp

Chemical Peels as Field Therapy for Actinic Keratoses: A Systematic Review

BACKGROUND

Actinic keratoses (AKs) are a common premalignant cutaneous neoplasm and can progress to squamous cell carcinoma. A variety of treatment options are available for field therapy of diffuse AKs.

OBJECTIVE

This review systematically analyzes the use of chemical peels for treatment of AKs.

MATERIALS AND METHODS

A systematic review of PubMed was performed searching from 1946 to March 2020 to identify the literature on chemical peels for AKs.

RESULTS

Of the 151 articles identified, 5 met inclusion criteria for review. Four of the reviewed articles demonstrated the efficacy of chemical peels in reducing AK count and minimal adverse effects. In some studies, chemical peels exhibited potential to prevent additional AK formation and development of keratinocyte carcinomas.

CONCLUSION

Chemical peels are an efficacious and affordable treatment option for field treatment of AKs. With improved patient tolerance and adherence, chemical peels are an attractive option for field therapy of AKs for both dermatologists and patients.

Combined Carbon Dioxide Laser Resurfacing and TCA Chemical Peel

Currently, various modalities such as phenol and TCA peels and dermabrasion are available for regeneration of the aged skin. A prior study by our group has demonstrated the clinical effectiveness of CO2 laser resurfacing in treating actinically damaged skin of the entire face with concomitant histologic improvement characterized by elimination of the solar elastosis and replacement by new collagen bundles. In the present study, we have taken this approach one step further and are presenting results of a series of 130 patients treated with combined CO2 laser resurfacing and trichloracetic acid (TCA) chemical peeling. The laser is used primarily for wrinkles, keratotic lesions, and pigmentary changes; and TCA is used to blend affected and unaffected skin. Fewer complications were noted with CO2 laser resurfacing/TCA peels than with phenol peels or dermabrasion. This combined technique can be a useful modality in the cosmetic as well as therapeutic treatment of the aged skin, as marked clinical and histologic improvement has been demonstrated.

Maximizing benefits and minimizing risk with CO2 laser resurfacing

Laser resurfacing using the high-energy, pulsed and scanned CO2 laser produces the most dramatic improvement in severe photo-induced facial rhytides and deeply atrophic scars. More recently, the use of short- and long-pulsed erbium lasers in conjunction with CO2 laser resurfacing has been shown to speed healing by removing the upper layer of thermally induced necrotic tissue. The Er:YAG lasers are more superficial ablative tools that inflict less residual thermal damage on the tissue, thus allowing healing to occur without the requisite internal clearance of excessive debris. With continued research and advances in laser surgery, cutaneous resurfacing will be further enhanced with improved outcomes and lessened morbidity.

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.

Cutaneous laser resurfacing

Cutaneous resurfacing with the new generation of carbon dioxide and erbium lasers has recently come into favor for the treatment of facial rhytides, photodamage, and scarring. The precise control of these resurfacing lasers over the extent of tissue vaporization minimizes thermal damage to the skin while maximizing therapeutic efficacy. Proper use of resurfacing lasers is contingent upon a complete understanding of their clinical, histologic, and ultrastructural effects, as well as an appreciation of the principles of laser safety. An organized approach to the preoperative, intraoperative, and postoperative management of the patient undergoing laser resurfacing will be provided, including a discussion of prevention and treatment of postoperative side effects and complications. (J Am Acad Dermatol 1999;41:365-89.)

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be familiar with the clinical, histologic, and ultrastructural effects of resurfacing lasers and be able to discuss the preoperative, intraoperative, and postoperative management of patients undergoing laser resurfacing.

Manual resurfacing and trichloroacetic acid for the treatment of patients with widespread actinic damage. Clinical and histologic observations

BACKGROUND

A facial resurfacing regimen combining manual abrasion of the skin and 25% trichloroacetic acid has been reported to produce excellent results, but the histologic depth of injury produced by this technique has not been studied.

OBJECTIVE

To describe our experience with this technique treating patients with extensive actinic damage and to determine the histologic depth of injury produced.

