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.

Trichloroacetic acid 10% injection for treatment of conjunctival inclusion cysts

Purpose: To evaluate the effect of intra-lesional injection of Trichloroacetic acid (TCA) 10% in patients with conjunctival inclusion cysts.Methods: This prospective case series study included all patients with conjunctival inclusion cyst who were referred to our referral center from August 2016 to August 2018. All patients received TCA 10% injection into the conjunctival cyst, and outcomes of the intervention were evaluated at least 6 months later.Results: Ten patients with mean age of 24 ± 17.6 (range 6-65) years including three children received TCA 10% injection into the conjunctival cyst. We included 6 anophthalmic and 4 ophthalmic cases. All patients were treated successfully and no recurrence of the lesion was observed in any case. Mean follow up duration was 18.1 ± 8.3 (range 6-28) months.Conclusion: Intra-lesional injection of TCA 10% is a safe, simple, and effective treatment in patients with conjunctival inclusion cysts including ophthalmic cases and anophthalmic cases, both in adults and in children. This concentration may avoid ocular surface complications.

Filling Up the Valleys

Man has tried and sought to erase wrinkles and scars for millennia. Sadly, however, the most effective and permanent techniques have fallen into disuse and neglect due to lack of training in universities, lack of awareness on the part of both physicians and patients, and heavy mass marketing of injectable fillers. Dermal grafting is a standard, time honored method for permanent correction of deep facial defects. Our goal as dermatologists is to generate the best results for our patients, and also to develop our personal skills and talents to the utmost.

Asymptomatic intrathyroidal pyriform sinus fistula mimicking thyroid cancer: A case report and literature review

RATIONALE

There have been many reports of non-thyroidal lesions which can be mistaken for thyroidal lesions on ultrasound (US) examination. However, it is not known that pyriform sinus fistula (PSF) can manifest as an incidental thyroid nodule and cause serious complication on fine-needle aspiration (FNA).

PATIENT CONCERNS

We present a 34-year-old man with PSF incidentally detected on US. US examination showed hypoechoic nodule with several bright echogenic spots at the uppermost part of left thyroid gland. With the suspicion of thyroid cancer, although there would have been some morphologic changes between the 2 US examinations, FNA was performed.

DIAGNOSES

Cytologic specimen revealed some clusters of ciliated columnar cells mixed with inflammatory and lymphoid cells. On computed tomography (CT) before FNA, there were tiny air bubbles within the thyroid nodule. Laryngoscopy revealed fistula originating from the pyriform sinus.

INTERVENTIONS

After FNA, he had to undergo tracheostomy and removal of abscess due to infectious complication.

OUTCOMES

The deep neck abscesses and infections were controlled after the treatment. At 1 year after FNA, successful chemocauterization with 40% trichloracetic acid solution was performed for PSF found on laryngoscopy.

LESSONS

PSF can manifest as an incidental thyroid nodule mimicking thyroid cancer. Special care should be taken when FNA is planned for the nodule with air foci and morphologic changeability at the uppermost part of left thyroid gland.

Efficacy of Trichloro-Acetic Acid Peel Alone Versus Combined Topical Magnesium Ascorbyl Phosphate for Epidermal Melasma

OBJECTIVE

To compare the efficacy in terms of reduction in melasma area and severity index (MASI) score by more than 10 of a combination of 20% trichloro-acetic acid peel plus 5% topical magnesium ascorbyl phosphate versus 20% trichloroacetic acid peel alone in the treatment of epidermal melasma.

STUDY DESIGN

Randomized controlled trial.

PLACE AND DURATION OF STUDY

Department of Dermatology, Lady Reading Hospital (LRH), Peshawar, from May 2012 to May 2013.

METHODOLOGY

Patients aged 18 - 65 years, with Fitzpatrick skin type III-V were divided into two equal groups having 74 patients each. Detailed history was taken and Wood's lamp examination done to rule out mixed and dermal melasma. Melasma area and severity index (MASI) score was calculated for every patient. Priming was done for all patients with tretinoin cream applied once daily at night for 2 weeks, and to use a broad spectrum sun block cream before sun exposure. Patients in group Awere subjected to combined treatment, i.e. trichloro-acetic acid peel 20% (weekly) plus magnesium ascorbyl phosphate cream (applied once daily), while patients in group B were subjected to trichloro-acetic acid peel 20% (weekly) alone. Treatment was continued for 6 weeks. After completion of treatment, MASI score was recalculated. Proportion of patients with significant MASI score reduction was compared using chi-square test with significance at p < 0.05.

RESULTS

Male and female patients were 11 (14.9%) and 63 (85.1%), respectively in group A, whereas 13 (17.6%) and 61 (82.4%) in group B. The mean age in group Awas 30.28 ±8.08 years, and 29.36 ±6.84 years in group B. Significant MASI score reduction in group Awas seen in 60 (81.1%) patients and in group B 49 (66.2%, p= 0.040).

CONCLUSION

Combination of trichloro-acetic acid peel and topical magnesium ascorbyl phosphate cream was significantly more effective than trichloro-acetic acid peel alone in treatment of melasma.

Metaplastic Ossification in a Cutaneous Pyogenic Granuloma: A Case Report

Cutaneous ossification may occur in association with a variety of cutaneous neoplasms and inflammatory conditions, such as pilomatricomas, basal cell carcinomas, nevi, chondroid syringomas, venous stasis, and scars. However, it has rarely been reported in pyogenic granuloma, a relatively common benign vascular tumor of the skin and mucous membranes. We herein presented a rare case of cutaneous pyogenic granuloma with ectopic ossification on the big toe of a 37-year-old man, with high recurrence despite repeated CO2 laser ablations. We propose the hypothesis that vascular endothelial growth factor (VEGF) and bone morphogenetic proteins (BMPs) play pathologic roles in the development of ectopic bone formation in pyogenic granuloma.

