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  1. WARNING!!!! Acid Peels Can Harm Your Skin, cause severe burns, and further scaring. Do not think the highest percentages will help if you are not experienced. Please Study fully and read as much as you can. Always spot treat when trying anything. If you have any doubts have a dermatologist do it. They are experienced handling the acid. Watch as many Youtube Videos as you can on your peel, start with a spot test somewhere out of the way, then try a diluted (use water) treatment 8-12% and move up to higher percentages IF YOU CAN HANDEL IT! Never go above 35% and even this can lead to burns! Start Low & work up!!!!!!!!! A test spot trial is your friend, you only have one face. This goes for most acid peels, order the highest percentage, DILUTE (w/ Water) them down to 12-15%, and build up what you can handle. Case Study: AVOID Major Burns From Acid Please Learn a lesson from the below poster who used 80% TCA . Never use that much! Acid is serious stuff. 1) Always dilute down to 8 to 12% with water any acid (ie. half of TCA 35% is 17.5% and add a little more water to get it down). Do a test spot to see how your skin reacts. 2) Never do full strength till you know how you react. 3) Acids are gradual, start low, and work up a little at a time (each treatment). 35% should be your max for full face peels, many never get there as it's to strong. For TCA Cross, you can buy stronger acid but the same applies, start low, and then gradually work up higher. TCA can be treated by doctors at 100%. We never do this!!!! If your skin can handle it 50% is high and never ever drip any excess acid (wring it out with gloves, or get all of it off with your toothpick). 4) Drops / excess = burn scars (even the tiniest amount of TCA or other acid works). Toothpicks /wood pick up acid even if you wipe them dry. 5) Use vaseline around the eyes, eyebrows around the nose, lips, and smile lines by the mouth. Acid will not work with vaseline. Vaseline can also be put around a scar that is being treated to protect the surrounding skin. 6) Always wear rubber gloves 7) Do not use those fan brushes, you have no control and will cause burns, use gauze and wring it outwith no excess, or a toothpick that fits in your ice pick scar (test before acid) dip it into the acid and dab any excess on a paper towel. No drips. 8) In case of emergency immediately put your dissolved baking soda water over the area to stop the Acid 9) IF you have any darkness in your skin, you can tan you may cause hyperpigmentation and excess redness. Some ethnicity's cannot use TCA (light skin types don't have this issue unless the percentage is too high), either use very diluted (water) acid and do a test spot. Or darker skin types have done well with Glycolic and Salycilic acids. 10) Never TCA Cross (high acid amount) in the middle of a scar that is wide. TCA cross is for very narrow ice picks, the narrower the better. You would be better with a dilute spot peel (full facial peel) than to widen already wide spots. TCA Cross at high percentages of acid must have defined borders to touch all the walls of the scar. 11) Acid widens the scar, while this may soften it be aware it may make it look worse, do a test spot first. Microneedle, then the next month do a peel, repeat, this can help even things out. 12) We suggest makeup artists choice for TCA and other peels. They have excellent customer service, and do not sell acids that are industrial grade (not medical) like Amazon and ebay (you don't want this on your skin).'s store above has a great glycolic peel. 13) Always remember after care: A wet wound is a happy wound, some great ones to apply a few times a day are vaseline, aquaphor, triple antibiotic cream, or biafine (European for burns, doesn't react like some to vaseline). Use diluted (Water) white vinegar on a gauze daily to pat the area (kills bacteria and makes things peel), never rub! Normal soap unless it's gentle can make your face react after a peel. 14) If you have major burns goto the hospital ASAP! 15) An doubt have your med spa or doctor do the peels, acid peels are the number one way people get burns or make their scars worse, less is more, and spot treat to see what you can take. 16) Darker skin types and Asian skin may not be able to use TCA, please do a test spot, at a very dilute amount (water), see how you react. Ethnic skin types do well with Glycolic and, Salycilic Acids. TCA may result in permanent darkening of the skin in the area where the peel was used. However, this problem can be overcome if TCA 20% is used after a Jessner’s solution for darker skin types. Hydroquinone aka skin bleach should be used 2 weeks before and 3 weeks after, retin a or tretinorin, AHAs, Kojic Acid, Alpha Arbutin, etc. to prepare your skin’s surface, and even out the skin tone itself. * Vitamin C Serum is also recommended to use with this treatment as preparation to avoid any hyperpigmentation. 17) Frosting for 15-20 minutes is a good indicator, as Deeper peeling will have frosts that can last up to an hour. Any frosting lasting over an hour is a serious problem and damaging the skin.If you are frosting for 3 days go seek a doctor, major 911 emergency (The deeper the burn the less you feel because your nerves are fried)! 18) Men have as a general rule thicker skin and tolerate deeper peeling with higher percent acids. 19) After acetone (without fragrance nail polish remover) a Jessners or Salicylic peel can be applied to further remove the top layers so the TCA can reach the papillary dermis. The hope is just to reach the top or lower papillary(depending on what depth of peel you are going for) and not the reticular dermis where scarring Will occur if damaged. Most doctors will not do over 35% TCA these days for full face / spot peels. 20) Proline/ lysine and L' ascorbic (aka vitamin c serum) acid prior and post treatments, collagen supplement, and high protein diet, may help you produce extra collagen 21) You should not have a chemical peel if you will continue to have excessive sun exposure. Active Herpes Simplex (have a doctor prescribe Zovirax for you), Warts, history of Keloidal scarring, any type of recent facial surgical procedures. You should not have a chemical peel if you've used Accutane in the last year (it will increase your chances of scarring), or if you are pregnant or lactating. If you have any auto immune diseases, have had any recent radioactive or Chemotherapy treatments - have sunburn, windburn or broken skin or have recently waxed or have recently used a depilatory such as Nair or use Vaniqua 22) Make sure you have a supply of SPF (100% uva & uvb) to protect your skin before and after the peel. A minimum of 30 is required. 23) Do not scrub your skin, let the shower take off the scabs, or pick!!! >> The gentleman at the bottom of this page would be best to goto the derm or med spa and have V-beam for the redness or IPL, BBL, Photofacials, 1064nm laser. He should be using aloe Vera and honey or Emu oil for his burns or triple antibiotic, silicone liquid is also good for scars. Burn gels are sold at the store often called hydro gels. ___________________________________________________________________________________________ Different Kinds of Acid Peels ** We recommend Makeup Artists Choice for their excellent customer service and support of their acid peels. TCA is the best all around peel for the acne scar suffer, it allows similar benefits of laser treatments at home without the fat loss and thermal damage. You can slowly step your way up to TCA peels through other peels, and the alternative peels have other advantages like hyper pigmentation, acne, and skin tone when you don't want the down time of TCA resurfacing. TCA is normally done in the Winter or early Spring as it requires one to hibernate during recovery and avoid the sun, it is part of many yearly beauty routines. Glycolic Acid (Alpha Hydroxy) A good all-around acid for normal-oily skin types to exfoliate the skin. More harsh than lactic acids. An alpha hydroxy, this peel penetrates the epidermis-only. Jessner Based in alcohol, this is a drying peel best suited for oily, acneic skin types. Containing both alpha and beta hydroxies along with resorcinol, this peel penetrates more deeply than an alpha or beta peel, but less deeply than a TCA. Not recommended for sensitive skin. Not recommended for dry skin. Lactic Acids (Alpha Hydroxy) Milder than glycolic acid, and typically better for working on hyperpigmentation problems. Our formulation contains licorice extract, an effective skin lightening additive. Appropriate for normal, dry, or oily skin. An alpha hydroxy, this peel penetrates the epidermis-only. A good all around peel for the beginner. Contraindication: Do no use if you have milk allergies. Mandelic Acid (Alphy Hydroxy) An alpha hydroxy acid, Mandelic Acid is derived from bitter almonds. The molecular structure of mandelic acid is larger than better known alpha hydroxy acids such as glycolic acid and lactic acid. This means it takes longer to penetrate the skin's surface and is much less irritating. Excellent for acne, large pores, blackheads, wrinkles, lines, sun damaged skin, extremely sensitive skin and darker skin tones. Contraindications: Do not use if you have nut allergies. Phytic Acid (neither an alpha nor a beta) A superficial peel with exfoliating properties. Desirable for skin types that cannot tolerate AHA's. Derived from rice, this product is excellent for anti aging, skin smoothing, brightening, Melasma and general discolorations. Acne clients will see skin clearing. Those with PIH (post inflammatory hyper pigmentation) will see excellent results. Pumpkin Exfoliating Masque w/5% Glycolic Acid A wonderful combination of enzymatic properties, along with an alpha hydroxy acid to exfoliate the skin, refine texture and brighten skin tones. Salicylic Acid (Beta Hydroxy) Oil soluble, thus making these acids perfect for oily/acne skin that needs deep pore cleansing and loosening of blackheads. Use the 3% or 8% strengths as a "first-step" when using alpha hydroxy acid peels to remove all oils from the skin, or use alone 3/4 times per week for oil/blackhead control. Use the 15% or 10% once a week only. A beta-hydroxy, this acid penetrates the upper layers of the epidermis only. Contraindications: Do not use if you are allergic to aspirin products. Trichloreacetic Acid (TCA) Deeper peeling class of acids used for acne, lines, wrinkles, hyperpigmentation, scarring. Longer lasting results, more intensive. This peel penetrates the epidermis, into the upper layers of the dermis, thus producing a more effective peeling experience. Always begin with a low strength with this particular acid. TCX We formulated this peel with a proprietary blend of acids to work on a number of skin care issues by including the following acids: Mandelic Acid, Salicylic Acid, TCA, Glycolic Acid, Lactic Acid, Citric Acid, Phytic Acid. Total acid content is 30%. Great for acne, softening of acne scars, anti aging benefits, fading of skin discolorations. Consider this your all-in-one peel. Non Acid Enzyme Peel All natural enzymes from papaya (papain) and pineapple (bromelain), safely dissolve surface skin debris and leave skin feeling soft, cleansed and refreshed. Our enzyme peel is professional strength, exactly what you would get in a very high-end salon. Use this product if you have sensitive skin that is non-tolerant of acid usage. Professional Enzyme Peel (non acid) Source: Source: Peel Depth (Higher percentage can lead to more risk of side effects) Superficial: Salicylic Acid (Beta Hydroxy), & Glycolic Acid (Alpha Hydroxy), Trichloreacetic Acid (TCA) 0-20% - Slicylic Acid is my favorite, it unclogs the pores (great for acne) and gives a light peel, can be done more often than TCA peels, Used for skin upkeep, takes off the epidermis for fresh cell turnover and purging Medium: Trichloreacetic Acid (TCA) 20-35% or 20% to 50% TCA Cross - Used for scars and ageing rejuvenation, goes down to the upper to mid dermis Deep: Phenol Peel, 35-100% TCA - This is serious stuff, normally your put under and doctors apply peel in surgery can take off various layers of dermis, similar to dermabration with thinning the skin, used for ageing rejuvenation and deep scarring ___________________________________________________________________________________________ Picking the Best Peel By Dr. Rullan * I love microneedling and 30% salicylic plus mandelic (< gentle and unclog pores) acid peels and TCA of course they are like having lasers at home. Remember peeps dilute w/ water and see your skins reaction (spot test) don't go crazy on your skin without knowing. Peels successfully treat a variety of cases of melasma, acne scars and sun-damaged skin, dermatologist Dr. Peter Rullan told colleagues, but he says it's crucial to select the right peel for the right patient. And in some cases, he says, lasers can offer better results, either in conjunction with peels or alone. Rullan, M.D., has a private practice in Chula Vista, Calif., and is a volunteer clinical professor of dermatology at the University of California at San Diego. He described his recommendations at the 2016 CalDerm Symposium, a continuing education seminar offered by the California Society of Dermatology & Dermatologic Surgery. Some of the new fractionated and minimally ablative laser devices can achieve comparable results to the peel, but it’s more expensive to use the devices compared to the low-cost alternative of peeling. Consider a pretreatment skin preparation with bleaching agents and topical tretinoin, and use antivirals, especially if treating near the lips. Active Acne For active acne Dr. Rullan recommends 30% salicylic, Jessner’s and VI peels. "I routinely do 30% salicylic on patients on low-to-medium doses of isotretinoin," he says. "For isotretinoin, I like 20 mg/day initially, and based on tolerance and need, I slowly titrate upward." Dr. Rullan adds monthly Vbeam Perfecta pulsed dye laser for red acne scars, even while the patient is on low-dose isotretinoin. "I use 10-msec and 8 joules, 7 mm spot size, followed immediately by a 30% salicylic peel or wash if the patient has active acne lesions," he says. "The red marks from recent acne lesions respond very well to the laser, and acne lesions such as comedones and papules dry out or exfoliate with the salicylic peel." Dr. Rullan offers several cautions: "Buffered glycolic works well for comedonal acne but cannot be done while using topical or systemic retinoids because it can cause blisters," he says. "And although they're effective, Jessner’s peels can cause post-inflammatory hyperpigmentation (PIH) in skin types 4-6." Boxcar Acne Scars For small boxcar or ice pick acne scars Dr. Rullan likes to mix a TCA peel with laser. "I do CROSS – Chemical Reconstruction of Skin Scars – with 30% TCA for thin skin, 60% for medium, and 100% for thick-skinned patients. It must be applied with a toothpick to avoid spillage onto the shoulders of the scars," he says. "It can be done in all skin types with minimal risk of PIH, but if done incorrectly it can widen the scars temporarily." "If I see rolling scars, then I do Nokor 18-gauge needle subcision before I do the CROSS with TCA," he adds. If appropriate, Dr. Rullan follows CROSS immediately with either fractional Erbium or CO2laser based on available downtime or severity of scars. He cautions that "Combining CROSS with ablative lasers is better than just lasers alone, since lasers cannot ablate the lateral walls of box or ice pick scars. Many of the patients that come to me have been very disappointed with the results and the cost of their CO2 laser peels for scars." Other treatment approaches, he says, can include dermabrasion, 2-day phenol chemabrasion for spot or full-face scarring, excision, punch elevation and punch grafting. Melasma "Melasma cannot be cured with any peel," Dr. Rullan states, but a 30% salicylic peel can be appropriate. He describes it as the "safest peel," one that provides a "very superficial" level of penetration. Dr. Rullan also recommends 70% glycolic acid peels – another kind of peel considered very superficial – and 20% salicylic plus mandelic acid peels. He points to a recent study of 90 patients in India with melasma [Dermatol Surg. 2016 Mar;42(3):384-91]. Patients were randomly assigned to peels with glycolic acid 35%, 20% salicylic plus mandelic acid and phytic combination. Patient skin was most tolerant of salicylic plus mandelic acid, the researchers reported. The also found that 35% glycolic acid and salicylic plus mandelic acid peels were more efficacious than the phytic combination. After 12 weeks, the melasma area and severity index scores in the patients decreased by 62%, 61% and 45%, respectively. In addition, a variety of other treatments can be appropriate for melasma, Dr. Rullan says, including, but not limited to, protection from heat and sun, hydroquinone 2%-6%, retinoids, glutathione 500 mg BID, and anti-inflammatory medications. Photoaging Dr. Rullan prefers pre-packaged peel kits for treatment of photo aging. "Commercial kits provide a well-defined procedure and post-op care that helps the physician and the staff gain confidence in chemical peels," he says. For mild photoaging, Dr. Rullan prefers a “superficial” level of penetration. He points to ZO 3-step stimulation peel (10% TCA, 17% salicylic acid, 5% lactic acid and 6% retinol cream), VI Peel Precision (30% phenol, 7% TCA plus salicylic and tretinoin acid, but no croton oil) and Jessner's 15-20% TCA. For moderate photoaging, he prefers "medium depth" peels via Jessner's 25% TCA and TCA peels assisted by blue dye. "These peels actually improve fine wrinkles and lentigos but do not provide the amount of skin tightness and lifting that a croton oil/phenol peel can do, especially for deep wrinkles in the mouth region." "They help the patients get a fresher, more even complexion that appears more glowing and with only a five-day turnaround,” Dr. Rullan says. “For example, you do the peel on Wednesday, they look pink and dry for two days, and then exfoliate for two or three days max during the weekend." Things to Watch Out For Dr. Rullan cautions about post-inflammatory hyperpigmentation from ablative lasers, intense pulse light and strong chemical peels. "If the patient has oily skin and acne scars and is skin type 4 or darker, you will get PIH when doing medium and deep chemical or CO2 laser peels," he says. "No pre-op regimen with hydroquinone or tretinoin will prevent it. I find it more effective to start them on very low-dose isotretinoin – when qualified – if you start seeing PIH after the peel has healed. I use doses like 10-20 mg daily for 30 days." Getting an Education in Peels "Learning peels is difficult because the residency and fellowship programs do not teach them in workshops," Dr. Rullan says. "I teach them in residency programs, and for some third-year residents this is the first time they have ever been taught peels." To gain experience and feel more comfortable Dr. Rullan suggests they join the International Peeling Society and attend workshops or courses. "Commercial kits provide a well-defined procedure and post-op care that helps the physician and the staff gain confidence in chemical peels," he says. “They should feel safe doing the 30% salicylic on acne and melasma patients. And I suggest applying 35% TCA on individual AKs – actinic keratosis -- to