A 15% Trichloroacetic Acid + 3% Glycolic Acid Chemical Peel Series Improves Appearance of Hand Lentigines: An Evaluator-Blinded, Split-Hand Prospective Trial.

BACKGROUND: Improving the appearance of lentigines on the hands is a key component to hand rejuvenation. Soft tissue fillers revolumize hands, but do not address pigmentary changes. OBJECTIVE: This study investigated the effiacy of a 15% trichloroacetic acid (TCA) + 3% glycolic acid (GA) combination peel in improvement of appearance of hand lentigines. METHODS: A prospective evaluator-blinded, split-hand study was performed using a 15% TCA + 3% GA peel to treat patients with hand lentigines. Subjects received a total of 3 treatments at 4-week intervals on 1 hand, with the other hand serving as an untreated control. Final photographs were taken 12 weeks after the last treatment. Two blinded board-certified dermatologists graded improvement in hand lentigines using a 5-point scale. RESULTS: Eighteen of 20 patients completed the study (90%). The mean age was 64.4 years (SE 1.6, range 51-71). The mean pain scores were 3.8 (SE 0.4) on a 10-point scale (1 = no pain, 10 = extremely painful). Blinded evaluators correctly identified the after-treatment photographs in 16 patients (88%). Physician and patient-graded mean improvement of lentigines was significant for treated versus control hands ( p < .01). No adverse events were noted. CONCLUSION: A series of three 15% TCA + 3% GA peels are effective and safe in the treatment of hand lentigines.

[Intraoperative pleurodesis with talc and trichloroacetic acid for exudative pleuritis]. / Intraoperatsionnyi plevrodez tal'kom i trikhloruksusnoi kislotoi pri ekssudativnykh plevritakh.

OBJECTIVE: To compare the efficacy of chemical pleurodesis with talc and trichloroacetic acid during thoracoscopy. MATERIAL AND METHODS: Thoracoscopy with pleural biopsy was performed in 355 (83.5%) out of 424 patients with pleural effusion. Pleurodesis was ensured by intraoperative insufflation of talc powder (n=135) and application of 33% trichloroacetic acid solution to parietal and visceral pleura (n=19) in patients with malignant (125), inflammatory (6), post-traumatic (4), tuberculous (3), pancreatogenic (8) and hepatogenic (8) effusions. Drainage tubes were removed if daily drainage output volume was less than 100 ml or complete lung inflation was observed. RESULTS: Post-pleurodesis drainage took 7.1±5.4 days. Two patients developed bumpy rashes that were initially interpreted as carcinomatosis. However, these rashes were later identified as tuberculosis. Retrospectively, these patients were not good candidates for pleurodesis. Pleurodesis with talc suppressed exudation in 89.6% of cases. Complications developed in 4 cases (3%): pneumonia (1) and pleural empyema (3). These complications were associated with a violation of technical procedure of pleurodesis, i.e. procedure in rigid lung, atelectasis (1) and bronchopleural fistula (2). Mean duration of drainage after trichloroacetic acid-induced pleurodesis was 7.9±6.7 days. This procedure was effective in 84.2% of cases, and there were no complications. There are no previous reports on the use of this pleurodesis technique in the literature. Mean duration of drainage after talc-induced pleurodesis was decreased up to 6.9±5.4 days in patients with malignant pleural effusion (p<0.05), after trichloroacetic acid-induced pleurodesis - up to 7.5±8.1 days (p>0.05) compared to patients without pleurodesis (9.1±11.2 days). CONCLUSION: Pleurodesis with talc or trichloroacetic acid during thoracoscopy is effective for pleural effusions following malignancies, liver, kidney and cardiac diseases with decompensation. Essential requirements are adequate lung inflation, no atelectasis and bronchopleural fistula.

Trichloroacetic Acid in Different Concentrations: A Promising Treatment Modality for Vitiligo.

