Sách Giáo Khoa Về Lột Da Hóa Học (Chemical Peels – Ấn Bản 2)

92      Textbook of Chemical Peels
active inflammation. Lasers, intense pulsed light (IPL), derm-
abrasion, and microdermabrasion also have been suggested
but often cause postinflammatory hyperpigmentation (PIH).
TCA can be an excellent treatment for melasma as it elimi-
nates the melanin stored in the papillary dermis and epider-
mis (Figure 13.8). Mesotherapy has been recently reputed as an
effective treatment of melasma.8
If the melanin responsible for the melasma is too deep,
TCA will only be effective after many repeated sessions. In any
event, the TCA peel must be combined with effective sun pro-
tection and appropriate postpeel care in the long term. Simple
aqueous solutions of TCA also require the skin to be prepared,
to even out penetration and prevent common pigmentary
changes.
See Chapter 16 for the protocol for treating melasma.
Postinflammatory Hyperpigmentation
and Berloque Dermatitis
PIH (Figure 13.9) and berloque dermatitis9 usually respond well
to TCA; they can be treated in the same way as melasma but
have a better prognosis as the original trauma disappears after
treatment, unlike melasma, which often persists or recurs.
Freckles
Freckles (Figure 13.10) are small, clearly delimited, benign pig-
mented macules that appear on areas of sun-exposed skin in
patients with a light skin phototype. They are never present at
birth but can start to appear from the age of 3 years, and there is
an autosomal dominant pattern of genetic transmission. They
result from melanocyte hypertrophy, although not from an
increase in melanocyte numbers. In the basal and suprabasal
layers, more melanin is synthesized and transferred between
the melanocytes and keratinocytes. This increased mela-
nin synthesis could result from melanocyte clones that have
mutated following UV exposure. The structure of the epider-
mis remains normal, apart from the parabasal keratinocytes,
Figure 13.6  Early photoaging: treatment of rosacea on the cheeks with a radiofrequency device (Ellman) and four applications of Easy
TCA (basic protocol). Daily care: Vit. E Anti-oxydant cream.
Figure 13.7  Melasma on the forehead: centrofacial. Other kinds
of melasma include malar and mandibular.
Table 13.1  Types of Melasma
Purely epidermal
There is a lot of melanin in the basal and
suprabasal layers of the epidermis. It is
occasionally found throughout the
epidermis. A Wood’s light5 increases the
contrast between the melasma and
normal skin. This is the most common
type of melasma.
Dermal
Melanin accumulates in the macrophages
of the papillary and/or reticular dermis.
A Wood’s light does not increase the
contrast.
Mixed
epidermal–dermal
Wood’s light accentuates the contrast in
some areas and not in others, but an
“epidermal” area can hide an “underlying
dermal” area.

TRICHLOROACETIC ACID: INDICATIONS AND CONTRAINDICATIONS      93
which contain more melanin in relation to the neighboring
unpigmented cells.
A peel to the basal layer lightens the freckles, sometimes
only temporarily. A peel to the Grenz zone removes many
freckles and lightens others. A peel to the papillary or reticular
dermis eliminates freckles altogether (Figure 13.11).
Easy TCA, Easy TCA PC, Unideep (TCA), and Lip & Eyelid
(phenol) can all be used as treatments for freckles, although phe-
nol will generally not be used as the TCA can eliminate them
by itself. Other treatments have been suggested. As freckles
(d)
(c)
(b)
(a)
Figure 13.8  Melasma on the forehead in a patient with skin phototype VI: (a) The condition before peeling. (b) Results of the following
treatment: two sessions of Easy TCA to the Grenz zone, combined with Blending Bleaching Cream. As the results were unsatisfactory,
the practitioner decided to use a deeper treatment. After two Easy TCA peels, the patient was given two Unideep peels to the papillary
dermis, (c) still combined with Blending Bleaching Cream and Melablock 50+. The peel to the papillary dermis was applied locally to the
most resistant parts of the melasma. (d) End result.
Figure 13.10  Freckles.
Figure 13.9  Postinflammatory hyperpigmentation after a road
accident (see Chapter 5).

94      Textbook of Chemical Peels
grow darker on exposure to UV rays, using a sunscreen helps to
lighten them. Tyrosinase inhibitors, antioxidants, and tretinoin
and its precursors can be used in conjunction with the peels to
improve or prolong results.
Postacne Scarring
TCA has some effect on shallow scars but can only improve
the general condition of the skin and cannot eliminate scars
altogether. TCA can be combined with sandpaper abrasion (see
the discussion of abrasive peels in Chapter 15) or scar subcision
before the acid is applied. Even a phenol peel cannot always
guarantee to heal acne scars. High concentrations of TCA can
be directly applied on acne scars, levelly, with good results.
Dilated Pores
Although it has been claimed that TCA has a circular contrac-
tion effect that narrows the follicle opening, it appears that it
has a limited effect on dilated pores, or, at best, the results are
difficult to predict. Patients should never be promised visible
results for dilated pores. Any results should be considered a
bonus and not taken for granted. Using an abrasive technique
before applying Easy TCA may give promising results, but
this remains to be confirmed with more experience. High-
concentration TCA can successfully treat dilated pores or pike
acne scars.
Seborrheic Dermatitis
Seborrheic dermatitis is a chronic dermatologic problem, often
needing lifelong treatment. Flares of seborrheic dermatitis can
be treated by corticoids cream that will soften the immuno-
logic inflammatory reaction. A long-term treatment should be
applied; the illness needs a permanent care. Seborrheic derma-
titis could improve after chemical peels but also could risk local
infection. Recommendations are to pretreat seborrheic dermati-
tis before applying a chemical peeling.
Widespread Flat Warts
Flat warts are localized skin-colored papules that primarily
appear on the back of the hands, the forearms, and the face.
Clinically visible flat warts do not respond to moderate con-
centrations of TCA (10%–30%), and higher concentrations
(40%–50% m/m) often produce only temporary or incomplete
results. Figure 13.12 shows how flat warts on the back of the
hand reacted to a combined treatment of Only Touch and Easy
TCA. Smaller flat warts can disappear completely, as can sub-
clinical flat warts. Medium-size warts will come back, and they
will sometimes need shaving with a radiofrequency scalpel
(Ellman), for example. Not only are larger warts impermeable
to TCA, but also their very size prevents the TCA from getting
around them to “undermine” and treat them from underneath
(Figure 13.13). They should be treated by shave excision at the
same time as the others are being treated with a peel.
Sensitive Skin
Abnormal skin sensitivity is a clear sign of dysfunction of the
skin’s protective properties against a hostile environment.
Sensitive skin should be treated until its tolerance to exter-
nal aggression returns to normal. Many products cause skin
allergies that are not always easy to identify because they may
manifest as “overreactive” or “oversensitive skin.” In the case of
allergy, it is best to avoid using too many cosmetic products and
stick to a few well-tolerated creams.
Actinic Keratoses
The treatment of actinic keratoses, like photoaging, is a com-
mon indication for chemical peels (Figure  13.14). The chemi-
cal elimination of actinic keratoses reduces the incidence of
basocellular and/or spinocellular cancers.10
Other localized treatments (e.g., cryotherapy or laser) could
also be suggested, but they are only applied to visible lesions
(a)
(b)
Figure 13.11  Freckles before (a) and after (b) a peel to the papil-
lary dermis (Unideep). A peel to the papillary dermis improves the
quality of the skin, removes the freckles, and improves the fine
lines, but does not treat wrinkles.
Figure 13.12  Appearance of the hand after two sessions of Only
Touch and three sessions of Easy TCA (for further details, see
Chapter 15). The flat warts have disappeared. Note that the flat
wart treated with radiofrequency is still healing. The fine visible
flaking all over the hand comes from an Easy TCA peel applied to
even out the Only Touch and treat the subclinical lesions.

TRICHLOROACETIC ACID: INDICATIONS AND CONTRAINDICATIONS      95
and  leave clinically undetectable microlesions to develop. A
chemical peel, on the other hand, will treat all lesions, both vis-
ible and subclinical ones, and will improve long-term progno-
sis. In comparisons between TCA peels to the papillary dermis
and the application of a 5-fluorouracil (5-FU) cream, the peels
fare better, as applying 5-FU gradually causes severe and rather
nasty-looking dermatitis (Figure 13.15). Patients and friends can
find the long, drawn-out treatment difficult to bear. A medium-
depth TCA peel, on the other hand, is generally a one-time treat-
ment (or a few sessions at most).
Oncological Indications
As Vergereau and colleagues11 remind us, after a biopsy to con-
firm the diagnosis and depth of a lesion, TCA is indicated in the
treatment of primitive malignant intraepidermal and intrader-
mal tumors (depending on the depth of action of the TCA: TCA
has to act deep enough). Keratoses that have developed into
Figure 13.15  Appearance of keratoses during treatment with
5-FU.
Figure 13.14  Keratoses: peel solutions penetrate the keratoses
slowly. This photograph shows the slow penetration of phenol
through keratoses during a full-face peel.
(b)
(a)
Figure 13.13  (a) Multiple flat warts. (b) Localized frosting of the flat warts after multiple applications of Only Touch. Note that the thicker
dome of the flat warts is impermeable even to concentrated TCA. The wart in the middle is too thick, and should be shaved with (Ellman)
radiofrequency.

96      Textbook of Chemical Peels
microinvasive spinocellular or basocellular carcinomas can be
treated with deep TCA peel without leaving any scars: Only
Touch easily reaches the reticular dermis. Nondegenerated len-
tigo maligna (Hutchinson’s freckle or Dubreuilh’s melanosis) is
also given as a potential indication for TCA, although phenol is
no doubt more effective.
Acne
All common types of acne can be treated with TCA. Severe
acne, such as acne necrotica, acne conglobata, or acne fulmi-
nans, should first be treated medically and the inflammation
eliminated before the cosmetic use of peels. Oral isotretinoin
(13-cis-retinoic acid) is the gold-standard treatment for severe
acne (Box 13.1), but new retinoids come to light regularly.
A combination of techniques proves worthwhile. Acne
responds well to a TCA peel to the basal layer or the Grenz
zone, whether it is comedonal, microcystic (Figure  13.16),
papular, or papulopustular. Deeper peels, to the papillary
dermis, should not be used when acne is still active, because
of the increased risk of infection (see Chapter 37). The num-
ber of open or closed comedones can be expected to decrease
after several TCA peels. The Easy TCA technique allows com-
edones and microcysts to be opened immediately before the
peel, which gives faster and better results. Seborrhea is often
reduced after TCA peels, and seborrheic dermatitis improves
significantly (although only temporarily). Acne improves
more quickly when treated with Easy TCA than it does when
treated with tretinoin, benzoyl peroxide11 creams, glycolic or
azelaic acid creams, or “purifying” creams used alone. These
creams do, however, play an important part in the postpeel
treatment of acne. Pigmented acne scars usually respond
well to TCA. Shallow scars gradually soften. Ice-pick scars
do not respond at all to TCA. A combination of sandpaper
abrasion followed by Easy TCA—a technique similar to the
one described later in this chapter for the treatment of stretch
marks—can significantly improve postacne scarring, even on
the back.
Xanthelasma
Eyelid xanthelasma has been presented as a good indication for
TCA and dichloroacetic acid. Nevertheless, the high concentra-
tions required make it relatively dangerous compared with the
“chemical blepharoplasty” technique using phenol, which is
more effective and easier to control than highly concentrated
TCA.
It must be remembered that xanthelasma is associated
with dyslipidemia in 50% of cases. It can also be symptomatic
of hepatobiliary disorders (biliary atresia and biliary cirrhosis)
when associated with cholesterol deposits that start to build up
in the hands and feet before spreading. Monoclonal gammapa-
thies have also been described in association with xanthelasma.
A local deep phenol peel (Lip & Eyelid Formula) is, on the con-
trary, a good treatment for xanthelasma.
Stretch Marks
Countless suggestions have been made for the treatment of
stretch marks, but none of them have been truly effective.
Some techniques are not deep enough and others not exten-
sive enough. Superficial, intraepidermal, basal, Grenz zone,
and papillary techniques can only improve the appearance of
stretch marks temporarily but cannot reduce their size or depth.
Some peels have been developed to give the atrophic base of the
stretch marks a similar color to that of the surrounding skin;
they contain resorcinol, which is oxidized to match the normal
skin color. The results of these peels are good, but only tempo-
rary. Deep techniques, limited to the deepest part of the stretch
marks, can do no more than tighten the little collagen that is left
and slightly stimulate the few surviving fibroblasts. In spite of
the fact that these localized treatments reach the deepest part
of the stretch marks, the results are always disappointing. That
is why the author developed a technique for treating stretch
marks consisting of sandpaper abrasion followed by Easy
TCA peel solution and postpeel cream. The excellent results
achieved with this method are due to the fact that the atrophic
base of the stretch marks contracts at the same time that the
cells on the edge of the stretch marks are being stimulated. The
results seem to be permanent. See the description of this tech-
nique in Chapter 15.
Even if the results are less dramatic compared to the che-
moabrasive technique, the “pixel peel” technique also can be
BOX 13.1  Isotretinoin for Acne
• Tablets dosed at 10 mg or 20 mg
• Total cumulative dose 120 mg/kg
• Daily dose 0.3–0.5 mg/kg
For example, for a patient whose weight is 70 kg, the
total cumulative dose is 8400 mg.
• Daily dose of 0.3 mg/kg = 21 mg/day
•
Accumulated dose for a month: 600 mg
•
Total duration of treatment
•
8400/600 = 14 months
• Daily dose of 0.5 mg/kg = 35 mg/day
•
Accumulated dose for a month: 1050 mg
•
Total duration of treatment
•
8400/1050 = 8 months
Figure 13.16  TCA will reduce the number of lesions and the
inflammation of this type of microcystic acne. Opening the micro-
cysts with a No. 11 scalpel blade or a needle and removing the
blackheads with a comedone extractor immediately before apply-
ing Easy TCA will produce faster and better results.

TRICHLOROACETIC ACID: INDICATIONS AND CONTRAINDICATIONS      97
used for stretch mark treatment (see Chapter 38 for details).
Some advantages of this techniques are that it is much less
aggressive than chemoabrasion and can be used for darker
phototypes: A microneedling is used for multiperforating the
skin immediately before applying an Easy TCA peel. Needles
should be 1–2.5 mm long and induce bleeding. The author uses
AD Roll TD, a CE-certified sterile medical device produced by
Aesthetic Dermal SL (Spain). The patented device includes a
600-needle roller and a 12-needle stamp that is embedded in
the handpiece.
Other Indications
These include alopecia areata, liposuction scars, neurogenic
excoriations, and rosacea. TCA has often been used to treat vit-
iligo but without success.
GENERAL CONTRAINDICATIONS FOR TCA
•
General rundown condition.
•
Epidermolysis or dermolysis bullosa.
•
Active bacterial, mycotic, or viral skin infections.
•
Depression or personality disorder.
•
Tendency to scratch.
•
IQ insufficient to understand the events surrounding the
application of the peel solution.
•
Expectations of miraculous and life-changing results.
•
Refusal to make follow-up visits.
•
Severe progressive neoplasic disorders.
•
Immunodeficiency.
•
Insulin-dependent diabetes, depending on the depth of
the peel and the risk of infection. Type 2 diabetes is not
a contraindication for peels. Patients with stable insulin-
dependent diabetes can be given a peel to the Grenz zone.
•
Prior treatment with isotretinoin, if the peel is to the Grenz
zone.
•
Ehlers–Danlos syndrome, keloid scars, if the peel is to the
papillary dermis.
•
Extensive telangiectasias; these should be treated before
peeling.
NOTES

1. Easy TCA in the basic protocol.

2. For more details, see Chapter 1.

3. A mesolift is a mesotherapy technique that involves injecting
various products into the dermis: hyaluronic acid, vitamins,
trace elements, DMAE, polylactic acid, etc.

4. In South Asian, Southeast Asian, or Middle Eastern patients,
melasma can appear before the age of 10, while it is rarely seen in
Caucasian patients before puberty.

5. It is not possible to do a Wood’s light examination on very dark
skin types.

6. To date, however, it has not been possible to reproduce the
melasma by applying these cosmetics intentionally.

7. The mask of pregnancy tends to lighten naturally and even dis-
appear in patients with a light phototype unless they are taking
estrogens and progestogens, which can cause the mask of preg-
nancy to persist.