Oxidative damage and alterations in antioxidant enzyme activities in the kidneys of rat exposed to trichloroacetic acid: protective role of date palm fruit

In this study, we investigated the antioxidant and protective properties of date fruit aqueous extract (DFAE) on trichloroacetic acid (TCA)-induced nephrotoxicity in rat. Oral administration of TCA as drinking water (0.5 and 2 g/L) daily for 2 months caused nephrotoxicity as evident by elevated levels of plasma creatinine, urea, and uric acid. Activity of antioxidant enzymes, catalase (CAT) and glutathione peroxidase (GPx), was decreased, whereas superoxide dismutase (SOD) activity and malondialdehyde (MDA) level were increased along with histopathological injuries. The oral administration of DFAE (4 mL/kg/day) to TCA-treated groups proved some significant correction by increasing the antioxidant activity of the CAT and GPx enzymes and normalizing the SOD activity and the MDA level (p < 0.05). It also protected kidney's histology and normalized the functions of this organ. It could be concluded that DFAE has a protective role against TCA-induced oxidative stress in rat, thereby protecting the renal tissue from TCA-induced damage.

Comparative study of topical 80% trichloroacetic acid with 35% trichloroacetic acid in the treatment of the common wart

BACKGROUND

Common warts caused by the human papillomavirus (HPV) are considered to be the most common infectious skin disease. No individual treatment for common warts is effective as monotherapy in eradicating the lesions. The aim of this study is to evaluate the clinical efficacy of a 35% and an 80% trichloroacetic acid (TCA) solution in the treatment of the common wart.

METHODS

In this single-blinded clinical trial, 62 eligible patients with common warts referred to the dermatology clinic of Ghaem Hospital in Mashhad, Iran. Patients were randomly divided into two groups, each treated with a TCA solution (group A, TCA 80%; group B, TCA 35%) once per week until complete clearance of the lesions or for a maximum duration of six weeks. Seven patients were excluded from the final analysis (one patient in group A and six patients in group B) for various reasons, including irregular follow-up, using physical tools such as razor blades to remove the lesion, and failure to complete treatment; and 55 patients were included in the final analysis.

RESULTS

Improvement to treatment responses was classified as: no change (no changes in the number of warts), mild (clearing of less than 25% of warts), moderate (clearing of 25% to 75% of warts), and good (clearing of more than 75% of warts). At the end of follow-up, the clinical improvement of group A (n=30) was: 10 patients (33.3%) with a mild response, 6 patients (20%) with a moderate response, and 14 patients (46.7%) with a good response. In group B (n=25), 16 patients (64%) showed a mild response, 6 patients (24%) a moderate response, and 3 patients (12%) a good response. There was a statistically significant difference in improvement between the two treatment groups (P=.017). Improvement was greater with a higher concentration of TCA solution.

CONCLUSION

This study showed that a different concentration of TCA solution was an effective form of treatment for common warts. Trichloroacetic acid 80% is more effective, but this solution must be used only with careful consideration by a physician.

Antimicrobial topical agents used in the vagina

Vaginally applied antimicrobial agents are widely used in the vagina in women with lower genital tract infections. An 'antimicrobial' is a general term that refers to a group of drugs that are effective against bacteria, fungi, viruses and protozoa. Topical treatments can be prescribed for a wide variety of vaginal infections. Many bacterial infections, such as bacterial vaginosis, desquamative inflammatory vaginitis or, as some European authors call it, aerobic vaginitis as well as infection with Staphylococcus aureus or group A streptococci, may be treated in this way. Candida vulvovaginitis is a fungal infection that is very amenable to topical treatment. The most common viral infections which can be treated with topical medications are condylomata acuminata and herpes simplex. The most often encountered protozoal vaginitis, which is caused by Trichomonas vaginalis, may be susceptible to topical medications, although this infection is treated systemically. This chapter covers the wide variety of commonly used topical antimicrobial agents for these diseases and focuses on the individual therapeutic agents and their clinical efficacy. In addition, potential difficulties that can occur in practice, as well as the usage of these medications in the special setting of pregnancy, are described in this chapter.

Current therapy for condyloma acuminata of the patients attending female STD Unit, Siriraj Hospital

OBJECTIVE

To describe the treatment pattern of condyloma acuminata in female.

MATERIAL AND METHOD

The 5-year medical records of 449 women treated for genital condyloma acuminata at the Gynecologic Infectious Diseases and Female Sexually Transmitted Disease (GID-FSTD) unit were reviewed. Data included the distribution of age, client by category, anatomical site and size, serologically coexisting sexually transmitted infection (STI), and treatment modalities.

RESULTS

About half, 50.1%, of treatment was the application of topical trichloroacetic acid; followed by podophylline in the proportion of 35.5%. While the electric cauterization and imiquimod applications were uncommon therapy. Two-fifth ofthe subjects, 40.7%, was completely cured, and the remaining cases required additional management.

CONCLUSION

The present setting, the wide range of treatment available is reflection of the fact that there is no ideal management.

Evaluation of three different strengths of trichloroacetic acid in xanthelasma palpebrarum

BACKGROUND

Xanthelasma is a common cutaneous condition that presents in the periocular region. Essentially benign, treatment is of cosmetic importance.