BACKGROUND: Despite the recent advances in the treatment of vitiligo, results are still largely unsatisfactory and many patients show either weak or no response to treatment. Few clinical trials have investigated the use of trichloroacetic acid (TCA) to induce repigmentation in stable vitiligo. OBJECTIVE: To evaluate the efficacy and safety of TCA, in different concentrations, for the treatment of stable localized vitiligo. METHODS: The study included 100 patients with acral/nonacral stable vitiligo. Trichloroacetic acid was applied, as a monotherapy, to the vitiliginous patches at different concentrations according to the treated site every 2 weeks until complete repigmentation or for a maximum of 6 treatment sessions. Follow-up was done every month for 6 months to detect any recurrence. RESULTS: Eyelid vitiligo showed the highest response to TCA treatment (excellent response in 80% of cases), followed by the face, trunk, and extremities. Lower response rates were noticed in the hands and feet vitiligo. Adverse effects were transient and insignificant in few patients. CONCLUSION: Trichloroacetic acid seems to be a potential, cost-effective, well-tolerated therapeutic option for the treatment of vitiligo in the adults and pediatric populations.

Comparison of Three Different Therapies for Cutaneous Leishmaniasis and Identification of the Etiologic Isolates in Isfahan, Iran.

BACKGROUND: In Iran, zoonotic and anthroponotic cutaneous leishmaniasis (CL) are caused by Leishmania major and L. tropica respectively. Despite extensive studies, no effective therapies have ever been reported for CL. The main objective of this research was to determine and compare the three different protocols for treatment of CL patients referring to Skin Diseases and Leishmaniasis Research Center (SDLRC), affiliated to Isfahan University of Medical Sciences, Isfahan, Iran from September 2017 to October 2018. METHODS: In a randomized controlled parallel groups clinical trial, 150 selected CL patients who met our inclusion criteria were randomly assigned to one of the three therapy groups: A, intra-lesional glucantime plus 50% trichloroacetic acid (TCA), B, intralesional glucantime and C, systemic glucantime. All patients in the three groups received the complete course of treatment and were followed for 6 months. To identify the etiologic agents, smears from their lesions were prepared and PCR-RFLP was used after parasite culture. Also, clinical characteristics, history of previous involvement, endemic emigration and demographic data were collected. RESULTS: The results showed that the mean value of healing period was 53.12 ± 25.88 (median: 45, IQR: Q1 = 30-Q3 = 77) days in group A, 57.22 ± 44.02 (median: 42.5, IQR: Q1 = 30-Q3 = 60) days in group B, and 73.56 ± 41.08 (median: 71, IQR: Q1 = 45-Q3 = 90) days in group C; the observed differences were statistically significant (P=0.024). There was a significant difference between group A and group C (P = 0.049), and between group B and group C (P = 0.047) in terms of mean healing period. Finally, complete recovery rates of 80%, 62% and 42% were shown in the three medicinal groups of A, B and C, respectively (P = 0.022). CONCLUSION: In this study, the average duration of lesion healing among the three groups was the shortest in patients with IL glucantime plus 50% TCA treatment regimen. Also, the use of 50% TCA in patients suffering from CL was associated with a significant improvement in the depth of scars, the time and the percentage of recovery, and the low cost of this agent in the treatment of CL.

Trichloroacetic acid model to accurately capture the efficacy of treatments for postinflammatory hyperpigmentation.

