Localized TCA peel for static facial wrinkle: case series

Submitted on: 02/02/2023
Approved on: 21/02/2023
Financial support: None.
Conflict of interest: None.
How to cite this article: Scabora R, Cunha MG, Machado Filho CDS. Localized TCA peel for static facial wrinkle: case series. Surg Cosmet Dermatol. 2023;15:e20230221.

Abstract

Since antiquity, chemical peelings are still widely used to treat skin aging. There are a variety of substances, techniques, and considerations for each type of peeling. However, this case series aims to present a non-described form of application of trichloroacetic acid (TCA) and retinoic acid to treat fine static wrinkles on the face. The technique consists of applying the TCA peeling directly to the facial rhytids and, subsequently, retinoic acid peeling all over the face for 6 hours.

Keywords: Chemexfoliation; Trichloroacetic acid; Skin aging; Chemical abrasion

INTRODUCTION

The skin aging process occurs through two mechanisms: chronological and extrinsic aging. While the first refers to the natural and chronological skin senescence, with the appearance of fine static wrinkles, xerosis, and cutaneous atrophy, the second is associated with accelerated aging mainly due to photodamage caused by chronic exposure to ultraviolet radiation (UV) and is marked by the accentuation of deep dynamic wrinkles, skin neoplasms, and actinic melanosis in photoexposed skin. Although each group is studied alone, the skin aging process occurs through the simultaneous action of both mechanisms.^1,2,3,4

Chemical peels are a way to treat skin aging, based on a layered effect, resulting in desquamation at various depths with a positive cosmetic result on the skin. They correspond to a practical and accessible tool in the daily routine of the dermatologist. However, they are not exempt from risks, such as post-inflammatory hyperpigmentation, discomfort, and changes in scarring.^2,4,5,6

Peeling is superficial when it causes an effect restricted to the epidermis; medium, when it acts up to the papillary dermis; and deep, when it reaches the reticular dermis.^2,4,5,6 This selective effect depends on factors such as skin condition and preparation, application technique, the substance used, and, mainly, the number of layers applied. Trichloroacetic acid (TCA) 30-50%, for example, is generally considered a medium peel when applied in a single layer. Despite so many variables, the quality of the frost generated by the TCA peel allows clinical inferences on the depth of action of the procedure.^2,5

The intracellular action of retinoic acid results in multiple positive effects on the skin.⁴ It promotes dermal deposition of collagen and glycosaminoglycans, regularizes epidermal keratinization, and favors melanin dispersion. It is a superficial peel and its effect may also depend on how long the product remains on the skin.^4,6,7

This case series aims to report the localized application of the 30% TCA peel combined with the 5% retinoic acid peel on the entire face as a treatment option for static fine facial wrinkles.

CASE REPORT

We treated four patients, aged between 50 and 84 years, with skin phototypes II to IV and complaints of facial wrinkles related to skin aging, consisting specifically of fine static rhytids, in addition to deep dynamic rhytids, located mainly in the frontal, periorbital, perioral, mental, and masseteric regions. Also, other signs of skin senescence were present, such as atrophy, xerosis, actinic melanosis, and sagging.

Patients were photographed before treatment and 30 days after completion. The treatment consisted of daily use of 0.025% retinoic acid creams, moisturizer with ceramides, and SPF 30 sunscreen, associated with 10 mg of lutein orally for skin preparation. After 30 days, we performed the first session of the combination of chemical peels.

Initially, we cleaned the entire face of the patients using cotton with 70% alcohol. Then, TCA 30% in alcoholic solution was applied only to the facial rhytids, both fine and deep, using a needle and fine cotton in several layers until the formation of pearly white frost and local erythema. After that, 5% retinoic acid cream was applied all over the face and kept for six hours (Figure 1).

The subjective analysis of the pre and post-treatment photographs taken by the applicator and by an evaluator revealed the attenuation of fine and deep wrinkles on the face, in addition to the expected improvement in other signs of skin aging (Figure 2). Patients reported adverse events of skin peeling for approximately three days over the entire face and more intense and lasting in the places of TCA application (about five days). However, they considered it tolerable and without sequelae. We performed three sessions with intervals of 30 days between them.