OBJECTIVE

Evaluation of varying strengths of trichloroacetic acid (TCA) in xanthelasma palpebrarum.

METHODS

Three strengths of TCA were used on 51 patients randomly after categorizing their xanthelasma into papulo-nodular, flat plaques and macular lesions. The average number of sittings was calculated in each category and patients were reviewed fortnightly.

RESULTS

Papulo-nodular lesions required an average of two applications with 100%, 2.67 with 70% and 4.16 with 50% TCA. Flat plaques responded to an average of 1.43, 1.50 and 3.55 sittings with 100%, 70% and 50% TCA, respectively. Macular lesions responded to only one application of all strengths of TCA applied. Eleven patients developed hypopigmentation, five had hyperpigmentation and one developed mild scarring.

CONCLUSION

100% TCA gives the best results in papulo-nodular lesions, 100% or 70% TCA give similar results in flat plaque xanthelasma and in macular lesions 50% is sufficient. Hypopigmentation is the commonest side effect, followed by hyperpigmentation. Scarring is a minor problem.

A comparative split-face study of cryosurgery and trichloroacetic acid 100% peels in the treatment of HIV-associated disseminated facial molluscum contagiosum

A comparative split-face study of 20 participants with disseminated facial molluscum contagiosum (MC) and human immunodeficiency virus (HIV) infection was conducted to assess treatment with cryosurgery (left side of the face) versus trichloroacetic acid (TCA) 100% peels (right side of the face). A total of 2 treatments were administered at 4-week intervals. At week 8, treatment with TCA 100% proved to be superior to cryosurgery with an average reduction in lesion count of 90% versus 55%, respectively. Demonstrating a statistically significant rate of lesion clearance (P < or = .05), TCA 100% appears to be more effective than cryosurgery at treating disseminated facial MC lesions in the setting of HIV infection.

Successful treatment of lupoid cutaneous leishmaniasis with glucantime and topical trichloroacetic acid (a case report)

Lupoid leishmaniasis is a unique form of cutaneous leishmaniasis characterized by unusual clinical features and a chronic relapsing course, mostly caused by infection with Leishmania tropica. In this clinical form, 1-2 yr after healing of the acute lesion, new papules and nodules appear at the margin of the remaining scar. Herein, we describe a case of this clinical form that was resistant to 2 courses of treatments: systemic glucantime and then a combination therapy with allopurinol and systemic glucantime. However, marked improvement was seen after a combination therapy with topical trichloroacetic acid solution (50%) and systemic glucantime, and there were no signs of recurrence after 1 yr of follow-up.

The induction of hepatocellular neoplasia by trichloroacetic acid administered in the drinking water of the male B6C3F1 mouse

The prevalence (percent of animals with a tumor) and multiplicity (number of tumors per animal) of hepatocellular neoplasia in the male B6C3F1 mouse exposed to trichloroacetic acid (TCA) in the drinking water were determined. Male mice were exposed to 0.05, 0.5, and 5 g/L TCA for 60 wk (Study 1), to 4.5 g/L TCA for 104 wk (Study 2) and to 0.05 and 0.5 g/L TCA for 104 wk (Study 3). Time-weighted mean daily doses measured for the low, medium, and high dose groups were consistent over the three studies, 6-8, 58-68, and 572-602 mg/kg-d for the 0.05, 0.5, and the 4.5-5 g/L treatment groups, respectively. No significant changes in animal survival were noted across the studies. A significant increase in the prevalence and multiplicity of hepatocellular tumors was found in the 58-68 and 572-602 mg/kg/d TCA dose groups. Nonhepatoproliferative changes (cytoplasmic alterations, inflammation, and necrosis) in mice treated with TCA were mild and dose related. A TCA-induced increase in liver palmitoyl CoA oxidase activity, a marker of peroxisome proliferation, correlated with tumor induction. A linear association was found between peroxisome proliferation and tumor induction. Sporadic increases in the labeling index of nuclei outside of proliferative lesions were observed at carcinogenic doses throughout the studies. Given that there are no compelling data demonstrating genotoxic activity of either TCA or any metabolite, data are consistent with an epigenetic mode of action. The studies provide dose-response data on the development of hepatocellular neoplasia in male mice over a lifetime exposure to TCA. A no-observed-effect-level (NOEL) of 6 mg/kg/d was calculated for neoplastic and nonproliferative liver pathology.

Evaluation of nasal symptoms and mucociliary function in patients with allergic rhinitis treated with chemosurgery using trichloroacetic acid

PURPOSE

We treated allergic rhinitis with trichloroacetic acid (TCA) applied to the inferior turbinates. Further clinical evaluations were made to determine the effect of TCA application on symptoms of allergic rhinitis. We also report the results of measurement of the mucociliary transit time (saccharin time) and nasal airway resistance.

MATERIALS AND METHODS

A group of 54 patients with perennial allergic rhinitis was treated with 80% TCA applied to the inferior turbinate. Further clinical evaluations were made to determine the effect of TCA application on symptom scores of allergic rhinitis. We also report the results of measurement of the mucociliary transit time (saccharin time) and nasal airway resistance in those cases.

RESULTS

The most common complaint, nasal obstruction, improved effectively in 82% of cases, watery rhinorrhea in 86%, and sneezing in 86%, 1 year after treatment. A significant decrease in scoring was noted for subjective nasal obstruction, watery rhinorrhea, and sneezing. Nasal airway resistance was effectively reduced 1 year after treatment, and the difference was statically significant. In our study, saccharin time appeared to be shortened in the early and late periods after the TCA application. There was a statistical difference between the before- and after-treatment groups.