learn the wounding and healing process." ___________________________________________ Guide to LA/GA Peels Lactic Acids (Alpha Hydroxy) Milder than glycolic acid, and typically better for working on hyperpigmentation problems. Our formulation contains licorice extract, an effective skin lightening additive. Appropriate for normal, dry, or oily skin. An alpha hydroxy, this peel penetrates the epidermis-only. A good all around peel for the beginner. Contraindication: Do no use if you have milk allergies I was never much into Lactic, but of course I am allergic to milk ;-P Buy as high as possible and water it down. Saves you money. They are just making sure you start low and go higher in case there is any issues. I always advise buying the max percentage to save $$, otherwise they will be selling you watered down peels at various strengths. I think they sell to Europe, you can always email them and ask, they have great customer service. Looks like 40% is a beginner Lactic. Things You'll Need Mild Cleanser Acetone without fragrance aka Nail Polish Remover LA/GA Peel Kit Neutralizer(baking soda) Moisturizer/Spf Gauze or Cotton Balls These are the stuff i used: A mild Cleanser- Neutregena Deep cleanse Acetone without fragrance aka Nail Polish Remover LA/GA Peel Kit: MUAC GA kit Neutrilizer: ph prep solution from MUAC or Baking Soda and water Moisturizer: Neosporin (Triple antibiotic cream) Now that we have gathered all the materials we need, its time to start our very 1st peel..... We will be following these simple procedures during this tutorial Cleanse Prep Apply LA/GA Peel Rinse Neutralize Moisturize/Protect/Soothe 1. Cleanse: Always cleanse prior to a peel, you want a clean canvas, oil and dirt free...Use a mild cleanser one thats not too harsh and wont make your skin sensitive....Avoid cleanser that are suited for acne skin because they cointain salyclinic acid....... DO NOT USE KOJIE SAN...big no no To cleanse....... Choose cleanser of choice Apply Cleanser to face: Rinse Face You have just successfully cleansed your face, it should be clean, smooth and oil-free, go ahead and dry off your face...Proceed to next step 2. Prep: Prepping your face is vital prior to a peel, a well preped skin wil allow your peel to penetrate deeper, which may be more effective You can either Prep your skin by using Acetone without fragrance aka Nail Polish Remover, rubbing alcohol or using the pH Prep solution that came with your kit. Use Acetone AKA Nail Polish Remover without fragrance. Apply gauze or with cotton ball there might be a slight tingling sensation, after you have finished applying your acetone, allow face to completely dry for 5min.....You have now successfully preped your face.....Proceed to Next step 3. Applying your peel: This where the fun begins, now that you have cleansed and preped your face you are now ready to apply your peel, Beginners i strongly urge you to begin at a low percentage....40% LA/GA are very mild for 1st timers...i also recommend getting peels from make up artist choice(MUAC) the best method to apply your peel is by gauze or cotton ball To Begin.... Wear Gloves! You can use vaseline around eyes, sides of nose the crease when you smile aka nasolabial folds, lips especially the sides, eyebrows Pour a small amount of peel solution in a cup Dip gauze or cotton ball into the LA/GA solution....wring out with hand any excess Apply to face...starting with forehead and working around the perimeter of your face Continue to work around the edge of your face and applying Make your way inward towards your nose By this time you should be feeling the acid on your face, to some it might be mild tingling but to others it might be a little harsh, IF YOUR FEEL DISCOMFORT>>>STOP< RINSE AND CALL IT A DAY Allow the peel to stay on for no longer than 1-5min, 8min being the depends on your skin's sensitivity on how the peel will react on your skin, my 1st peel had me skipping around the bathroom floor, i washed off in a matter of 3min 4.Rinse: Once you have reached the 5min mark, it is now time to rinse of the solution.. Simply rinse with water (you can use soap) 5. Neutralize: After you have rinsed your face with water, you want to rebalance the ph of your face...[/B] You can use the ph Prep solution that came with your kit to neutralize Also you can Neutralize with baking soda and water Baking Soda receipe: 2 cups of water 2 teaspoons of baking soda Stir together.... Rinse face with the baking soda solution to netralize, then rinse with cold water to finish You have know successfully applied your LA/GA peel and neutralized this point you can examine your more than likely will appear red and irritated but this is normal....your face is just reacting to the acid 6. Moisturize/Protect/Soothe After you have rinsed and neutralized your face, go ahead and dry off your face, the next step is probably gonna be the most important step post peel You need to soothe your skin and keep it well moisturized and also protected, it is gonna be sensitve for the next 48hrs Choose Moisturizer, you can use anything from Aloe ver gel to Zinc oxide creams or Eucerin...i used neosporin triple antibiotic cream Once you have applied your moisturizer, I am proud to say that you have successfully completed your 1st LA/GA peel Important: For the next 48hrs your skin will become sensitive and therefore you must protect it from the sun, so wearing a sunblock is important 30spf+ also you might or might not notice any peeling, LA peels in general dont peel, they tend to have mild flakings Also dont scratch, pick, or rub your face, just allow your face to heal on its own and remember to MOISTURIZE!!!! ____________________________________________________________________________________________________________________ Glycolic and lactic acids are both AHAs, i.e. Alpha Hydroxy Acids tikvica Veteran Member 2 618 posts Gender: Female Posted June 20, 2006 · Report post INTRODUCTION: (to make things a bit clearer) Glycolic and lactic acids are both AHAs, i.e. Alpha Hydroxy Acids. Lactic acid is slightly milder, so it is recommended to people whose skin is more sensitive, to first time users, people constantly exposed to sun (although this does not mean you should not wear a sunscreen at all times), and people with darker skin tone. AHA's are skin exfoliants, which work on the skin, unlike BHAs which work inside the pore. AHAs are beneficial for skin in many ways, among them: reducing light scars and red marks and signs of photoageing, and getting back that beautiful even skin color and natural glow. SPF is a must everyday if you want to use the peel! The procedure and risks are the same for both acids. BEFORE DOING THE PEELS: Make sure your skin is more or less clear - a bunch of inflamed pimples will probably only get worse, since your skin, together with them, will be overly irritated after the peel. A few pimples in not so serious condition is ok. Do not use if you were on accutane in the last 6 months, or perscription topical retinoids in the last month. If you use non-prescription topical retinoids, i suggest you stop them one week before starting the peels, and wait one week after finishing the peels to start them again. The reason for these precautions is that accutane and topical retinoids lead to thinning of the skin, thus to extreme skin sensitivity. not following the instruction above may lead to skin injuries and scars. ** Pre Peal: Use Acetone AKA Nail Polish Remover (without fragrance, 100%, to avoid irritation) this removes grease / sweat/ sebrum so the peel work. WHEN BUYING ACID: i suggest 30% to start with. please do not try anything stronger at home, by yourself. some salons and derms go up to 50%, but after all they are proffessionals and know how to deal with it. 30% will bring you great results, especially b/c most of you have young and gentle skin that reacts much better and faster to lower percentages. high percentages of GA are usually meant for older/ageing skin. Be sure to check the percentage, the PH (it has to be lower than 4 in order to be effective) and i suggest buying brand names or from reliable sellers. Ph under 6.5 means that the substance is acidic, 6.5-7.5 being neutral, above 7.5 being alkaline. But, in order for the peel to be successful, ph above 4 won't do much, it will be a mild exfoliant. Most of the 30% ga peel are ph 2.2-2.8, which is probably what you should look for when buying an acid. IMPORTANT: I am not a doctor or a trained aesthetician. I am writing this with knowledge i have from my own experience with glycolic acid, with lots of instructions from my aesthetician and with what i read in various articles. INSTRUCTIONS: 1. whatever you do, please follow these steps. Glycolic acid is an ACID and if you're not careful, even low percentage can cause burns and/or hyperpigmentation and/or various other side effects if used properly, GA can bring lots of benefits to your skin 2. You will have much better results if you first prepare your skin with glycolic acid 5% (more sensitive skin) or 10% (not so sensitive skin) toner (alternatively lotions with same percentage). Apply the toner 2-3 times a day, start 7 days before the first peel. Use the lotion all the time, between and after the peels. apply generously. this is an important step, since lots of people, myself included, had much better results with involving a ga or la product into their daily regimen, prior to and during the peel. 3. Your face should be completely clean and dry beofre the peel. it is best to wait at least 15min after washing your face, to make sure the skin is completely dry, since water can neutralize the acid. 4. THE PEEL: gently apply over your whole face, even the areas that are not affected by scars, leave it for up to 6 minutes (depending on the sensitivity of the skin). when you feel burning (unpleasant tingling) and notice redness, take it off. it is very important that you follow the process all the time in the mirror and have everything prepared for rinsing the acid, as a second longer can cause burns. i suggest that you do part by part of your face, in that way, you'll be more able to control what's going on. for example, first do the forehead, that after it reacts, remove and than do one cheek, then the other one, then nose and chin. apply extremely gently. no rubbing in. from my experience there are times when it becomes unbearable after only 2-3 times, but there are times, when i almost don't feel a thing. it probably depends on various reasons and skin condition of that day you can apply the acid with your fingers, or you can alternatively use a brush or a cotton swab. FIRST TIME USERS: Please start with 2-3min time, then you can gradually increase by a minute. 5. TAKING THE ACID OFF it is very important to remove it AS SOON as your skin starts to get red and/or you experience unbearable tingling and/or the temperature of your skin raises. you can either remove the acid with a neutralizer (sodium bicarbonate eg.) or you can just rinse it with lots of water. water has a much higher ph than a peel does, so it will neutralize it, no worries.i suggest taking it off with only lots of water (cold or lukewarm, never hot), but i suggest always having some baking soda on your side just in case, b/c with it you can react faster. 6. IMPORTANT NOTICE be careful not to let the acid into your eyes. it's acid. you must not put the acid on the eye area and be very careful not to touch any of that thin sensitive skin around the eyes with it. if you're a first time user, do the peel every 7 days for the first series of peels, then gradually you can shorten the time between the peels, but never do them more often than every 4 days. you should do six peels in a series, make a break for at least one month and then continue the same. it's best do the peels in the evening never expose yourself to direct sunlight at least 1 hour after applying the toner (if you're using one), don't do the treatments in the summer, or if you know you'll travel somewhere where you'll be exposed to direct sunlight most of the time, always use SPF cream when you're going out and never use sunbeds or other artificial tanning stuff during and at least three weeks after the treatment. also avoid other sensitive areas like the line under your lower lip and around the nose. 7. after rinsing, tap dry, very gently and apply a moisturizer (if you're using moisturizers with active ingredients, like AHA eg. don't use that one after the peel, but find sth that is very neutral and nourishing - like jojoba oil, emu oil, aloe vera or panthenol, eg.) 8. COMMON SIDE EFFECTS: excessive dryness excessive oiliness breakouts increased skin sensitivity flaking 9. DO NOT: exfoliate your skin during the treatment, because glycolic acid is an exfoliator itself, and, due to increased skin sensitivity, you can cause dmage to the skin by excessive exfoliation. Also, do not use products containing BP, SA, retinoids, or any other active ingredient 24hrs prior to the peel and 24hrs after the peel. If your concern is mainly redmarks, i suggest you also try the following: 1. sleep - rest is important for the cells to function properly and cell healing comes in sleep. 2. eat healthy, drink lots of water and never forget your vitamin c - skin healing also comes from the inside 3. never use products on your face that can be drying, irritating or harsh in any other way to your skin - dry and/or orritated skin cannot heal itself as easily as healthy skin can. you can find a list of common skin irritants here: 4. don't ever ever touch your face! touching a pimple irritates your skin even more and can result in even bigger and stronger redmarks 5. always wear a sunscreen. you can find a list of recommended sunscreens here: some AHA products you might want to consider: Paula's Choice 8% Alpha Hydroxy Acid Gel Neutrogena Healthy Skin Face Lotion anything from Alpha Hydrox ProActiv Revitalizing Toner There are also quite a few studies done on the effect of glycolic, lactic and salicylic acid peels on asian and black skin, for treating various skin conditions, from hyperpigmentation to melasma. if you are of color, i suggest reading those studies before doing the peel (there are quite a few of them, so i won't link them here, also since lots of them are in pdf. i suggest you google "acid peel asian" or "acid peel black") _________________________________________________________________________________________________________________ Salicylic and Mandelic, Good Basic Peels This was my favorite before I jumped on the TCA bandwagon. It's a good stepping stone before you go TCA. Great for acne and hyperpigmentation, cleans out the pores, Salicylic is made of similar components of Asprin hence it's effect on redness. You don't have to neutralize Salicylic or Mandelic peels with baking Soda or wash. Some people pre peel with this before their TCA peels to help give a more even peel and break up the oil layer of the epidermis. I also like Mandelic which is quite similar to this and has anti acne properties as well. From Amazon : " Salicylic Acid is a great kertolytic which means it helps loosen the bonds between skin cells to promote exfoliating. It is the only hydroxy acid which is oil soluble which allows it to penetrate into clogged pores. It can be used more frequently than the other peels without must risk for irritation. The 30% solution For use only after you have acclimated your skin to the 20% peel. LIGHT SCARS AGING SKIN WARTS ACNE VULGARIS LESIONS UNDER THE SKIN (TRAPPED OIL) LIP CREASES LIGHT SCARS HYPERPIGMENTATION WHITE SPOTS BLACK SPOTS LIVER SPOTS SUN DAMAGED SKIN CONTROLS ALL TYPES OF ACNE DULL AND WORN SKIN." alicylic acid is oil soluble, thus making this acid perfect for oily/acne skin that needs deep pore cleansing and loosening of blackheads. Benefits: Cleans pores Removes oily residue from skin Helps to clear acne Helps to loosen blackheads Other important cautions: --Because salicylic acid is in the aspirin-family, it's important for clients who are allergic to aspirin products to avoid using this product. --If you are pregnant or lactating, consult with your OB/GYN before using chemically based products. --Always patch-test the skin before using acid-based products. If you experience irritation, rinse immediately with cool water. --Wait 24-48 hours to see if irritation develops. --Do not apply to red, irritated skin. --Do not use manual exfoliants, nor scrubbing brushes within 24 hours of use. --Do not use drying acne products, other acids, nor retinoids for 48 hours before using this, and do not resume for 48 hours after the peel. --Chemical peels cause the skin to be photo-sensitive, so be sure to use sun protection after your peel. Here is the Mandelic Peel from Makeup Artists Choice "Mandelic acid is an alpha hydoxy acid derived from bitter almonds.The molecular structure of mandelic acid is larger than better known alpha hydroxy acids such as glycolic acid and lactic acid. This means it takes longer to penetrate the skin's surface and is much less irritating. Do not use if you have nut allergies. It also works on darker skin types unlike some acids." What is Mandelic Acid? Mandelic Acid is an alpha hydroxy acid. Derived from bitter almonds, it has a number of benefits for the skin. The molecular structure of mandelic acid is larger than better known alpha hydroxy acids such as glycolic acid and lactic acid. This means it takes longer to penetrate the skin's surface and is much less irritating. Benefits --Rapidly exfoliates dead skin cells and surface debris from the skin. --Mandelic acid has antimicrobial/antibacterial properties, making it an excellent choice for all types of acne, including cystic acne. --Loosens blackheads for easy extraction. --Cleans and refines pores. --Refines the tone and texture of the skin, brightens. --Mandelic acid is excellent for clients with darker skin tones. It does not cause the unwanted, lighter skin tone changes that you might experience with other AHA's. --Mandelic acid inhibits the growth of melanin, the cause of brown patches, freckles, uneven skin tone and other sun-related skin care issues. --Mandelic acid, with continued use, can help repair sun damaged skin. --Mandelic acid reduces lines and wrinkles without the irritation of other AHA's. --Mandelic is typically an excellent exfoliator for clients suffering from Rosacea. What can I expect when using this peel?Upon application, within the first minute-or-so, you will feel very little topical sensation... it will be a warm tingling sensation. This acid penetrates more slowly than others, due to its larger molecular size, but don't be fooled. It *is* processing your skin, so please follow directions as written and use a non-acid moisture post peel. Post peel you'll see some light flaking, perhaps more apparent around the mouth and nasal areas. General Cautions: Never use manual exfoliators nor scrubbing brushes within 24 hours of using a peel. Stop Retin A, benzoyl peroxides, acne products and any other drying agents 24 hours before and after using an alpha hydroxy or beta hydroxy peel. If you are allergic to aspirin products, never use a salicylic acid nor beta hydroxy peel. Never apply a peel without doing a patch-test first and waiting 48 hours for results. Never apply a chemical peel to inflamed skin. Always read product directions in their entirety and don't take shortcuts. Use our BellEvolve Advanced Repair Cream for skin that has been chemically over processed. It contains advanced healing agents that will quickly get your skin back to normal. When in doubt about a caution, please write or call us for more information. ______________________________________________________________ TCA, Microneedling, Subcision w/ Filler give the best results for Acne Scars! ** Look at Those Below Pics... Combination Therapy in the Management of Atrophic Acne Scars Shilpa Garg and Sukriti Baveja J Cutan Aesthet Surg. 2014 Jan-Mar; 7(1): 18–23. doi: 10.4103/0974-2077.129964 Go to: Abstract Background: Atrophic acne scars are difficult to treat. The demand for less invasive but highly effective treatment for scars is growing. Objective: To assess the efficacy of combination therapy using subcision, microneedling and 15% trichloroacetic acid (TCA) peel in the management of atrophic scars. Materials and Methods: Fifty patients with atrophic acne scars were graded using Goodman and Baron Qualitative grading. After subcision, dermaroller and 15% TCA peel were performed alternatively at 2-weeks interval for a total of 6 sessions of each. Grading of acne scar photographs was done pretreatment and 1 month after last procedure. Patients own evaluation of improvement was assessed. Results: Out of 16 patients with Grade 4 scars, 10 (62.5%) patients improved to Grade 2 and 6 (37.5%) patients improved to Grade 3 scars. Out of 22 patients with Grade 3 scars, 5 (22.7%) patients were left with no scars, 2 (9.1%) patients improved to Grade 1and 15 (68.2%) patients improved to Grade 2. All 11 (100%) patients with Grade 2 scars were left with no scars. There was high level of patient satisfaction. Conclusion: This combination has shown good results in treating not only Grade 2 but also severe Grade 4 and 3 scars. KEYWORDS: Ablative laser for scars, dermaroller for scars, subcision INTRODUCTION Acne is prevalent in over 90% adolescents and it persists into adulthood in approximately 12%-14% of cases with psychological and social implications.