8. See

9. Berloque dermatitis is an acquired hypermelanosis resulting
from contact photodermatitis caused by a sensitizing agent (per-
fume or metal in jewelry). Berloque, or berlock, dermatitis gets
its (misspelled) name from the French word breloque, meaning a
trinket or charm that is attached to a bracelet. These charms are
often of poor quality and cause contact allergies in the shape of
the trinket itself.
10. McCollough EG, Langsdon PR, Maloney BP. Chemical Peel
with Phenol. In: Roenigk RK, Roenigk HH (Eds.). Dermatologic
Surgery, Principles and Practice. 2nd ed. Oxford: Marcel Dekker,
1996: 1147–60.
11. Vergereau R, Trauchessec JM, Peyronnet B. Le new peel. Journal
de Médecine Esthétique et de Chirurgie Dermatologique. 1990, XXII
(68): 243–55.

14
Trichloroacetic acid
Classic semiology
PREPARING THE SKIN
Prepeel care is discussed in Chapter 2, and additional informa-
tion can be found in Chapter 12. The safety of peels employing
trichloroacetic acid in simple aqueous solution (TCA-SAS) has
been greatly improved by systematic preparation of the skin
before peeling. Preparing the skin helps improve microcir-
culation, increase glycosaminoglycan synthesis, increase the
number of mitoses in the basal layer keratinocytes, stimulate
production of epidermal growth factors, deactivate melano-
cytes, and even out and deepen the effect of the TCA.
One month before a peel with TCA-SAS (Soft Peel), the
patient should apply a cream consisting of hydroquinone (4 g),
micronized hydrocortisone acetate (0.5 g), paraffin oil (16 g) or
emulsifier based on polyglycol stearate (21.5 g), and excipient
qs 100 g, twice a day. Tretinoin is then mixed into this cream in
gradually increasing quantities. The concentration of tretinoin
is increased every week to reach a final concentration of 0.3%.1
Dermatitis develops due to the tretinoin: irritation with flaking
and redness signals that the skin has been properly prepared
and guarantees a successful peel. However, the need to use a
technique to enhance and even out penetration of the TCA–SAS
proves that the action of TCA–SAS is uneven and inadequate.
The need to apply hydroquinone twice a day at a concentra-
tion of 4% as a preventive shows how aggressive the peel is
to the skin and how it triggers postinflammatory pigmentary
changes. In short, the introduction of skin preparation before
a TCA–SAS peel and adding adjuvants greatly improves safety
and is still essential to compensate for the inadequate and
uneven penetration of this type of peel, as well as to reduce the
risk of complications, especially pigmentary changes.
It is interesting to note that the first time the author
presented Easy TCA at a congress of the Belgian Society of
Cosmetic Medicine in Brussels in 1997, there was an outcry. The
peel was shouted down, demonized, and criticized even before
it was presented, as it flew in the face of the all too recent dogma
of aggressive skin preparation that then held sway. Anyone
tempted to use it was told that their worst nightmares would
come true if they did not prepare the skin beforehand. It was
soon proved that the Easy TCA2 technique is valid and that,
apart from specific cases such as the treatment of stretch marks
or resistant melasma, this peel does not require any skin prepa-
ration. The doomsayers gradually fell silent, and the sworn
enemies of Easy TCA started to talk about the relative merits
of preparation and eventually the pointlessness of preparing
the skin in many cases. Preparing the skin is now considered as
an additional tool for many peels. It is an optional step in some
cases but remains essential when using TCA–SAS.
Treatment with oral isotretinoin is essential in some
cases of severe acne but is contraindicated before a peel to the
papillary dermis. An Easy TCA peel to the basal layer,3 on the
other hand, can be performed without any risk of complications
and can produce excellent results for severe acne that has been
treated beforehand with oral isotretinoin.
APPLICATION OF TCA–SAS
It is easy to summarize the application of TCA-SAS.
Day –30 to Day 0
Prepeel preparation (see also Chapter 2) involves the following:
•
Deactivation of melanocytes.
•
Thinning and evening out of the stratum corneum.
•
Stimulation of keratinocyte regeneration.
•
Botulinum toxin, coagulation of telangiectasias, excision of
benign tumors, cleaning the skin, and so forth.
•
Obtaining photographs, informed consent, and other legal
documents.
Day 0
This day involves the taking of photographs, settling in, disin-
fection, and degreasing. The patient is photographed from five
angles, with and without flash (see Chapter 34). The patient is
placed in the dorsal supine position; good lighting is needed to
monitor the skin and any changes in skin tone. The skin is dis-
infected with a sterile swab soaked in alcohol, and degreased
with a sterile swab soaked in acetone. Good ventilation must
be ensured so that the patient does not inhale the alcohol or
acetone fumes.
Local Anesthetic
Local anesthetic is never needed when TCA is used to treat
the epidermis to the Grenz zone. It may be necessary when the
TCA reaches the papillary or reticular dermis.
Applying the TCA–SAS
TCA–SAS can be applied with any type of applicator.
Effect of the Type of Applicator
A rough-textured applicator (sterile gauze) abrades the skin,
causing surface injury as it deposits the acid on the skin. This
helps the TCA penetrate more deeply.
Effect of Pressure of Application
The pressure of application also plays a role in determining the
depth of action of the TCA. The harder the solution is applied,
the more deeply the TCA will penetrate. A swab held in the hand
has less abrasive force than a swab held with Kocher forceps.
A smooth applicator does not abrade the skin while
depositing the acid, and the action of the TCA remains more
superficial. Using a brush to apply the same number of coats of
the same TCA solution with the same concentration produces a

Trichloroacetic acid: Classic Semiology      99
more superficial peel than using a swab. The depth of action of
the same peel solution can therefore be varied simply by chang-
ing the applicator or the pressure of application.
Effect of Speed of Application
The speed of application of TCA is not in itself important, because:
•
Unlike alpha-hydroxy acid (AHA) solutions, TCA does not
have to be neutralized.
•
Unlike phenol solutions, TCA is not toxic.
The speed of application depends on:
•
The patient’s sensitivity: A very sensitive patient will find
it difficult to stand the burning sensation of the TCA on
the whole face and will be better off if the TCA is applied
zone by zone.
•
The surface area being treated: Only Touch can be applied
quickly on lentigines, as only small areas are affected by the
burning from the acid. Large areas (e.g., the back) should be
treated by TCA zone by zone for the patient’s comfort.
•
The depth of the peel: Applying TCA is painful, but an
intradermal peel is far more painful than an intraepider-
mal peel. An intradermal peel should be applied zone by
zone for the patient’s comfort, while an intraepidermal
peel can be applied in one pass.
Symptomatology of TCA Application
Applying TCA causes protein coagulation more or less rapidly,
depending on the formulation of the peel, its concentration,
prior preparation of the skin, the pressure of application, the
skin type, etc. A 35% m/m TCA coagulates proteins.
Different symptoms appear gradually: see Table 14.1 and
Figures 14.1–14.9.
A low-concentration formula is applied in several
coats; the doctor can progressively see each of the symptoms
described in Table 14.1, and can stop whenever he wants.
A high-concentration formula penetrates very rapidly,
and the symptoms come in such quick succession that it is
impossible to see them clearly. The technique is much quicker
but the doctor cannot choose when to stop.
Two endpoints are worthy of more attention:
•
Scattered pinpoint and cloudy-white frosting signal the
most superficial peel to the dermis: this is the limit of effec-
tiveness (see Chapter 15).
•
Even pink–white frosting signals a peel to the papillary
dermis: this is the safety limit (see Chapter 23).
Table 14.1  Symptoms Following TCA Application
Symptom
Depth of peel
Type of flaking
Erythema
Intraepidermal
No or little risk of visible flaking
Scattered pinpoint frosting
Near the basal layer (Figure 14.1)
Sunburn-type flaking (Figure 14.2)
Cloudy-white frosting
Peel has reached the Grenz zone (Figure 14.3)
Flaking: light, thin skin (Figure 14.4)
Even pink-white frosting (Figure 14.5) and
“epidermal sliding”
TCA is in the papillary dermis (Figure 14.6)
Sliding (wrinkling) can be seen when skin is
pinched and corresponds to coagulation of
anchoring fibers between dermis and epidermis
Flaking: more or less brownish
skin, depending on phototype
and photodamage (Figures 14.7
and 14.8)
Pure white frosting (Figure 14.9), gradual
disappearance of epidermal sliding
TCA has reached reticular dermis
Gray-white frosting, epidermal sliding has gone
TCA is in reticular dermis
Gray frosting and/or yellowish patches (phenol)
Deep reticular dermis
TCA should no longer be used for
peels to deep reticular dermis
Figure 14.1  Scattered pinpoint frosting.
Figure 14.2  Flaking after scattered pinpoint frosting.

100      Textbook of Chemical Peels
Figure 14.3  Cloudy-white frosting.
Figure 14.4  Flaking after cloudy-white frosting.
Figure 14.5  Even pink-white frosting (the differences in color
come from the presence of melasma). The contours of the eyes
have been chemically resurfaced locally.
Figure 14.6  The skin wrinkles when pinched between the fingers.
Figure 14.7  Flaking after a papillary peel on a light skin photo-
type with little photodamage.
Figure 14.8  Flaking after a papillary peel on a light skin photo-
type that has been badly damaged by the sun.

Trichloroacetic acid: Classic Semiology      101
POSTPEEL CARE
Postpeel care is also discussed in Chapter 3. In short, postpeel
care is extremely important and depends on the skin type, the
depth of the peel, and the dermatological problem being treated.
It is more important than preparation when using Easy TCA
or Unideep. “Peelers” quickly learn that applying a peel solu-
tion is extremely easy; one does not need a university degree to
take a cotton bud and get skin to frost gradually. The choice of
indications and managing postpeel care are different matters,
and a thorough knowledge of medicine is essential to do them
properly.
NOTES

1. Preparing the skin with tretinoin before the peel accelerates
postpeel healing.

2. Easy TCA was called “Easy Peel” at the time. The name was
changed when Easy Phytic peel was released, to avoid any confu-
sion between the two “Easy” peels: Easy TCA, a combination of a
TCA peel and Easy Phytic, uses alpha hydroxy acids (AHAs) and
phytic acid. See Chapter 11 for more information on this peel.

3. The peel produces scattered pinpoint frosting only.
Figure 14.9  Pure white frosting from a peel to the reticular
dermis.

15
Easy TCA and Easy TCA Pain Control
Description and basic protocols
INTRODUCTION: IMPORTANCE OF
LANGERHANS CELLS IN RELATION
TO PEELING SIDE EFFECTS
In 1968, Paul Langerhans discovered the presence of a particu-
lar type of epidermal cell in humans, which is now named after
him. The Langerhans cell (LC) is a mobile dendritic cell that has
no desmosomes and is found in most multilayered malpighian
epithelia. LCs make up 2%–5% of epidermal cells. They come
from the medulla, migrate toward and within the skin, and stay
within the epidermis for 2 weeks at the most.
LCs have three functions:
1.
Constant monitoring of the antigenic environment.
2.
Inspection of foreign molecules.
3.
Custody of the foreign invaders while the lymphocyte sys-
tem reacts with an appropriate immune response.
It is easy to understand how important LCs are when one
imagines the impressive number of potential antigen contacts
over the entire epithelial surface of the body. When the entire
epidermis is destroyed by certain peels, this affects not only the
keratinocytes and the LCs, but also other dermal dendritic cells
(DDCs) that are potentially antigen-presenting cells. New gen-
erations of sentinel cells migrate rapidly from the bone marrow
to the epidermis, which is being rebuilt after the peel, but this
process is not effective immediately. Moreover, the first LCs to
arrive as reinforcements on the battlefield of the skin are “over-
whelmed” as soon as they reach the dermis by the different
types of antigen stimulation that they have to face on skin that
has lost its impermeability and physical defenses. The stratum
corneum can be compared to the ramparts of a medieval city
and the Langerhans cells to the soldiers who have to defend it.
The likelihood of unexpected bacterial and viral compli-
cations occurring will be even higher, as there are fewer cells in
the skin capable of an immune response. It is important to con-
sider these basic notions of biology to better understand what
happens and anticipate which type of peel might be associated
with a higher incidence of complications in the form of bacte-
rial or viral infections. It then seems obvious why applying peel
solutions capable of destroying the epidermis and part of the
dermis on a skin with active herpes, acne, or other infectious
disorders is strongly contraindicated. Any medical staff suffer-
ing from respiratory or nose-and-throat infections should be
kept well away from the patient, and the doctor’s hands should
always be surgically disinfected before applying medium or
deep peel solutions.
Superficial peels with alpha hydroxy acids (AHAs), on
the other hand, are known to cause very few bacterial or viral
complications after peeling, as their direct action is limited to
breaking up the spaces between corneocytes.1 Even if the peel
penetrates too deeply in places, it is, quite logically, exceed-
ingly rare for an AHA peel to cause complications in the form
of infection, when the endpoint is focal or localized frosting.
With AHAs, the stratum disjunctum (SD), the outermost
layer of the epidermis that makes the skin feel rough, flakes
immediately. The skin, having lost its topmost layer, immedi-
ately feels softer to the touch.
The risk of bacterial or viral complications with medium
or deep peels could lead doctors to think that, in order to avoid
these problems, only superficial peels should be performed
and patients with active acne or herpes should not be treated.
With a medium or deep peel, herpes prevention consists of
a sandwich treatment with aciclovir, which is not well toler-
ated by patients with sensitive stomachs. For patients with
acne, caution limits the range of treatment choices to careful
superficial peels (which have limited effectiveness even after
repeated sessions). We are forced to put off, sometimes indefi-
nitely, performing “medium-depth” peels on patients with
acne or herpes who have not responded to preliminary medi-
cal treatment.
The development of Easy TCA (ETCA), however, has
introduced another possibility for treatment. In many indica-
tions, ETCA can produce the results of a medium peel with
only the complication risks—usually nonexistent—of a super-
ficial peel. ETCA can be applied quite successfully to active
acne lesions, and the presence of herpes lesions on the lips is
only a formal contraindication to the peel applied following the
basic protocol. It is still advisable to avoid treating patients with
active herpes, however. Then again, if herpes were to develop
in the course of an ETCA peel, it would be reasonable to think
that it was fortuitous and not directly related to the treatment.
To date, there has been no reported incidence of herpes spread-
ing after the application of ETCA (basic protocol).
With regard to acne, in 80% of cases, the first application
of ETCA to active papulopustular facial lesions improves their
number and severity by 50%, and the lesions seem to heal with-
out scarring. ETCA is applied on the basis of one peel per week
for 4 weeks that clear the lesions almost completely without
having to resort to antibiotics. Deep wrinkles and acne scars
do not disappear: they lie deep under the skin and even phenol
or carbon dioxide laser resurfacing cannot always treat them.
A combination of several different techniques is clearly needed
in these indications.
Although the face can be treated separately, the neck
should always be treated at the same time—to at least the
seventh cervical vertebra—to ensure a better “tightening
effect.” Ideally, all visible areas should be treated: face, neck,
décolletage, forearms, and hands (Table 15.1).