CONCLUSIONS

We concluded that TCA treatment was quite effective for controlling nasal allergic symptoms and that it does not damage the mucociliary function.

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.

Combined trichloroacetic acid peel and topical ascorbic acid versus trichloroacetic acid peel alone in the treatment of melasma: a comparative study

BACKGROUND

Melasma is a common acquired hypermelanosis that is difficult to treat. Several chemical peeling agents were used in treatment of melasma. Topical vitamin C was also used with minimal side effects.

AIM

To compare the effect of 20% trichloroacetic acid (TCA) peel alone vs. 20% TCA peel combined with topical 5% ascorbic acid in cases of epidermal melasma.

PATIENTS AND METHODS

Thirty women with bilateral epidermal melasma (Fitzpatrick skin types III and IV) were divided into two groups (A and B, 15 patients each). Before therapy, digital photography and a melasma area and severity index (MASI) score were done for each patient. Groups A and B were primed for 2 weeks before TCA peel. Group B also applied 5% ascorbic acid topically once daily; 20% TCA peel was done for all patients weekly until clearance of melasma or for a maximum of six peels. Group B continued to use 5% ascorbic acid topically in between peels and during the 16-week follow-up period. Patients were assessed at the end of peeling sessions and at the end of follow-up by photography, MASI score, and a global evaluation by the patient.

RESULTS

Group B compared with group A showed a significant decrease in MASI score at the end of TCA peels (P < 0.001) and at the end of the 16-week follow-up period (P < 0.003). Global evaluation showed that 13 patients (87%) in group B improved or maintained their improvement compared with only 10 patients (67%) in group A.

CONCLUSION

Topical ascorbic acid combined with 20% TCA peel in melasma improves the results and helps in maintaining the response to therapy.

Medical Therapies for Chronic Menorrhagia

An estimated 10%-30% of menstruating women experience menorrhagia at some time during their reproductive lives. Acute menorrhagia may present as an emergency requiring prompt medical or surgical intervention. Chronic menorrhagia affects a woman's quality of life in her work, family, and social interactions. Medical management is the first line of therapy for chronic menorrhagia. Agents that have been used to treat menorrhagia include iron, cyclooxygenase inhibitors, desmopressin, antifibrinolytics, gonadotropin-releasing hormone agonists, androgens, combined oral contraceptives, and progestins. Progestins can be administered systemically or locally and may be given cyclically or continuously. Increased use of effective medical therapies has the potential to reduce the number of surgical procedures, such as endometrial ablation and hysterectomy.

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.

Facial resurfacing for nonmelanoma skin cancer prophylaxis

OBJECTIVE

To determine the effect of facial skin resurfacing for treatment of actinic keratoses (AKs) and prophylaxis against new primary basal and squamous cell carcinomas in individuals with previous nonmelanoma skin cancer (NMSC) or severe photodamage.

DESIGN

Randomized, prospective 5-year trial.

SETTING

Dermatology and otolaryngology clinics of a Veterans Affairs hospital.

PATIENTS

Thirty-four patients with a history of facial or scalp AKs or basal or squamous cell carcinoma were enrolled. Five of 7 eligible patients who declined study-related treatment were used as controls. Twenty-seven patients were randomized to 3 treatment arms; 3 patients were discontinued from the study.

INTERVENTIONS

Carbon dioxide laser resurfacing, 30% trichloroacetic acid peel, or 5% fluorouracil cream applied twice daily for 3 weeks.

MAIN OUTCOME MEASURES

Reduction in the number of AKs was measured 3 months after treatment. The incidence of new NMSC in treated areas was assessed between January 1, 2001, and June 30, 2005. Times from baseline to diagnosis of first skin cancer were compared between the treatment and control groups.

RESULTS

Treatment with fluorouracil, trichloroacetic acid, or carbon dioxide laser resulted in an 83% to 92% reduction in AKs (P< or =.03), a lower incidence of NMSC compared with the control group (P<.001), and a trend toward longer time to development of new skin cancer compared with the control group (P=.07). However, no significant differences were noted among the treatment groups.

CONCLUSION

All 3 modalities demonstrated benefit for AK reduction and skin cancer prophylaxis compared with controls and warrant further study in a larger trial.

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.

The Blue Peel: how to do it less expensively and faster

One well accepted and popular method worldwide for trichloroacetic acid peels is the Obagi Blue Peel technique (Obagi Medical Products, Long Beach, CA). The peel solution is prepared by mixing a fixed volume of 30% trichloroacetic acid with the commercially available Blue Peel base. The authors suggest modifications for performing the peeling faster and less expensively: 1) preparing a larger volume of peel solution from each tube of Blue Peel base; 2) using higher concentrations of peel solution to reduce the number of coats necessary for reaching the desired depth of peel; and 3) storing the solution, as there is no need to adhere to the manufacturer's instructions to prepare the solution immediately before conducting the peel procedure to ensure homogeneity of the solution. The prepared solution can be stored at least 1 year.

Neuroembryopathic effect of trichloroacetic acid in rats exposed during organogenesis

BACKGROUND

Halogenated hydrocarbons such as trichloroacetic acid (TCA) are among the most common water supply contaminants in the world. This study examines the effect of TCA on the developing brain of the Charles Foster rat.

METHODS

Adult pregnant rats were placed in the test group and exposed to various concentration of TCA (i.e., 1000, 1200, 1400, 1600, and 1800 mg/kg body weight [b.w.]) by oral gavage throughout the period of organogenesis from Gestation Day (GD) 6-15 of gestation. Trichloroacetic acid was administered in the form of trichloroacetate, which is reduced to TCA in the body. The control mother rats were administered an equal volume of distilled water. Fetal brains were examined for their external and histological malformation.

