Case Study: Administering a TCA peel

By Amanda Wilson / 13 Jul 2020

Nurse prescriber Amanda Wilson shares an introduction to using a medium-depth peel to improve rhytids and pigmentation

Consultation

A 63-year-old female patient presented to me requesting treatment for rhytids and pigmentation in order to look her best and improve her skin for her upcoming wedding, which was taking place in two months’ time. The patient had previously been a long-term smoker and had undergone previous treatments with toxins and various skincare, with limited results. She didn’t have any significant medical history and had previously only had toxin treatment to the forehead region. During the consultation we discussed all available treatment options. We decided that a medium-depth chemical peel would be the best course of action; the advantage being it would allow for skin tightening as well as textural improvements. I felt that it was also the best option due to the extent of the patient’s smoker lines and depths of rhytids. Other treatment options which were discussed in combination were needling with radiofrequency, pharmaceutical-grade skincare products, botulinum toxin and dermal filler treatment.

Choosing a peel

Chemoexfoliation, or chemical peeling, is a commonly-used method of skin ablation using specific caustic agents that result in quick, uniform, predictable chemoablation to a desired depth that ultimately results in an improved appearance to skin.1

The caustic agents used within chemical peels cause controlled keratocoagulation; a denaturation of the proteins in the dermis and epidermis. This results in a release of proinflammatory cytokines and chemokines.2 Consequently, there is an activation of the normal healing response cascade, which includes stimulation and deposition of new dermal collagen and elastin, reorganisation of proteins and dermal connective tissue, as well as regeneration of new keratinocytes.3 This then results in rejuvenation and thickening of the dermis and epidermis. Moreover, the resulting exfoliation that takes place improves superficial and medium-depth pigmentation.3 When deciding the depth of a chemical peel, the following should be considered: type of chemical, concentration, number of applications, Fitzpatrick skin type of the patient, and the condition being treated. A superficial peel will only penetrate the epidermis, medium-depth peels treat the epidermis and papillary dermis, while deep peels allow for controlled tissue injury right down to the reticular dermis (Figure 1).1

A medium-depth peel was suitable for this patient because we wanted to target the papillary dermis layer for her rhytids and pigmentation. This type of peel can have around 10 days’ downtime, so the patient was counselled for this accordingly during the consultation.

As medium-depth peels initiate keratocoagulation down to the papillary dermis, they allow for more impactful rejuvenation of the epidermis and dermal layers in one treatment sitting.4 When used correctly, medium-depth peels can demonstrate excellent clinic efficacy for rhytids, actinic keratoses, melasma and superficial acne scarring.4 There are a number of peeling agents on the market (Figure 2). Common medium-depth peels are 70% glycolic and 30-50% trichloroacetic acid (TCA) blends, for example, Jessner’s solution. Many brands also combine peeling agents with their own technology, for example the Obagi Blue Peel, which was chosen for this treatment.5 As it is not significantly absorbed by the skin, it does not produce systemic complications.6 TCA is a popular and commonly-used peel to treat manifestations of ageing, however careful consideration must be made in patient selection as some darker Fitzpatrick skin types can experience hyperpigmentation.4 Higher concentrations of TCA come with high risks of complications such as allergic reactions, toxicity, and ectropion, and are therefore less commonly used.7

Pre-procedure

For chemical peels, it’s necessary to prepare the skin pre-procedure. This is done using primers such as hydroquinone and tretinoin or retinol-based products, which aim to increase cell turnover, strengthen the cell membrane and reduce the risk of any pigmentation post treatment.7 For this patient, Obagi Nu-Derm System was prescribed for 18 weeks of treatment beforehand, ensuring that she used Obagi Tretinoin 0.1% for two full tubes. This significantly reduced the risk of post-inflammatory hyperpigmentation, which can be of concern when administering medium-depth peels.7 Use of a broad-spectrum sunscreen of at least factor 30 was also recommended.

Treatment

After thoroughly cleansing the skin, the peel was applied. The chemical peel selected was the Obagi Blue Peel; 2ml of a 30% TCA peel was mixed using the Obagi Blue Peel base, which equates to a concentration of 20% TCA Obagi Blue Peel. Proper application technique is critical with medium-depth peels to avoid inadvertent reapplication of the solution. Clinicians should treat the face sequentially by applying to the forehead and temples first, followed by cheeks and chin, and finally the delicate areas around lips and eyelids, as was done with this patient. The peel was then carefully feathered around the jawline and brow areas to prevent obvious areas of demarcation.5 The treatment took around 30 minutes and the patient was advised that a bluish tint would remain on the skin but usually washes off within 24 hours. She was informed that her skin would begin to peel within the next two to three days and should be healed between the seventh and 10th day.

Result and post-treatment care

A long-term maintenance programme with topical agents is necessary to preserve the results of chemical peels and prevent recurrence. Post-treatment care should incorporate broad spectrum, high factor sunscreens and bleaching agents.7 The patient was prescribed Obagi Nu-Derm products for aftercare which incorporate cleansers, toners, hydroquinone, alpha hydroxy acids, moisturisers and SPF protection. A follow-up appointment was scheduled three months after the treatment, in which we discussed treatment satisfaction and ongoing skincare maintenance. The patient was very happy with treatment results and could see an improvement in her rhytids, pigmentation and pores. She also had kept a peel diary to monitor the results from the peel and indicated that 10 days post-peel application, her pores were diminished, fine lines had improved and her skin felt glowing and soft.

Potential side effects and complications

For medium-depth peels, the complications which can occur are post-inflammatory pigmentation, superficial bacterial or fungal infection, reactivation of herpes simplex virus, scarring, milia, acneiform eruption and greater thickness desquamation/epidermolysis.8 The patient did not experience any of these complications as a result of treatment.

Key considerations for medium-depth peeling

• Patient selection and assessment is key

• Prime the skin prior to medium to deep depth peels

• Be wary of the complication risks and how to deal with these should they occur

• Discuss downtime with the patient before deciding on the correct peel type to use

• Manage patient expectations for best results

• Consider combination treatments

Summary

Chemical peels can be used for the treatment of pigmentary disorders, textural improvements, rhytids and scarring. The depth of peel selected will make a difference to the treatment outcomes and downtime for the patient. In my experience, priming the skin with Obagi Nu-Derm System drastically reduces the risk of post inflammatory hyperpigmentation post procedure and also enhances treatment results.

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