Easy TCA and Easy TCA Pain Control: Description and basic protocols      103
GENERAL DESCRIPTION
A growing number of doctors consider ETCA to be the safest
and easiest trichloroacetic acid peel, and it is used in more than
70 countries worldwide.
ETCA comes in two main presentations: Easy TCA
Classic and Easy TCA Pain Control. Both are certified as Class
II medical devices.
Easy TCA Classic is the most popular form of Easy TCA;
it has been used since 1996. Easy TCA Pain Control represents
the most recent evolution of the peel. The peeling solution is a
patented formula, containing nontoxic amounts of phenol.
The clinical difference between the peels is that Easy
TCA Pain Control tends to be 80% less painful and 25% more
efficient than Easy TCA Classic. Frosting appears more quickly
and is stronger when Easy TCA Pain Control is used; a deeper
frosting induces a much milder burning sensation.
Nevertheless, Easy TCA Pain Control is not intended for
use after microneedling and is contraindicated after abrasion.
Easy TCA Classic
Presentations
•
Easy TCA Starter 4: Kit for 4 peelings.
•
Easy TCA Classic 12: Kit for 12 peelings.
•
Easy TCA Classic 24: Kit for 24 peelings.
Kit Contents
The number of items varies and is adapted to the number of
planned peels.
•
Base solution: Solution containing four AHAs, antioxi-
dants, trace elements, and saponins.
•
Starter 4: 4 ampoules of base solution.
•
Classic 12: 12 ampoules of base solution.
•
Classic 24: 2 vials of base solution.
•
Aktivator  TCA 50%: Solution TCA concentrated at
50% w/w.
•
Each kit contains a vial of Aktivator TCA 50% adapted
to it.
•
Postpeel mask: Cosmetic cream to be applied immediately
after the peel.
•
Each kit contains one or several tube(s) of postpeel
mask, depending on needs.
•
The application of the postpeel mask, once, immedi-
ately after obtaining the desired skin frosting, imme-
diately alleviates the burning sensation.
•
Various: One or more dosing cards for dosing the postpeel
mask, small container for mixing the TCA with the base solu-
tion, protective plastic tube to prevent cut fingers when break-
ing open an ampule, cotton swabs, and instructions for use.
Easy TCA Pain Control
Presentations
•
Easy TCA Pain Control: Kit for 4 peelings.
•
Easy TCA Pain Control 12: Kit for 12 peelings.
Kit Contents
The number of items varies and is adapted to the number of
peels provided.
•
Pain Control base solution: Solution containing four AHAs,
antioxidants, trace elements, saponines, and phenol.
•
Kit for 4 peelings: One 8 ml vial.
•
Kit for 12 peelings: One 25 ml vial.
•
Aktivator  TCA 50%: Vial containing a 50% w/w TCA
solution.
•
4 peelings: One 3.4 ml vial.
•
12 peelings: One 10 ml vial.
•
Postpeel mask: Cream designed to control inflammation
and burning after the peel.
•
4 peelings: One 10 ml tube.
•
12 peelings: Three 10 ml tubes.
•
Various: One or more dosing cards for dosing the post-
peel mask, a small container for mixing the TCA with Pain
Control base solution, cotton buds, and instructions for use.
Base Solution to Be Mixed with TCA
The base solution itself does not contain trichloroacetic acid;
it is intended to be mixed with a specific volume of Aktivator
TCA at 50% w/w. The base solutions for the Easy TCA Classic
and the Easy TCA Pain Control are very similar. The Easy TCA
Pain Control base solution contains a specific phenol concen-
tration that makes the peel 25% more efficient and 85% less
painful than the Easy TCA Classic. The phenol in the Easy TCA
Pain Control base solution does not reach a potentially toxic
concentration.
The Easy TCA Classic and Pain Control peeling solutions,
reconstituted by the addition of Aktivator TCA, have an acid
pH of +/–1. This pH, which is much lower than the solution’s
pKa, means that the base solution is composed primarily of free
and potentially active acids and contains no partially neutral-
ized acids.2 The TCA concentration of both the Easy TCA Classic
and Easy TCA Pain Control peels is 15% m/m.
Figure 15.1 compares the formulations of a TCA in simple
aqueous solution (TCA-SAS) and the Easy TCA Classic, base
solution.
THE LEGAL POINT OF VIEW
A TCA-SAS is a simple mixture of trichloroacetic acid crystals
and water (see Chapter 12). Such a simple solution is less expen-
sive than a more complex solution but, as explained in Chapter
12, it has its limitations. TCA-SAS is legally produced by phar-
macies only, and for medical use. In European countries, at
least, a physician is not legally allowed to mix TCA crystals
and water to prepare a solution that he will apply on a patient;
this is usually considered as an illegal practice of pharmacy.
However, a physician is legally allowed to mix a TCA solution
(Aktivator TCA) with the base solution of a kit that is CE Class
II certified because the components of the kit are largely con-
trolled, validated, and legal for medical use.
Table 15.1  Volume of ETCA Solution for One Peel (As a
Rough Guide; See the Different Protocols for Details)
Procedure
Approximate volumes (ml)
Face only
1.2–1.5
Face and neck
1.5–2
Face, neck, and décolletage
2.5–3
Face, neck, décolletage, hands,
and forearms
3–4

104      Textbook of Chemical Peels
Easy TCA Pain Control has the advantage of being the
only (as far as the author knows) phenol-containing peel that is
CE certified and legal for utilization.
Note that unlike a CE Class II medical device, a Class I
medical device needs no external control. Class I represents a
self-certification only. When the single logo CE appears on a
box, without four numbers after it, it means that the CE is a
self-certification, without external control. For example, for
TCA or phenol-containing peels, CE 1234 indicates a medical
device duly certified by an external controlled “notified body”;
CE alone, without four numbers, indicates a self-certified medi-
cal device. Evidently, CE 1234 presents a stronger guarantee of
security and efficacy than the self-certified CE.
THE EFFICACY POINT OF VIEW
While water itself has no clinically visible efficacy, the compo-
nents of the Easy TCA base solution have a specific efficacy.
•
The four AHAs of the formula allow a faster and deeper
penetration of the other actives. They have an anti-free-
radical action.
•
Saponins are natural extracts known as glycosides that have
special foaming and soapy properties. As a glycoside, a sapo-
nin may have binding properties for water in the skin. Some
studies show that saponins have an antimicrobial effect and
enhance skin healing. They are mainly used in peelings to
even out the penetration of the TCA through the skin.
•
Ascorbic acid has an anti-free-radical action and protects
the solution itself as well as the skin it is applied on. It is
also an acidifying agent and a buffer.
•
Phytic acid is a good antioxidant and tyrosinase inhibitor.
It protects against the risk of hyperpigmentation and post-
peel inflammation.
•
Super oxide dismutase (SOD) is a metalloproteinase with
a strong, natural antioxidant feature that protects cells
against peroxidation. It is an important molecule that can,
for example, prevent the superoxide radical (O2–) from
reacting with the NO radical to produce peroxinitrile,
which is extremely toxic to cells.
•
Trace elements are necessary to the activity of many
enzymes and skin metabolism.
When comparing a TCA-SAS solution to the base solution,
it is clear that the Easy TCA base solution helps the penetration
and the activity of the TCA; it protects the skin against the negative
action of the free radicals that are immediately produced when the
acids react with skin components. As a consequence, application
of Easy TCA is less painful than application of TCA-SAS solutions.
POSTPEEL MASK CREAM
The postpeel mask cream, which is highly antioxidant, contains
many ingredients. The doctor applies it only once, immediately
after the required level of frosting has been achieved.
The cream’s formulation is responsible for a significant
proportion3 of the beneficial results of ETCA. It stops the burn-
ing sensation almost immediately and greatly reduces the risk
of postpeel complications (see Chapter 5). Its components are
discussed later in this chapter.
While postpeel care is discussed in detail in Chapter 3, it
is important to mention that after TCA-SAS application, medi-
cations are needed to control side effects. Side effects occur quite
frequently and are often the reason doctors prefer using meth-
ods other than TCA peels. The postpeel mask used immediately
after an Easy TCA peel controls, in minutes, the inflammation
produced by the peel. It quickly stops the cycle of self-main-
tained oxidative reactions, burning sensation, and erythema.
Often, the patient leaves the clinic without any visible sign of
the Easy TCA peel.
After the Easy TCA Pain Control peel, the postpeel mask
is mainly intended to control postpeel inflammation rather
than burning or pain, because Easy TCA Pain Control produces
much less discomfort than other peels. Immediate control of
postpeel inflammation limits the risk of side effects.
Figure 15.2 compares the Easy TCA (and Easy TCA Pain
Control) postpeel mask with the medications used after a TCA-
SAS peel.
TCA IN WATER SOLUTION, POSTPEEL CARE
Hydroquinone
After a TCA-SAS peel, hydroquinone is used to combat postin-
flammatory hyperpigmentation (PIH). See Chapter 37 for
examples of PIH and more information about hydroquinone.
TCA in water solution
Water
+ TCA
+ TCA
Phytic acid,
ascorbic acid
SOD
2- Monocarboxylic AHAs
1- Dicarboxylic AHA
1- Tricarboxylic AHA
Trace elements
Antioxidants
Saponines
4 alpha hydroxy acids:
Easy TCA
Figure 15.1  TCA compared to Easy TCA.

Easy TCA and Easy TCA Pain Control: Description and basic protocols      105
Tretinoin
Tretinoin is used to stimulate the skin basal layer turnover and
speed up the healing process. However, it also limits the trans-
formation of keratinocytes into corneocytes. A new horny layer
will not quickly appear, and full skin protection will not be
restored. The consequence is potential long-term sensitivity of
the skin after the peel. When used in the postpeel period, treti-
noin seems to slow down the building of the skin architecture
and extend the duration of erythema.
Corticoids
Corticoids are used to control postpeel inflammation because
of their antimetabolic effect on melanocytes. Nevertheless, they
present a catabolic effect that also could slow down skin regen-
eration and induce skin thinning and telangiectasies if used for
an excessive amount of time.
Nonsteroidal Anti-Inflammatories
Indomethacin 2% is sometimes used as part of a more complex
formula for controlling postpeel inflammation. Tranexamic acid
should be used before the melanin is synthesized, very soon
after a chemical peel. The effectiveness of nonsteroidal anti-
inflammatories (NSAIDs) is lower than that of corticoids.
COMPONENTS OF THE EASY TCA AND EASY
TCA PAIN CONTROL POSTPEEL MASK
The Easy TCA Classic and Easy TCA Pain Control peels use the
same postpeel mask formula.
Antioxidants
PIH often occurs after chemical peels as a direct result of
melanocyte to oxidative reactions or to complex chain reac-
tion mechanisms. The mechanism of PIH is well understood,
but it is clear that many inflammatory mediators and reactive
oxygen species are liberated by the interaction of the chemi-
cal peeling agent and the skin. For example, TCA breaks cell
membranes and liberates cell components that are not pro-
inflammatory as long as they are enclosed in the cell. When
cells walls are broken, the plasma content is liberated and
many potentially pro-inflammatory components reach extra-
cellular spaces where they induce inflammation. After a peel,
long lasting and progressive liberation of these pro-inflamma-
tory components induces long-term stimulation of melano-
cytes and, finally, PIH.
Antioxidants can block the cycle of postpeel inflamma-
tion, avoiding long-term melanocyte stimulation and therefore
reducing the risk of PIH after an Easy TCA peel.
Vitamins A, C, E, and H
Vitamins A, C, E, and H have potent antioxidant, regenerative,
and anti-inflammatory effects.
Vitamin A
The postpeel mask cream contains retinol microencapsulated
in cyclodextrin. Vitamin A is involved in the processes of cell
division and differentiation that helps the epidermis regenerate
after the peel from the cells of the basal layer (Figure 15.3).
Retinol induces the expression of retinoic acid-binding
protein (RABP) and regulates cell migration in the skin epithe-
lium, which is vital for skin regeneration after a peel. Retinol
exerts a strong antioxidant activity; encapsulating retinol pro-
vides better bioavailability of the vitamin and protects the
skin against oxidation. Keratinocytes have the enzyme tools
required to convert retinol into retinoic acid (the corresponding
carboxylic acid), which is the molecule ultimately responsible
for the effect of vitamin A.
Retinol can be considered as a tretinoin precursor
because, when encapsulated in cyclodextrins, it enters easily
into the skin, and when liberated from the cyclodextrin, it is
transformed by epidermal enzymes into retynaldehyde and
finally retinoic acid. This kind of natural tretinoin production
seems not to induce the slowdown of keratinocytes–corneo-
cytes transformation and not interact with the postpeel skin
permeability. Vitamin A modulates cellular proliferation and
TCA in water solution
Easy TCA postpeel mask
Anti-oxidant
Vitamins (A, C, E, H...)
Antityrosinases
Phytic acid
Tretinoin precursors
Growth factor (bFbF)
Fatty acids
Organic silicium
Seleniomethionine
Trace elements
Enoxolone
SOD
Medications usually used during
the postpeel period for limiting
or curing side effects.
Duration of use, up to 30–90 days
Main components of postpeel mask
used once only after peel.
Hydroquinone
Tretinoin
Corticoids
N.S. ANTI-INFLAMMATORIES
Figure 15.2  TCA compared to Easy TCA postpeel.

106      Textbook of Chemical Peels
differentiation. At the level of the dermal matrix, it increases
collagen and hyaluronic acid synthesis, and decreases metallo-
proteinases-mediated extracellular matrix damage.
Vitamin A deficiency makes the skin at risk of impaired
wound healing. Vitamin A increases fibroblast proliferation.
Vitamin C
Magnesium ascorbyl phosphate (MAP) is more effective than
ascorbyl palmitate (AP), as its active function by esterification
protects the MAP against oxidation and provides an antioxi-
dant effect that is of higher quality and longer lasting than that
of ascorbyl palmitate, a molecule in which the enediol function
of the “2” carbon atom is not protected by esterification.
Vitamin C deficiency is linked with a reduced immunity
response, an increased risk of infection, reduced collagen syn-
thesis, poor angiogenesis, and higher capillary fragility.
Vitamin C is a powerful antioxidant, effective in aqueous
solutions, that scavenges free radicals and prevents the break-
down of protein chains. It protects other antioxidants, which
is an advantage in situations involving oxidative stress, such
as infected or uninfected wounds and in the postpeel healing
period. Vitamin C has many roles in wound healing, and vita-
min C deficiencies result in impaired healing.
Vitamin E
Tocopheryl acetate is the most stable ester of vitamin E. It is
readily hydrolyzed by esterases into pure vitamin E after it
has been absorbed by the skin. The advantage of the acetate
form is that it forms a reservoir that gradually releases the vita-
min E inside the skin. Vitamin E scavenges free radicals that
could damage neighboring tissue. It blocks oxidative chain
reactions by inhibiting the formation of lipoperoxides inside
the cell, and in this way protects the nucleic acids and pro-
teins. Vitamin E is an antioxidant, and its lipophilic proper-
ties allow it to stabilize cellular membrane integrity. Vitamin
E also has anti-inflammatory properties and decreases the risk
of scar formation. Topical Vitamin E is widely used as an anti-
scarring agent, even if it seems not to be able to speed up skin
regeneration.
Vitamin H (Coenzyme R, Biotin, Vitamin B8)
The metabolic action of vitamin H is mediated through biotin-
dependent enzymes that actively synthesize purines. It is a sta-
ble monocarboxylic acid, soluble in water and alcohol, and acts
as a coenzyme as well as a growth factor, even in very small
quantities. Biotin deficiencies cause scaly dermatitis, hyperker-
atosis, and alopecia. Topical application of biotin reduces the
secretion of sebum.
Antityrosinases
Antityrosinases block the synthesis of melanin from tyrosine.
They act at several levels of the chemical pathway. When applied
immediately after a peel, they penetrate the basal layer more
quickly and greatly reduce melanin production. However, they
are not able to remove the melanin already in the keratinocytes.
Their action allows the melanocytes to produce less melanin
and transfer less melanin to the keratinocytes.
When used on an existing melasma or PIH, after induc-
ing a lower melanin synthesis, the epidermal turnover still has
to bring to the surface these keratinocytes containing less mela-
nin to obtain a clinical result. When topical antityrosinases in a
cream are used alone, clinical result can last up to 8 to 10 weeks.
Phytic Acid
Phytic acid is an antioxidant and tyrosinase inhibitor that
protects against the risk of hyperpigmentation and postpeel
inflammation.
Epidermal Growth Factor
Epidermal growth factor (CG-bFGF) stimulates epidermal
cell growth and has an antiscarring effect, which aids wound
healing.
Fatty Acids
Polyunsaturated fatty acids (PUFA) limit the destructive effects
of wound inflammation. The mechanism is not yet well under-
stood, but it appears that omega-3 and omega-6 fatty acids
 
ROL
Retinol
Enzyme
RA
RAR
Retinyl
esters
ARNm
Stockage
Enzyme
RAL
Retinaldehyde
RA
Retinoic
acid
Intrakeratinocytic
production
Protein
synthesis
(a)
(b)
Figure 15.3  (a) Retinol encapsulated in cyclodextrin. (b) From retinol to retinoic acid.