RESULTS

On GD 19, TCA administration led to an initial increase of brain weight at 1000 mg/kg b.w. and then a weight reduction after TCA doses of 1200 mg/kg b.w. and over. The brain of the formalin-fixed fetuses at 1000 and 1200 mg/kg b.w. showed hydrocephalus with breech of the ependymal lining, altered choroids plexus architecture, and increased apoptosis. At doses of 1400 mg/kg b.w. and above, the brain showed not only enhanced apoptosis of the neuronal cells, but extravasation of erythrocytes within the cortical parenchyma, vacuolation of the neuropil, and multiple cavity formation.

CONCLUSION

With an increase in dose of TCA i.e., 1200 mg/kg b.w. and above, there is enhanced apoptosis, leading to increased neuronal death, which consequently led to the reduction in the brain weight as compared to controls. The fetal central nervous system is susceptible to the toxic effect of TCA.

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.

Intrauterine instillation of trichloroacetic acid is effective for the treatment of dysfunctional uterine bleeding

OBJECTIVE

To evaluate the effectiveness of trichloroacetic acid (TCA) instillation into uterine cavity for the treatment of dysfunctional uterine bleeding (DUB).

DESIGN

Prospective clinical study.

SETTING

A university research hospital.

PATIENT(S)

Ninety women participated who had dysfunctional uterine bleeding.

INTERVENTION(S)

Ninety-five percent of TCA was instilled into uterine cavity for endometrial ablation in women with dysfunctional uterine bleeding who want conservative treatment. Participants in group 1 received only TCA; participants in group 2 received a single dose of gonadotropin-releasing hormone analogue 1 month before the procedure.

MAIN OUTCOME MEASURE(S)

All participants underwent an evaluation that included cycle history, body mass index measurement, and transvaginal ultrasonography of pelvis, diagnostic hysteroscopy and endometrial biopsy.

RESULT(S)

At the end of 12 months of the treatment, amenorrhea rates in group 1 and group 2 were 26.7% vs. 31.1%, with pooled amenorrhea, hypomenorrhea, and eumenorrhea rates of 95.6% vs. 97.8%, respectively. There was no significant difference between the groups vis-a-vis postprocedure results. More than 90% of women who have this procedure are satisfied with the results. There were no observed negative effects or related complications with this treatment.

CONCLUSION(S)

An instillation of TCA into uterine cavity produces acceptable results and provides conservative management of DUB.

Patterns of treatment and resource utilization in the treatment of external genital warts in England and Wales

Our objective was to identify patterns of treatment and resources used in achieving complete clearance of external genital warts (EGWs) A retrospective case note review was carried out at six genitourinary medicine (GUM) clinics in the UK. Case notes from 2366 patients presenting with EGWs were reviewed and 1200 patients with complete episodes of care were identified. Analysis showed that staff-applied therapy dominated treatment practice but there was considerable diversity in treatment modalities across study sites. The average number of visits was 5.71 visits for males: 6.25 visits for females but a substantial minority of patients attended significantly in excess of these averages. Approximately two-thirds of patients failed to achieve complete clearance of warts with their initial therapy. There is little consistency in treatment patterns of care for EGWs across the sites studied. Initial therapy choices are largely ineffective, requiring changes in treatment modality and multiple clinic visits. Increased utilization of patient-applied therapies might result in increased cost effectiveness.

Interactions in the tumor-promoting activity of carbon tetrachloride, trichloroacetate, and dichloroacetate in the liver of male B6C3F1 mice