[1,2,3] In some patients with acne, the inflammatory response results in permanent, disfiguring scars from either increased tissue formation or due to loss or damage of tissue. Hypertrophic scars and keloids are examples of scars that result from increased tissue formation. Scars with loss or damage of tissue can be classified into icepick, rolling and boxcar scars.[4] There is no standard treatment option for the treatment of acne scars. Medical management of atrophic scars can be done by using topical retinoids. Surgical management can be done using punch excision, elliptical excision, punch elevation, skin grafting and subcision depending on the type of scar. Procedural management includes microdermabrasion, chemical peels, percutaneous collagen induction by microneedling and dermabrasion. Tissue augmentation can be done using xenografts, autografts and homografts. Various ablative and non-ablative lasers and light energies are also available for treatment of atrophic acne scars.[5] Out of these multiple treatment options, treatment has to be tailored to patient's needs, tolerance, and goals along with the physician's assessment, skills and expectation. Patient should be counselled that the ultimate goal of any intervention is to improve the scars and no currently available treatment will attain total cure or perfection. In 1995, Orentreich and Orentreich described subcision as a method of subcuticular undermining of scars using a tri-beveled hypodermic needle. This results in lifting the scar by releasing the papillary dermis from the binding connections of the deeper tissues and by the formation of connective tissue that results from the course of normal wound healing.[6] It is mainly used for the treatment of rolling type of atrophic scars.[4] The mechanism hypothesised for action of percutaneous collagen induction using dermaroller is that it creates thousands of microclefts through the epidermis into the papillary dermis. These wounds create a confluent zone of superficial injury which initiates the normal process of wound healing[7] with release of several growth factors. This stimulates the migration and proliferation of fibroblasts resulting in collagen deposition[8] which continues for months after the injury.[9] Another hypotheses states that on penetration of skin with the microneedles, the cells react with a demarcation current which in addition to the needles own electrical potential results in release of various growth factors. This cuts short the healing process and stimulates the healing phase.[10] Dermaroller also opens pores in upper layers of epidermis and allows creams to be absorbed more effectively by the skin. Fifteen percent tricholoroacetic acid (TCA) peel is superficial peeling agent. It causes exfoliation, improves the skin texture and induces collagen synthesis.[11] The aim of our study was assessment of combination therapy using subcision, dermaroller and 15% TCA peel for the management of atrophic acne scars. The rationale for combining these three minimally invasive procedures was their additive action on acne scars. Subcision releases the scars from the underlying adhesions which should be the first step for any treatment for acne scars. Microneedling with dermaroller causes collagen induction along with enhancing absorption of tretinoin cream. Fifteen percent TCA peel causes improvement in skin texture as well as collagen induction. Hence by combining these three minimally invasive modalities one can release the scars, enhance collagen induction, increased penetration of topical agents and resurface the skin. MATERIALS AND METHODS Fifty patients with atrophic acne scars were enrolled in this study. Exclusion criteria were patients with active acne, active herpes labialis, patients on systemic retinoids, evidence or history of keloid scars, pregnancy or lactation, history of any facial surgery or procedure for scars and patients with unrealistic expectations. All the patients were counselled for surgical intervention and written informed consent was taken. The atrophic acne scars were graded by a single non-treating physician using Goodman and Baron Qualitative scar grading system [Table 1].[12] Table 1 Goodman and Baron Qualitative scar grading system Patient's skin was primed using topical tretinoin cream 0.05% at night along with sunscreen with a minimum SPF of 30 during the day for 2 weeks prior to starting the treatment. At the start of treatment, subcision was performed only once using a 24G needle. One day after the subcision, patient was called for the first sitting of microneedling with dermaroller containing 192 needles of needle size 1.5 mm. Eutectic mixture of lignocaine 2% and prilocaine 2% cream was applied under occlusion for 1 hour to the affected areas which was removed using gauze. Thereafter topical tretinoin cream 0.05% was applied to the affected area. Treatment was performed by rolling the dermaroller in vertical, horizontal and diagonal directions in the affected area until appearance of uniform fine pinpoint bleeding. Then the area was wiped with saline soaked gauze and tretinoin cream 0.05% was applied and washed off after 30 minutes. Two weeks after dermaroller, patient was called for 15% TCA peel. Whole face was cleansed using spirit and degreased using acetone. Fifteen percent TCA peel was applied with cotton tipped applicator on full face. Appearance of speckled white frosting was the end point of treatment with peel. After using dermaroller and 15% TCA peel, patient was instructed to apply sunscreen in the morning and mometasone furoate cream 0.1% twice daily for 5 days after which sunscreen was continued in the morning with tretinoin cream 0.05% applied at night time. Patient was asked to discontinue topical tretinoin cream application 2 days prior to TCA peel. Thereafter, dermaroller and 15% TCA peel were repeated alternately after every 2 weeks for six sessions of each and this was taken as the end point of our study. In some patients who developed inflammatory lesions of acne during treatment, capsule doxycycline or topical clindamycin cream 1% was given as and when required. Any adverse effects and interference in daily activities post-treatment were noted. Patients were evaluated for results 1 month after the last procedure was performed. Post-treatment scars were graded again by the same physician using Goodman and Baron Scale. Patient graded their response to treatment as poor, good, very good or excellent with 0-24%, 25-49%, 50-74% and 75-100% improvement, respectively, in their acne scars. The patients were followed up for 1 year at two monthly intervals to observe the sustenance of improvement in scars. Digital colour facial photographs were taken before treatment, during each visit of treatment, at 1 month after the last procedure and at 2 monthly intervals for 1 year after the last procedure. Patients were instructed to continue application of topical tretinoin cream 0.05% for 1 year after the last procedure. Statistical analysis Descriptive statistics such as mean and standard deviation are calculated. Data is presented in frequencies and their respective percentages. Data was entered and analysed using SPSS version 18. RESULTS Out of 50 patients, 49 patients completed the treatment. Out of 49 patients 2 patients were treated with capsule doxycycline during the treatment protocol due to active acne eruptions. Out of 49 patients there were 30 females and 19 males with age group between 18-39 years with mean age of 25.6 ± 5.2 yrs. 9 patients (18.4%) had Type III Fitzpatrick skin type, 32 (65.3%) type IV and 8 (16.3%) patients had type V Fitzpatrick skin type. Pre treatment melasma was present in 3 (6%) patients. Out of 49 patients who completed the treatment, 16 patients had Grade 4, 22 patients had Grade 3 and 11 patients had Grade 2 scars before treatment. The physician's assessment of response to treatment based on Goodman and Baron Qualitative scar grading system is summarised in Table 2. In patients with Grade 4 scars, 10 patients (62.5%) showed improvement by 2 grades i.e., their scars improved from Grade 4 to Grade 2 of Goodman Baron Scale [Figure [Figure1a1a and andb].b]. Six patients (37.5%) with Grade 4 scars showed improvement by 1 grade [Figure [Figure2a2a and andb]b] with scars being obvious at social distances of 50 cm or greater. In 22 patients with Grade 3 scars, 5 patients (22.7%) showed improvement by 3 grades i.e., they were left with no scars at all [Figure [Figure3a3a and andb],b], Two patients (9.1%) improved by 2 grades and as per Grade 1 they were left with only hyper-pigmented flat marks [Figure [Figure4a4a and andb]b] and 15 patients (68.2%) showed improvement by 1 grade by moving to Grade 2 [Figure [Figure5a5a and andb]b] as per Grade 2 their scars were not obvious at social distances of 50cm or greater. All 11 patients (100%) who had Grade 2 scars before treatment showed improvement by 2 grades in their scars and were left with no scars [Figures [Figures6a6a–b and and7a7a–b]. Hence all 49 patients (100%) had improvement in their scars by some grade with no failure rate. In patients with Grade 4 scars [Table 3], 12 patients (75%) graded their response to treatment as very good with 50-74% improvement in their acne scars after treatment and 4 patients (25%) had good improvement in their scars with 25-29% improvement. In patients with Grade 3 scars, 8 patients (36.4%) graded their response to treatment as excellent with 75-100% improvement in their scars and 14 patients (63.6%) reported the response as very good with improvement between 50 and 74%. All 11 patients (100%) with Grade 2 scars graded their response after treatment as excellent with improvement between 75 and 100%. Poor response with 0-24% improvement in scars was reported by none of the patients. Improvement in scars was first noted in majority of the patients after completing two sitting of dermaroller and peel. At the end of 1-year of follow-up, it was observed that all the 49 patients sustained the level of improvement in their grade of scars which was attained at the end of the last procedure [Figure [Figure8a8a–c]. Although improvement in the scars as noticed by the patient and the physician continued in the follow up period of 1 year, there was no further shift in the grade of scars. Table 2 Physician's assessment of response to treatment based on Goodman and Baron Qualitative scar grading system Figure 1 (a) Grade 4 acne scars; (b) Improvement in acne scars from Grade 4 to Grade 2 after treatment Figure 2 (a) Grade 4 acne scars; (b): Improvement in acne scars from Grade 4 to Grade 3 after treatment Figure 3 (a) Grade 3 acne scars; (b) Post-treatment patient had no scars Figure 4 (a) Grade 3 acne scars; (b) Improvement in acne scars from Grade 3 to Grade 1 after treatment Figure 5 (a) Grade 3 acne scars; (b) Improvement in acne scars from Grade 3 to Grade 2 after treatment Figure 6 (a) Grade 2 acne scars; (b) Post-treatment patient had no scars Figure 7 (a) Grade 2 acne scars; (b) Post-treatment patient had no scars Table 3 Patient's assessment of response to treatment Figure 8 (a) Grade 4 acne scars; (b) Improvement in acne scars from Grade 4 to Grade 2 after treatment; (c): Sustenance of improvement in acne scars from Grade 4 to Grade 2 at 1 year of follow-up There was improvement in rolling, boxcar and linear tunnel type of scars with little or no improvement in ice pick scars. All patients tolerated the procedure well. Side effects were mild and transient. Post-dermaroller transient erythema and oedema lasted for 1-4 days with a mean of 2.4 ± 0.7 days. Post-peel exfoliation of skin was present from 2 to 7 days with a mean of 4.4 ± 1 day. Only three patients (6%) developed post-inflammatory hyper-pigmentation (PIH) which was treated with sunscreen in the morning and triple combination of tretinoin, hydroquinone and mometasone at night time. The PIH subsided after 5 months of topical treatment. One patient (2%) developed mildly tender cervical lymphadenopathy each time after dermaroller which lasted for around 3 weeks and subsided on its own. There was no interference in daily activity with no loss of days at work. DISCUSSION This study has shown good results in patients with severe Grade 4 and 3 acne scars with 10 (62.5%) patients with Grade 4 scars moving to Grade 2 and 5 (22.7%) patients with Grade 3 scars improving to have no scars at the end of treatment. In Grade 2 scars all the 11 patients (100%) showed improvement by 2 grades and were left with no scars. Hence, all 49 (100%) patients showed improvement in their scars by some grade with no failure rate. The physician's analysis also correlated with the patient's assessment of improvement in scars with 12 (75%) patients with Grade 4 scars reporting improvement as very good, 8 (36.4%) patients with Grade 3 scars as excellent and 11 (100%) patients with Grade 2 scars as excellent with poor response reported by none of the patients. The procedure was well tolerated by all the patients. Post-procedure there was no loss of work days and side effects were mild and transient. In spite of patients being of Type III, IV and V Fitzpatrick skin type, only three patients (6%) developed PIH during the treatment, which subsided within 5 months of topical therapy. It has the advantage of being an office procedure and in being cost-effective. Topical tretinoin 0.05% favours the development of a regenerative lattice-patterned collagen network rather than the parallel deposition of scar collagen found with cicatrisation. Since dermaroller opens pores in the upper layer of epidermis and allows creams to be absorbed more effectively, it is for this reason that topical tretinoin was applied during dermaroller and kept for 30 minutes post-procedure to maximise its absorption in skin. Also the improvement in the grade of scars was sustained in the follow-up period of 1 year. Although ablative laser resurfacing is generally considered to be the most effective option for scar resurfacing, it is associated with significant damage to the epidermis and basal membrane with associated inflammation which causes erythema, scarring and pigmentation problems.[13,14,15] It also has a long downtime. In comparison, percutaneous collagen induction does not induce post-operative dyspigmentation as the epidermis and basal membrane are left intact.[16] CONCLUSIONS As the demand for less invasive, highly effective cosmetic procedures is growing, this combination of treatment for acne scars has shown good results not only in Grade 2 but also in severe Grade 4 and 3 acne scars. The treatment is well tolerated in Fitzpatrick skin types III, IV and V with no failure rates or loss of days at work. There is a high level of patient satisfaction, minimal downtime and the treatment is cost-effective to the patient. To our knowledge, this is the first study using this combination of therapy in the management of atrophic acne scars and the first in which topical tretinoin cream was applied both during and immediately after doing dermaroller. __________________________________________________________________________________________________________________ Indian Dermatol Online J. 2014 Jan-Mar; 5(1): 95–97. doi: 10.4103/2229-5178.126053 PMCID: PMC3937506 Subcision plus 50% trichloroacetic acid chemical reconstruction of skin scars in the management of atrophic acne scars: A cost-effective therapy Jasleen Kaur and Jyotika Kalsy1 Treatment of acne scars is a dilemma both for the treating physician and the patient as no oral or topical medicine works and it is associated with emotional and psychological stress. Acne scars are classified into three different types: Atrophic, hypertrophic, or keloidal. Atrophic scars are the most common type of acne scars. They have been further classified into three types as described by Jacob et al.[1] into ice-pick scars, rolling scars, and boxcar scars. Most of the patients with atrophic acne scars have more than one type of scars. Various treatment modalities like punch excision and elevation, subcision, chemical peeling using various strengths of TCA, micro-needling, ablative, non-ablative lasers and fillers either singly or in combinations have been described in literature with varying results. Most of these procedures require costly equipment and materials and not affordable by many people. Subcision or subcutaneous incision-less surgery is a term coined by Orentreich and Orentreich[2] in 1995 as the treatment option for atrophic acne scars. Here hypodermic 18 no. needle is used to break the fibrotic strands that tethered the scars to the underlying tissues leading to uplifting of scars. Combining subcision with other scar revision techniques or repeated subcisions may be beneficial to the patients.[3] TCA chemical reconstruction of skin scars (CROSS)[4] is another useful method for treatment of atrophic acne scars. It involves focal application of 50-100% of TCA with a wooden applicator on the base of an atrophic scar, which causes precipitation of proteins and coagulative necrosis of cells in the epidermis. There is necrosis of collagen in the papillary and upper reticular dermis. Healing is rapid because of sparing of adjacent normal tissues and adnexal structures. So there is reorganization of dermal structural elements and increase in collagen content that leads to filling of the atrophic scar. While going through the literature, we found that different studies have used subcision and CROSS TCA alone or in combination with other techniques as well as their comparative studies but we did not find any study combining these two techniques together to the best of our knowledge. Encouraged by that, we combined subcision and TCA cross in all types of scars as subsicion breaks the dermal tethering of the scar tissue and TCA will remodel the collagen underneath the scar which treats the basic pathology of the scar to some extent. In our study, 10 female patients between the age group of 20-35 years of skin type 4 and 5 with atrophic acne scars on the face were randomly selected. Most of the patients had more than one type of atrophic scars of grade 4 severity as described by Goodman.