Easy TCA and Easy TCA Pain Control: Description and basic protocols      107
control some cytokines liberation and limit their activity. PUFA
are therefore indicated after peels to reduce the risk of scarring
and speed up skin healing.
Organic Silicium (Trimethylsilanol
Monomannuronate)
Organic silicium is strongly linked to proteoglycans and muco-
polysaccharides, hyaluronic acid, and chondroitin sulfate. It
plays an important role in skin healing and is essential in anti-
aging treatments.
Organic Selenium and Selenio-Methionine
Selenium is a trace element that accelerates skin healing; it
penetrates more easily when combined with methionine. The
postpeel mask contains a combination of selenium and methio-
nine, which improves healing after laser resurfacing or a peel,
and prevents seborrheic dermatitis. Selenium is a component of
glutathione peroxidase (GPX), an antioxidant enzyme that helps
fight peroxidation. Selenium helps reduce inflammation by low-
ering the number of hydroperoxide intermediates in cyclooxy-
genase and lipoxygenase reactions. It prevents the production of
inflammatory and immunosuppressive cytokines and stimulates
cellular immunity and humoral immunity. Combining it with
vitamin E reinforces its protective action. Selenium and methio-
nine have a tretinoin-like effect without causing irritation.
Trace Elements
Optimal skin repair requires a balanced concentration of
several micronutrients. Zinc is a co-factor for RNA and DNA
polymerase and can impair wound healing. Magnesium is a
co-factor for many enzymes (protein and collagen synthesis).
Copper is a required co-factor for cytochrome oxidase, SOD,
and natural collagen cross-linking.
Superoxide Dismuthase
SOD blocks O2 free radicals. It is the only enzyme that can
detoxify the extremely toxic superoxide free radical.
Enoxolone
Enoxolone is a natural inflammatory whose structure provides
anti-inflammatory properties without the antimetabolic prop-
erties of cortisol. It has a modulatory effect on neural signaling
through gap junction channels (Figure 15.4).
Urea and Glycerol
Urea and glycerol both have well-known moisturizing properties.
Allantoine
Allantoine stimulates the skin renewal process. Soothing and
anti-irritant, it regulates the inflammatory process. It also helps
the skin retain water and helps eliminate dead cells.
Rhamnosoft
Rhamnosoft is a biosaccharides mixture. Its anti-inflammatory
action includes biologic attenuation of inflammation, which
inhibits PGE2 liberation. Rhamnosoft also inhibits intercellu-
lar proinflammatory message transfer between cells, blocking
postpeel inflammation. In addition, its antiseptic properties
limit bacterial adhesion on surfaces.
Note:  The fact that the peel solution has been applied on the
skin beforehand has a significant effect on the rate of penetra-
tion of the postpeel cream’s ingredients. The cream penetrates
much more deeply after a peel than on untreated skin: the
skin is far more permeable immediately after a peel, sebum
and corneocytes no longer function as a barrier, and the purely
water-soluble ingredients can penetrate the altered epider-
mis  rapidly. In this way, large quantities of antityrosinases,
healing stimulants, protectors, and antioxidants can reach the
dermis.
The postpeel mask has a pH of 6.5; it is not a neutralizing
cream.
INDICATIONS
Easy TCA Classic and Easy TCA Pain Control have a wide
range of indications and depths of action (Table 15.2). Easy TCA
Classic can be used on both the face and the body, regardless
of previous microneedling or dermabrasion. Easy TCA Pain
Control is only indicated for facial treatment, and the notice for
use warns against its use after microneedling or dermabrasion
to avoid a too fast penetration of phenol.
Easy TCA can be applied to the face, hands, neck, décol-
letage, and body. Easy TCA Pain Control can be applied to a
maximum of 4% of the body (e.g., the face). The décolletage can
be treated separately.
Abrasive or Microneedling Protocols
These protocols include stretch marks, acne scars on the face
and body, keratosis pilaris, and badly damaged décolletage.
Easy TCA Classic can be used after dermabrasion or micronee-
dling (see Chapters 21 and 29). Easy TCA Pain Control is not
recommended after microneedling and is prohibited after
dermabrasion.
Deeper Protocols
Easy TCA or Easy TCA Pain Control can be applied as a peel
to the papillary dermis, when a sufficient number of coats are
gradually applied to produce even pink-white frosting and
“epidermal sliding.” The protocol developed to treat stretch
marks also has been used successfully for facial rejuvenation,
in combination with Easy TCA Classic.
Combined Protocols
Easy TCA Classic or Easy TCA Pain Control can be combined
with other treatments, including the following (see Table 15.3):
•
A peel to the papillary dermis: Unideep
•
A localized peel to the reticular dermis: Only Touch
H
H
O
HO
HO
O
H
H
H
H
HO
OH
OH
O
O
(b)
(a)
Figure 15.4  (a) Enoxolene and (b) cortisol.

108      Textbook of Chemical Peels
•
Localized phenol for lip and eyelid wrinkles: Lip & Eyelid
Formula. A combination of local Lip & Eyelid Formula and
Easy TCA Pain Control is effective for wrinkles around the
eyes or mouth that are not strongly associated with pho-
toaging. If they are strongly associated with photoaging,
combination with easy phen light is better.
•
Electric hair removal, skin cleaning, botulinum toxin, wrin-
kle filling, minor surgery, coagulation of telangiectasias,
mesotherapy, slimming diets (to stop face sagging), etc.
•
Lasers and flashlamps. These are not strictly contrain-
dicated but should be judged on a case-by-case basis,
depending on the type of equipment used.
•
Pixelized laser treatment (fractional laser). Easy TCA
Classic is very effective immediately after skin laser pixel-
ization. This combination allows using a reduced laser flu-
ence, which limits potential side effects. Easy TCA Classic
penetrates the tiny holes created by the laser and induces a
pixelized deeper peel that boosts results and help the skin
recover very quickly.
Depth of a Peel
The depth of a peel must be chosen before the peel is performed,
taking into account the indications and the patient’s skin type.
The examples in Table 15.4 are not binding or limiting.
PREPARING THE EASY TCA CLASSIC SOLUTION
The base solution must be activated by adding TCA at 50%
m/m. Easy TCA Classic is presented in two main forms:
1.
As a cosmetic product: In this case, the kit contains no TCA
and the pharmacist should be asked to prepare the follow-
ing TCA–SAS solution at 50% m/m.

TCA crystals      10 g

Distilled water  10 g

pf 20 g of TCA aqueous solution
2.
As a Class II medical device class: In this case, the kit con-
tains Aktivator TCA 50%.
To activate the peel,4 a precise quantity of the base solu-
tion has to be injected into:
•
Each ampoule of the Easy TCA starter (four peels) or the
Easy TCA Classic kit (12 peels), or
•
Each of the two bottles of base solution for Easy TCA
Classic 24 peels, or
•
The vial of base solution for Easy TCA Pain Control.
This solution, prepared in advance, ideally should be kept
in the refrigerator if stored for long-term use. In normal-use con-
ditions, the solution can be stored at room temperature (20–22ºC).
Table 15.5 shows the presentations available.
PREPARING THE EASY TCA KITS
Details for preparing the kits are written on the inside cover of
the box. Every peel should be carefully prepared, following the
instructions, to avoid complications.
Table 15.3  Combined Protocols
Easy
TCA
Easy TCA
Pain Control
Easy Phen
Light
Reticular dermis application
–
–
x
Papillary dermis application
x
x
x
Unideep together with
x
x
–
Only Touch together with
x
x
–
Local Lip & Eyelid
together with
x
x
x
Hair removal
x
(x)
–
Skin mechanical cleaning
x
–
–
Skin abrasion
x
–
–
Botulinum toxin immediately
before
x
x
–
Skin microneedling
x
(x)
–
Wrinkle filling
(hyaluronic acid)
x
x
–
Telangiectasies coagulation
before
x
(x)
(x)
Mesotherapy before
x
x
–
Fractional laser
x
(x)
–
x: Can be combined
(x): Not recommended; depends on the medical decision
—: Can’t be combined
Table 15.2  Indications for Easy TCA or Easy TCA Pain Control
Type
Subtype
Easy TCA or Easy TCA Pain Control basic protocol
Acne
Comedonal
Frosting points
Microcystic
Frosting points
Papular
Frosting points
Papulo pustular
Frosting points
Pustular
Frosting points
Other types of acne (conglobata,
necrotica, etc.)
(-) Peelings not indicated
Scars
Pigmentary postacne scars
Frosting point or clouds
Hypertrophic postacne scars
(-) Simple peel not active
Deep scarring (pike, scars, etc.)
postacne
(-) Simple peel not active
After dermabrasion or microneedling (not Easy TCA Pain Control)
Stretch marks
(-) Simple peel not active
After dermabrasion or microneedling (not Easy TCA Pain Control)
Pigment
Melasma-chloasma
Frosting points or clouds
PIH
Frosting points or clouds
Aging
Photoaging
Frosting points up to papillary dermis
Chronoaging
Deep phenol peel associated with surgery
Smoker’s skin
Easy TCA/Easy TCA Pain Control frosting points up to papillary dermis
Keratosis—solar lentigine
Easy TCA/Easy TCA Pain Control in touch on facial keratosis
Hands–décolletage–scalp: use Only Touch + Easy TCA

Easy TCA and Easy TCA Pain Control: Description and basic protocols      109
PREPARING THE PATIENT
As a general rule, when a basal layer depth or Grenz zone depth
is chosen, no skin preparation is necessary in the weeks preced-
ing the peel or even immediately before the procedure. It is not
necessary to clean or degrease the skin, or to remove makeup5
(except for impermeable makeup with a silicone base).
If the doctor wants the skin to be cleaned, it should be
cleaned carefully, without irritating it or increasing its permea-
bility. Skin Tech’s prepeel cleansing foam is recommended, as it
does not increase skin permeability and has a physiologic pH of
4.5 that brings the skin back to its natural acidity before the peel.
Exceptions
Skin preparation is optional before Easy TCA (depths 3/7—
basal layer to 4/7—Grenz zone). Antipigment preparation is
recommended for deeper protocols or higher phototypes (FZ–
Fitzpatrick, 5/7): apply Skin Tech Blending Bleaching Cream
twice daily for 3–4 weeks prior to a peeling depth 4/7 or 5/7.
For a peeling depth of 5/7, prevention of herpes simplex
is mandatory for patients with a history of classical herpes.
SUITABLE APPLICATOR
Different types of applicator can be used, but experience shows
that the best results are achieved using a double cotton bud
(Figure 15.5). A single cotton bud cannot withstand “­scratching”
pressure6 and bends. Two cotton buds, on the other hand, can
stand the right amount of pressure, and allow easy, quick, and
precise application.
BASIC PROTOCOL
Cotton Buds
Two cotton buds should be soaked in the ETCA solution that
has been made in the glass container (Figure 15.6). Any excess
solution should be removed by squeezing out the cotton buds
on the rim of the glass container (Figure 15.7).
Peeling Application
Easy TCA Classic or Easy TCA Pain Control is usually applied
with circular movements, using the cotton buds (called “appli-
cators”) included in the kit.
Application of the First Layer
Divide the face into seven different areas (see Figure 15.8). Soak
the applicators in the peeling solution, squeeze them dry on the
edge of the glass container to eliminate the excess solution, and
Table 15.5  Differences between CE and No CE Easy TCA Kits
Cosmetic
Easy TCA
Classic
4 peels (starter kit)
Kit contains
no TCA
12 peels (classic kit)
24 peels (large kit)
Medical
device
Easy TCA
Classic
4 peels (starter kit)
Kit contains
TCA
12 peels (classic kit)
24 peels (large kit)
Easy TCA
Pain Control
4 peels
12 peels
Table 15.4  Indications vs Depth of Peels
Indications
Type of peel
Suitable phototype
Depth of peel
Active acne, dry skin, anti-aging
Intra epidermal peel
Or basal layer peel
All phototypes
Depth 2/7
Depth 3/7
Melasma, chloasma, photoaging
ETCA to the basal layer
Phototypes 4-6
Depth 3/7
ETCA to the Grenz Zone
Phototypes 1-3
Depth 4/7
Lentigines
FACE: Focal touch with ETCA or ETCA
PC - Hands, forearms, décolletage: focal
touch Only Touch peel
Phototypes 1-4
Depth 5/7
Phototypes 1-4
Depth 6/7
Stretch marks, acne scars, deep wrinkles
Anterior chemoabrasion
Phototypes 1-3
Depth 5/7 to 6/7
Figure 15.5  A single cotton bud cannot withstand sufficient
pressure.
Figure 15.6  Soaking the cotton buds.

110      Textbook of Chemical Peels
apply them to the first area using regular circular movements.
Let this first layer dry completely and check the “result.” Repeat
this process for each area.
The “result” is not a volumetric notion (milliliters) or a
temporal concept (minutes) but rather a clinical sign:
•
Erythema: Sign of peeling depth 2/7 (intraepidermal)
•
Frosting points: Sign of peeling depth 3/7 (basal layer)
•
Frosting clouds: Sign of peeling depth 4/7 (Grenz zone)
If the desired frosting was obtained with the first layer,
immediately apply the correct amount of the Skin Tech post-
peel mask on the treated skin (see the dosing card in the kit).
If the desired frosting has not been obtained with the first
layer, reapply the Easy TCA solution to the face as described
below.
Application of Subsequent Layers
Divide the face into three different areas (frontal and lateral
areas; see Figure  15.9) and apply the peeling solution using
circular movements. Let this second layer dry and check the
“result” (see previous section). Repeat the application if nec-
essary (dividing the face into three different areas) and allow
each layer to dry until the required frosting is obtained.
The “clinical sign” corresponds to the depth achieved
(rash, spots, or clouds); that is considered the “end of the peel.”
At this time, apply the correct amount of the Skin Tech postpeel
mask (see dosage card).
Application of the Postpeel Mask
Apply the Skin Tech postpeel mask cream in the amount deter-
mined by the kit’s dosing card. The postpeel mask stops skin
pain, erythema, swelling, and heat in a few seconds, and drasti-
cally reduces the risk of side effects.
Immediate Postpeel
The postpeel mask should remain in place for at least 8 hours
before being washed with Skin Tech cleansing foam. The cleanser
will bring the skin’s pH back to its natural level (pH 5.5).
Predictable Effects during the First Week Postpeel
Dry skin begins to peel on the third day (sometimes later in the
case of a first peel) and finishes by the sixth day. The desquama-
tion intensity depends on the depth of the peel.
•
Depth 2/7 (intra-epidermal): Desquamation is almost
invisible.
•
Depth 3/7 (basal layer): Desquamation lasts for 3 days,
similar to a sunburn.
•
Depth 4/7 (Grenz zone): The skin may darken in peeling
zone 4/7 and results in a more visible peeling.
Table 15.6 summarizes the process.
Application Sequence for Each Coat
The first coat of ETCA is applied in sequence on the face
(Figure 15.10), area after area. This coat should be left to dry.
If the application is even, following the recommendations
Figure 15.7  Squeezing out the cotton buds.
Figure 15.8  The seven areas of the face.
Figure 15.9  The frontal and lateral areas of the face.
Table 15.6  Basic Peeling Process
Peeling
Application
First coat
Second and
subsequent coats
End point
Immediate
postpeel care
Easy TCA Classic
2 cotton buds,
circular motion
Divide the face
into 7 areas
Divide the face
into 3 areas
Frosting points
Postpeel mask
Easy TCA Pain Control
Frosting clouds

Easy TCA and Easy TCA Pain Control: Description and basic protocols      111
described earlier, this first coat should not cause any prob-
lems. It must be allowed to dry completely before the second
coat is applied. The doctor applies the number of coats needed
to produce the first pinpoint frosting or, at the most, cloudy-
white frosting.
Thin Skin versus Normal or Thick Skin
The number of coats necessary to produce the first pinpoint
frosting depends on the patient’s skin type (Table  15.7).7 An
easy way to determine the thickness of the patient’s skin is
by simply “pinching” the cheek where the cheekbone is most
prominent (Table 15.8).
End of Application of ETCA Peel Solution (Basic Protocol)
The postpeel mask cream should be applied as soon as pin-
point frosting occurs (Figure 15.11).8 After the appearance of
pinpoint frosting, applying another coat of ETCA solution
produces cloudy-white frosting (Figure 15.12).
If the pinpoint frosting occurs quickly (which can occur
with very permeable skin), the postpeel mask can be applied
even if the acid has not completely dried. If the pinpoint frost-
ing appears slowly (which can occur with less permeable skin),
the postpeel mask should be applied after the skin has com-
pletely dried.
Potential Depths of Action
The potential depths of action of Easy TCA Classic and Easy
TCA Pain Control are summarized in Table 15.9.
Table 15.7  Number of Coats Needed to Achieve Pinpoint
Frosting (A Rough Guide)
Skin type
Number of coats
Thin skin
1 only
Skin treated with AHA, benzoyl peroxide, etc.
1 only
Skin treated with retinoic acid
1 only
Normal skin
1–2
Thick and oily skin
2–4
Table 15.8  Thickness of Pinched Skin
Thickness (cm)
Skin type
<1
Thin
1
Normal
>1
Thick
2
3 4
6 7
5
4
Cotton Buds Movements:
No
No
5
6
7
1
1
2
3
Figure 15.10  The sequence for application on the face. For the
first coat of peeling: The double cotton buds are moistened before
applying the solution to each area (1 to 7); the solution is applied
using a circular motion. For the second coat, if necessary, the face
is divided into three areas only: first area = forehead area limited
by a line from the tragus up to the external canthus. The lower part
of the face is divided into two areas by a central vertical line. For
the second and subsequent coat(s), the double cotton buds are
moistened three times only, for applying the peel solution on each
of the three areas.
Figure 15.11  Pinpoint frosting.
Figure 15.12  Cloudy-white frosting.