Interactions between carcinogens in mixtures found in the environment have been a concern for several decades. In the present study, male B6C3F1 mice were used to study the responses to mixtures of dichloroacetate (DCA), trichloroacetate (TCA), and carbon tetrachloride (CT). TCA produces liver tumors in mice with the phenotypic characteristics common to peroxisome proliferators. DCA increases the growth of liver tumors with a phenotype that is distinct in several respects from those produced by TCA. These chemicals are effective as carcinogens at doses that do not produce cytotoxicity. Thus, they encourage clonal expansion of initiated cells through subtle, selective mechanisms. CT is well known for its ability to promote the growth of liver tumors through cytotoxicity that produces a generalized growth stimulus in the liver that is reflected in a reparative hyperplasia. Thus, CT is relatively non-specific in its promotion of initiated cells within the liver. The objective of this study was to determine how the differing modes of action of these chemicals might interact when given as mixed exposures. The hypothesis was that the effects of two selective promoters would not be more than additive. On the other hand, CT would be selective only to cells not sensitive to its effects as a cytotoxin. Thus, it was hypothesized that neither DCA nor TCA would add significantly to the effects produced by CT. Mice were initiated by vinyl carbamate (VC), and then promoted by DCA, TCA, CT, or the pair-wised combinations of the three compounds. The effect of each treatment or treatment combination on tumor number per animal and mean tumor volume was assessed in each animal. Dose-related increases in mean tumor volume were observed with 20 and 50mg/kg CT, but each produced equal numbers of tumors at 36 weeks. As the dose of CT was increased to >/=100mg/kg substantial increases in the number of tumors per animal were observed, but the mean tumor size decreased. This finding suggests that initiation occurs as doses of CT increase to >/=100mg/kg, perhaps as a result of the inflammatory response that is known to occur with high doses of CT. When administered alone in the drinking water at 0.1, 0.5 and 2g/l, DCA increased both tumor number and tumor size in a dose-related manner. With TCA treatment at 2g/l in drinking water a maximum tumor number was reached by 24 weeks and was maintained until 36 weeks of treatment. DCA treatment did not produce a plateau in tumor number within the experimental period, but the numbers observed at the end of the experimental period were similar to TCA and doses of 50mg/kg CT. The tumor numbers observed at the end of the experiment are consistent with the assumption that the administered dose of the tumor initiator, vinyl carbamate, was the major determinant of tumor number and that treatments with CT, DCA, and TCA primarily affected tumor size. The results with mixtures of these compounds were consistent with the basic hypotheses that the responses to tumor promoters with differing mechanisms are limited to additivity at low effective doses. More complex, mutually inhibitory activity was more often observed between the three compounds. At 24 weeks, DCA produced a decrease in tumor numbers promoted by TCA, but the numbers were not different from TCA alone at 36 weeks. The reason for this result became apparent at 36 weeks of treatment where a dose-related decrease in the size of tumors promoted by TCA resulted from DCA co-administration. On the other hand, the low dose of TCA (0.1g/l) decreased the number of tumors produced by a high dose of DCA (2g/l), but higher doses of TCA (2g/l) produced the same number as observed with DCA alone. DCA inhibited the growth rate of CT-induced tumors (CT dose = 50mg/kg). TCA substantially increased the numbers of tumors observed at early time points when combined with CT, but this was not observed at 36 weeks. The lack of an effect at 36 weeks was attributable to the fact that more than 90% of the livers consisted of tumors and the earlier effect was masked by coalescence of tumors. Thus, the ability of TCA to significantly increase tumor numbers in CT-treated mice was probably real and contrary to our original hypothesis that CT was non-specific in its effects on initiated cells. It is probable that the interaction between CT and TCA is explained through stimulation of the growth of cells with differing phenotypes. These data suggest that the outcome of interactions between the mechanisms of tumor promotion vary based on the characteristics of the initiated cells. The interactions may result in additive or inhibitory effects, but no significant evidence of synergy was observed.

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.

Chemical ablation of endometrium with trichloroacetic acid

OBJECTIVES

The aim of this study was to assess the efficacy of topically applied trichloroacetic acid (TCA) for endometrial ablation in patients with dysfunctional uterine bleeding (DUB). This trial has also compared the advantages of prethinning the endometrium with danazol and goserelin acetate before ablation with TCA.

METHODS

This prospective trial was conducted on 90 volunteer cases. Patients were allocated into three treatment groups comprised of 30 patients. In group I cases underwent dilatation and curettage before endometrial ablation. In group II cases were administered danazol before ablation. Cases in group III received goserelin acetate on the same day and 28 days after ablation. Endometrium was evaluated by biopsy, transvaginal ultrasonography and hysteroscopy. Endometrial ablation was performed with 95% TCA. All of the patients were evaluated 3 and 6 months after TCA application.

RESULTS

After 6 months of treatment, the success rate was recorded as 83% in the first group, 92.3% in the second group and 96.6% in the third group. The mean length of uterine cavity was reduced in all groups, being only significant in Goserelin group (P<0.5). Endometrial thickness was decreased significantly in all treatment groups (P<0.001).

CONCLUSIONS

This study concluded that endometrial ablation by TCA may readily be performed as an alternative treatment method in the management of DUB. Moreover, suppression of endometrium with danazol or especially with goserelin acetate before ablation, resulted in significant success rate.

The induction of oxidative stress and cellular death by the drinking water disinfection by-products, dichloroacetate and trichloroacetate in J774.A1 cells

The in vitro toxicity of the drinking water disinfection by products dichloroacetate (DCA) and trichloroacetate (TCA) were studied using the J774A.1 macrophage cell line. DCA and TCA were added to cell cultures at concentrations ranging between 8-32 mM and incubated for 24, 36 and 60 h. DCA and TCA effects on cellular viability, lactate dehydrogenase (LDH) release and superoxide anion (SA) production by the cells, as well as superoxide dismutase (SOD) activities of the cells were determined. DCA and TCA caused time- and concentration-dependent increases in cellular death, in LDH release and production of SA by the cells. The compounds also caused modulations in SOD activities of the cells, with increases observed at the lower concentrations and/or shorter periods of incubations and suppression with the higher concentrations and/or longer periods of incubation. The results of the study indicate that DCA and TCA induce macrophage activation and that the activation is associated with cellular toxicity. Also, DCA and TCA are found to be equitoxic to J774.A1 cells.

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.

Topical applications of trichloroacetic acid as therapy for nasal allergy

A group of 22 patients (27 nostrils) with nasal allergies was treated with 80 w/v trichloroacetic acid applied to the inferior turbinates. Patients were then evaluated prospectively based on both subjective responses and clinical examinations. Allergic symptoms were reduced significantly, especially those involving nasal obstruction and watery rhinorrhea. Nasal airflow resistance also improved after treatment (P < 0.001). Nasal provocation testing revealed a significant decrease in post-treatment responses (P < 0.001). No severe side effects were noted after treatment. Findings demonstrated that local application of trichloroacetic acid is a safe, effective and simple treatment for outpatients with symptomatic nasal allergies.

Medium-depth chemical peels in the treatment of acne scars in dark-skinned individuals

BACKGROUND

Multiple modalities are available for treating acne scars, one of which is chemical peeling.

OBJECTIVE

To evaluate the efficacy of medium-depth peels in the treatment of acne scars.

