Trichloroacetic Acid 10–30%

TCA produces superficial peeling when used in strengths from 10% to 30% [38]. At these strengths, TCA is indicated for the treatment of fine rhytids, actinic damage, mild epidermal dyschromia, reduction of superficial keratoses, scars, and comedone formation. Treatment intervals between applications of this superficial chemical peeling agent are generally within 7–28 days [7]. As a general rule, repeating the application before the erythema has faded from the previous treatment may enhance penetration of the successive application and produce deeper wounding [39].

TCA precipitates epidermal proteins and causes necrosis and exfoliation of normal and actinically damaged cells. TCA is nontoxic systemically and is neutralized by serum in superficial dermal blood vessels [19]. Partial epidermal exfoliation occurs with 20% TCA; therefore, a series of peels may be necessary in order to optimize the rejuvenating effects of papillary dermal remodeling [40].

Prior to starting the peel, the face is cleansed/degreased with alcohol- or acetonesoaked sponges. Then the TCA agent (10–30%) is applied to the face with short, gentle strokes using only light pressure. Proceeding clockwise or counterclockwise is according to preference, but returning to an already painted area must occur before 2 min have passed to allow the acid to be neutralized before more solution is applied. One or two applications of TCA solution to the entire face produce a transient frost and mild erythema. The depth of penetration of the peeling solution is related to the number of coats applied. Protein precipitation results and leads to exfoliation without vesiculation.TCA is self-neutralizing and does not require water or bicarbonate to terminate the action of peeling. Patients experience a temporary burning and stinging sensations that can be relieved with cool compresses and cool air blown over the skin by an electric fan [41]. Superficial TCA peels are well tolerated by most patients and thus do not require sedation. Of note, topical anesthetics should be avoided because they can increase peel depth by increasing stratum corneum hydration [42]. In the subsequent 24–48 h, the skin turns brown, which is followed by exfoliation by the third to fifth day. Complete re-epithelialization takes place within a week to 10 days. Depending on the desired affects, the patient may undergo a second treatment within a week or two [43].


Postprocedure regimen should include the use of sunscreen, avoidance of excessive sun exposure, and the daily application of a moisturizer. Once the skin is re-epithelialization (postoperative days 7–10), the patient may resume their pre-rejuvenation regimen (such as AHAcontaining moisturizers once a day, topical hydroquinone preparations, and tretinoin therapy nightly).

Complications from superficial peeling agents are usually minor and reversible, including transient hyperpigmentation, prolonged erythema (<3 months), colloid milia, acne flares, reactivation of latent facial herpes simplex virus (HSV) infection, and superficial bacterial infection [44]. Scarring in the absence of supervening infection is highly unlikely [43].

One common problem for the physician is discerning the degree of evenness of the application of 10–30% TCA because the frost produced is minimal and transient. To avoid skip areas and to ensure an even application of acid, some manufacturers add sodium fluorescein to the solutions, rendering the preparation visible under a Wood’s lamp. This technique helps to detect skip areas and avoids overcoating [45]. Another TCA peel modification is Obagi “blue peel,”which contains a nonionic blue color base with glycerin and saponins, which slows the penetration and release of TCA in the skin by reducing the surface tension of the TCA, water, and glycerin. This results in a homogeneous TCA-oil-water solution and provides a gauge to the depth of the peel [46].A light blue end point signifies exfoliation to the papillary dermis while a medium/dark-blue endpoint denotes coagulation to the immediate upper reticular dermis. The lighter procedure results in skin tightening whereas the deeper procedure results in skin leveling. The minimal recommended waiting period before repeating a blue peel is 6–8 weeks, and two to three blue peels may be required for maximum benefit [42].