112      Textbook of Chemical Peels
End of Application
The peeling session is over after the postpeel mask cream has
been applied (Figure  15.13a and b). The inflammatory reac-
tion is beginning; therefore, the production of oxidants must
be stopped quickly and the free radicals must be scavenged to
break the cycle of self-perpetuating inflammation. The postpeel
mask cream reduces the risk of complications. The Easy TCA
or Easy TCA Pain Control solution has permeabilized the skin:
the components of the postpeel cream are rapidly absorbed
and ready to act precisely where the free radicals have been
produced. It scavenges the free radicals to reap the advantages
of inflammation (stimulation of the regeneration processes)
but not the disadvantages (uncontrolled and self-perpetuating
inflammation), which are the cause of most postpeel complica-
tions. The patient should be warned not to wash the treated
area until the next morning and to leave the postpeel mask to
work for at least 6 hours. The next morning, the treated area
should be washed with a mild soap or cleansing lotion and
rinsed with water. No metal jewelry should be worn next to the
skin on the treated areas for 48 hours.
Postpeel Mask Efficacy
A patient underwent a first peeling session on her décolletage
to treat small and large lentigines. A combined treatment was
used:
1.
Focally touch the large lentigines with one cotton bud
soaked with 0.15 ml of Only Touch peel. Do not press
the product on the skin and do not allow a long con-
tact time. Several successive touches are allowed until a
white frosting appears. After white frosting appears, do
not apply more product, because the white frosting will
progressively become gray, which is a sign of a focal deep
reticular penetration.
2.
Small lentigines also need to be treated because they will
become large. Easy TCA Classic is used. Typically, two
or three coats are applied until frosting clouds appear
(Figure 15.14).
At the end of peel application, the postpeel mask was
selectively applied on the left part of the patient’s décolletage,
and the anti-inflammatory effect could be seen a few minutes
after application. Pain dissipated on the left side, and redness
also began to dissipate (Figure 15.15).
Post Peel Mask
SKIN
TECH
2 g
3 g
1 g
2×0.5g
Post Peel Mask
SKIN
TECH
0.5 g
0.5 g
0.5 g
0.5 g
(a)
(b)
Figure 15.13  (a) Dosage card from the ETCA kit. One side of this card shows icons; beside each one is the quantity of cream needed for
each zone. To treat the face, 2 g are needed, while to treat the face and neck, 3 g are needed. (b) The lines on the other side of the card
help to correctly dose the postpeel cream: 1 line is equivalent to 0.5 g of postpeel cream (2 lines = 1 g and 4 lines = 2 g).
Table 15.9  Potential Depths of Action of ETCA
Depth of ETCA peel
Clinical signs
Repetition of ETCA
Superficial: partial removal of the epidermis
Erythema without frosting
4 peels: 1 per week
Basic protocol: removal of the epidermis. The
peel reaches the basal layer.
Pinpoint frosting
4 peels: 1 per week
Basic protocol: removal of the Grenz zone. The
peel reaches the Grenz zone.
Cloudy-white frosting
4 peels: 1 per week
Medium protocol: removal of the papillary dermis
Even pink-white frosting
After 1 month
Abrasive protocol: removal of the reticular dermis
Skin liquefaction after 24 hours
After 1 month
Figure 15.14  Application of Only Touch peel.

Easy TCA and Easy TCA Pain Control: Description and basic protocols      113
Five Minutes after Postpeel Mask Application
The anti-inflammatory effect is clearly visible on the left side,
compared to the right side. Edema and burning sensation dis-
appeared; the area was notably less hot compared to the other
side. Erythema is in phase of disappearing. Note the sharp dif-
ference between the area treated with postpeel mask and the
untreated side.
Ten Minutes after Postpeel Mask Application
The postpeel mask’s anti-inflammatory effect is nearly com-
plete on the areas treated with Easy TCA Classic up to the Grenz
zone. A large surface of skin has already returned to a normal
color, without any sign of inflammation. The areas treated with
focal application of the Only Touch peel are reacting more
slowly; the cream needs more time to reach the deep reticular
dermis and is partially diluted into the huge edema created by
the application of the focal deep TCA peel. Nevertheless, it is
apparent that many of the lentigines treated with Only Touch
show reduced redness and swelling (Figure 15.16).
Twenty Minutes after Postpeel Mask Application
Nearly all of the left side inflammation has disappeared. The
area located on the border of the nontreated area seems to have
resisted the action of the postpeel mask. This could result from
its proximity to a large area of inflammation that could “con-
taminate” the border area with persisting pro-inflammatory
components (Figure 15.17).
In summary, the postpeel mask suppresses a majority of
the signs of inflammation in less than 30 minutes. Even through
it suppresses the burning pain induced by acid application, it is
not a neutralizing cream. The postpeel mask has a quick and
strong anti-inflammatory action that can break the cycle of self-
maintained inflammation, which is potentially responsible for
many side effects.
DAILY CARE ROUTINE
Starting the day after any peeling, sun protection (Skin Tech
Melablock-HSP SPF 30 or 50+) is required and must be applied
until the end of the second week after the last peeling (applica-
tions at 9 a.m., 1 p.m., and 3 p.m.).
On the day after the first peeling, the patient should
begin applying, once or twice a day, the appropriate Skin Tech
creams described in Table 15.10, until the problem disappears.
The ETCA sessions are just the start of the skin treat-
ment. The peels should be combined with appropriate daily
care to effectively combat the signs of aging. Skin Tech’s care
creams have been specially designed to be applied not only in
combination with the peels but also in the long term (at least 6
months) to maintain results.
Precautions
The patient should avoid aggressive scratching or picking at the
flaking areas of skin, and should call the doctor with any ques-
tions or concerns, no matter how minor.
WEEKLY REPETITION OF EASY TCA
OR EASY TCA PAIN CONTROL
The ETCA basic protocol (basic protocol to achieve scattered
pinpoint frosting) is repeated four times,9 at weekly intervals
for a facial peel and at twice-weekly intervals for a body peel.
This repetition is one of the peel’s built-in safety features;
applying just one ETCA peel may not be enough and may cause
complications (Figure 15.18).
Easy TCA Pain Control could be applied in a slightly
different way. It is more efficient than Easy TCA classic, and
Figure 15.15  Postpeel mask on décolletage.
Figure 15.17  Postpeel mask on décolletage after 20 minutes.
Figure 15.16  Postpeel mask on décolletage after 10 minutes.

114      Textbook of Chemical Peels
two or three sessions might be sufficient for the patient. If the
peeling was deep (to the ­papillary dermis), the next peeling
can be performed only when all the signs of the first peel have
disappeared.
Repetition of Facial Peels
A schematic illustration of the repetition of ETCA treatment for
facial peels is shown in Figure 15.19. Eight days is the average
frequency; the outside limits are a minimum of 5 days (if the
condition of the skin allows) and a maximum of 15 days.
Repetition of Body Peels
Body skin is not as permeable nor does it have the same capac-
ity for regeneration as facial skin. For this reason, body peels
can be repeated only once every 2 weeks on average. The out-
side limits are a minimum of 10 days (if the skin allows) and a
maximum of 30 days.
Repetition of Abrasive Protocols
Abrasive protocols are repeated once a month. After four ses-
sions,9 a rest period of 4–6 weeks allows the skin to regenerate
fully and the results to be improved or maintained through the
use of appropriate cosmeceuticals.
Abrasive protocols alter the reticular dermis and cause a
definitive and irreversible skin reaction. The results achieved
in each session can therefore be considered definitive, and the
rest period of 4–6 weeks is a minimum. The subsequent peel
can, however, be planned well ahead of the last one: 3 months,
6 months, 1 year, and so on.
SKIN REGENERATION CYCLE
This chapter has described how to induce a cycle of skin regen-
eration: four successive peels followed by (at least) 6 weeks
of applying suitable care creams represents a cycle of skin
regeneration.
Table 15.10  Skin Tech Postpeel Creams
For acne
Purifying Cream: very hydrating cream suitable between peeling sessions or Purigel
gel: suitable for long-term treatment, after the end of the peeling sessions
For pigmentation
Blending Bleaching Cream 2 or 3 times/day
For dry skin
Vit. E Anti-oxydant cream as many times as necessary or Nutritive Cream Vit. A-C-E
Lipoic Complex as many times as necessary
Aging skin
DHEA-Phyto Cream, mainly for patients over 40 years old or ATROFILLIN cream for
patients suffering from subcutaneous fat atrophy
For skin laxity
ACTILIF cream 2 times/day: tensing effect due to DMAE
For postpeel erythema
IPLase Mask; also suitable after lasers, radiofrequencies, radiotherapy, etc.
Sun protection
Melablock-HSP 30 for cloudy-rainy weather, phototypes 1–3
Melablock-HSP 50+ for sunny areas, phototypes 4–6
Generally, if any cream produces a sensation of intense heat, suspend the application for a few days.
Daily care
8 days 8 days 8 days
1st
ETCA
2nd
ETCA
3rd
ETCA
4th
ETCA
1st
ETCA
1st
ETCA
2nd
ETCA
2nd
ETCA
3rd
ETCA
3rd
ETCA
4th
ETCA
4th
ETCA
8 days
8 days
8 days
8 days
8 days
8 days
Figure 15.18  Diagram showing repeated cycles of skin regeneration. A maximum of three cycles is possible. More than 90% of cases are
treated in one cycle. It is extremely rare to have to apply a third cycle.
NUTRATITIVE CREAM VIT. A-C-E LIPOIC COMPLEX morning/evening(moisturizer)
CLEANSER twice a day
Sun protection: MELABLOCK-HSP® SPF 50+
8 days
8 days
8 days
8 days
6-week period
REPEAT
if necessary
DAILY
CARE
NO SEASON LIMITATION
PROFESSIONAL
ADVICE
1st
2nd
3rd
4th
5th
EASY TCA CLASSIC sessions
EASY DROXY COMPLEX PEEL sessions
Figure 15.19  Repetition of Easy TCA on the face.

Easy TCA and Easy TCA Pain Control: Description and basic protocols      115
What to Do after the First Skin Regeneration Cycle
A single cycle of regeneration is enough to achieve the desired
results in the vast majority of cases, but when the results of the
first cycle are deemed inadequate, another regeneration cycle
can be repeated after 6 weeks of applying cosmeceuticals at
home, if the doctor believes that applying more peels will help
improve the patient’s skin (see Figure 15.18). Up to three regen-
eration cycles can be repeated in some cases.
MAINTAINING RESULTS IN THE LONG TERM
Easy TCA or Easy TCA Pain Control, in base protocol, is more
of a stimulating peel than a destructive one, and there is no risk
of repeated peels making the skin less capable of regenerating
in the future. One regeneration cycle per year (four peels plus
6 weeks of postpeel care), combined with daily care creams,
helps the skin stay healthy in the long term. This technique is
commonly known as SYFE, or “Stay Young Forever.”
TREATING PHOTOAGING AND SMOKERS’ SKIN
Applying the Peel
The Easy TCA or Easy TCA Pain Control basic protocol can be
used to treat the visible signs of aging: dull, dry, wrinkled skin
and uneven skin tone. To combat the signs of photoaging, the
basic protocol should be followed as described above. Four (some-
times five) peels should be applied in all, at weekly intervals.
NOTES

1. The breakdown of the corneodesmosomes has deeper repercus-
sions in the skin (see Chapter 6).

2. See Chapter 6 for more information on the relationship between
pKa and peels.

3. Which some doctors judge to be more than 75%.

4. The amount of TCA at 50% m/m that should be injected into
each bottle of base solution is usually 4.8 ml. There are different
types of presentation kits (Classic kit for 12 peels, Classic kit for
24 peels, and Starter’s kit for 4 peels), and it is preferable to refer
to the information contained in each kit.

5. See the discussion at the start of Chapter 14 regarding differ-
ences between ETCA and TCA–SAS peels.

6. Recall that the penetration depth of TCA also depends on the
pressure with which it is applied: it is recommended to apply the
same amount of pressure as when scratching.

7. This is why there is usually a lot of solution left when pinpoint
frosting appears. The volume of solution allowed for is to treat
oily, thick, and resistant skin.

8. With some protocols, it is recommended to produce cloudy-
white frosting locally (see Chapters 16 and 22 on the treatment of
melasma and lentigines).

9. Four times is, of course, an average. If the results are obvious,
the treatment can be stopped after three sessions. If results are
slow to appear and the skin is thick, up to six peels might be
necessary.

16
Treating melasma, chloasma, and postinflammatory
hyperpigmentation
The histological features of melasma and chloasma are dis-
cussed elsewhere in this book. The standard recommendations
for treatment often mention only the topical applications treti-
noin, hydroquinone, fluorinated corticosteroids, sun protec-
tion, and tyrosinase inhibitors; chemical peels are considered
as a last resort because of their potential to turn melasma into
postinflammatory hyperpigmentation (PIH). Conventional
peels require conscientious prepeel preparation to avoid this
danger. Easy TCA (ETCA), in combination with appropriate
postpeel care, can be used to treat melasma without the con-
straints of prepeel preparation (Figures 16.1–16.5). Laser ther-
apy is not recommended for treating melasma because lasers
are difficult to use and have been linked to many common side
effects. The numerous evolutions and promises of laser therapy
have not solved these problems.
Before performing an Easy TCA Classic or Easy TCA Pain
Control peel, it is not usually necessary to prepare the skin, but
for patients with long-standing or resistant melasma or with a
skin phototype higher than Fitzpatrick III, preparing the skin
can be worthwhile and improve results:
PREPARING THE SKIN
The following are recommended to prepare the skin before the
peel:
•
Blending Bleaching Cream (see Chapter 3): Applied twice
a day on the melasma itself and once a day on the rest of
the face.
•
Melablock-HSP 50+ (see Chapter 3): Applied all over the
face in the morning and then reapplied every 3 hours on
the melasma itself.
Practitioners should understand that while a peel elimi-
nates the constituted stock of melanin, it does not act on mela-
nin synthesis. Blocking melanin synthesis or melanosomes
transfer is needed to insure a long-term result (see Table 16.1).
In other words, Easy TCA can eliminate the melanin
responsible for the melasma but will not act on melanin syn-
thesis, which means it will not prevent melanin neo-synthesis.
Preventing the melasma from recurring requires long-term
daily care with products that block the chemical and enzyme
pathway from tyrosine to the large polymer melanin.
APPLYING THE EASY TCA PEEL SOLUTION
Refer to Chapter 15 for details about the correct application of
Easy TCA. Melasma can be treated in two different ways:
1.
The basic protocol can be used, as in cases of diffuse, epi-
dermal pigmentation.
2.
A focal, deeper application only on the melasma area
can be used. A first coat of ETCA solution is applied to
the melasma and left to dry completely (Figure 16.6). The
desired endpoint is cloudy pink-white frosting that is the
same shape as the melasma plus 1 cm. If there is no frost-
ing after the first coat, additional coats of ETCA solution
must be applied until cloudy pink-white frosting occurs.
There is no set number of coats required, and there is no
way of knowing in advance how many to apply. Each coat
of ETCA solution must be left to dry completely before
applying the next coat if the skin has not frosted suffi-
ciently. More resistant skin shows cloudy pink-white frost-
ing only after three or four coats.
Once localized cloudy frosting has been achieved on the
melasma, the ETCA solution is applied to the whole face, fol-
lowing the instructions for the basic protocol.
It is up to the doctor whether this last coat should go over
the frosting on the melasma as well:
•
If the frosting on the melasma is pink and even, with
some epidermal sliding,1 the ETCA solution should not be
applied there again.
•
If the frosting is uneven, the ETCA solution can be applied
to the melasma again at the same time it is being applied
to the whole face.
The previous coat must be completely dry before another
coat can be applied.
APPLYING THE POSTPEEL MASK
The ETCA postpeel mask cream is applied to the whole face,
starting from the melasma. A little more of the postpeel mask
is applied to the melasma itself.2 The components of the ETCA
postpeel mask cream work directly and specifically on pig-
mentation. If possible, after the mask has been applied, the face
should not be washed until the following morning.
POSTPEEL DEVELOPMENTS
The acids dehydrate the keratinocytes and make the melasma
appear darker the day after the peel and for several days after-
ward (Figure 16.6). This is not a pigmentary change. The dark-
ening of the melasma in the first few days after the first ETCA
peel is, on the contrary, a positive prognostic factor, a sign that
the acid is working.
REPEATING THE PEEL
The ETCA peel is repeated four times at weekly intervals (see
Chapter 15). The doctor can change the total number of peels as

Treating melasma, chloasma, and postinflammatory hyperpigmentation      117
Table 16.1  Active Products against Melanin
Products that
can
Nonlimitative list
Remarks
Prevent melanin
synthesis
Tretinoin, tranexamic
acid, or other
anti-inflammatory
molecules
They typically have
little effect on
melasma after the
melanin has been
transmitted to
keratinocytes.
Lower melanin
synthesis
Azelaic acid, arbutine,
hydroquinone, kojic
acid, licorice
extracts, resveratrol
and oxyresveratrol,
polyphenols, vitamin
C, phytic acid
Accelerate
epidermal
turnover, to
limit the
transfer of
melanin
through
melanosomes,
to reduce
melanin, etc.
Arbutin, glabridin,
niacinamide,
retinoids, and
linoleic and linolenic
acids
Chemical peels,
especially, allow
the destruction of
the cells containing
melanin, to
eliminate the
actual epidermal
(or dermal,
depending on the
peeling depth)
stock of it.
Figure 16.1  Melasma on the neck. The position might suggest
poikiloderma of Civatte, but there is neither telangiectasias nor any
atrophy of the skin around the follicle.
Figure 16.2  On the third day after ETCA treatment, epidermal
melanin has been eliminated.
Figure 16.3  Results after four ETCA peels and Blending Bleaching
Cream.
Figure 16.4  Treatment of melasma with ETCA and Blending
Bleaching Cream. Patient with light skin phototype.
Figure 16.5  Treatment of melasma with ETCA and Blending
Bleaching Cream. Patient with dark skin phototype.