[5] In all the patients, there were no active acne lesions and none of them were on oral isotretinoin 3 months prior to inclusion in our study. Patients with keloidal tendencies, bleeding diathesis, and history of recurrent herpes simplex were excluded. Complete hemogram, random blood sugar levels, and viral markers were done in all the patients. Written consent after explaining the risks and benefits of treatment was taken from all the patients along with pre-/post-procedure photographs. Subcision followed by 50% TCA CROSS was done at 4 weeks interval for three sessions. Patients were followed-up monthly for improvement in scars up to 6 months. Priming was done 2 weeks prior to the treatment with 2% hydroquinone and tretinoin 0.025% cream at night and sunscreen more than 30 sun protection factor (SPF) was given in the morning. Procedure was carried out after application of topical anesthetic cream for 45 min followed by infiltration of 2% Xylocaine with normal saline under aseptic conditions. A no. 18 hypodermic needle attached to a syringe was introduced horizontally underneath each scar and was moved back and forth till the snapping sound was heard. We used no. 18 hypodermic needle because it is cheap and easily available. Homeostasis was maintained by pressure. We cleaned the entire area with normal saline which was followed immediately by 50% TCA with the tip of a toothpick by pressing hard on the entire area of depressed atrophic acne scars irrespective of the type of scar and frosting was taken as the end point, antibiotic cream was applied, and patient was sent home. Patient was advised to apply antibiotic cream twice daily followed by sunscreen in the morning. Erythema, edema, and crusting lasted for 7-10 days in all the patients to varying severity. After 10 days, the patient was advised to apply azelaic acid 20% cream at night. Results were evaluated on the basis of global scar grading system, visual improvement by photographs and patient satisfaction. The global acne scarring classification is a four-category qualitative system by Goodman[5] based on scar morphology and ease of masking by makeup or normal hair patterns. Grade 1 means macular scarring only, Grade 2 is mild atrophy, which is not visible beyond 50 cm and can be easily masked by makeup, Grade 3 is moderate atrophy obvious at social distance not easily masked by makeup while Grade 4 is severe atrophy. Percentages in improvement were calculated as a combination of the three parameters, i.e. global scar grading system by Goodman, visual improvement by photographs showing the change in the grade and patient satisfaction, which was assessed by giving a questionnaire to the patient where they had to rate their improvement on 0-10 point scale. Excellent >70% Good 50-70% Fair 30-50% Poor <30% We labeled results as excellent when there was a two-grade change in the scars observed by the dermatologist both by grading system, photographs, and patient rated his improvement as more than 7 [Figures [Figures11 and and33]. Figure 1 Sites involved right cheek. (a) Post-acne scars mostly ice pick, boxcars and few roller scars. (b) Decrease in number and depth of scars Figure 3 Site involved is left cheek and left temple. (a) Many ice pick scars and a few boxcars and very few rolling scars. (b) Decrease in depth and size of scars Results were taken as good when there was one-grade improvement in acne scars observed by the dermatologist both by grading system, photographs, and patient rated his improvement as 5, 6, or 7 [Figure 2]. Figure 2 Sited involved right cheek. (a) Multiple post-acne ice pick and roller scars. (b) Decrease in size and depth of all the scars Results were taken as fair when there was improvement in acne scars observed by the dermatologist by photographs only and patient rated his improvement as 3, 4, or 5. Results were taken as poor when there was no improvement in acne scars observed by the dermatologist either by photographs or by grading system but it was only subjective improvement as told by the patient when they rated it between 1 and 3. In all the patients, scar grading improved from grade 4 to grade 2 and results were graded excellent, good, and fair in 6, 3, and 1 patients respectively [Table 1]. Although in various studies best results with CROSS TCA are seen in ice-pick scars but since in our study we combined it with subcision, results were equally good even in rolling scars and boxcars scars. Post-inflammatory hyperpigmentation was transient in three patients, which persisted for 15-20 days post-procedure, which further decreased over the time period with 20% azelaic acid and in one case, the mild hyperpigmentation persisted even at the end of 6 months in spite of the best efforts for reasons not known. The patients were also happy with the results except for the one where hyperpigmentation persisted. Although the procedure has a downtime in the form of erythema, edema, and crusting, it is comparable to all other resurfacing procedures and the problem of post-inflammatory hyperpigmentation can be judiciously tackled with the proper and repeated use of sunscreens and lightening agents. Each procedure when done individually has downtime of few days. So, we tried to reduce it by combining the two procedures. Hence, it can be concluded that subcision combined with TCA CROSS is a simple, safe, and cost-effective procedure, which does not require any specialized or costly equipments or materials or any special training and can be performed as an out-patient-department procedure by any budding dermatologist. __________________________________________________________________________________________________________________ How to Do TCA CROSS for Icepicks and Small Boxcars - Note: Spot TCA Peels are done in a similar way without toothpicks (guaze instead) and no more than 35% strength Items you will need: Toothpick or wood part of swab broken off to fit inside scar (sandpaper), TCA Acid 35-50%, Paper Towel, Baking Soda dissolved water, Vaseline / triple antibiotic / or biafine / hydrogel burn section first aid, Acetone aka nail polish remover (without fragrance, 100%) , rubber gloves, small container for acid (glass or ceramic), mirror 1) Wash face with a gentle soap, nothing to harsh or acidic. Let it dry fully 2) Use the Acetone aka nail polish remover (without fragrance, 100%) to pre treat the area (de grease it). 3) Sand down your toothpick (Sandpaper) to fit into scar (you want to touch the bottom of the scar not the side walls as much as possible) or break a wooden swab stick and make it fit into the scar, TCA Cross does better on scars with defined walls all around, the closer the walls the scar the better it will heal. Icepicks and "small" boxcars can be treated. Bigger scars should be treated with weaker acid dilution over the effected area (soften the transition to the surrounding skin), not just inside the spot. 4) Put on those gloves 5) put vaseline anywhere you think is important to protect. The acid will not react there. Nose, lips, around eyes, eyebrows, smile lines. You can also surround the area with vaseline if you wish for extra protection but it's not necessary. 6) Pour a little acid or drop it into the glass or ceramic. Add equal amount to half it. You should always do test spots before you treat all your scars. This can be done at a dilute amount 20% if doing TCA Cross, and less for a full face or spot peel 8-12%. You are seeing how you heal, how it looks, and how you react to the acid. 7) Use your toothpick or wooden q-tip swab. Dip it in the TCA. You will take your paper towel and get any excess off. Drips make burns, wood holds acid, even if you cannot see it. The smallest amount works, not excess. You are pressing firmly into the icepick or box car but not spreading it outside of that scar, reach the bottom of the scar but never break the skin by pressing to hard. 8) It should start to turn white, if it does not, you may in 5 mins do it again (if your at a lower dilution for that test spot, it will not turn white and that's ok, white is only at higher amounts). Turning White assumes you have reached the appropriate strength for your skin and it's not too much. 9) Some people in case of emergency or to stop it because it hurts too much, take their dissolved baking soda water and stop the acid. TCA is self neutralizing, hence the white it is reaching the keratin in the skin. Never wash it off with soap (ouch!). 10) Put your vaseline, triple antibiotic cream, hydrogel from the first aid section for burn stuff, or biafine my favorite on the spot. You can take some antihistamine and or Tylenol if you need for pain and swelling. 11) Daily put more of the above to keep it moist, and once or twice a day used diluted (Water) vinegar to pat with gauze the area, never rub. This clean and kills bacteria, also it makes it peel naturally. 12) If you need to use acne stuff, only put it on the spots, never the scab or wound 13) If your in the shower, it can make the scab fall off, this is bad, splash your face, don't let it fall off. 14) Do not pick, it will make it worse. 15) Only do these peels once a month, more and you will make it deeper. 16) After the scab has fallen off you can use honey and aloe vera to heal the red spot or triple antibiotic cream. 17) Wet Green tea bags help with redness and soothing 18) The scar will not be flat, that takes multiple treatments, it will lessen a percentage as it raises the bed or bottom of the scar, ... I suggest microneedling, and alternating months doing peels for collagen production. 19) Ethnic skin (darker) types may not be able to use TCA, please do a test spot, at a very dilute amount (water), see how you react. Ethnic skin types do well with Glycolic and, Salycilic Acids. TCA may result in permanent darkening of the skin in the area where the peel was used. However, this problem can be overcome if TCA 20% is used after a Jessner’s solution for darker skin types. 20) Avoid any sun exposure whatsoever in the days following the peel (Use Sunscreen After). Further Reading on TCA Cross: ___________________________________________________________________________________________ How to Do TCA Spot Peels or Full Face TCA Peels Full Face peels are great upkeep and many do them yearly to have fresh skin. For acne scar suffers, or those with smaller issues use spot peels (large pores, rolling, or boxcars). You alternate your peels with every other month (everything should be completely healed). This continues on for a year(s). If you spot peel make sure you feather the edges by using a more diluted weaker acid around the edge to feather out the treatment area. 1) Pre Peal: Use Acetone AKA Nail Polish Remover (without fragrance, 100%, to avoid irritation) this removes grease / sweat / sebrum so the peel work. You may now use a Salicylic, Glycolic, or Jessner peel but this is not required. 2) Do not apply Retin A / tretinorin or a leave-on acid product the day before your peel – Let it rest for 1 day. Never use abrasive products (scrubs) immediately prior to a peel. 3) Those with darker skin (or Asian) prone to hyperpigmentation please prepare your skin by using hydroquinone (skin bleach) a few weeks before and after treatment, also vitamin c serum, and spot test at lower levels to see how you handle the acid / healing. 4) Items you will need: medical gauze or paper towel, TCA Acid 35%, Baking Soda dissolved water, Vaseline / triple antibiotic / or biafine / hydrogel burn section first aid, Acetone aka nail polish remover (without fragrance, 100%) , rubber gloves, small container for acid (glass or ceramic), mirror 1) Wash face with a gentle soap, nothing to harsh or acidic. Let it dry fully 2) Use the Acetone aka nail polish remover (without fragrance, 100%) to pre treat the area (de grease it). 3) In a bowel or container combine your water and TCA acid (to a low enough percentage, hopefully you have already done a small test spot to see how you heal and can handle that percentage, starting percentage is 12-15%, your slowly working your way over many peels to as much as you can handle of 35%, some never reach that and that's ok). 4) Put on those gloves 5) put Vaseline anywhere you think is important to protect. The acid will not react there. Nose, lips, around eyes, eyebrows, smile lines. You can also surround the area of treatment with Vaseline if you wish for extra protection but it's not necessary. 7) Use your gauze. Dip it in the TCA. You will take your paper towel and get any excess of (wring it out). Drips make burns, gauze holds acid, even if you cannot see it. The smallest amount works, not excess. 8) It will only turn white at higher percentages, otherwise you won't see anything, if you feel nothing you may in 5 mins do it again (if your at a lower dilution for that test spot). 9) Some people in case of emergency or to stop it because it hurts too much, take their dissolved baking soda water and stop the acid early. Never wash it off with soap (ouch!). 10) Put your Vaseline, triple antibiotic cream, hydrogel from the first aid section for burn stuff, or biafine my favorite on the spot. You can take some antihistamine and or Tylenol if you need for pain and swelling. 11) Daily put more of the above to keep it moist, and once or twice a day used diluted (Water) vinegar to pat with gauze the area, never rub. This clean and kills bacteria, also it makes it peel naturally. 12) If you need to use acne stuff, only put it on the spots, never the scab or wound 13) If your in the shower, it can make the scab fall off, this is bad, splash your face, don't let it fall off. 14) Do not pick, it will make it worse. 15) Only do these peels once a month, more and you will make it deeper. 16) After the scab has fallen off you can use honey and aloe vera to heal the red spot or triple antibiotic cream. 17) Wet Green tea bags help with redness and soothing 18) The scar will not be flat, that takes multiple treatments, it will lessen a percentage as it raises the bed or bottom of the scar, ... I suggest microneedling, and alternating months doing peels for collagen production. 19) Ethnic skin (darker) types may not be able to use TCA, please do a test spot, at a very dilute amount (water), see how you react. Ethnic skin types do well with Glycolic and, Salycilic Acids. TCA may result in permanent darkening of the skin in the area where the peel was used. However, this problem can be overcome if TCA 20% is used after a Jessner’s solution for darker skin types. 20) Avoid any sun exposure whatsoever in the days following the peel (Use Sunscreen After). The collagen production will continue for the next several months. 21) If anything does not “look or feel” right to you, see a doctor for an evaluation! (Lessons learned from Doing A TCA Peel Wrong) Medium Depth Chemical Peels Gary D. Monheit, M.D. Associate Professor Department of Dermatology University of Alabama at Birmingham Birmingham, Alabama Synopsis Medium Depth Chemical Peeling Gary D. Monheit, M.D. The combination medium depth chemical peel – Jessner’s solution + 35% TCA, has been accepted as a safe, reliable and effective method for the treatment of moderate photoaging skin. ** Pre Peal: Use Acetone AKA Nail Polish Remover (without fragrance, 100%, to avoid irritation) this removes grease / sweat/ sebrum so the peel work. Chemical peeling involves the application of a chemical exfoliant to wound the epidermis and dermis for the removal of superficial lesions and improve the texture of skin. Various acidic and- basic chemical agents are used to produce the varying effects of light to medium to deep chemical peels through differences in their ability to destroy skin. The level of penetration, the nature of destruction and the inflammatory response determines the level of the peel. The stimulation of epidermal growth through the removal of the stratum corneum without necrosis consists of light superficial peel. Through exfoliation, it thickens the epidermis with qualitative regenerative changes. Destruction of the epidermis defines a full superficial chemical peel inducing the regeneration of the epidermis. Further destruction of the epidermis and induction of inflammation within the papillary dermis constitutes a medium-depth peel. Then, further inflammatory response in the deeper reticular dermis induces new collagen production and ground substances which constitutes a deep chemical peel.1 These have now been well classified and usage has been categorized for various degenerative conditions associated with photoaging skin based on levels of penetration. The physician, thus, has tools capable of solving photoaging skin problems that may be mild, moderate or severe with agents that are very superficial, superficial, medium-depth, and deep peeling chemicals. The physician must choose the right agent for each patient and condition. Medium depth peeling is thus defined as the use of a chemical agent to wound skin through papillary dermis. It is most useful for the removal of epidermal or superficial lesions and to improve skin texture in moderate photodamaged skin (grade II Glogau photoaging skin)2. Medium depth peeling agents create changes through necrosis of the epidermis and part or all of the papillary dermis with an inflammatory reaction in the upper reticular dermis. The procedure is performed to remove actinic keratoses, mild photoaging of the skin including rhytides, treat pigmentary dyschromias, and improve depressed scars.3 (Table I) Trichloracetic acid has been the gold standard in quantitating chemical peel strength and depth. Ten to 30% has been quantitated as superficial wounding while above 50% is deep chemical peeling. The level, 35-50% trichloracetic acid is the spectrum of medium depth peeling. It is standard to think of 45 or 50% trichloracetic acid corresponding to a wounding level of mid to deep reticular dermis. This concentration of trichloracetic acid, though, has been found unreliable and associated with a higher incidence of pigmentary dyschromia, textural change, and even scarring.4 In an attempt to reduce the morbidity of higher concentration trichloracetic acid, a combination of products have been devised that improve the absorption of the lower concentration of trichloracetic acid without the associated complications.5 The combination peels include: Solid carbon dioxide freezing with trichloracetic acid 35%. Jessner's solution + 35% trichloracetic acid. Glycolic acid 70% plus 35% trichloracetic acid. The combinations produce a more even peel with deeper penetration of the wounding agent without the associated complications of higher concentration trichloracetic acid. This chapter will review the scope of medium depth peeling, the patients and conditions most commonly treated, the techniques of