METHODS

A total of 15 patients (14 women and 1 man) were seen between November 1998 and March 2000. A medium-depth chemical peel was performed. The peel was performed using a combination of Jessner's solution followed by the application of 35% trichloroacetic acid (TCA). The mean age of patients who entered the study was 28 years. A total of 42 peeling sessions were performed: 13 patients had the full three-session regiment, 1 patient had two sessions, and 1 had only one session.

RESULTS

Patients in our study had two forms of acne scars, the atrophic saucer or crater-like form and the pitted (ice-pick) form. Improvement occurred in all except one of our patients. Significant improvement (greater than 75% clearance of lesions) occurred in 1 patient (6.6%), moderate improvement (51-75% clearance) in 8 patients (53.3%), mild improvement (26-50% clearance) in 4 patients (26.6%), minimal improvement (1-25% clearance) in 1 patient (6.6%), and no response in 1 patient (6.6%). All patients had different combinations of the above two forms. Four patients (26.6%) had mainly pitted scars and deep atrophic scars. The clinical response in those patients was moderate, mild, minimal, and no response, respectively. The remainder of our patients had mainly atrophic scars of moderate depth. Nine patients (73.4%) suffered from transient postinflammatory hyperpigmentation. In two of them it was preceded by erythema that lasted for more than 1 month. All patients were free of noticeable pigmentation 3 months after the final peel. Patients in whom hyperpigmentation did not develop were of light brown complexion.

CONCLUSION

We conclude that medium-depth chemical peel is a safe and effective method of treating acne scars even in patients with dark complexion.

Trichloroethylene, trichloroacetic acid, and dichloroacetic acid: do they affect fetal rat heart development?

Trichloroethylene (TCE), trichloroacetic acid (TCA), and dichloroacetic acid (DCA) are commonly found as groundwater contaminants in many regions of the United States. Cardiac birth defects in children have been associated with TCE, and laboratory studies with rodents report an increased incidence of fetal cardiac malformations resulting from maternal exposures to TCE, TCA, and DCA. The objective of this study was to orally treat pregnant CDR(CD) Sprague-Dawley rats with large bolus doses of either TCE (500 mg/kg), TCA (300 mg/kg), or DCA (300 mg/kg) once per day on days 6 through 15 of gestation to determine the effectiveness of these materials to induce cardiac defects in the fetus. All-trans retinoic acid (RA) dissolved in soybean oil was used as a positive control. Soybean oil is commonly used as a dosing vehicle for RA teratology studies and was also used in this study as a dosing vehicle for TCE. Water was used as the dosing vehicle for TCA and DCA. Fetal hearts were examined on gestation day (GD) 21 by an initial in situ, cardiovascular stereomicroscope examination, and then followed by a microscopic dissection and examination of the formalin-fixed heart. The doses selected for TCA and DCA resulted in a modest decrease in maternal weight gain during gestation (3% to 8%). The fetal weights on GD 21 in the TCA and DCA treatment groups were decreased 8% and 9%, respectively, compared to the water control group and 21% in the RA treatment group compared to soybean oil control group. The heart malformation incidence for fetuses from the TCE-, TCA-, and DCA-treated dams did not differ from control values on a per fetus or per litter basis. The rate of heart malformations, on a per fetus basis, ranged from 3% to 5% for TCE, TCA, and DCA treatment groups compared to 6.5% and 2.9% for soybean oil and water control groups. The RA treatment group was significantly higher with 33% of the fetuses displaying heart defects. For TCE, TCA, and DCA treatment groups 42% to 60% of the litters contained at least one fetus with a heart malformation, compared to 52% and 37% of the litters in the soybean oil and water control groups. For the RA treatment group, 11 of 12 litters contained at least one fetus with a heart malformation. Further research is needed to quantify the spontaneous rates of heart defects for vehicle control rats and to explain the disparity between findings in the present study and other reported findings on the fetal cardiac teratogenicity of TCE, TCA, and DCA.

The effect of dichloroacetic acid and trichloroacetic acid on DNA methylation and cell proliferation in B6C3F1 mice

The chlorine disinfection by-products, dichloroacetic acid (DCA) and trichloroacetic acid (TCA), are carcinogenic in mouse liver. We have previously reported that DCA and TCA induced DNA hypomethylation in mouse liver. In the present study, we determined the temporal association for DNA hypomethylation and cell proliferation. Female B6C3F1 mice were administered daily doses of 500 mg/kg DCA or TCA by gavage and sacrificed at 24, 36, 48, 72, and 96 hours after the first dose. The proliferating cell nuclear antigen-labeling index in the liver was increased at 72 and 96 hours by both DCA and TCA, that is, at 72 hours the index was 1.00 +/- 0.21, 0.51 +/- 0.11, and 0.095 +/- 0.016 for DCA, TCA, and the vehicle control, respectively. The mitotic index was also significantly increased at 96 hours. The promoter region for the c-myc gene was hypomethylated only at 72 and 96 hours and not at the earlier sacrifices. Similarly, the methylation of the c-myc gene in the kidney and urinary bladder was decreased only at 72 and 96 hours. In summary, enhancement of cell proliferation and decreased methylation of the c-myc gene were first observed simultaneously at 72 hours after the start of exposure. Thus, the results support the hypothesis that DCA and TCA induce DNA hypomethylation by inducing DNA replication and preventing the methylation of the newly synthesized strands of DNA.

Medium-depth chemical peels

The combination medium-depth chemical peel (Jessner's solution +35% TCA) has been accepted as a safe, reliable, and effective method for the treatment of moderate photoaging skin. This article discusses the procedure in detail, including postoperative considerations.