DISCUSSION

Chemical peels are an essential tool to treat skin aging. However, to achieve the desired result, it is necessary to understand and master the depth of action of this procedure. Thus, it is fundamental to know how to combine the different factors involved in this act to maximize the cosmetic effect and minimize the risks inherent to the procedure. Phototype, skin preparation, application technique, daily care, and photoprotection are essential for an adequate outcome.^2,5,6

The daily use of moisturizers and retinoic acid beforehand is crucial to even out the skin. It happens through different mechanisms: reduction of the stratum corneum thickness; normalization of epidermal keratinization; increased melanin dispersion; and stimulation of dermal deposition of collagen fibers.^4,6 This process results in a more regular absorption of the peeling and an additive effect, both epidermal and dermal. Also, oral antioxidants, such as lutein, associated with daily photoprotection helped minimize the risk of post-inflammatory hyperpigmentation, not rarely associated with TCA peel, especially in higher phototypes.^2,5,6

TCA peel has been indicated to treat fine wrinkles on the face for years. It has a dermal effect through an inflammatory response that promotes subepidermal collagen deposition and elastic fiber reorganization.^2,5,6,7,8 This peeling is classically applied throughout the anatomical region to be treated. However, pain, discomfort, longer recovery time, risks of post-inflammatory hyperpigmentation, and unsightly scarring sometimes reduce the number of patients willing to undergo this treatment, especially in cases of localized facial wrinkles.^3,7,8 Due to these factors, this case series considered the localized application of TCA 30% directly on the wrinkles of previously prepared skin, combined with subsequent 5% retinoic acid peel all over the face, to treat fine facial rhytids and improve the skin's general appearance.

Technically, 30% TCA peel in fine facial wrinkles treatment aims to form a pearly white frost with mild local erythema. It suggests an extension of involvement to the papillary dermis, which is desired in this case.² This clinical evaluation is essential, as it minimizes excessive, exaggerated, or insufficient attitudes regarding the application technique, which, together with all other skincare considered, favors a more precise and safe procedure, with less risk of adverse events and unwanted results.^2,5,6 Despite this consideration, it is the localized application of TCA that should be highlighted, in the opinion of the authors, as it promotes a new way of approaching and treating static fine facial wrinkles with less risk of unwanted depigmentation and discomfort, whether due to the use of a smaller quantity of the product, or due to the smaller area manipulated with TCA, which also makes the procedure more practical, safe, and effective for the patient.

The finalization with retinoic acid peeling all over the face also aims to reduce other signs of skin aging, in addition to the rhytids, accelerate the epidermal renewal process, and prepare the skin for subsequent sessions.

CONCLUSION

Chemical peels have historically been a helpful tool to treat skin aging. The TCA peel, thus, is classically used to treat fine static facial wrinkles. However, patient discomfort and the possibility of complications such as post-inflammatory hyperpigmentation and unsightly scarring may hinder the use of this tool. Therefore, a new way of applying the substance, locally, only in facial wrinkles, can collaborate to minimize risks and maximize the procedure efficiency.

AUTHORS' CONTRIBUTION:

Rodrigo Scabora
ORCID: 0000-0002-3153-3980
Statistical analysis; approval of the final version of the manuscript; study design and planning; preparation and writing of the manuscript; obtaining, analyzing and interpreting data; effective participation in research guidance; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases; critical review of the literature; critical review of the manuscript.
Marisa Gonzaga da Cunha
ORCID: 0000-0002-4186-0643
Statistical analysis; approval of the final version of the manuscript; study design and planning; preparation and writing of the manuscript; obtaining, analyzing and interpreting data; effective participation in research guidance; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases; critical review of the literature; critical review of the manuscript.
Carlos D'Apparecida Santos Machado Filho
ORCID: 000-0003-4362-1563
Statistical analysis; approval of the final version of the manuscript; study design and planning; preparation and writing of the manuscript; obtaining, analyzing and interpreting data; effective participation in research guidance; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases; critical review of the literature; critical review of the manuscript.

REFERENCES:

1. Kammeyer A, Luiten RM. Oxidation events and skin aging. Ageing Res Rev. 2015;21:16-29.

2. Sitohang IB, Legiawati L, Suseno LS, Safira FD. Trichloroacetic acid peeling for treating photoaging: a systematic review. Dermatol Res Pract. 2021:3085670.

3. Baumann L. Skin ageing and its treatment. J Pathol. 2007;211(2):241-51.

4. Sumita JM, Leonardi GR, Bagatin E. Tretinoin peel: a critical view. An Bras Dermatol. 2017;92(3):363-6.

5. Soleymani T, Lanoue J, Rahman Z. A practical approach to chemical peels: a review of fundamentals and step-by-step algorithmic protocol for treatment. J Clin Aesthet Dermatol. 2018;11(8):21-8.

6. Truchuelo M, Cerdá P, Fernández LF. Chemical peeling: a useful tool in the office. Actas Dermosifiliogr. 2017;108(4):315-22.

7. Lee KC, Wambier CG, Soon SL, Sterling JB, Landau M, Rullan P, International Peeling Society, et al. Basic chemical peeling: superficial and medium-depth peels. J Am Acad Dermatol. 2019;81(2):313-24.

8. Kadhim KA, Al-Waiz M. Treatment of periorbital wrinkles by repeated medium-depth chemical peels in dark-skinned individuals. J Cosmet Dermatol. 2005;4(1):18-22.