application, wound healing, and complications. Trichloracetic Acid Trichloracetic acid has become the gold standard of chemical peeling agents for its long history of usage, its versatility in peeling, and its chemical stability. It has been useful in many concentrations because it has no systemic toxicity and can be used to create superficial, medium or even deep wounds in the skin. Trichloracetic acid is naturally found in crystalline form and is mixed weight-by-volume with distilled water. It is not light sensitive, does not need refrigeration and is stable on the shelf for over six months. The standard concentrations of trichloracetic acid should be mixed weight-by-volume to accurately assess the concentration. That is, 30 gm. trichloracetic acid crystals mixed with 100 cc. distilled water will give an accurate 30% concentration, weight by volume. Any other dilutional system - volume dilutions and weight by weight, are inaccurate in that they do not reflect the accepted weight by volume measurements. Since TCA itself is an agent more likely to be fraught with complications, especially scarring, in strengths of 50% or higher, the higher concentration has fallen out of favor.6 It is for this reason that the combination products along with a 35% TCA formula have been found equally effective in producing this level of control damage without the risk of side effects. Brody first developed the use of solid CO2 applied with acetone to the skin as a freezing technique prior to the application of 35% trichloroacetic acid. The preliminary freezing appears to break the epidermal barrier for a more even and complete penetration of the 35% trichloroacetic acid.7 Monheit then demonstrated the use of Jessner’s solution prior to the application of 35% trichloroacetic acid. The Jessner’s solution was found effective in destroying the epidermal barrier by breaking up individual epidermal cells. This also allows a deeper penetration of the 35% TCA and a more even application of the peeling solution.8 Similarly, Coleman has demonstrated the use of 70% glycolic acid prior to the application of 35 % trichloroacetic acid. Its effect has been very similar to that of Jessner’s solution.9 (Table II) All three combinations have proven to be as effective as the use of 50% trichloroacetic acid with a greater safety margin. The application of acid and resultant frosting are better controlled with the combination so that the “hot spots” with higher concentrations of TCA can be controlled, creating an even peel with less incidence of dyschromias and scarring. The combination peel produces an even, uniform peel. The Monheit version of the Jessner’s solution – 35% TCA peel is a relatively simple and safe combination. The technique is used for mild-to-moderate photoaging including pigmentary changes, lentigines, epidermal growths, dyschromias, and rhytids. It is a single procedure with a healing time of seven to ten days. It is useful also to remove diffuse actinic keratoses as an alternative to chemical exfoliation with topical 5-fluorouracil chemotherapy. Topical chemotherapy is applied for three weeks creating erythema, scabs and crusts for up to six weeks.10 The combination peel will produce similar therapeutic benefits within ten days of healing. It thus reduces the morbidity significantly and gives the cosmetic benefits of improved photoaging skin. Skin preparation is of vital importance to encourage correct healing and avoid complications. Agents used prior to the peel to prepare the skin correctly include:11 (Table III) Sunscreen Exfoliations - abrasive cleansers, 5-10% glycolic acid lotion Tretinoin .05% used six weeks to three months prior to the peel Bleaching products - hydroquinone 4-8% used in patients with pigmentary dyschromias and those with type III-VI Fitzpatrick skin pigmentation. Anti-viral agents in selected patients with history of facial HSV I infections. The procedure is usually performed with mild preoperative sedation and nonsteroidal antiiflammatory agents. The patient is told that the peeling agent will sting and burn temporarily and aspirin is given before the peel and continued through the first twenty-four hours if the patient can tolerate the medication. Its inflammatory effect is especially helpful in reducing swelling and relieving pain. If given before surgery, it may be all the patient requires during the postoperative phase. For full-face peels, though, it is useful to give preoperative sedation (diazepam 5 to 10 mg orally) and mild analgesia, meperidine 25 to 50 mg (Demerol – Winthrop, New York), and hydroxyzine hydrochloride 25 mg intramuscularly (Vistaril – Lorec, New York). The discomfort from this peel is not long lasting, so short acting sedatives and analgesics are all that are necessary.12 Vigorous cleaning and degreasing is necessary for even penetration of the solution. The face is scrubbed gently with Ingasam (Septisol - Vestal Laboratories, St. Louis, Missouri) four-inch by four-inch gauze pads and water, then rinsed and dried. Next, an acetone preparation is applied to remove residual oils and debris. The skin is essentially debrided of stratum corneum and excessive scale. A thorough degreasing is necessary for an even penetrant peel. The physician should feel the dry, clean skin to check the thoroughness of degreasing. If oil is felt, degreasing should be repeated. A splotchy peel is usually the result of uneven penetration of peel solution due to residual oil or stratum corneum, and a result of inadequate degreasing. After thorough cleaning, the Jessner’s solution is applied with either cotton-tip applicators or 2” x 2” gauze. (Table V) The Jessner’s solution is applied evenly with usually one or two coats to achieve a light but even frosting. The frosting achieved with Jessner’s solution is much lighter than that produced by TCA and the patient is usually comfortable, feeling only heat. A mild erythema appears with a faint tinge of splotchy frosting over the face. Even strokes are used to apply the solution to the unit area covering the forehead to the cheeks to the nose and chin. The eyelids are treated last creating the same erythema with blotchy frosting. (Fig 1). The application of Jessner’s solution alone is equal to a superficial or light chemical peel.13 After the Jessner’s solution has dried, the TCA is applied. The TCA is painted evenly with one to four cotton-tipped applicators that can be applied over different areas with light or heavier doses of the acid. Four cotton-tipped applicators are applied in broad strokes over the forehead and also on the medial cheeks. Two mildly soaked cotton-tipped applicators can be used across the lips and chin, and one damp cotton-tipped applicator on the eyelids. Thus, the dosage of application is technique dependent on the amount used and the number of cotton-tipped applicators applied. The cotton-tipped applicator is useful in quantitating the amount of peel solution to be applied. Care must be taken to ensure the acid is not dripped inadvertently over unwanted areas such as neck or eyes. The white frost from the TCA application appears complete on the treated area within 30 seconds to 2 minutes. Even application should eliminate the need to go over areas a second or a third time, but if frosting is incomplete or uneven, the solution should be reapplied. Thirty-five percent TCA takes longer to frost than Baker’s formula or straight phenol, but a shorter period of time than the superficial peeling agents do. The surgeon should wait at least 3 to 4 minutes after the application of TCA to ensure the frosting has reached its peak. He then can document the completeness of a frosted cosmetic unit and touch up the area as needed. Areas of poor frosting should be retreated carefully with a thin application of TCA. The physician should achieve a level II to level III frosting. Level I frosting is erythema with a stringy or blotchy frosting, seen with light chemical peels. Level II frosting is defined as white-coated frosting with erythema showing through. A level III frosting, which is associated with penetration through the papillary dermis, is a solid white enamel frosting with little or no background of erythema.14 A deeper level III frosting should be restricted only to areas of heavy actinic damage and thicker skin. Most medium-depth chemical peels use a level II frosting and this is especially true over eyelids and areas of sensitive skin. Those areas with a greater tendency to scar formation, such as the zygomatic arch, the bony prominences of the jawline, and chin, should only receive up to a level II frosting. Overcoating trichloroacetic acid will increase its penetration so that a second or third application will drive the acid further into the dermis, creating a deeper peel. One must be careful in overcoating only areas in which the take up was not adequate or the skin is much thicker. (Fig 2) Anatomic areas of the face are peeled sequentially from forehead to temple to cheeks and finally to the lips and eyelids. The white frosting indicates keratocoagulation or protein denaturation of keratin and at that point the reaction is complete. Careful feathering of the solution into the hairline and around the rim of the jaw and brow conceals the line demarcation between peeled and non-peeled skin. The perioral area has rhytids that require a complete and even application of solution over the lip skin to the vermilion. This is accomplished best with the help of an assistant who stretches and fixates the upper and lower lips while the peel solution is applied. Certain areas and skin lesions require special attention. Thicker keratoses do not frost evenly and thus do not pick up peel solution. Additional applications rubbed vigorously into the lesion may be needed for peel solution penetration. Wrinkled skin should be stretched to allow an even coating of solution into the folds and troughs. Oral rhytides require peel solution to be applied with the wood portion of a cotton-tipped applicator and extended into the vermilion of the lip. Deeper furrows such as expression lines will not be eradicated by peel solution and thus should be treated like the remaining skin. Eyelid skin must be treated delicately and carefully. A semidry applicator should be used to carry the solution within 2 to 3 mm of the lid margin. The patient should be positioned with the head elevated at 30 degrees and the eyelids closed. Excess peel solution on the cotton tip should be drained gently on the bottom before application. The applicator is then rolled gently on the lids and periorbital skin. Never leave excess peel solution on the lids because the solution can roll into the eyes. Dry the tears with a cotton-tipped applicator during peeling because they may pull peel solution to the puncta and eye by capillary attraction. (Fig 3) The solution should be diluted immediately with cool saline compresses at the conclusion of the peel. The Jessner’s-TCA peel procedure is as follows: The skin should be cleaned thoroughly with Septisol to remove oils. Acetone or acetone alcohol is used to further debride oil and scale from the surface of the skin. Jessner’s solution is applied. Thirty-five percent TCA is applied until a light frost appears. Cool saline compresses are applied to dilute the solution. The peel will heal with 0.25% acetic acid soaks and a mild emollient cream. There is an immediate burning sensation as the peel solution is applied, but this subsides as frosting is completed. Cool saline compresses offer symptomatic relief for a peeled area as the solution is applied to other areas. The peel reaction is not neutralized by saline solution as the reaction is completed when frosting occurs.15 The compresses are placed over the face for 5 to 6 minutes after the peel until the patient is comfortable. The burning subsides fully by the time the patient is ready to be discharged. At that time, most of the frosting has faded and a brawny desquamation is beginning. Postoperatively, edema, erythema, and desquamation are expected. With periorbital peels and even forehead peels, eyelid edema can occur and may be enough to close the lids. For the first 24 hours, the patient is instructed to soak four times a day with a 0.25% acetic acid compress made of 1 tablespoon white vinegar in 1 pint of warm water. A bland emollient is applied to the desquamating areas after soaks. After 24 hours, the patient can shower and clean gently with a mild nondetergent cleanser. The erythema intensifies as desquamation becomes complete within 4 to 5 days. Thus, healing is completed within 1 week to 10 days. At the end of 1 week, the bright red color has faded to pink and has the appearance of a sunburn. This can be covered by cosmetics and will fade fully within 2 to 3 weeks. The medium-depth peel is dependent on three components for therapeutic effect: (1) degreasing, (2) Jessner’s solution, and (3) 35% TCA. The amount of each agent applied creates the intensity and thus the effectiveness of this peel. The variables can be adjusted according to the patient’s skin type and the areas of the face being treated. It is thus the workhorse of peeling and resurfacing in my practice as it can be individuated for most patients we see. The medium-depth chemical peel thus has five major indications: destruction of epidermal lesions – actinic keratoses resurfacing the level II or III moderate photoaging skin pigmentary dyschromias mild acne scars blending photoaging skin with laser resurfacing and deep chemical peeling Actinic keratoses This procedure is well suited for the patient with epidermal lesions such as actinic keratoses which has required repeated removal with either cryosurgery or chemoexfoliation (5-fluoruracil). The entire face can be treated as a unit or subfacial cosmetic unit such as forehead, temples, and cheeks, and can be treated independently. Active lesions can be removed, as well as incipient growths as yet undetected, will be removed as the epidermis is sloughed. Advantages for the patient with photodamaged skin include a limited recovery period – 7 to 10 days, with little post operative erythema after healing.16 There is little risk of pigmentary changes either hypopigmentation or hyperpigmentation, thus, the patient can return to work after the skin has healed.(Fig 4) Moderate photoaging skin Glogau level II or III damage responds well to this peeling combination with removal of the epidermal lesions and dermal changes that will freshen photoaging characterized as sallow, atrophic skin with fine rhytides. This peel is favored over deeper resurfacing procedures such as CO2 laser and deep peel in that it will heal in ten days with minimal risk of textural or color complications. It, though, is only designed for medium-depth damage. (Fig 5) Pigmentary dyschromias Though color change can be treated with repetitive chemical peeling, the medium-depth peel will be a single treatment preceded and followed by the use of bleaching agents and retinoic acid.17 In most cases, the pigmentary problems are resolved with this single peel as an adjunct to the skin care program. Blending other resurfacing procedures In a patient in which there is advanced photoaging changes such as crow’s feet and rhytides in the periorbital and/or perioral area with medium-depth changes on the remaining face, a medium-depth peel can be used to integrate these procedures together. That is, laser resurfacing or deep chemical peeling can be performed over the periorbital and perioral areas that has more advanced photoaging changes, while the medium-depth chemical peel is used for the rest of the face. This will blend the facial skin as a unit so that the textural and color changes will not be restricted to one area. The patients requiring laser resurfacing in a localized cosmetic unit will have the remaining areas of their face blended with this medium-depth chemical peel. Patients having laser resurfacing or deep peeling to the perioral or periorbital areas alone develop a pseudo hypopigmentation that is a noticeable deformity. The patient requiring laser resurfacing at a localized cosmetic unit will have the remaining areas of their face blended with this medium-depth peel. The alternative – a full-face deep peel or laser resurfacing has an increased morbidity, longer healing and risk of scarring over areas such as the lateral jaw line, malar eminences, and forehead. If deep resurfacing is needed only over localized areas such as perioral or periorbital face, a blending medium-depth peel does reduce morbidity and healing time.18 (Fig 6) Results This medium depth peel will produce superior results for the conditions listed.(Table III) Removal of actinic keratoses, both present and incipient, affords the patient a single procedure with healing time within one week to ten days, as a preventive therapeutic modality for the removal of precancerous growths over the face.(Fig 4) A comparison study of the efficacy of Jessner's solution plus 35% trichloracetic acid with 5-Fluorouracil documented superior effectiveness of this single procedure with a significant reduction in morbidity.19 It is, thus, an effective, safe and simple single procedure that can be used to remove actinic keratoses and epidermal growths as both a therapeutic and cosmetic procedure. Glogau grade II photoaging skin can be effectively treated for improvement in both texture, color change, and epidermal growths with a medium depth Jessner's - TCA peel. Of equal importance to the procedure is choosing the correct patient for the procedure. Patients with superficial textural changes and those with epidermal growths seem to respond best to this peel. Fine wrinkles, cross-hatched lines, sallow color changes of photoaging along with the crinkly appearance are the textural changes that will respond to this peel. Additionally, epidermal growths such as freckles, lentigenes, actinic keratoses, and seborrheic keratoses will also respond well.(Fig 5) The more advanced changes seen with deeper grooves and wrinkles, pebbly appearance of the skin and more pronounced gravitational changes of Glogau III and IV photoaging skin require either deep chemical peeling or laser resurfacing. Using trichloracetic acid or any of its combinations as a deep chemical peel for these more advanced indications will only risk potential side effects and complications. Pigmentary dyschromias such as melasma, blotchy hyperpigmentation, and pigmentary growths do respond well to medium depth chemical peeling. This is especially suited for those problems which have not resolved well with medical treatment or repeated light chemical peeling. Epidermal pigment seems to respond the best and this can be identified with Wood's light examination. Dermal pigment will show some response but not as effective as epidermal pigment. This combination peel is effective in that it will fully remove the epidermis as well as have an effect on melanocytes in the pilar apparatus during reepithelialization. It is important that these patients be prepared correctly with 4-8% hydroquinone, tretinoin and sunscreen begun at least six weeks prior to the peeling procedure. The bleaching agent is reinstituted after reepithelialization and tretinoin six weeks later. It should be continued for up to three months after the chemical peel and sunscreen used for longer period of time to insure the dyschromia does not return. There are many bleaching agents on the market today which have some lightening effect, but hydroquinone is the most effective. When localized areas of the face have advanced or severe photoaging such as deeper wrinkles around the eyelids and rhagades on the lips, the combination Jessner's trichloracetic acid peel can be used to blend the remaining areas of the face if they have only moderate photoaging of the skin. Thus, eyelids and lips can be resurfaced with a pulsed carbon dioxide laser and the remainder of the face treated with the Jessner's - trichloracetic acid peel. In this instance, the peel should be performed first in the manner described above and then appropriate anesthesia, eye protection and preparation be used to laser the designated areas. Healing will occur in the usual manner for either laser or peel with soaks and occlusive ointments. This is an effective method of reducing morbidity with deeper agents to areas that don't need them. It will also blend the photoaging skin, texture, color and appearance to that of the laser treated skin.