118      Textbook of Chemical Peels
well as the intervals between them, depending on the condition
of the patient’s skin. The minimum recommended interval is
5 days and the maximum 15 days.
DAILY POSTPEEL CARE
Postpeel care is essential to achieve optimum results and avoid
complications (Table 16.2).
Lightening creams (Blending Bleaching Cream) and sun
protection (SPF 50+) should be applied beginning on the morn-
ing after the first ETCA peel.
MELANIN SYNTHESIS AND HOW BLENDING
BLEACHING CREAM WORKS
Figures 16.7 through 16.15 illustrate the process of melanin syn-
thesis from the amino acid tyrosine up to effective melanin.
COMBINATION OF EASY TCA AND
BLENDING BLEACHING CREAM
The complex formulation of Blending Bleaching Cream makes
it highly effective. This effectiveness is the reason Blending
Bleaching Cream is a required element in treatments for pig-
ment problems.
(b)
(a)
(d)
(c)
Figure 16.6  (a) Melasma before treatment. (b) Cloudy-white frosting after application of ETCA solution. (c) Flaking on third and fourth
day. (d) Results after day five with the second ETCA combined with Blending Bleaching Cream.
Table 16.2  Postpeel Care
Boost the results
Blending Bleaching Cream during the regeneration cycle
• On the whole face in the morning
• On the melasma only at midday and in the evening
Protect against stimulation from the sun’s
rays
Melablock-HSP 50+
• Every 3 hours (during the cycle)
• Sun avoidance (6 months–1 year)
Maintain the results
(6 months–1 year daily care maintenance)
Blending Bleaching Cream: 3 days per week
• Melablock-HSP 30: morning and midday
• Four ETCA or ETCA Pain Control sessions repeated once or twice a year as necessary

Treating melasma, chloasma, and postinflammatory hyperpigmentation      119
Keratinocyte
Melanin transport
Melanosome
Golgi apparatus
Tyrosinase + transport
vesicle
Ribosomes on
ENDOPLASTIC
RETICULUM
Nucleus
Cell membrane
Figure 16.7  Melanin synthesis (courtesy of Skin Tech).
Active products of Blending Bleaching have to reach quickly the basal
layer: Ethylene diglycol concentrates active products around
the basal layer
Tyrosinase is synthesized by ribsomes or E.R. then
transferred to Golgi where it works on tyrosine (transport
proteins with clip-clap system) to build melanin polymer
Tyrosine
DOPA
Dopaquinone
Basolateral plasma membrane
Nucleus
Membrane-bound
polyribosomes
on ER
Golgi
apparatus
Keratinocyte
Melanin transport
Melanin granule
(no tyrosinase activity)
Melanosome III
(tyrosinase + melanin)
Melanosome II
(tyrosinase + melanin)
Tyrosinase
synthesis
Tyrosine
Rough endoplasmic
reticulum
Golgi
Melanin synthesis pathway
Melanosome
Tyrosinase
transport vesicle
Tyrosinase
Tyrosinase
Oxidation
Oxidation
Figure 16.8  The tyrosinase pathway.

120      Textbook of Chemical Peels
Tyrosine
Tyrosinase
Arbutine
Morus extracts
Aspergillus (Kojic)
Licorice - glabridin
Morus extracts:
Contain OXYRESVERATROL 30 × more
active compared to kojic acid
Contains MULBERROSIDE (A, B, F);
MULBERROFURANE; MORACIN (N, O, C)
NON competitive inhibition of
tyrosinase
Inhibit oxidation of tyrosine by tyrosinase
Arbutin:
Direct derivative of hydroquinone
The glycosidic bond is hydrolyzed
in vivo by the normal skin
microflora leading to the controlled
release of hydroquinone
Arbutin acts by tyrosinase
activity inhibition
Licorice -
contains i.e. glabridin
Tyrosinase inhibitory properties
Anti-inflammatory properties
ASPERGILLUS extracts
contains natural kojic acid (KA)
KA acts by inhibiting the production of
free tyrosinase
Potent antioxidant
Tyrosinase
DOPA
Dopaquinone
Oxidation
Oxidation
Figure 16.9  Interrupting the tyrosinase pathway.
Tyrosine
Tyrosinase
Tyrosinase
Phaeomelanin
Aspergillus
extracts
and kojic acid
Oxidative polymerization of HBTA
(Cysteinyldopa oxidized in -> HBTA
5-hydroxy 1,4-benzothia-zinylalanine
Vit C (ascorbyl phosphate Mg)
ANTIOXIDANT
is able to reduce back dopaquinone into DOPA,
avoiding dopachrome and melanin formation
DOPA
Dopaquinone
Back reduction
Oxidation
Oxidation
Figure 16.10  Two additional methods to avoid dopaquinone converting into the next subproduct (dopachrome).

Treating melasma, chloasma, and postinflammatory hyperpigmentation      121
As mentioned earlier, Blending Bleaching Cream inhib-
its melanin synthesis at the melanocyte level and also inhibits
the transfer of melanosomes to keratinocytes, but it does not
remove the actual skin stock of melanin.
•
The cream’s latency of action when used as a unique treat-
ment is 8 weeks.
•
Using it in combination with alpha hydroxy acid (AHA)
or trichloroacetic (TCA) peels is ideal because the skin’s
higher postpeel permeability allows the cream to pen-
etrate deeper and faster, increasing and speeding up the
results.
Potential Problems Persistent Dark
Ring on the Edge of the Melasma
In this case the pink-white frosting has not gone beyond the
edge of the melasma; it should go 1 cm beyond. The peel could
not work on the melanin around the edges (Figure 16.16).
Recurrence
To prevent the melasma from recurring:
•
It is important to check that the patient has kept up with
postpeel care.
•
The four ETCA peels should be repeated once or twice a
year.
•
The need for the following should be stressed:
•
Sun protection with Melablock-HSP 50+.
•
Blending Bleaching Cream.
•
A strong corticosteroid can be applied to the melasma
immediately after the postpeel mask cream, after every
peel, to reduce any inflammation.
•
The use of 5% hydroquinone (and 0.05% tretinoin) in com-
bination with the Blending Bleaching Cream should be
evaluated.
Melasma Chart
Figure 16.17 gives general advice about decisions to be made
during a full course of melasma treatment. Note that the advice
represents a personal point of view only. Medical treatments
depend on the diagnosis and the treatment decision of the prac-
titioner, who has full responsibility for treatment decisions and
possible side effects resulting from them.3
POSTINFLAMMATORY HYPERPIGMENTATION
With topical treatment alone, PIH usually has a good prog-
nosis. Blending Bleaching Cream or a prescription cream
Tyrosine
5-6 Indolequinone
5-6 Dihydroxyindole
DCT
Tyrosinase
Phaeomelanin
2 active molecules
acting at this level
11 active molecules acting as
antityrosinase
2 active molecules (ALA-P and kojic acid)
act as anti dopachrome tautomerase and
therefore limit polymerization
14 active molecules acting at these levels
Melanin
Polymerization
Leucodopachrome
Dopachrome
DOPA
Dopaquinone
Back reduction
Figure 16.11  The melanin pathway.

122      Textbook of Chemical Peels
5-6 Dihydroxyindole
Melanin
Polymerization
1-aminoethyl phosphinic acid
(ALA-P) kojic acid
DCT
ALA - P (albatin)
Stabilizes DOPACHROME
Inhibits dopachrome tautomerase
Opposes further spontaneous polymerization
Figure 16.12  The ALA-P pathway to melanin (courtesy of Skin Tech).
Tyrosine
5-6 Indolequinone
5-6 Dihydroxyindole
Phaeomelanin
Melanin reduction
Licorice extracts
Ascorbyle Phosph.Na
Eumelanin
Polymerization
Leucodopachrome
Dopachrome
DOPA
Dopaquinone
Back reduction
Figure 16.13  Eumelanin + phaeomelanin + reduced melanin = mixed melanin (courtesy of Skin Tech).

Treating melasma, chloasma, and postinflammatory hyperpigmentation      123
with hydroquinone 2%–4% and effective sun protection
(Melablock-HSP 50+) should be used. PIH tends to improve
gradually and naturally, and disappears completely if it is
not too severe and the melanocytes are not stimulated by UV
photons.
PIH, whether caused by trauma (e.g., a mosquito bite,
scratch, or wound), laser or intense pulsed light (IPL) treat-
ment, or another peel, usually responds to four sessions
of  ETCA following the same guidelines as for melasma
treatment.
Phaeomelanosome
Melanocyte
Dendrite
Nucleus
Kojic acid
Inhibits dendritization
Eumelanosome
Premelanosome
Basal membrane
??
Melanin grains
Melanosomes
Keratinocytes
Melanocyte
Figure 16.14  The influence of kojic acid (courtesy of Skin Tech).
Kojic acid
inhibits dendritization
Basal layer
Receptors triggered by free
radicals initiate production
of tyrosinase enzyme
Basal layer
Tyrosinase activates
melanocyte to start
producing melanin
Epidermis layer
Melanin is transfered from
melanocyte to skin’s surface
Figure 16.15  The effect of the sun on the skin. Left: Free radicals produced by sun exposure switch on melanin production. Retinol,
tocopherol, vitamin C, kojic acid, and licorice oppose oxidative processes are induced by UV and responsible for inflammatory response.
Right: Melanin accumulates in the epidermal cells. Retinol stimulates epidermal turnover; allantoin is a keratolytic and a moisturizer.

124      Textbook of Chemical Peels
Figure 16.16  Persistence of a dark ring on the edge of the melasma.
Melasma
1st Peel
2nd Peel
Daily Care
(DC*)
Blending
Bleaching
Cream
(morning & evening)
+
Melablock-HSP
SPF 50+ or 30
(9am 12pm 3pm)
Suspend Peels
Blending Bleaching 2x/day
+ Hydroquinone 3%
+ Melablock-HSP SPF 50+
6-8 weeks
then peel again
according to phototype
ETCA* GZ* on melasma
+ BL* rest of face
+DC*
Before peel, check if
1 week
Worse
Stable
Better/Cured
3rd Peel
Before peel, check if
1 week
ETCA* BL* Full face
+ DC*
+ Hq*
ETCA* BL* Full face
+ DC*
Phototypes 1-3
Phototypes 4-6
Worse
Stable
Better/Cured
Suspend Peels
ETCA* GZ* on melasma
+ BL* rest of face
+DC* + Hq*
ETCA* BL* Full face
+ DC*
1 week
4th Peel
Before peel, check if
Worse
Stable
Better/Cured
Suspend peels
Last ETCA* BL* Full face
+DC*: 3-12 months
1st Peel
2nd Peel
ETCA* BL* Full face
Before peel, check if
1 week
Worse
Stable
Better/Cured
3rd Peel
Before peel, check if
1 week
ETCA* BL* Full face
+DC*
+Hq*
ETCA* BL* Full face
+ DC*
Worse
Stable
Better/Cured
Suspend peels
ETCA*1 BL* Full face
Hq*+DC*
ETCA* BL* Full face
+ Daily care
1 week
4th Peel
Before peel, check if
Worse
Stable
Better/Cured
Suspend peels
Last ETCA* BL* Full face
+DC*: 6-12 months
ETCA* GZ* on melasma
+ BL* rest of face
+DC* + Hq*
PREPEEL CONDITIONING
3-4 weeks
Blending Bleaching Cream
2 times a day
+ Hydroquinone 3%
2 times a day
+ Melablock HSP SPF 50+
9am - 12pm - 3pm
*ETCA: Easy TCA - *BL : Basal layer - Frosting points - *GZ: Grenz Zone - Frosting Clouds exactly on melasma - *Hq: Hydroquinone 6% 2x/Day to be mixed 50/50 with Blending Bleaching immediately before applying - *DC : Daily Care
Figure 16.17  The melasma chart.

Treating melasma, chloasma, and postinflammatory hyperpigmentation      125
NOTES

1. Fine wrinkling of the skin when pinched: the acid coagulates
proteins that ensure cohesion between the dermis and epider-
mis, and the epidermis slides on the dermis to which it is no
longer firmly attached.

2. The quantities of postpeel mask cream have been overestimated
to allow for more cream to be applied in certain areas. Each small
tube contains 10 g of postpeel mask, and 8 g is enough to do four
basic facial protocols.

3. Also see:

17
Treating acne
Classic recommendations for treating acne with peels are the
following:
1.
Treat acne to stop infection and stop inflammation, using
antibiotics, retinoids, hormonal treatments, and so forth.
Eventually, clean the skin, opening comedones, papules,
and pustules.
2.
Only when acne is no longer active, begin peels for a better
cosmetic appearance.
Clinical experience has shown that there is a much
faster—yet largely unknown—method to eliminate acne, with-
out using antibiotics or retinoids. It is very simple to physically
extract from the skin the cause of infectious acne, and at the
same time regenerate good skin architecture.
The treatment that will be described in this chapter con-
sists of extracting open or closed comedones and pustules, and
applying an Easy TCA or Easy TCA Pain Control peel immedi-
ately after extraction.
EXTRACTION OF COMEDONES, ELIMINATION
OF MICROCYSTS AND PUSTULES
After disinfecting the skin, the comedones are extracted using
a comedone extractor. Pustules and microcysts (closed com-
edones) are extracted by cutting the thin epidermal layer that
covers them and gently pressing the skin to push them out.
Epidermal cutting can be done with a No. 11 scalpel blade or,
more simply, a needle (18-gauge).
The doctor will judge whether he or she prefers to extract
all the comedones before the first of the four Easy TCA (ETCA)
peels or to extract only some of the comedones before each peel.
Patients usually prefer the second option as it is less aggressive.
The choice depends on the number of comedones to be
extracted: if there are only a few lesions, they all can be extracted
at the same time; numerous lesions should be extracted pro-
gressively before each of the four ECTA sessions (Table 17.1).
EXAMPLES OF INDICATIONS
Indications include comedonian acne (Figure 17.1), microcystic
acne (Figure 17.2), typical juvenile acne (Figure 17.3), and papulo
pustulous acne (Figure 17.4).
APPLYING THE PEEL SOLUTION
As soon as the comedones have been removed, the ETCA or
Easy TCA Pain Control (PC) solution is applied following the
basic protocol (Chapter 15). The solution penetrates and disin-
fects the openings left by the comedones. This localized pen-
etration has not been reported to have any negative effect.
The irritation caused by extracting the comedones can,
however, cause the ETCA/Easy TCA PC solution to penetrate
more deeply and produce “cloudy” rather than “pinpoint”
frosting. To reduce the risk of cloudy frosting developing, the
cotton buds should be squeezed out properly before applying
the ETCA/Easy TCA PC solution.
Whether all acne lesions will be opened at the same time
before the first peeling session or progressively before each
session is a decision the doctor must make. Note that opening
many acne lesions could cause a strong inflammatory reaction
and be painful for the patient. A better option seems to progres-
sively open acne lesions before each peeling session. Figure 17.5
shows how to progressively eliminate physically acne lesions
before every peeling session.
CARE BETWEEN AND AFTER PEELS
Care creams (Table  17.2) should be used beginning on the
morning after the first peel. The skin should be cleaned in the
morning and evening with a cleanser.
Between Peel Sessions
•
In the morning, Purifying Cream should be applied to the
whole face.
•
In the evening, Purifying Cream should be applied only to
the areas with acne.
Long-Term Maintenance Treatment
Oil-free Purigel should be applied once or twice a day accord-
ing to medical advice. The four ETCA peeling sessions are
repeated once or twice a year.
Combined Antibiotic Treatment
The doctor will decide if it is necessary to perform a com-
bined medical treatment. For example, if papular acne does not
improve after the first two sessions, the peel should be com-
bined with 100 mg/day of minocycline.
Treating Acne Side Effects
•
Postacne pigmentation on the face (Figure  17.6) can be
treated in the same way as melasma, combining ETCA
(basic protocol), Blending Bleaching Cream, and sun pro-
tection (Melablock-HSP 25+ is sufficient).
•
Postacne pigmentation on the décolletage can be treated
in the same way, but there is also an abrasive protocol
designed especially for the décolletage: abrasion plus
occlusion of the postpeel mask without the application of
acid (see Chapters 20 and 21).
•
Postacne pigmentation on the back does not respond readily
to ETCA alone. The protocol developed for treating stretch
marks produces excellent results—not only on the residual
pigmentation but also on the depth of the acne scars.
•
Facial acne scars can be treated by dermabrasion followed
by peeling (see Chapter 21).
Figures 17.7–17.9 show more results for acne treated with
ETCA peels. ETCA can treat the activity of acne, but acne scars