METHOD

We treated 40 patients using manual resurfacing and trichloroacetic acid, primarily for widespread actinic keratoses. Resurfacing tools included silicone carbide sandpaper, drywall screen, electrocautery tip cleaners, abrasive pads, scalpel blades, and curettes. Four patients underwent sequential biopsies to evaluate the depth of wounding using this technique.

RESULTS

Manual resurfacing combined with trichloroacetic acid consistently produced excellent cosmetic results and nearly complete eradication of actinic keratoses. Histologically, treated areas showed replacement of the dermal elastotic band by newly formed collagen, a significantly deeper level of wounding than the Jessner's/35% trichloroacetic acid peel. There was no evidence for foreign body granulomas clinically or histologically as a result of the abrasive materials.

CONCLUSIONS

The deeper level of this peel explains the improved cosmetic outcome and greater eradication of actinic keratoses. This treatment is particularly well suited for patients with extensive photodamage and widespread actinic keratoses.

Long-term efficacy and safety of Jessner's solution and 35% trichloroacetic acid vs 5% fluorouracil in the treatment of widespread facial actinic keratoses

BACKGROUND

Few studies have examined the long-term efficacy of fluorouracil (FU) or chemical peels for the treatment of actinic keratoses (AK). Our earlier work examined the efficacy and safety of a medium-depth chemical peel compared with the standard regimen of topical FU in the treatment of widespread facial AK through 12 months.

OBJECTIVES

To determine long-term efficacy of both treatments by extending our observations through 32 months.

METHODS

Fifteen patients with severe facial actinic damage were treated on the left side with a single application of Jessner's solution and 35% trichloroacetic acid and on the right side with twice daily applications of 5% FU cream for 3 weeks. Parameters evaluated at 1, 6, 12, and 32 months included counts of visible AK, random skin biopsies from both treatment areas, development of intercurrent neoplasms, and surveys assessing sun exposure.

RESULTS

Eight patients were available for reevaluation at 32 months. Both treatment sides showed a reduction in mean number of AK at 12 months followed by an increase in mean AK number between 12 and 32 months. Improvements in biopsies of clinically actinically damaged skin were seen in keratinocytic atypia, hyperkeratosis, parakeratosis, and inflammation at all treatment times during the study with both treatments. Three squamous cell carcinomas developed in the patients after initial treatment; one developed on the side treated with the peel, and two developed on the side treated with fluorouracil. Surveys failed to demonstrate an association between sun exposure and clinical response.

CONCLUSION

Based on these findings, patient with widespread actinic keratoses treated with medium-depth chemical peel or with 5% FU should be reevaluated yearly or every 1.5 years for reappearance of AK and retreatment.

Clinical improvement of photoaged skin with 50% glycolic acid. A double-blind vehicle-controlled study

BACKGROUND

Although there is increasing interest in the use of glycolic acid in the treatment of photoaged skin, to our knowledge, no controlled study has been done to assess the efficacy or the mode of this agent.

OBJECTIVE

The purpose of this study was to determine whether 50% glycolic acid can improve photoaged skin and to study the histological basis for this improvement.

METHODS

Forty-one volunteers were recruited into this double-blind vehicle-controlled study. Glycolic acid (50%) or vehicle was applied topically for 5 minutes to one side of the face, forearms, and hands, once weekly for 4 weeks. Punch biopsies were taken at pretherapy and at 5 weeks for histologic study.

RESULTS

Significant improvement noted included decrease in rough texture and fine wrinkling, fewer solar keratoses, and a slight lightening of solar lentigines. Histology showed thinning of the stratum corneum, granular layer enhancement, and epidermal thickening. Some specimens showed an increase in collagen thickness in the dermis.

CONCLUSION

The results of this study demonstrate that the application of 50% glycolic acid peels improves mild photoaging of the skin.

Dermabrasion for prophylaxis and treatment of actinic keratoses

BACKGROUND

After dermabrasion, patients with actinic keratoses remain free of new lesions for many years. This clinical effect has been alluded to for 40 years in the dermatologic literature. However, there has been no consensus on how long this clinical benefit actually lasts.

OBJECTIVE

To ascertain the longevity of the beneficial effect of dermabrasion, clinical records of patients who underwent this procedure for treatment of actinic keratosis were reviewed.