(Fig 6) Post-Operative Care and Complications The four stages of wound healing are apparent after a medium depth chemical peel.20 They include: Inflammation Coagulation Reepithelialization Fibroplasia At the conclusion of the chemical peel, the inflammatory phase has already begun with a brawny, dusky erythema that will progress over the first twelve hours. With the medium depth peels, the epidermis will begin to separate, creating a leathery, dry, cracking appearance to the epidermis. This is an accentuation of pigmented lesions on the skin as the coagulation phase separates the epidermis, producing serum exudation, crusting and pyoderma. It is during this phase that it is important to use debrident soaks and compresses as well as occlusive salves. These will remove the sloughed necrotic epidermis and prevent the serum exudate from hardening as crust and scab. I prefer the use of 1/4% acetic acid soaks found in the vinegar water preparation (one teaspoon white vinegar, one pint warm water), as it is antibacterial, especially against pseudomonas and gram negatives. In addition, the mildly acidic nature of the solution is physiologic for the healing granulation tissue, mildly debrident, as it will dissolve and cleanse the necrotic material and serum. Occlusive dressings including bland emollients and salves and biosynthetic membranes. For medium depth peeling, I prefer the occlusive salves as these can be monitored carefully day by day for potential complications. Reepithelialization begins on day three and continues until day seven to ten. Occlusive salves promote faster reepithelialization and less tendency of delayed healing.21 The final stage of fibroplasia continues well beyond the initial closure of the peeled wound and continues with neoangiogenesis and new collagen formation for three or four months. Prolonged erythema may last two to four months in unusual cases of sensitive skin or with contact dermatitis. New collagen formation can continue to improve texture and rhytides for a period up to four months during this last phase of fibroplasia. Many of the complications seen in peeling can be recognized early on during healing stages. The cosmetic surgeon should be well acquainted with the normal appearance of a healing wound in its time frame for medium depth peeling. Prolongation of the granulation tissue phase beyond one week may indicate delayed wound healing. This could be the result of viral, bacterial or fungal infection, contact irritants interfering with wound healing, or other systemic factors. A red flag should alert the physician that careful investigation and prompt treatment should be instituted to forestall potential irreparable damage that may result in scarring. Thus, it is vitally important to understand the stages of wound healing in reference to medium depth peeling. The physician then can avoid, recognize and treat any and all complications early on. Specific complications will be discussed in the appropriate chapter. Longterm care of peeled skin would include sunscreen protection for up to six months along with reinstitution of medical treatment such as low strength hydroxy acid lotions and tretinoin. Re-peeling areas should not be performed for six months from the previous peel. If any erythema or edema persists, the peel should not be performed as the re-injury may create complications. This peel should not be performed on undermined skin such as facelift or flap surgery performed up to six months prior to the peel.22 The evolution of medium depth chemical peeling has changed the face of cosmetic surgery. It has introduced new techniques into the armamateria of the cosmetic surgeon to treat problems that previous have been approached with tools inadequate to obtain the results for moderate photoaging skin or with overly-aggressive treatment using deep peeling agents. The combination peels have provided some of the more popular tools needed to approach a burgeoning population with photoaging skin. Go to: _________________________________________________ Dilute and Have Emergency Baking Soda Water to Neutralize! Don't go buy TCA Acid at high percentages which is car part cleaner on various places on the internet and think my scars are bad so I will put the strongest possible. This is your face not concrete!!!! Always Dilute Full Face or Spot Peels: 12-15% and test on a small area TCA Cross Dilute your acid to 20% and spot treat one tiny spot and see (how you heal, how long it takes, etc). -- The person below has ethnic darker pigmented skin (This also can happen to lighter Asian skin, ...Caucasians have less pigmentation reaction), dilute more depending on your skin type and test . Anyone with darker skin must also skin bleach cream (hydroquinone) before & after acid or laser procedures. ________________________________________________________________________________ Complications of Medium Depth and Deep Chemical Peels Nanma Nikalji, Kiran Godse, Jagdish Sakhiya,1 Sharmila Patil, and Nitin Nadkarni INTRODUCTION Chemical peel is the most popular and common non-invasive cosmetic procedure done since the 18thcentury. The earliest use of caustic preparations for peeling procedures was described in the Egyptian medicine in the Ebers papyrus as early as 1550 BC.[1,2] Dermatologists began to show interest in peeling in the 19th century. In 1874 in Vienna, the dermatologist Ferdinand von Hebra used the technique to treat melasma, Addison's disease, and freckles. In 1882 in Hamburg, Paul G. Unna described the actions of salicylic acid, resorcinol, trichloroacetic acid (TCA), and phenol on the skin. During the first half of the 20th century, phenol and TCA were used in several centers. Alpha-hydroxy acids (AHAs) became available as superficial peeling agents in late 1980s and the 1990s. AHAs are used in treating aging skin, melasma, photoaging and acne. They are classified as superficial, medium, and deep peels. The superficial chemical peels are very safe when used properly but can cause itching, erythema, increased skin sensitivity, epidermolysis, allergic and irritant contact dermatitis, and post-inflammatory hyperpigmentation (PIH). All peels can cause activation of herpes viral infection, whereas medium and deep peels can cause scarring. Deep peels are no longer popular in Indian skin. They can cause milia, secondary infection, and scarring. Go to: COMPLICATIONS OF CHEMICAL PEELS Chemical peeling involves the application of a chemical agent of a defined strength that results in exfoliation of the skin followed by regrowth of new skin leading to skin rejuvenation. It is a technique-dependent procedure. Although rare, complications may occur including persistent erythema, milia, scarring, etc.[3] Go to: CLASSIFICATION Intraoperative[4] Incorrect peel pharmacology Accidental solution misplacement Post-operative Local infection Contact dermatitis Improper care during healing Based on the time of onset, complications can be immediate or delayed. Immediate (within minutes to hours after peeling):[5] Irritation, burning, pruritus, and pain Persistent erythema Edema Blistering Delayed (within a few days to weeks): Infections (bacterial, herpetic, and candidal) Scarring, delayed healing, milia, and textural changes Hyperpigmentation, hypopigmentation, and lines of demarcation Loss of cutaneous barrier and tissue injury Acneiform eruptions Allergic reactions, toxicity, and ectropion Accidental Ocular complications. Usually, complications are minor and are more common in dark-skinned individuals. They are seen more in medium and deep depth peels. Go to: PAIN AND BURNING Prolonged sun exposure, inadequate application of sunscreen, using topical retinoid or glycolic acid immediately after peels can lead to this complication. Paradoxically, in some patients, sunscreens can themselves cause contact sensitization or irritant dermatitis.[6] Pain and burning is commonly encountered during a peel procedure in sensitive skin. It can persist up to 2-5 days after the peel till re-epithelialization is completed. Treatment Immediate ice application reduces the pain and burning sensation Topical calamine lotion soothes the skin Topical steroids such as hydrocortisone or fluticasone reduce the inflammation Emollients to moisturize the skin Sunscreens to prevent PIH. Persistent erythema It is characterized by the skin remaining erythematous beyond what is normal for an individual peel. Erythema disappears normally in 3-5 days in superficial peel, 15-30 days in medium peel,[4] and 60-90 days in deep peel. Erythema persisting beyond the above-mentioned time is abnormal and is an alarming sign. It is a predictor of potential scarring. Causes Usage of topical tretinoin just before and after peel Isotretinoin administration (<0.5 mg/kg body weight) prior to peel Minimal amount of alcoholic beverages[7] Contact dermatitis Contact sensitization Exacerbation of pre-existing skin disease Genetic susceptibility. It is due to angiogenic factors stimulating vasodilation which indicates that the phase of fibroplasia is being stimulated for a prolonged period of time. Hence, it can be accompanied by skin thickening and scarring. Treatment Topical, systemic, or intralesional steroids if thickening is occurring Pulsed dye laser to treat the vascular factors. Pruritus It is more common after superficial and deep peels, although may occur following re-epithelialization.[8] It may be due to contact dermatitis to a topical agent (retinoid) If papules, pustules, and erythema occur along with pruritus, it is suspected to be contact dermatitis and treatment should start as early as possible to prevent PIH Care should be taken not to start any new topical agent during maintenance period after peel If erythema with pruritus or burning or stinging, rule out active infection or flaring of an underlying skin condition. Edema It is more common with medium and deep peels occurring within 24-72 h of chemical peeling. In case of superficial peels, care should be taken while peeling patients with thin, atrophic, dry skin and in the periocular area since edema can occur in these settings because of deeper penetration.[8] Treatment Usually subsides spontaneously Application of ice Systemic steroids (short courses). Blistering It is more common in younger patients with loose periorbital skin and around eyes. Deeper peels, especially AHAs, can cause epidermolysis, vesiculation, and blistering especially in the sensitive areas such as nasolabial fold and perioral area. TCA 50% and glycolic acid 70% can cause blistering [Figure 1]. Figure 1 Blistering seen post-chemical peel on cheeks Prevention The nasolabial folds, inner canthus of the eye, and corners of the mouth should be protected with petroleum jelly. Ocular complications Accidental spillage of any chemical peel agents in the eyes can cause eye injuries in the form of corneal damage. Treatment In cases of accidental spillage, the eyes should be flushed copiously with normal saline to prevent corneal damage. If phenol peels have been used, flushing should be done with mineral oil instead of saline. Referral to an ophthalmologist should be done. Prevention Extreme care should be taken while peeling the periorbital area Dry swab stick should be kept ready to absorb any tears Peeling agents should not be passed over the eyes. Ectropion of the lower eyelid It is usually seen after a Baker Gordon phenol peel.[8] Predisposing factors Older patients with senile lid laxity Patients who have undergone previous transcutaneous blepharoplasty Patients with thin skin. Treatment Most of the time the process is self-limiting and corrects spontaneously or with conservative care. Go to: CONSERVATIVE CARE Massaging of lower lid skin Adequate taping of the eyelid, especially at night Protection of the globe with artificial tears.[9] Go to: INTRALESIONAL STEROIDS Surgical repair Prevention Be cautious when using phenol in the periorbital area to avoid burning in the eye. An assistant should always have a clean dry cotton-tipped applicator in his hand which should be used to absorb any tears that may drip down the face or into the temporal area.[9] Inherent errors Incorrect peel pharmacology With resorcinol combinations, TCA, or phenol formulas, evaporation of the alcohol or water vehicle base can occur, inadvertently producing a stronger solution. Accidental solution misplacement Avoid accidental spillage of the solution Never move the cotton-tipped applicators directly over the eye area Go to: INFECTIONS They are rare in TCA and phenol peels since these peels are bactericidal. Impetigo and folliculitis (streptococcal and staphylococcal) Pseudomonas or Escherichia coli infections.[10] Go to: PRE-DISPOSING FACTORS Prolonged application of biosynthetic membranes or thick occlusive ointments and poor wound care. Clinical features Delayed wound healing Folliculitis Ulceration, superficial erosions, crusting, and discharge. Treatment of bacterial infections Swab for culture and sensitivity Appropriate antibiotics: Topical and oral Wound cleaning with potassium permanganate soaks or acetic acid soaks three to four times a day Topical mupirocin for gram-positive infections Light debridement. Candidal infections Recent intake of oral antibiotics is often a pre-disposing factor Superficial pustules can occur in candidal infections Immunocompromised patients Diabetics Oral thrush Prolonged topical steroid use. Treatment Topical clotrimazole, 1% Systemic anti-fungals (fluconozole, 50 mg/day). Herpes simplex infection It is characterized by reactivation of herpes simplex on face and perioral area presenting as sudden appearance of grouped erosions associated with pain. Treatment Active herpetic infections can easily be treated with anti-viral agents. A course of Valaciclovir, 1 g twice daily for 10 days may be given. If detected early and treatment is given on time, they do not scar.[11] Prevention Patients with a positive history of herpes simplex should be given 400 mg of acyclovir three times a day beginning on the day of the peel and continuing for 7-14 days, depending on whether it is a medium depth or deep chemical peel. Few recommend acyclovir 200 mg five times a day or valaciclovir, 1 g times a day starting 2 days before a peel and continued for 14 days. It is preferred to treat all patients with anti-viral agents regardless of a positive history as many patients do not remember prior herpes simplex infection that may have occurred years ago. A negative history of cold sores cannot predict development of post-operative herpes simplex virus infection after a procedure.[10,11] Since all anti-viral agents inhibit viral replication in the intact epidermal cell, the drug would not have an inhibitory effect until the skin is re-epithelialized, which is 7-10 days in medium and deep peels. In the past, these agents were discontinued at 5 days and in these patients, clinical infection became apparent in 7-10 days. Prevention of infections Frequent post-operative visits should be done so that it can be ensured that appropriate home wound care is being performed and to minimize the risk of infection. Avoid occlusive dressing in the immediate post-operative period because of its propensity to promote folliculitis and streptococcal and staphylococcal infections. Delayed healing Prolongation of granulation tissue beyond 1 week to 10 days signifies delayed healing. Presence of persistent erythema is a sign of the wound not healing normally. It could be due to the following: Infections Contact dermatitis Systemic factors Diminished or absent skin appendages may impair epidermal regeneration with delayed wound healing.[12] Presence of vellus hairs may indicate that epidermis is capable of regenerating after a chemical peel in spite of previous radiation for cancer.[3] Treatment Treatment of infections already discussed Debridement if necessary Treatment of contact allergic or irritant dermatitis with steroids Change of contact agents or protection with a biosynthetic membrane. Daily dressing along with a close watch on healing skin is a must. Prevention Strict sun avoidance and use of broad spectrum sunscreens before and after the peels indefinitely Hypopigmenting agents (hydroquinone, kojic acid, and arbutin) should be strictly enforced in the post-peel period too. Treatment Triple combinations of hydroquinone, tretinoin, and steroids should be started once re-epithelialization is completed. Hypopigmentation [Figure 2] superficial peels Figure 2 Hypopigmentation seen post-peel Transient lighter complexion is seen due to sloughing off of the epidermis and removal of excess melanin. Medium peels More prolonged hypopigmentation because of removal of basal layer Especially with 50% TCA and phenol peels. Hyperpigmentation It can occur any time after a peel and can be persistent, if treated inadequately. It is the most common complication of TCA peeling. Complications from superficial peels are limited to transient hyperpigmentation or dyschromia especially in dark-skinned patients. With medium depth peels, irregular pigmentation can occur. Temporary accentuation of lentigines and nevi may also occur because the existing sun damage has been cleared. Patients should be warned that lesions like solar lentigines may initially disappear and then return after chemical peel. This occurs because the melanocytes that are responsible for pigmentation reside below the level of chemical peel [Figure 3]. Figure 3 Hyperpigmentation post-peel High-risk groups Types III-VI skin Types I and II skin following intense sun exposure and tanning or use of photo-sensitizing agents Use of photosensitizing agents such as Non steroidal anti-inflammatory drugs, oral contraceptives, etc. Early exposure to sunlight without adequate broad spectrum sunscreens Estrogen containing medication, e.g., oral contraceptives and hormone replacement therapy Treatment Retinoic acid, 0.05% cream in combination with 4% hydroquinone once or twice daily for 3 weeks or longer if necessary Hydrocortisone cream can be used for several weeks as needed if erythema due to retinoic acid poses a concern Use of sunscreen with Sun protection factor 30. In some cases, a superficial peel (glycolic acid, 30-40%) is used to hasten resolution. Prevention Good skin care regimens can sustain more long-lasting results though studies have shown that peeled skin returns to its baseline status within 2-6 months without maintenance therapy. Strict sun avoidance and use of broad spectrum (ultraviolet A and sunscreens before and after the peels indefinitely Pre-treatment with a depigmenting agent and tretinoin In case of superficial peels, start at low strengths and titrate up very slowly Cessation of use of birth pills during peripeel period because it may invoke pigmentary changes. Incorporate broad spectrum sunscreens/bleaching agents (hydroquinone, kojic acid, arbutin)/retinoids/AHAs and beta-hydroxy acids/other anti-oxidant cosmeceuticals and bleaching creams singly or in combination as post-peel skin care regime. Skin depigmentation Bleaching effect can be seen after phenol peels. It is often noticed in the jaw neck region where untreated skin in the neck appears more obvious as it abuts the newly rejuvenated cheek or periorbital skin. This appearance may be desired in some but in patients undergoing regional facial peeling, this bleaching may become noticeable and troublesome. It is due to melanocytes losing their function to produce melanin. Lines of demarcation These are seen in medium and deep depth peels in darker skin types. They can be prevented by feathering edges using peeling agents of lower concentrations to merge with surrounding normal skin. Milia These are inclusion cysts which appear as a part of the healing process and are more common with dermabrasion than chemical peels. It is usually seen during the first few weeks of the recovery period. The post-peel care of deeper peeling may cause milia by occluding the upper pilosebaceous units with ointments. Thicker-skinned patients have been said to be in greater risk. Treatment Milia often resolve spontaneously with normal cleansing of the face. Sometimes, extraction or gentle electrodessication is effective. Prevention Returning to gentle epidermabrasion after re-epithelialization or the use of tretinoin both before and after peeling may retard their appearance. Texture changes Temporary appearance of enlarged pores post-peel can occur due to removal of stratum corneum. If the wounding agent is not capable of peeling below the defect, lacks the surfactant to provide an even depth of wounding, or has a very high surface tension, then uneven results will be produced from the selection of this inadequate wounding agent to peel below defect depth. Patients with telangiectasias may notice a worsening after phenol peeling which can be treated with vascular lasers. Atrophy It is characterized by the loss of normal skin markings in the absence of scarring. It may occur with phenol peels but has not been usually seen with superficial or medium depth TCA peels. Periorbital skin is very prone since it is physiologically thinner than most facial areas.