Treating acne      127
Table 17.1  Protocol for Extraction
Action
Material needed
Details
Skin disinfection
Alcohol or chlorexidine
Extract the “acne lesions”
Comedone extractor
18-gauge needle
No. 11 scalpel blade
Extract blackheads (comedone extractor) (Figure 17.1).
Open microcysts and pustules (needle, blade) (Figures 17.2, 17.3, and 17.4).
Do not touch papules.
If there are only a few lesions, all lesions can be extracted together, just
before the first of the four ETCA peels; if there are many lesions, some can
be extracted before each of the ETCA sessions.
Apply peeling solution
Easy TCA
or
Easy TCA Pain Control
Immediately after extracting the acne lesions, apply the ETCA (or ETCA PC)
solution on the whole face and allow it to dry completely before applying
more coats.
End point: Pinpoints of frosting appear or, at the most, localized cloudy-white
frosting.
Apply the postpeel mask
cream
Postpeel mask
The ingredients of the ETCA or ETCA PC postpeel mask stimulate skin
regeneration and reduce the risk of side effects, thanks to their anti-
inflammatory and antioxidant action.
Do not wash the skin for at least 6 hours after application of the mask to
allow the active ingredients in the postpeel mask and the peel solution to
work.
Repeat the peel four times
at weekly intervals
Eventually extract
comedones and open
other acne lesions
before each peeling
Repeating the peels in the proper manner ensures good results and reduces
the risk of side effects. The doctor decides on the interval between peeling
sessions, depending on the condition of the patient’s skin.
Minimum interval between two peels: 5 days (if less than 5 days, the peel
might be too deep).
Maximum interval between two peels: 15 days (if more than 15 days, results
will be less satisfactory).
Maintenance treatment
Skin Tech Cleanser
Skin Tech Purifying Cream
Skin Tech Purigel
Cleanse the skin every morning and evening with Skin Tech Cleanser
(balances skin pH at 5).
Extract blackheads/whiteheads and microcysts once a month.
Repeat one session of four ETCA peels, once a year.
As long as peelings are done, apply Purifying Cream twice a day. Two weeks
after the last peeling, stop using Purifying Cream and substitute it with
Purigel once a day for a long-term maintenance program.
(b)
(a)
Figure 17.1  (a) Comedones before treatment. (b) Immediately after comedone extraction and ETCA peels.

128      Textbook of Chemical Peels
that remain after ETCA should be treated using the anterior
abrasion technique described in Chapter 21. Additional tips are
listed in Table 17.3.
Normal Evolution and Problem Solving
Results should be evident after the first few peels. If this is not
the case, the doctor should develop an etiological diagnosis and
suitable treatment: antibiotics, hormone therapy (cyproterone
acetate), or a combination of treatments (Table 17.4).
GENERAL REMARKS ON TREATING
ACNE WITH PEELS
Speed of Results
When treating acne, as with melasma, obtaining results quickly
is a positive sign that could indicate excellent end results. If the
acne or melasma improves after the first session, the patient can
usually be guaranteed satisfactory and rapid results. If, on the
other hand, the situation has not started to change after the sec-
ond ETCA session, it is likely that results will be slow and only
partial, and other treatments should be combined with the peels
(antibiotics with acne and hydroquinone with melasma). It is best
to notify patients of these possibilities before starting treatment.
Figure 17.2  Microcystic acne.
(a)
(b)
Figure 17.3  (a, b) Detail of the temple area of a young patient
with papulopustular acne treated with ETCA and Purifying Cream.
(a)
(b)
 
Figure 17.4  (a) A patient with acne that did not respond to a 3-month course of tetracycline. The antibiotics were stopped and four ETCA
peels were applied at weekly intervals combined with Purifying Cream. (b) The results at the end of the first regeneration cycle—there is
no scarring.

Treating acne      129
Treatment Must Remain Multifocal
•
Normalize the rate of exfoliation/hyperkeratinization by
enhancing elimination of dead cells and hydrating the skin
properly: retinyl palmitate, glycolic acid, and glycyrrhet-
inic acid.
•
Eliminate or reduce infection: disinfectants, tea tree oil,
and azelaic acid.
•
Help the pilosebaceous units drain: glycolic acid, lactic
acid, retinyl palmitate, glycyrrhetinic acid, and azelaic
acid.
•
Eliminate or reduce inflammation: tea tree oil, glycyrrhet-
inic acid, and azelaic acid.
•
Reduce sebum production: thiosome.
The protocols established for treating acne with ETCA in
no way prevent the doctor from choosing the treatment that is
best for the patient based on his or her knowledge and personal
experience.
ETCA helps combat acne lesions by exfoliating the skin
chemically and through use of the postpeel mask cream. Daily
care helps maintain the results of dermatological or systemic
acne treatments. No peel can change the genetic makeup of a
Table 17.2  Comparison between Purifying and Purigel Creams
Purifying Cream
Purigel
Antiacne moisturizing cream for daily
care between peeling sessions
Non-oily gel for long-term
maintenance daily care
Glycolic acid (8%): softens the skin,
prevents pores from clogging,
stimulates epidermal turnover (pH 4)
Thiosome: lowers sebum
production
Retinol: tretinoin precursor, helps
drain the pilosebaceous units
Burdock extracts:
anti-inflammatory,
antibacterial
Vitamin E (tocopheryl acetate)
anti-free-radical, breaks the vicious
circle of oxidation–inflammation
Keratolytic
Triclosan: antiseptic, anti-
inflammatory, antimycotic
Triclosan: antiseptic,
anti-inflammatory,
antimycotic
Glycyrrhetinic acid: hydrates,
antipruritic, anti-allergic
Salicylic acid: unclogs
pores, keratolytic
Tea tree oil: extract of an Australian
shrub, as active as benzoyl
peroxide but without the pro-oxidant
effect—antibacterial, antiviral,
antimycotic, anti-inflammatory
Menthol/camphor: fresh
skin sensation
= Open comedones, subcutaneous cysts, pustules, IMMEDIATELY before peels
6 weeks regeneration
8 days
Sun protection: Melablock HSP 30
8 days
8 days
Time line
2nd
3rd
1st ETCA
session
4th ETCA
session
Purifying Cream
Purigel
Figure 17.5  Treatment plan for acne.
Figure 17.6  Active acne and acne pigmentary sequellae on a phototype 5 patient. Result of treatment with ETCA, 4 peels, 1 peel/week,
in combination with Blending Bleaching Cream and sun protection.

130      Textbook of Chemical Peels
Figure 17.7  Acne, before and after ETCA peel.
Figure 17.8  Acne, before and after ETCA peel.
Figure 17.9  Acne, before and after ETCA peel.

Treating acne      131
particular individual or his or her skin. For example, applying
an acid does not reduce androgen production or change the
sensitivity of sebocyte membrane receptors or the strength of
5-alpha reductase. The peel works on other parameters, such
as intercorneocyte cohesion or unclogging the openings of
the pilosebaceous units. Maintaining the results in the long
term depends on prolonged treatment with Purifying Cream,
which should be applied twice a day, starting on the day
after the first peel and continuing to at least 6 weeks after the
last peel. Long-term maintenance of the results sometimes
requires continued use of Purifying Cream or Purigel for sev-
eral months.
Table 17.3  Frequent Questions and Answers about Acne Treatment
What happens when the acid
penetrates through the openings left
by the extracted lesions?
ETCA solution disinfects everything. There have
been no reported adverse effects from this
focal deeper penetration. On the contrary, it
provides “deep pixelized stimulation.”
The irritation resulting from handling the
lesions can cause the ETCA solution to
penetrate more deeply and cause
cloudy-white frosting instead of pinpoint
frosting.
When should I begin applying daily
care?
Purifying Cream daily care starts the next day
after the first peeling session, or even before it.
Purifying Cream should be applied until the
end of the second week after the last peeling.
Purigel should be initiated 2 weeks after the
end of the peeling sessions; continue until
the acne is stabilized.
Should I use a sun protection?
Sun protection and sun avoidance are mandatory
after any peeling. Melablock-HSP, SPF 30 or
50+
For acne, Melablock-HSP SPF 30 is usually
sufficient.
Table 17.4  Frequent Problems in Acne Treatment and How to Solve Them
Difficulty extracting comedones
Place hot water compresses on the skin and try again, or try again after having done one
ETCA. Suction devices can be used to help extract comedones.
The patient is on isotretinoin
(Roaccutane).
It is better to delay the treatment for a few months; if you cannot delay, treat the patient very
carefully; do not go beyond pinpoint frosting. No peel beyond the basal layer should be
performed on patients who are taking oral retinoic acid.
The patient is using AHAs, tretinoin, or
topical benzoyl peroxide.
These products reduce skin permeability to different degrees. There is a risk of increased
penetration, so be careful how much ETCA you use. Do not go beyond pinpoint frosting.
Aggravation of the acne after the first
session
Give the patient oral antibiotics and continue with the ETCA. Antibiotics commonly used:
oxytetracycline (500 mg/d), doxycycline or minocycline (100–200 mg/d); erythromycin
(500 mg 2x/d).
Aggravation of acne, and the patient
already is using antibiotics
Check the patient’s hormonal status and use of contraceptive pill, continue treating the patient
with antibiotics (eventually shift to another kind of antibiotherapy), and continue doing ETCA.
Acne recurrence after few weeks of
improvement
Continue the maintenance treatment, repeat another four ETCA peels, or switch to
Roaccutane.
How long is daily maintenance needed?
Peelings can reorganize the skin architecture and eliminate the visible signs of acne. They
cannot treat the cause of acne (i.e., peelings do not affect 5-alpha reductase activity).
Maintenance treatment should be employed as long as the skin needs it—as long as the
body produces acne.
The patient does not want any flaking.
Use Easy Phytic Solution or Easy Droxy Complex peel: these AHA peels offer good results in
cases of acne, without flaking. They are the best choice for teenagers and people with active
social lives.
Use a nonpeeling technique: daily application of Dermasebex foam until acne inflammation
disappearance, then two or three times/week for maintenance.
Folliculitis barbae
Unless it requires treatment with oral antibiotics, folliculitis of the beard can be treated in the
following manner: Open the “whiteheads” with the tip of the No. 11 scalpel. Drain the
infection by squeezing gently and disinfect the skin. Apply ETCA to the whole face until
pinpoint frosting occurs. Apply the postpeel mask. Daily care: Apply Purigel after showering.
Using Dermasebex foam for shaving (mechanical) or after shaving (electrical) prevents
folliculitis barbae from developing.

18
Treating multiple keratoses on the scalp
A balding scalp often shows signs of accelerated photoaging,
with scattered lentigines and/or keratoses. Many peeling treat-
ments are available (Table 18.1).
PREPARING FOR THE PEEL
A peel for treating keratoses or lentigines of the scalp should
be quite deep—the average depth is 5/7 or 6/7. This depth
of peel applied on a large, low-permeability surface can be
quite painful for the patient, because several coats usually
are needed to reach the correct depth. The first coats are not
too painful, but as the acids make their way to the deep der-
mis, inflammatory pain develops and the passes of cotton
buds begin to feel like cuts with razor blades to the patient.
Analgesics or nerve blocks are therefore recommended for the
patient (Table 18.2).
This chapter describes the application of Easy TCA, Easy
TCA Pain Control, or Unideep to treat scalp keratoses. The use
of Lip & Eyelid Formula and Easy Phen Light is described in
Chapters 34, 35, and 36.
APPLYING THE EASY TCA (OR EASY
TCA PAIN CONTROL) SOLUTION
The first coat of the peeling solution is applied to the whole
scalp and left to dry. Additional coats are then applied as nec-
essary to achieve an even white-gray frosting of the skin.
The keratoses are relatively impermeable to acids. If a
focal application of peeling solution has not been done, the
frosting typically is uneven (Figure  18.1). As soon as there
are signs of epidermal sliding, the frosting is sufficient
(Figure 18.2) (see Chapter 14). The acid works by “undermin-
ing,” or going underneath, the keratosis. Each coat is left to
dry before applying the next one. Up to five coats of Easy
TCA are sometimes required. Other peels listed in Table 18.3
require fewer coats.
POSTPEEL DEVELOPMENTS AND CARE
Flaking occurs after at least 1 week and lasts 4–5 days. On
days 1–6, IPLase cream should be applied to combat the
formation of free radicals and reduce erythema; vitamin E
­antioxidant should be applied many times a day to achieve
good ­hydration. Vaseline could then be applied to help
the flaking as soon as it starts. Effective sun protection
(Melablock-HSP 50+ or 30) and avoiding sun exposure are
essential.
The treatment is repeated two to four times, every
2 weeks, intervals if flaking has stopped.
Results can be maintained in the long term with a com-
bination of topical treatment (tretinoin, DHEA-Phyto, Renutriv
ACE, etc.) and a series of several ETCA peels a year, with even-
tual local applications of Only Touch. Figure 18.3 outlines scalp
postpeel care.
TIPS
How to Accelerate Penetration
of the Acid Solution
Gentle abrasion with sandpaper, microneedling, or intraepi-
dermal erbium laser treatment (fractional laser) can help
accelerate penetration of the ETCA solution. These com-
bined techniques are not suitable when a phenol-containing
peeling solution is used, for evident toxicity reasons. When
­sandpaper abrasion is used, a topical anesthetic should be
applied (a swab with 2% lidocaine with adrenaline [epineph-
rine]) after the abrasion, before applying the acid. With an
erbium laser (not fractional), a nerve block or ring block is
necessary.
Relative Impermeability of Keratoses
Keratoses are relatively impermeable, and the acid needs more
time to get through them. Patience is required, and frosting
takes much longer to appear. Enough ETCA solution has been
applied when the skin immediately surrounding the kerato-
sis has frosted. Take care not to apply too much acid, because
the skin around the keratosis/lentigines could be completely
burned before the keratosis shows any frosting.
How to Determine the Total Number
of Coats Required
When the skin around the keratosis turns pink-white, it means
that a sufficient number of coats has been applied. When the
skin on the scalp is pinched between two fingers and epi-
dermal sliding occurs (Figure 18.2), the papillary dermis has
been reached. As soon as an even frosting occurs, the postpeel
mask cream should be applied and rubbed in. The peel is then
complete.
POSTPEEL PAIN
While the pain felt after a peel is bearable, the doctor can
make the patient more comfortable by prescribing a medium-
strength analgesic to be taken after the procedure and in the
evening before going to bed.
Figure  18.4 shows an example of a scalp treated with
ETCA peels.