METHOD

Retrospective review.

RESULTS

A total of 23 such patients with at least 2 years good clinical follow-up were identified. Their ages ranged from 33 to 76 years. One year after dermabrasion, 96% remained free of new actinic keratoses. The benefits of dermabrasion gradually diminished with 83% clear at 2 years, 79% at 3 years, 64% at 4 years, and 54% at 5 years. The average time after dermabrasion before the appearance of one actinic keratoses was 4 years (median, 4.5 years). Dermabrasion, however did not prevent the appearance of basal cell carcinomas in the perinasal area.

CONCLUSION

Dermabrasion provides long-term effective prophylaxis against actinic keratoses and presumably squamous cell carcinomas. The benefits last for an average of 4 years before even one new actinic keratosis reappears. Cryosurgery, 5-Fluorouracil, and chemical peels result in much shorter prophylaxis. Dermabrasion is the most effective modality for prevention of new actinic keratoses.

Combining manual dermasanding with low strength trichloroacetic acid to improve actinically injured skin

BACKGROUND

Motor-driven dermabrasion or deeper chemosurgical peeling improves photodamaged facial skin. However, these procedures each pose disadvantages that we felt could be largely ameliorated by combining manual dermasanding with low strength trichloroacetic acid peeling.

OBJECTIVE

To evaluate the effectiveness, safety, and reproducibility of a technique combining manual dermasanding and light peeling in treating actinically injured facial skin.

METHODS

Manual abrasion with moistened silicone-carbide sandpaper followed by application of a 25% trichloroacetic acid solution was performed on over 300 patients followed as long as 7 years.

RESULTS

Improvement was uniformly noted in luster, brightness, dyschromia, and rhytids. The procedure was easily mastered and results were reproducible. Postoperative pigmentary problems and scarring were extremely rare.

CONCLUSIONS

The technique demands minimal skill and experience, while providing pleasing results. There is no splatter or sharp lines of demarcation, and results suggest distinct advantages over motor-driven dermabrasion or deep peeling procedures.

Office dermatologic surgery and laser therapy

As the result of a dramatic increase in the incidence of skin cancer and the need for effective outpatient surgical treatment, dermatology is now a surgical as well as a medical specialty, and many procedures are commonly performed on an outpatient basis. Mohs micrographic surgery is used to remove basal cell and squamous cell carcinomas, and the resulting cure rates are high. Excisional biopsy can facilitate the early diagnosis of melanoma, while it is still in clinical stage I. Carbon dioxide lasers are commonly used to destroy epidermal lesions and yellow light lasers to destroy hemangiomas or other vascular malformations. Facial chemical peel (chemexfoliation) with trichloroacetic acid can improve the appearance of photoaged skin.

Pseudocyst of the auricle: successful treatment with intracartilaginous trichloroacetic acid and button bolsters

Pseudocyst of the auricle is an asymptomatic, noninflammatory cystic swelling that typically involves the anthelix of the ear and results from an accumulation of fluid within an unlined intracartilaginous cavity. We report a patient with a recurrent pseudocyst of the auricle and describe a new surgical technique for treating this condition by applying 50% trichloroacetic acid to the intracartilaginous cavity and utilizing external button bolsters for compressive therapy. This therapeutic approach is simple to perform in the office, results in permanent resolution of the pseudocyst, preserves the normal architecture of the external ear, and provides excellent postoperative and long-term cosmetic results.

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

The depth of wounds created by various concentrations and application techniques of trichloroacetic acid (TCA) in a porcine model is evaluated. The depth of tissue necrosis increased with the concentration of TCA. Tape occlusion did not deepen the wound but rather decreased its depth. An inverse relationship of wound depth to epidermal thickness is described.

Trichloroacetic acid peels revisited

Trichloroacetic acid (TCA) is a time-honored peeling agent that has no known systemic toxicity. Recent interest in reversing the effects of actinic damage has led to the utilization of combination therapies. Retinoic acid, solid CO2, pyruvic acid, Jessner's formula, and other agents have been used to increase the effectiveness of TCA and enhance peeling results. Repetitive peels with low concentrations of TCA can be effective for areas prone to scarring.