Postinflammatory hyperpigmentation (PIH) occurs following cutaneous injury and is common following resolution of acne especially in patients with skin of color. The objective of this study was to further validate a trichloroacetic acid (TCA)-induced PIH model and compare it to acne-induced PIH using topical bakuchiol, a botanical extract that has been shown to have antimicrobial, anti-inflammatory, antioxidant, and antiacne properties. A prospective, non-randomized clinical trial was conducted on subjects with skin phototypes IV-VI with a history of acne-induced PIH. Subjects applied bakuchiol or vehicle cream twice daily to 2 acne-induced and 2 TCA-induced PIH lesions for 28 days with a third lesion serving as a control in each group. Degree of improvement was defined as the change in the Investigator Global Assessment (IGA) score over 28 days of treatment. Twenty subjects (6 males, 14 females) completed the study. For TCA-induced PIH sites, there was a statistically significant (p < 0.05) degree of improvement with bakuchiol treatment (- 0.50 ± 0.18) compared to vehicle (0.05 ± 0.15) and control (- 0.06 ± 0.17). For acne-induced PIH, there was a greater degree of improvement for bakuchiol (- 1.06 ± 0.23) when compared to vehicle (- 0.56 ± 0.16) and control (- 0.69 ± 0.18); however, statistical significance was not reached (p > 0.05). TCA-induced PIH sites were uniform in size and pigment intensity thereby allowing better comparison among sites. This emphasizes the relevance of using this model for PIH which may help reduce the barriers in clinical trials and help improve access to treatments for patients who suffer from PIH. The results suggest that topical bakuchiol may decrease the severity of PIH.

[Successful combination of topical corticosteroids and trichloroacetic acid for the treatment of verrucous lichen planus]. / Succès de l'association dermocorticoïdes et acide trichloroacétique dans le traitement du lichen plan verruqueux.

BACKGROUND: Verrucous or hypertrophic lichen planus is a chronic inflammatory skin disease characterized by extremely pruritic thick hyperkeratotic plaques and is resistant to topical treatment. PATIENTS AND METHODS: Herein, we report three clinical cases of hypertrophic lichen planus successfully treated with a combination of topical steroids daily in occlusion and trichloroacetic acid (TCA) 50% with peeling every week. DISCUSSION: TCA is involved in regulating inflammation and scarring. Through its keratolytic properties it enhances the efficacy of topical steroids, whose action is hindered by hyperkeratosis. CONCLUSION: The combination of TCA and topical steroids offers a good alternative for the treatment of hypertrophic lichen planus.

Unusual clinical manifestation of seborrheic keratosis on the scalp successfully treated with topical trichloroacetic acid: an atypical case report.

Seborrheic keratoses (SKs) are benign tumor of the skin. They can occur anywhere, except the palms and soles. SKs commonly present as multiple, pigmented papules which is classically described as verrucous stuck-on papules or plaques. A case with multiple nodular appearance is a rare case and to our knowledge has never been reported. Here we report a rare case of multiple SKs on the scalp. On clinical evaluation, multiple, erythematous hyperkeratotic nodules were present. Dermoscopic and histopathological examination supported SKs. The patient was successfully treated with topical application of 80% TCA solution.

Trichloroacetic acid 10% injection for treatment of conjunctival inclusion cysts.

Purpose: To evaluate the effect of intra-lesional injection of Trichloroacetic acid (TCA) 10% in patients with conjunctival inclusion cysts.Methods: This prospective case series study included all patients with conjunctival inclusion cyst who were referred to our referral center from August 2016 to August 2018. All patients received TCA 10% injection into the conjunctival cyst, and outcomes of the intervention were evaluated at least 6 months later.Results: Ten patients with mean age of 24 ± 17.6 (range 6-65) years including three children received TCA 10% injection into the conjunctival cyst. We included 6 anophthalmic and 4 ophthalmic cases. All patients were treated successfully and no recurrence of the lesion was observed in any case. Mean follow up duration was 18.1 ± 8.3 (range 6-28) months.Conclusion: Intra-lesional injection of TCA 10% is a safe, simple, and effective treatment in patients with conjunctival inclusion cysts including ophthalmic cases and anophthalmic cases, both in adults and in children. This concentration may avoid ocular surface complications.

Effects of different therapeutic modalities for postacne scars on circulating collagen III.