Treating multiple keratoses on the scalp      133
Table 18.2  Prepeel Conditioning and Anesthesia
30 minutes before peel
Analgesics
The patient is given an acetaminophen plus codeine tablet or
other relatively strong analgesic. Anxiolytics can help very
anxious patients.
10 minutes before peel
Cleansing, balancing pH
The skin is cleansed using Skin Tech pre-peel cleanser, a foam
that balances skin pH to a physiological ph:5 average. Then the
skin is rinsed and dried.
Disinfecting, degreasing
The skin is then disinfected with alcohol and degreased with
acetone, which are left to evaporate.1
Just before peel
Nerve blocks
Anesthetic creams are not indicated for these treatments because
they are inefficient and modify skin pH, hydration, and
permeability.
The anterior half of the scalp is innervated by the frontal nerve. In
its intraorbital journey, this nerve divides into the internal and
external frontal nerves. The nerve branches emerge from the
supraorbital foramen and innervate the front of the skull after
traveling vertically upward. Blocking these nerve branches
anesthetizes the forehead as well as the first 6–10 cm of the
area normally covered in hair. For more details, see Chapter 33.
The lateral regions of the scalp are not innervated by the frontal
nerve, but by branches of the lower cervical plexus or the
auriculotemporal nerve.
The posterior region of the scalp is innervated by the occipital
nerve of Arnold, which is easily blocked by an injection of 2%
lidocaine with adrenaline (epinephrine).
The vertex of the scalp is innervated by all the nerve endings that
sensitize the skull. This region is therefore sometimes difficult to
anesthetize completely without doing a full circular nerve block
of the scalp.
Ring block: If the doctor does not want to or is not prepared to
perform nerve blocks, or if they are inadequate for more
sensitive patients, he can also do a tracer injection, 1 cm
beyond the outside edge of the zone to be treated, and a ring
block on the whole area to be peeled.
During application
Ventilation or cooling (3M Cold Pack)
can help ease the pain of the acid.
Some patients claim that the breeze or the cold induce more pain.
Table 18.1  Peels for Scalp Keratoses
Type of peel
Depth
Details
Superficial peels
AHA, BHA
1/7 to 3/7
Superficial peels are not efficient for this indication. The scalp skin
is very resistant, usually quite oily, and thick. Superficial acids
(glycolic, lactic, mandelic, salicylic, etc.) have a low potential for
treating scalp keratoses or lentigines.
Easy TCA (ETCA)
TCA
5/7
ETCA and ETCA PC can treat lentigines and not-too-large
keratoses using a papillary dermis protocol.
Easy TCA Pain Control
(ETCA PC)
TCA + Phenol
Unideep
TCA
5/7
This is a trichloroacetic acid papillary dermis peeling whose result
is similar to that of ETCA, but faster acting (see Chapter 23).
Easy Phen Light (EPL)
Phenol + TCA
6/7
EPL is a new light phenol peeling that works at the level of the
interface between the deep papillary dermis and the superficial
part of reticulary dermis.
Only Touch (OTP)
TCA
Focal 7/7 depth
Mosaic
technique
OTP is a high TCA concentration (average 45% w/w mixed in a
promoting base solution) peel that often is used with focal
application on keratoses up to the reticular dermis. It is always
used in association with a more superficial peeling applied on the
rest of the skin, at a depth of 3/7 to 5/7. This is called the “mosaic
technique.” One of the advantages of a mosaic treatment (focal
deep peeling associated with a more superficial peel) is a deeper
local action that offers fewer side effects and a faster recovery.
Lip & Eyelid Formula
Oil of phenol
7/7
Lip & Eyelid Formula is a deep phenol peel, up to the deep
reticulary dermis. It is a perfect option for patients with numerous
thick lesions. This formula can completely clean a scalp in only
one session. As a precaution, the scalp will be treated with a
deep phenol peel in a separate session, never together with the
face, for toxicity reasons.

134      Textbook of Chemical Peels
Table 18.3  Application of Easy TCA and Easy TCA Pain Control
Action
Needed for
Type of peel
Remarks
Focal application on
lentigines/keratoses,
using one cotton bud
soaked in the product
Large lentigines or thick
keratoses
Easy TCA
Focal white frosting. One touch of Lip & Eyelid can
be sufficient to induce the white frosting, while
three to five touches with Easy TCA will be
necessary to reach the same result, depending on
the skin permeability.
Easy TCA Pain Control
Unideep
Only Touch
Easy Phen Light
Lip & Eyelid Formula
Full area application
Small lentigines or keratoses
Easy TCA
When using phenol peels, about always consider
potential phenol toxicity (see Chapters 25–36). No
penetration promotion is allowed (abrasion,
microneedling, fractional laser, etc.). End point is
white or white-gray frosting.
Easy TCA Pain Control
Unideep
Easy Phen Light
Postpeel mask
Stopping immediate postpeel
inflammation and pain
All peels
Figure 18.1  Frosting—considered to be even because of the
large number of keratoses.
Figure 18.2  Epidermal sliding: this appears when the skin is
pinched after a peel to the papillary dermis.
Day 0:
Afternoon and evening
Apply postpeel mask
Day 6
Apply vaseline
Day 3 and 6
Check if infection
– 2 Weeks
= Scalp treatment
Protective home care
IPLASE (reduces erythema) 3x/d
Vit E antioxidant (moisturizing) every time the patient feels the skin tensed
Skin Tech cleanser (cleanse skin)
if PIH risk, give the patient Blending Bleaching 3 x/day 2 weeks before peeling
Blending Bleaching (pigment control) 2x/d
09 am, 12 pm, 03 pm
09 am, 12 pm, 03 pm
Melablock HSP, SFP 50+
Melablock HSP, SFP 30
0
S
S
1–2
3
4–5
6
7–8
9–14
15 to 30
After day 30
Smokers, polluted cities:
Pigment control:
Moisturizing:
Dry skin, + 40 years old:
Refill dermis:
Dermal tensor:
Nutritive ACE lipoic complex
Blending bleaching
Vit E antioxidant
DHEA Phyto
Atrofillin
Actilift
Specific home care
Figure 18.3  Scalp postpeel care.

Treating multiple keratoses on the scalp      135
NOTE
1. This is an exception to the normal ETCA procedure. The skin on
the scalp has to be disinfected and degreased because it is much
thicker and oilier than the skin on the face; the treatment has to
reach the papillary dermis.
(a)
(b)
(c)
(d)
Figure 18.4  (a) Scalp before treatment. (b) After two ETCA peels to the papillary dermis. (c) After three ETCA peels to the papillary der-
mis. (d) A year after treatment: maintenance with topical 0.05% tretinoin.

19
Treating aging skin of the hands and forearms
SIMPLE AGING, LENTIGINES,
KERATOSES, FLAT WARTS
Arms, forearms, and hands receive exactly the same treatment
protocol.
AGING OF THE HANDS
Over the last decade, facial rejuvenation treatments have been
developed and refined. Major technical advances have changed
the face of surgery as well as peeling and dermal filling tech-
niques. The results of these treatments are more and more natu-
ral. Surgical scars, less visible now than they were in the past,
can be softened even more by using peels or laser treatment
after surgery. The blade has more respect for the architecture
of the face, peels can maintain it perfectly well, and dermal fill-
ing techniques can even improve it. Cosmetic medicine helps
to hide imperfections that cannot be corrected by other means.
The use of gentler or less aggressive techniques has drastically
reduced the risk of permanent complications.
In short, nowadays, a person’s age is not written on his or
her face, and patients who are properly treated can easily claim
to be 15 years younger than they really are. The risk of this little
white lie being found out is minimal—as long as the individual
trying to guess the treated person’s age only looks at that per-
son’s face. The quality of the skin on the neck and décolletage is
often a sure sign of time spent in the sun or on a tanning bed.
Surgery can, of course, improve the tension of the skin on the
neck, but only certain peels can improve the quality of the skin
or make a telltale décolletage look younger. Even if the right
combination of techniques has been used to excellent effect and
a patient’s face, neck, and décolletage do not show their real
age, there is still a body area that can give away one’s age: the
hands. They are often the weakest link in the treatment chain, a
telltale sign of a patient’s real age and the fact that she or he has
had other treatments. There are always mittens, of course, but
who wears those year-round?
If you look at a patient’s hands, you notice that they start
aging fairly soon, often between the ages of 30 and 40. Small,
almost colorless, sessile tumors may start to appear, along with
small patches of hyperpigmentation; the skin dehydrates and
starts to wither. Between the ages of 40 and 50, the patches of
hyperpigmentation grow and solar keratoses may start appear-
ing. Between 50 and 70, in parallel with a decline in sex hor-
mone production (more gradual in men than in women), signs
of atrophy in the epidermis, subcutaneous fatty tissue, muscle,
and bone start to appear. Rheumatic disorders often develop
that deform the joints. The veins, which have become more sin-
uous, stand out through the thinned epidermis.
Very old hands are typically arthritic, atrophic (especially
in women), dehydrated, and covered in hyperchromic patches
and hyperkeratoses. The often fragile capillaries easily cause
bruising. Friction wounds are more frequent and more spectac-
ular, as the dermal papillae are no longer as deep and the epi-
dermis is not held as tightly to the dermis. Our calendar age is
not the only thing responsible for the aging process; our actions
are directly responsible for several contributing factors: smok-
ing, for example, either through vasoconstriction immediately
after smoke has been inhaled or through excessive production
of free radicals in the body, is one of the major causes of aging
that might well be termed autogenous as it is directly linked to
an individual’s behavior.
Avoiding repeated traumas; eating a balanced diet of
vitamins, antioxidants, and fatty acids; keeping out of the sun;
and good hormone levels all play an important preventive role
in keeping the hands looking young. But what can one do when
the damage is done, when the signs of aging are obvious and
a patient wants to have younger-looking hands? What can be
done to slow down the aging process once it has started? There
is a 10-year age difference between the hands of the patients
shown in Figure 19.1: the patient in (a) started menopause and
estrogen–progesterone hormone replacement therapy (HRT) 2
years previously; the patient in (b) has been in menopause on
estrogen-only HRT1 for 13 years. The signs of aging due to der-
mal, epidermal, fat, and muscle atrophy are clearly visible, and
10 years of (southern) sun have also left their mark on the skin.
Treatment of Simple Hand Aging
Figure 19.1 shows simple skin aging. Usually, all that is needed
to rejuvenate the skin on the hands is to regenerate the architec-
ture of the dermis and epidermis. This type of skin regeneration
is perfectly suited to Easy TCA (ETCA). Examples of this treat-
ment are shown in Figures 19.2, 19.3, and 19.4.
Applying the Easy TCA Peel
The process for applying the Easy TCA peel for a simple aging
treatment is outlined in Figure 19.5 and Table 19.1.
Treatment of Sun Lentigines on the Hands
Solar lentigines on the hands and overall photoaging usually
appear together and share the same etiology. Large lentigi-
nes are treated with a local application of Only Touch solution
(Figure 19.6). Small lentigines and overall photoaging can be
treated with ETCA or Easy TCA Pain Control. The Easy TCA
solution is applied to the entire hand, including the areas
treated with Only Touch. This is why the Only Touch applica-
tion should be stopped at the level of white frosting and not
gray frosting as we would need to see in case of a deep reticu-
lary dermis application. Easy TCA applied after Only Touch
will add more acids to the treated areas and deepen the effects
(Figure 19.7).
Only Touch Peel Presentation
The Only Touch kit contains a vial of base solution and a vial of
Aktivator TCA 80%, which contains trichloroacetic acid (TCA)
concentrated to 80% w/w. After mixing, the final concentration
of TCA is 43% w/w.

Treating aging skin of the hands and forearms      137
(a)
(b)
Figure 19.1  (a) Hand of a 50-year-old patient. (b) Hand of a 60-year-old patient.
(b)
(a)
Figure 19.2  (a, b) The dermis and epidermis restructuring after four ETCA sessions, at a rate of one peel every 2 weeks.
(a)
(b)
Figure 19.3  (a, b) The dermis and epidermis restructuring after four ETCA sessions, at a rate of one peel every 2 weeks.

138      Textbook of Chemical Peels
Only Touch Kit Contents
•
Base solution: One 5 ml vial containing a solution of four
alpha hydroxy acids (AHAs), antioxidants, trace elements,
and saponines.
•
Aktivator TCA 80%: One 3.8 ml vial containing a 80% w/w
TCA solution.
•
Various: A small container for mixing the TCA with the
base solution, cotton buds, and instructions for use.
(a)
(b)
Figure 19.4  Simple aging treated by four ETCA sessions, (a) before and (b) after. Daily care consisted of Skin Tech DHEA-Phyto twice a
day and Melablock-HSP 50+ at 9 a.m., 12 p.m., and 3 p.m.
Softly touch every lentigo with a
cotton bud soaked in Only Touch peel.
Several touches are needed
up to end point: white frosting.
1st coat Easy TCA
If 1st frosting points
If NO frosting points
ETCA postpeel mask
2nd coat Easy TCA
3rd coat Easy TCA
Let it dry
Let it dry
Figure 19.5  Application algorithm.
Table 19.1  Application of Easy TCA
Prepeel
preparation
Remove all jewelry.
No disinfection or degreasing of the skin is
needed, except if moisturizers or sun
protection have been applied.
Easy TCA
application
Two or three successive coats of ETCA solution
are applied to the hands. Do not try to achieve
frosting.
Each coat should be left to dry completely
before applying the next. If cloudy frosting
appears after the first or second coat, no
more coats should be applied.
Postpeel mask
application
When the last coat of solution has dried, the
postpeel mask cream is applied using the
quantities indicated on the dosage card, and
is left to work for at least 8 hours.
Flaking
Flaking often occurs after at least 1 week and
lasts around 4–5 days.
Postpeel care
Start the day after the first peel and continue for
at least 6 weeks after the last peel.
Three daily care creams are recommended for
simple hand aging treatment:
• DHEA-Phyto, containing DHAE phyto-
precursors to boost the anabolic potential of
the skin.
• Nutritive Cream Vit. A-C-E Lipoic Complex
to fight free radicals produced by exposure
to the sun or to chemical irritants.
• Melablock-HSP 30 or 50+ as a strong sun
protection.
Repeat Easy
TCA
Easy TCA is repeated four times, at 2-week
intervals, unless the skin has not finished
flaking.

Treating aging skin of the hands and forearms      139
Large and
deep lentigo
Subcutaneous
tissue
Dermis
Epidermis
Small and
superficial
lentigo
Large and
deep lentigo
Subcutaneous
tissue
Dermis
Epidermis
Small and
superficial
lentigo
Only
Touch
Only Touch Peel: focal deep tower technique
(a)
(c)
(b)
Large and
deep lentigo
Subcutaneous
tissue
Dermis
Epidermis
Small and
superficial
lentigo
Easy TCA
Only
Touch
(d)
(e)
(f)
Figure 19.6  (a) Large lentigines typically have a deep structure; small lentigines typically are superficial. (b) Solar lentigines before treat-
ment. (c) Large lentigines are treated by a focal deep tower technique: Only Touch peel. (d) Frosting induced by local applications of Only
Touch. (e) Superficial lentigines are treated with full-area application of Easy TCA as for simple aging. (f) Clinical results after treatment.

140      Textbook of Chemical Peels
Indications
Only Touch is indicated for the treatment of keratoses and
lentigines of the hands, forearms, and neck with a maximum
diameter of 1 cm, in phototypes FZ 1–4. Only Touch is only for
local application and never for large areas. For lentigines or
facial keratoses, local or focal application of Only Touch to the
Grenz zone (depth 4/7) should be followed immediately by an
application of Easy TCA 15% to the basal layer (depth 3/7) for
the whole zone, treated previously by Only Touch. This gives
the desired result with minimal residual erythema.
Contraindications
Only Touch should not be used in patients with phototypes
4–6. Avoid applying Only Touch on facial skin because it could
leave persistent red spots on the skin for months, combined and
in the case of postinflammatory hyperpigmentation (PIH). See
the “General Notice Peelings” section in the kit instructions. In
particular, do not apply Only Touch to patients who have had
or are undergoing treatments that might increase skin perme-
ability. Do not apply Aktivator TCA 80% without diluting it to
the recommended concentration, as this could cause perma-
nent scarring. Only Touch, used alone, can be associated with
hyperpigmentation changes, while ETCA prevents or treats
them. Therefore, both peels are used together in the treatment
of solar lentigines (Figure 19.8).
Only Touch should be carefully applied and never over
the white “elastic” frosting, without the skin becoming hard
when pinching. When the Only Touch application results in
gray or yellowish frosting, side effects (infection, delayed heal-
ing, scarring, or pigment problems) often occur (Table 19.2).
Combined Treatment for the Hands:
Peels and Fat Transfer
Solar lentigines are combined with atrophy of the integuments,
subcutaneous tissue, muscles, and bones. While peels can cor-
rect photoaging, they cannot correct hormone-induced atrophy.
Often the only option is a fat transfer combined with chemical
peels (Figures 19.9, 19.10, and 19.11).
A fat transfer, however, cannot prevent photoaging
and the development of lentigines. For this reason, Easy TCA
should be resumed yearly, even after a fat transfer.
Flat Warts
The hands of premenopausal patients often do not show evi-
dent signs of atrophic aging, but too much sun produces a
range of spots, sessile tumors, flat warts, and solar keratoses.
Small, flat warts can be treated successfully with Only Touch
combined with ETCA (Figure 19.12).
Only small, flat warts respond to Only Touch. Thicker, and
therefore more impermeable, lesions do not respond and should
be treated by shave excision with high-frequency shaving or lasers.
MAINTAINING RESULTS IN THE LONG TERM
Results can be maintained in the long term by using appropri-
ate daily care and repeating the peels once a year.
1st coat Easy TCA
If 1st frosting points
If NO frosting points
ETCA postpeel mask
2nd coat Easy TCA
3rd coat Easy TCA
Let it dry
Let it dry
Figure 19.7  Application algorithm for the hands.
(a)
(b)
Figure 19.8  (a) Appearance of the skin on the 8th day after Only Touch combined with ETCA; the scabs should not be pulled off. (b)
Appearance of the same hand on the 15th day: the scabs are gone.