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.

Chemical peel of nonfacial skin using glycolic acid gel augmented with TCA and neutralized based on visual staging

BACKGROUND

Until recently, standard techniques for laser or chemical peeling have not always provided consistent results when applied to the nonfacial skin.

OBJECTIVE

The author describes a more controlled chemical peel technique for nonfacial skin using 70% glycolic acid gel combined with 40% trichloroacetic acid (TCA). The method has given consistently good results on the skin of the neck, chest, arms, hands, back, and other nonfacial skin.

METHODS

More than 3100 patients were given skin peels of the neck, chest, and other areas of the body as indicated. Seventy percent glycolic acid gel was applied to the areas to be peeled, then immediately augmented with 40% TCA. Each area was carefully monitored for the end point and then neutralized with copious amounts of 10% sodium bicarbonate solution. The end point was determined by visual observation using a six-stage classification to determine the degree of peeling.

RESULTS

Clinical results were excellent, with smoother skin texture, decreased wrinkling and striae, and fading of lentigines and other pigmentary abnormalities. There was excellent blending into peeled facial skin and into adjacent areas of nonpeeled skin. Complications were minimal.

CONCLUSION

This technique can provide the benefits of skin peeling to nonfacial skin with excellent cosmetic results and minimal complications.

Hypomethylation and overexpression of c-jun and c-myc protooncogenes and increased DNA methyltransferase activity in dichloroacetic and trichloroacetic acid-promoted mouse liver tumors

Dichloroacetic acid (DCA) and trichloroacetic acid (TCA) are mouse liver carcinogens. Methylation of the c-jun and c-myc genes, expression of both genes and DNA methyltransferase (DNA MTase) activity were determined in liver tumors initiated by N-methyl-N-nitrosourea and promoted by DCA and TCA in female B6C3F1 mice. Hypomethylated and over-expression of c-jun and c-myc genes were found in DCA- and TCA-promoted liver tumors. DNA MTase activity was increased in tumors while decreased in non-involved liver. Thus, DCA- and TCA-promoted carcinogenesis appears to include decreased methylation and increased expression of c-jun and c-myc genes in the presence of increased DNA MTase activity.

In vivo kinetics of trichloroacetate in male Fischer 344 rats

Trichloroacetate (TCA) is a toxicologically important metabolite of the industrial solvents trichloroethylene and tetrachloroethylene, and a by-product of the chlorination of drinking water. Tissue disposition and elimination of 14C-TCA were investigated in male Fischer 344 rats injected iv with 6.1, 61, or 306 micromol TCA/kg body weight. Blood and tissues were collected at various time points up to 24 h. No metabolites were observed in plasma, urine, or tissue extracts. Overall TCA kinetics in tissues were similar at all doses. Based on similar terminal elimination rate constants, tissues could be divided into three classes: plasma, RBC, muscle, and fat; kidney and skin; and liver, small intestine, and large intestine. Nonextractable radiolabel, assumed to be biologically incorporated metabolites in both liver and plasma, increased with time, peaking at 6-9 h postinjection. The fraction of the initial dose excreted in the urine at 24 h increased from 67% to 84% as the dose increased, whereas fecal excretion decreased from 7% to 4%. The cumulative elimination of TCA as CO2 at 24 h decreased from 12% to 8% of the total dose. Two important kinetic processes were identified: a) hepatic intracellular concentrations of TCA were significantly greater than free plasma concentrations, indicating concentrative transport at the hepatic sinusoidal plasma membrane, and b) TCA appears to be reabsorbed from urine postfiltration at the glomerulus, either in the renal tubules or in the bladder. These processes have an impact on the effective tissue dosimetry in liver and kidney and may play an important role in TCA toxicity.

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.

Effect of pre-treatment with dichloroacetic or trichloroacetic acid in drinking water on the pharmacokinetics of a subsequent challenge dose in B6C3F1 mice

Dichloroacetate (DCA) and trichloroacetate (TCA) are prominent by-products of chlorination of drinking water. Both chemicals have been shown to be hepatic carcinogens in mice. Prior work has demonstrated that DCA inhibits its own metabolism in rats and humans. This study focuses on the effect of prior administration of DCA or TCA in drinking water on the pharmacokinetics of a subsequent challenge dose of DCA or TCA in male B6C3F1 mice. Mice were provided with DCA or TCA in their drinking water at 2 g/l for 14 days and then challenged with a 100 mg/kg i.v. (non-labeled) or gavage (14C-labeled) dose of DCA or TCA. The challenge dose was administered after 16 h fasting and removal of the haloacetate pre-treatment. The haloacetate blood concentration-time profile and the disposition of 14C were characterized and compared with controls. The effect of pre-treatment on the in vitro metabolism of DCA in hepatic S9 was also evaluated. Pre-treatment with DCA caused a significant increase in the blood concentration-time profiles of the challenge dose of DCA. No effect on the blood concentration-time profile of DCA was observed after pre-treatment with TCA. Pre-treatment with TCA had no effect on subsequent doses of DCA. Pre-treatment with DCA did not have a significant effect on the formation of 14CO2 from radiolabeled DCA. In vitro experiments with liver S9 from DCA-pre-treated mice demonstrated that DCA inhibits it own metabolism. These results indicate that DCA metabolism in mice is also susceptible to inhibition by prior treatment with DCA, however the impact on clearance is less marked in mice than in F344 rats. In contrast, the metabolism and pharmacokinetics of TCA is not affected by pre-treatment with either DCA or TCA.