[1] Go to: INTRALESIONAL STEROIDS Surgical repair Scarring Patchy erythema which may be indurated or persistent erythema can predict early scarring. The risk of hypertrophic scarring from medium depth peels is rare. If it occurs, it is most commonly seen along the mandibular region and in the perioral regions. TCA is more caustic than phenol and may be more likely to produce scarring [Figure 4].[13] Figure 4 Scarring seen on left cheek after peel Predisposing factors History of smoking History of recent intake of 0.5 mg/kg isotretinoin (during the previous 12 months). Clinically, it is safe to perform a peel on patients after their skin begins to produce normal oil. Before performing any resurfacing procedure, most practitioners recommend to wait for 18-24 months after high-dose isotretinoin has been stopped, except in case of superficial peels. Low-dose isotretinoin in the dose of 10-20 mg three times a week is found to be safe and effective during the peel period.[14] Recent facial surgery that required significant undermining Recent ablative resurfacing procedures including dermabrasion or laser within 6 months of procedure. Since re-epithelialization occurs from adnexal structures, some authors have theorized that patients recently treated for hair removal with lasers may have trouble healing after medium or deep depth peels.[15] Past history of keloids/hypertrophic scars. Overzealous application of TCA Medium depth peels on the areas like mandible, neck, and chest because these areas are more likely to scar Thin-skinned patients are more prone for scarring because the TCA is more likely to penetrate deep into the reticular dermis. Treatment Scar massage Topical/oral/intralesional steroids Surgical revision after scar maturation Pulsed dye laser therapy Silicon gel sheet. Systemic side-effects Phenol peels can cause cardiac, renal, and pulmonary toxicities. The best management of these complications is to avoid them. Cardiac arrhythmias In patients deliberately face peeled with phenol in 30-min time, tachycardia was usually noted first followed by premature ventricular contractions, bigeminy, paroxysmal atrial tachycardia, and ventricular tachycardia. Some progressed to atrial fibrillation,[16,17] Resorcinol resembles phenol in its systemic actions. Theoretically, similar complications might be induced if painted over one-third of body surface. A 40% peeling resorcinol paste applied daily for 3 weeks produced dizziness, pallor, cold sweat, tremors, and collapse on final application.[3,18] Resorcinol has an anti-thyroid activity. Hence, continuous application can cause myxedema. Repeated applications should be applied with caution in low body weight patients. Laryngeal edema Stridor, hoarseness, and tachypnea have been reported developing within 24 h of phenol peeling. It may be due to hypersensitivity reaction in a larynx already chronically irritated by cigarette smoke and may resolve with warm mist therapy. Anti-histamines prior to peel may prevent this. Toxic shock syndrome Physician should be alerted if patients develop fever, syncopal hypotension, vomiting, or diarrhea 2-3 days after a peel followed by scarlatiniform rash and desquamation. Other symptoms include myalgias, mucosal hyperemia, and hepatorenal, hematological or central nervous system involvement. Beta-lactamase-resistant antibiotics with large volumes of parenteral fluid should be given to prevent vascular collapse.[19,20] Prevention of complications Select only skin types I and II for deep peel Limit systemic levels of phenol due to absorption from skin Intravenous hydration with 0.5-1 of fluid (lactated ringers) before and during procedure to enhance phenol excretion and avoid renal toxicity.[15] Cardiac monitoring to detect any electrocardiography abnormality (premature ventricular contraction/premature atrial contractions).[21] In such cases, the procedure should be halted. In a series of full face phenol peels, the incidence of cardiac arrhythmias was 6.6%. Full face peels should be performed over a 60-90 min period of time. Each cosmetic unit (forehead, cheeks, nose, perioral, and periorbital areas) should be peeled in 15 min increments.[9] Peeling segments of the face in intervals with diuresis will allow metabolism and excretion of phenol and reduce arrhythmias.[3] Intraoperative oxygen to prevent arrhythmias. Allergic reactions Allergic contact dermatitis is more common with resorcinol, salicylic acid, kojic acid, lactic acid, hydroquinone, etc. Irritant contact dermatitis can be caused by glycolic acid. Any peel can cause irritant dermatitis when used with excessive frequency, inappropriate high concentration, and vigorous skin preparation using acetone or another degreasing solution. Deeper penetration of peel Predisposing factors Beginning a regimen with tretinoin Facial shaving Use of exfoliating scrubs. Prevention Closely examine condition of skin Elicit a good history from the patient prior to peel Correct patient and peel selection Priming of skin Post-peel care and sun protection Beware of habitual skin pickers Beware of those who have a tendency for PIH The complications of superficial and medium deep peels are summarized below Table 1 Table 1 Complications for peeling procedures[22] Go to: SUMMARY Chemical peels represent a flexible and useful tool for improving skin texture and the effects of ageing. The level of expertise of a dermatologist is crucial for the rate of side-effects and for the final peel results. Superficial peels are easy to perform and their complications are rare if appropriate pre-peel and post-peel care is taken. _________________________________________________________________________________ Chemical burn following 50% trichloroacetic acid for acne: Presentation of a case and a focused review Hannah Liua, , Amor Khachemouneb, , , Rashid M. Rashidc, 1. Introduction The use of chemical peels to improve the appearance and quality of skin has been described as early as 1550 BC in the Egyptian Papyrus Ebers (Bryan, 1974). Ancient Egyptian women, most famously Cleopatra, were known to bathe in sour milk to soften the skin. Since the 19th century, dermatologists have made use of various chemical agents to perform peels as a treatment for acne, pigmentary changes, actinic keratoses, and photoaging. In 2000, the chemical peel was the most popular minimally invasive cosmetic procedure with over 1 million treatments performed. Although this number has remained stable, in recent years peels have been surpassed by the rapid growth of botulinum toxin and soft tissue filler procedures (American Society of Plastic Surgeons, 2013). Trichloroacetic acid (TCA) holds an important place in the assemblage of chemical peeling agents, and is widely known for its safety and reliability. However, its use is highly technique-dependent and results rely heavily on the operator. TCA is frequently used dependably by the experienced practitioner, and there is a relative dearth of reports of complications related to TCA peels. Here we present a case of improper home usage of 50% TCA by a patient resulting in chemical burn. There are no similar reports in the peer-reviewed literature involving this strength of TCA, nor are there previously published histopathological data to support this unique complication. We also review adverse events related to chemical peels in the English literature. 2. Case synopsis A 38-year-old Asian male with Fitzpatrick Phototype IV skin was using 10% TCA at home for treatment of acne. Seeing that his acne was improving with this regimen, he sought to achieve faster and more dramatic results. The patient then purchased 50% TCA online and applied it to his face. Upon application he felt severe stinging and noted white frosting of the skin. He tried to wash off the TCA with cold water; however, over the next few days, noticed that his skin began to change color. He presented to clinic for a consultation and evaluation 4 days after using 50% TCA. On examination of his face (Fig. 1) there was intense hyperpigmentation of the skin with an almost ecchymotic color, and sharp lines of demarcation. The skin was non-tender and no hyperkeratosis or peeling was noted. A biopsy was performed of skin from an involved area on the forehead near the hairline. Fig. 1. Erythema and hyperpigmentation four days following 50% TCA application to the face (a) and temple (b). Figure options The microscopic specimen showed necrosis of the superficial spinous layer as well as focal full-thickness epidermal keratinocyte necrosis (Fig. 2). There was a mild superficial perivascular lymphocytic infiltrate with few neutrophils and eosinophils. Also, there was pigment found within many of the necrotic and remaining viable keratinocytes, likely contributing to the clinical findings. There was focal dermal pigment incontinence with few melanophages found in the papillary dermis. In addition, much of the epidermal pigment within the necrotic and remaining keratinocytes was retained. The histopathological findings correlated well with a chemical burn following TCA exposure. Fig. 2. Histopathological specimen from affected skin of the right forehead near the hairline showing epidermal necrosis and pigment incontinence. Figure options 3. Clinical course This patient was started on a regimen of fluocinolone 0.01% cream, hydroquinone 4% cream, and tretinoin 0.05% cream, as well as aggressive moisturization. He was also instructed to use sun protection by wearing a hat and applying sunscreen every few hours. Unfortunately, this patient was subsequently lost to follow-up. 4. Discussion TCA is one of the most widely used peeling agents, along with alpha-hydroxy acids (AHAs) and phenol. Unna first described the action of this inorganic acid on the skin in 1882 (Brody et al., 2000), and several authors soon followed. There are a multitude of indications for TCA peels including photoaging, rhytides, lentigines, actinic keratoses, acne, acne scars, melasma, and dyschromia. TCA works by precipitating proteins and inducing coagulative necrosis of the epidermis and/or papillary dermis. This is followed by sloughing off of the necrotic layers and reepithelialization via germinative centers of neighboring hair follicles over the next several days. TCA peeling also promotes dermal collagen remodeling, which can continue for months (Nguyen and Rooney, 2000). TCA has a protein dissociation constant (pKa) of 0.52, making it an inherently stronger acid than AHAs (pKa of glycolic acid – 3.83). TCA is self-neutralizing within minutes after application, and appearance of a white frost indicates the endpoint of the peel. TCA in strengths of 35% or less is used for superficial peeling whereas in strengths of 35–50% it is used for medium-depth peeling. When used alone at the higher concentrations, TCA is less predictable and is associated with an increased risk of adverse events, including hypertrophic scarring (Nguyen and Rooney, 2000). For this reason, TCA at lower concentrations is often combined with other peeling agents to achieve the desired depth while minimizing the side-effect profile. One common approach is to use 35% TCA after Jessner’s solution for treatment of actinic keratoses. Currently, there is a relative scarcity of reports in the literature on adverse events following TCA peels. It is likely that such events have been underreported, but are nevertheless quite rare. The risk of an adverse event following a peel is directly related to the depth of the peel, which in turn is determined based on the level of injury produced (Table 1). Complications associated with chemical peels can be divided into immediate onset effects, which occur within minutes to hours, and late onset effects, which occur in days to weeks (Nikalji et al., 2012) (Table 2). Our patient’s striking presentation following 50% TCA reflects hyperpigmentation in combination with persistent erythema. Hyperpigmentation is the most common complication occurring after a TCA peel (Nikalji et al., 2012). The mechanism underlying TCA induced hyperpigmentation may be related to the skin stress response system. A recent study suggests that TCA activates the skin stress response system by directly inducing pro-opiomelanocortin and melanocortin-1 receptor production by keratinocytes (Kimura et al., 2012). Persistent erythema is erythema lasting longer than expected for an individual peel (Monheit, 2004). It is often a predictor of scarring, and some authors assert that areas of erythema three weeks after a peel should be viewed as definite precursors to scars that must be treated aggressively (Rubin, 1995). Table 1. Level of peel, peeling agent, and depth of injury. DEJ – Dermal–epidermal junction. Level of peel Peeling agent Depth of injury Superficial 10–35% TCA, 30–70% AHA Epidermis +/− DEJ Medium 35–50% TCA, combination peels Papillary/upper reticular dermis Deep >50% TCA, phenol Reticular dermis Table options Table 2. Side effects and complications of TCA peels. Immediate onset (minutes to hours) Late onset (days to weeks) Erythema Herpes reactivation Irritation Secondary infection Burning Persistent erythema Pruritus Scarring and milia Pain Delayed healing Edema Acneiform eruptions Blistering Textural changes Photosensitivity Dyschromia (hyper or hypopigmentation) Contact dermatitis Lines of demarcation Atrophy and telangiectasias Ectropion and ocular complications Adapted from Nikalji et al. (2012). Table options Several factors predispose patients to hyperpigmentation following chemical peels. Ethnic or Fitzpatrick Phototype III–VI skin is particularly vulnerable to both hyperpigmentation and hypopigmentation. In addition, skin of color responds less predictably to chemical peels, and is more prone to hypertrophic scarring (Roberts, 2004 ; Salam et al., 2013). These factors preclude such patients from receiving deep peels, and warrant the use of great caution for superficial or medium peels, even by the experienced practitioner (Roberts, 2004 ; Salam et al., 2013). In addition, use of estrogen containing medications, photosensitizing drugs, and early exposure to sunlight all increase the risk for hyperpigmentation (Nikalji et al., 2012). In the case of our patient, skin type and improper self-administration of high strength TCA were the leading instigating factors. Preventative measures are the most ideal methods for avoiding complications related to chemical peels. Although there is no universally accepted protocol, several authors recommend pre-treating the skin with a combination of a topical retinoid, hydroquinone, and topical steroid applied daily for 2–4 weeks prior to the peel (Roberts, 2004; Salam et al., 2013 ; Fischer et al., 2010). Nanda et al. (2004) found that pre-peel priming with 2 % hydroquinone was effective in reducing the risk for hyperpigmentation, with similar improvements as those seen with 0.025% tretinoin at 12 weeks post-peel. However, the hydroquinone group had a statistically superior reduction in hyperpigmentation at 6 months. These agents, in addition to rigorous sun protection, are thought to suppress melanocytes (Bulengo-Ransby et al., 1993) prior to the peel and hence prevent hyperpigmentation. Some recommend continuing this regimen post-peel as well for maximal efficacy, and a similar approach is used to treat hyperpigmentation resulting from a peel. For refractory hyperpigmentation, laser treatment may be of benefit. In summary, chemical burn is a very rare complication following TCA peels. Here, we report the first case to our knowledge of a chemical burn from 50% TCA presenting with striking dyschromia. This clinical scenario emphasizes the importance of understanding the adverse effects of peeling agents, as well as the differential responses of ethnic skin to these treatments. Finally, physicians must be aware of the accessibility of these chemicals outside of the medical setting, and the potential for misuse.
  2. Hey folks, I'll keep it short and sweet. Long term reader, first-time poster. After reading countless posts, I formed a plan. The plan has been for the past year to dermaroll one month and then TCA Peel (30%) the next month. Kept this going in rotation with no issues. This peel, however, has gone south. Not only did I wake up a couple of hours late, as I’ve been coming down with a fever and have skyline windows, but my skin was peeling day’s quicker (3rd day of peel today). It's raw and I feel like I have screwed up badly and have been heavily depressed throughout the day. I believe it's because I used epiduo alongside. Don't ask why. I clearly wasn't thinking. Thoughts on what I could do? Or is it game over for me? Thanks all for the continued support of people trying to help their scars. I would also like to thank ' beautifulambition ' for his input on the website. God bless.
  3. Scar Success!

    Hi everyone, Here's my before and afters: Just wanted to post my success for moral support and encouragement for anyone else like me that thought they'd NEVER make progress. I had acne my whole life and it became cystic when I reached my late 20's. I had the worst acne of ANYONE I'd ever seen, I even had to have some surgical excision of cysts that never left. It was that bad. I don't use any acne products. I only wash my face once a day, don't even wash it in the mornings. I use coconut oil as a cleanser sometimes and a makeup remover if I wear make up. The pics are about 2 years apart. I attribute the improvement in scarring to derma-stamping, single needling, STOPPING retin-A, silicone mircro-droplet injections, TCA spot treatment on scars and eating a healthy diet with no soy, grains, or unsaturated oils. There are some red areas in this after pic because I recently did some TCA spot treating on a couple icepick scars but I don't break out anymore and this redness is temporary and easily covered with make up. I highly recommend derma-stamping and TCA for scars, when used cautiously and only if you've educated yourself on proper use. I really love using a 30%tca to spot treat small spots at a time because I don't have to hide in my house for 2 weeks that way, it's a slower longer process but I find that at least that way it actually gets done. As for stamping, I now do it once a month (or every 4-6 weeks) and I also just starting massaging my face and scars which feels good and brings blood flow to the surface of your skin making it healthier. There's a post somewhere on the forums here called "30min massage for scars" you can read which is very helpful too. I don't even use any cleansers except honey in the shower and sometimes coconut oil. I got rid of all the store bought, chemical laden crap. That being said, I do think salicylic acid, lactic acid and tca are good as long as they're not done too much, and health wise, I feel they're pretty safe to use. They're made from milk and fruit. I used to think it would never get better and I'm so glad I was patient, took pictures, kept learning, and kept persevering.
  4. So I've been reading a fair amount and it seems everywhere gives slightly different advice regarding TCA Peels. Basically I have mild to moderate boxcar (maybe VERY mild rolling/icepicks). I figured I should probably be doing at least something to help them and it seems TCA Peels have quite a few benefits. I have a few questions for you guys. Here are my questions For a beginner what percentage TCA do you think I should peel with?. (I've heard everywhere form like 7%-30%.) Would 12.5% even potentially make an impact on my scars or is it only the higher percentages that penetrate deeper? Can very mild peels (say 12.5%) actually improve acne scars over say the course of a year? Do you think I should go with a higher percentage to start? Where and how much should I purchase on my first go? Would love to hear any other advice as well. Thanks!!

    Help!!! I did TCA cross on some of my acne scars and they are super dark right now that not even makeup will cover them. Can yall recommend what to put on after doing TCA cross to help heal faster???
  6. I have not idea how I got this deep pitted pore. Can TCA help reduce this severity of this type of scar? It's very small but it's deep. Does anyone know a good practitioner in Northern NJ to help correct this? Thanks
  7. Hi everyone I'm using Retin-A cream. My skin is used to it, I don't have irritation, it's taking it really well. I'm thinking about TCA cross and I'm wondering how long should I wait after I stop using Retin-A?
  8. I have done 7 or 8 2-3 layer TCA 25% peels and havent had any issues. Im normally completely peeled by day 6 with no hyperpigmentation. I am going to attempt my 1st 35% peel and let it be my final peel until November. I havent done a peel since January 10th so I feel my face is ready for another. What steps should I take to do this peel that might be any different from the others and what should I expect to be different. I have been using Perfect Image Salicylic Deep Gel Cleanser for about a week now. Since I started using it my Peel time has been cut in almost half and Ive had much better skin texture immediately following a peel. I have also bought Cosmedica Pure Hyaluronic Acid Serum. I have never used it before and I am wondering if or when it should be used with a peel. Use it after peel is applied then by day 2 or 3 start using aquaphor or wait and use it once all skin has peel and just use aquapher after I have applied the peeling agent to my face and during the peeling process?
  9. Today marks Day 30 after my subcision and TCA Cross Method treatments. I was really inspired by the photos that Tamara Madden and another subscriber had posted on the web and wanted to see if subcision would work for me. I've attached their websites below: Here is a very brief overview of my journey with acne scar revision. I first developed cystic acne when I was in the eighth grade. By my senior year, I had several cysts on my right cheek which collapsed and left a rather large crater. My cystic acne really flared up in college and it was then that I went to a dermatologist for the first time and was placed on antibiotics. My acne stayed under control with antibiotics and topical creams (Retin-A and Benzol Peroxide) for several years. However, I kept getting cysts and decided to go on Acctuane. My skin EXPLODED with cystic acne lesions all over my face which left me with considerable scarring that I had not had before taking Accuntane. The good news, however, is that I never had another cystic lesion on my face after taking Accutane. Over the years, I've tried Glycolic and Lactic Acid Peels, Cryotheraphy, etc. to help diminish my scars. After reading about subcision on this website, I decided to talk to my dermatologist about it. He agreed to do the procedure on me along with the TCA Cross Method on March 16, 2009. Quite honestly, I am really glad that I had the procedure done. I took a week off of work and had some bruising and swelling, but no complications whatsoever. I decided to take tons of pictures to help document the process and help others learn more about it. Right Cheek (Pre-Subcision) Right Cheek (30 Days Post-Subcision) Some flattening of the rolling scars, but will need more subcision treatments. Left Cheek (Pre-Subcision) Left Cheek (30 Days Post-Subcision) Dramatic improvement over the baseline photo. Many of the "creases" and fine lines have disappeared in this photo. This photo kind of scares me......Acne scarring combined with aging is not a pretty site. The lighting is not quite the same, but the overall appearance of my scars has diminished. The reflection of the "man in the mirror" has definitely changed for the better and for that I am truly grateful. I recently went to get my haircut by a friend in a city nearby whom I had not seen in six years and had always "cringed" when I saw myself in the mirror due to the harsh lighting in there. This time, I kept looking at myself and saying, "Is that really me?" The man in the mirror that I was now seeing wasn't the same one I had seen in the past. The man I was seeing had smoother and healthier looking skin. As I mentioned above, I plan going for at least two more rounds of subcision followed by Pearl Laser in December of this year. I am not aiming for perfection as I know that is not truly attainable. As my photos show, I have seen incremental improvement and I will take any improvement that I can possibly get. I want to encourage ALL of you out there who have suffered from acne scars to do your research online, ask lots of questions, and find a competent and compassionate doctor who can help you. I have just ordered an LED light and hope to have it before my next round of subcision in May. Best wishes to you on YOUR journey to healing..... P.S. I have a blog on this website that will give you a good idea of what to expect if you decide that subcision is the right treatment for you.
  10. Skincare after TCA cross

    Hello everyone. I've been using TCA 25% peels for a while now with very good results. I've decided to try TCA cross on my scared pores and ice-pick scars. Yesterday scabs fell off and my scars are deeper - I read it's normal and should look better after few weeks. My question is: how should I treat my skin during those weeks when collagen production should do its job? I use Clarisonic daily or almost daily and I wonder - should I stop? (I don't want to make scars even deeper or somehow interrupt the process)
  11. I did the TCA cross (100%) on the 1st of February. All of the scabs are now off. It seems the best results are from the spots that the scabs remained on the longest. Three of them stayed on until the past couple of days, and they are almost level with the rest of my face already. I have some improvement with some of the others, some not so much. I am going to Cross again mid-March. I had quite a bit of redness in the scars when the scabs came off, but they have faded rather well. Is there a way to keep the scabs from coming off early? I would like them to stay on as long as possible. I wonder if I should wear bandages at night when I go to bed to keep them from rubbing on the pillow, and to keep me from scratching in my sleep (if I was). I am going to take "before" pictures before my next Cross. I am insecure about my face, obviously, but I will take pics through the next session and post them here. What is the best thing to put on after? I did the antibiotic ointment for the first 3 days then switched to copper peptides. Last week I bought the LaRoche-Posay Ciciplast and it seemed to take the redness away quicker. Any help is greatly appreciated!
  12. tca cross w professor chu

    checking in here as i inadvertantly posted misleading information in another thread. i had tca cross done by professor chu at hammersmith hospital 17 days ago now. early on i thought i had made remarkable progress, especially on the main scar (narrow boxcar on the tip of the nose). turned out that some of the '85%' fill-in i mentioned was actually the scab, which hung on in there for 16 days (without being really visible). fell off yesterday leaving the same indent- but happily, there is definite progress, i would say maybe 30%. the scar may be a little wider (i was warned this could happen) but certainly flatter, and the edges seem less sharp. so all in all im pleased. the downtime for this procedure is a drag - i peeled a lot- but worth it to me. with luck i should see further collagenisation in the coming weeks, and i have another visit scheduled for early january. i do feel confident that this will get me the results i want, but just wanted to warn that it takes commitment and that those who see instant results seem to be very much the exception. best wishes
  13. Hello Everyone! After reading through a LOT of information on this board, and even bookmarking a few posts for easy reference, I have decided to join the site. I can't seem to find what I am looking for and am hoping one of you knowledgeable people can help me! I recently purchased TCA 100% for Cross and TCA 15% for peeling (it is a kit). I have been using mandelic acid cleanser, toner and serum as a pre peel regimen to help see better results with the peel. I have watched videos and read a lot and feel very informed on both procedures so that I can do them safely. I did TCA Cross on two scars 12 days ago and have seen some improvement. I will Cross them again in a few weeks along with other scars, now that I know I can do this safely and not do further damage to my skin. Here is my question: How do I go about doing Cross and Peels together? I can't find information on that, other than one post and it didn't make sense to me. Can I apply my 15% TCA Peel, neutralize and cleanse and then do my TCA 100% with my toothpick on the individual scars? I am thinking this would be a no-no because the peeling of the 15% solution will pull off the scabs from the TCA 100% prematurely. Should I do them separately then? If so, which should I do first? How long should I wait between each procedure? Background: 46 year old female, small hormonal pimples along my jaw and on my neck with my cycle which is much better (nearly gone) with the mandelic acid, fair skin, left cheek ice pick scars and boxcar scars, right cheek three small scars, one scar on chin. I think they look worse to me than they really are, but I would like to improve my skin. Love this site! So great to read success stories and see people trying to help each other!! Catherine
  14. 1) did it always leave yours scars looking worse/deeper/wider/more intense than they looked pre-procedure? 2) If it did initially look worse, what happened several weeks to several months out? 3) Was the treatment successful for you (i.e., state the percentage improvement you obtained)? 4) If your scars did improve, a) what kind of scars did you have and were they mild, moderate or severe, b) how many sessions did it take to achieve those results? 5) Finally, did you DIY or have it professionally done? Thanks so much in advance for your response.
  15. Has anyone tried this method of TCA cross? Think this works better than other methods (ex. using a toothpick)? For the DIYs what method do you use? What size (gauge) needle do you think this is? Perhaps smaller would be better/safer (especially for scarred pores). Any amazon links? Thanks!
  16. Hi All, I need some advice and opinions. Four months ago i had subcision and TCA cross. The results for the most part have been satisfying. I have a combination of ice pick and boxcar scars on my temples. Friday i am supposed to go have my second treatment of TCA cross. What do you guys think of the results so far after one treatment? To me, they seem to have filled up after they expanded. The redness really does concern me. Do you guys think i should go for this next treatment?
  17. Hi all, I did it! I finally went ahead to get a prescription for epiduo! My skin has improved a lot over the years (from 2011) and dairy is the culprit from what I know. However, due to all the acne, my skin texture is all bumpy now and I do suffer from rolling and boxcar scars. Also, gluten seems to be play a role as well but it never used to affect me before. I noticed all the itchiness once my breakouts became really severe in around 2012, I would say. Any opinion on this? The main point of this post is to ask if anyone has done a tca peel (12.5%, I am a first-timer) while on epiduo AND starting on birth control (estelle) in the same week. I was going to start on epiduo tonight but I had already planned to do a tca peel on Friday (23rd Dec) and my period is estimated to start on Saturday (24th Dec). I am fine with putting off the usage of epiduo until the second week of Jan as I do believe my skin should have healed sufficiently by then. Just wondering if thi is a good plan. Can anyone enlighten me on whether epiduo improves skin texture? And also, whether doing 1 12.5% tca peel would improve my skin texture. That's my main concern as applying makeup is horrible and has been horrible for the past few years. Many thanks to anyone who help me out in this!
  18. Good day everyone! I'm back on tack. I used to visit this site, maybe a year ago or 2. I have a nose scar on thel eft side of my nose, upper nostrils. I used to apply TCA cross, would only cause swelling and would eventually go back to its original size. I tried needling it with 0.23mm micro needle, I thought it was healing, but then it again went back to original size. I do not know if I should still continue with needling since I learned that it is very dangerous to do needling on nose. Anyone with similar stories or success stories? Hope you could share. It is very depressing to hace these kind of scars. Not the the actual pic but very similar and deeper is my scar. Thanks in advance -pan
  19. Deep Nose Scar And Tca Cross

    So I decided to apply an 8% TCA on my nose. Just did it now. Stung a bit, frosted a bit, neutralized it with baking soda after 5 minutes. Will keep you posted!
  20. I'm basically looking for something that I can do cheap and easily at home. Already have a .75mm Dermroller for complexion and looking to buy a 1.5 mm Dermastamp for my scars. Does anyone have experience with Dermastamping and doing TCA peels? I have shallow pitted scars that you can see in my other posts. Do you think I will have any benefit at all? My skin is pretty bad as it is so I figured I could at least try to make the rest of my skin look decent in the meantime. I'm thinking Dermastamp every 1.5 months with a peel somewhere in between and add vitamin c serum. I will eventually get around to subcision and possibly TCA cross but I think I am at least a year or so away from that. Would love to hear if anyone has any experience/results from something similar. Overall I'm wondering if it would even be worth it.
  21. Hey everyone, Just wanted to post some before and after pics of my skin after various scar treatments. I want to let you all know to that scars can be improved and don't give up if they get you down. I would have considered mine severe before treating them, now I rate them as maybe moderate; but I still plan on doing more treatments, just figured id post some pics to help some of you out. Heres a very very general overview of what I've done over the years: Dermastamp 1.5mm + terproline TCA peel 30%, 15% various lactic acid peels That's it...however, I plan on getting some subcision and TCA cross done very soon, along with learning how to single needle and continuing dermastamping and spot treating with the 30% TCA. Also, If any of you are under the impression that you NEED lasers to treat severe scarring, I'm here to tell you that you don't. IMO, lasers are way too harsh and can actually do more harm than good. Look at every option and combine treatments, something will work for you. Good luck!
  22. Tca Cross?

    I am interested in doing the tca cross scar treatment at home. I haven't found much information about it online. I was wondering if anyone knows how exactly to do tca cross? Any links or videos would really help me and anybody else interested in doing tca cross at home. Are some scars too big to do tca cross on? What size are scars supposed to be to do tca cross on?
  23. Hi everyone, I suffered from cystic acne from the age of 16 it has now cleared up thankfully I only get an occasional whitehead but I was left with scarring. I did have some boxcar scarring and also some rolling scars so I researched and decided to get derma rolling (micro rolling) done, I done it once with a dermatologist but then started doing it myself at home and had some good results as my boxcar and rolling scars are now gone. Unfortunately I am still left with small pitted holes that look like open pores on my cheeks, I believe these are called icepick scars? I researched into these again and came across TCA so I went ahead and had a 50% deep TCA peel with a dermatologist as I read it has good results on scarring, I am now three days post peel and have started to peel but the new skin underneath still seems to have the icepick scars. I'm not sure if I'm judging too early and if they get better over time so I thought I'd ask on here to see if anyone has had one done and how long it took for results? Also if anyone thinks TCA cross would be a better option for icepick scars? Or if I should just continue on with derma rolling for results. Please give any advice you can. Thanks
  24. Ice pick scars uk.

    Hello, long time lurker, first time poster. I am looking to get TCA, to perform the cross procedure on my ice pick scars now my acne has finally calmed down. They are not the rolling type, but they look like large open pores although you can see the bottom on all of them so they are quite shallow. However TCA is hard to get in the uk, so I am looking to ship it. Main question is how easy is it to ship or will customs confiscate it? The supplier say they have shipped to the Uk successfully, and they seem genuine. Any help would be very welcome.
  25. I have a few mild to moderate icepick boxcar and rolling scars near my temple that I would like to improve. You can look through my post history to find some pictures. Looking for a decent doctor near MA, RI, CT, or even possibly NY or New Jersey. Would love to hear if anyone has had these procedures done in any of these states. Would also be willing to travel longer distances if anyone has had any great experiences. I appreciate the help. Treatments needed IMO are TCA Cross subcision and I might want fillers.