BACKGROUND: Therapies for postacne scarring act through modulation of elastin and collagen, and collagen III might therefore represent a biomarker of treatment effectiveness. PATIENTS AND METHODS: Patients (n = 70) with postacne scars and individuals without scars (n = 56) were included in this case-control study. Patients were treated with Dermaroller microneedling, trichloroacetic acid chemical reconstruction, punch excision, or scar subcision. Scar severity was graded immediately before and after treatment with a photographic quartile scale and the ECCA scale. Serum levels of collagen III were measured in control individuals and in patients, before treatment, 1 month after the first treatment session, and 4 months after the final session. RESULTS: Circulating levels of collagen III were significantly higher in patients with postacne scarring (24.1 ± 12.5) before treatment than in control individuals (2.6 ± 0.8). Circulating levels of collagen in patients were significantly lower 4 months posttreatment (14.3 ± 8.1) than at baseline. The mean percentage change in serum collagen III was positively correlated with both the mean percentage improvement by photographic evaluation (r = .530, P < .000) and the mean percentage change in the ECCA scale (r = .632, P < .000). CONCLUSION: Circulating collagen III is a biomarker for improvement of postacne scarring following different therapies.

Combination of continuous wave CO2 laser and topical application of trichloroacetic acid 50% vs CO2 laser alone the treatment of cutaneous leishmaniasis (A case series of 6 patients).

BACKGROUND: Cutaneous leishmaniasis (CL) is an endemic disease of Iran and despite self-healing nature of this disease and many suggested treatments, scar is usually inevitable results of the affection with this cutaneous infection. CO2 laser in CL has a specific thermolysis effect on infected tissues and application of trichloroacetic acid (TCA) 50% solution for treatment of leishmaniasis scars showed promising results. AIM: To evaluate CO2 laser plus TCA 50% versus CO2 laser alone for treatment of CL. PATIENTS/METHODS: In the current report, we present 6 cases of noduloulcerative CL that were treated successfully by the combination of the continuous wave CO2 laser plus topical application of TCA 50%. RESULTS: Five patients improved after 3 weeks of starting treatment, and 1 patient needed to repeat treatment. The scars were flat and good. CONCLUSIONS: The CO2 laser plus topical TCA 50% may be more effective in treatment of the cutaneous leishmaniasis and results in shorter healing time.

Comparative study of 15% trichloroacetic acid peel combined with 70% glycolic acid and 35% trichloroacetic acid peel for the treatment of photodamaged facial skin in aging women.

BACKGROUND: Photoaging (extrinsic aging) is caused by environmental exposure to ultraviolet radiation. Superficial and medium-depth chemical peels with trichloroacetic acid (TCA) are performed to reduce wrinkles, hyperpigmentation, dryness, and erythema caused by photoaging process. AIM: The aim of this study was to compare the efficacy and tolerability of 15% TCA peel against the combined 70% glycolic acid and 35% TCA for the treatment of photodamaged facial skin. PATIENTS/METHODS: Forty female patients with types II and III of Glogau photoaging scale were divided into two groups of twenty subjects (GA/TCA and 35% TCA). The GA/TCA group was treated with combination peeling of 70% GA and 15% TCA, whereas the 35% TCA group was treated with monopeeling of 35% trichloroacetic acid. Each patient was submitted to five sessions of these peels, with an interval of 14 days between each session. The following skin aging parameters were examined before treatments, before each session, and 3 months after the last application: hydration, elasticity, melanin index, and erythema index (MPA-5; Courage-Khazaka, Germany); and depth and volume of wrinkles (PRIMOS; GFMesstechnik GmbH, Germany). RESULTS: Both peel methods achieved significant improvement in all skin parameters: elasticity, hydration, melanin index, and erythema index. Significant differences between the GA/TCA and 35% TCA groups were found only for hydration and melanin index. GA/TCA was characterized by significantly higher values of the hydration parameter and lower values of melanin index compared with 35% TCA. Combination peel GA/TCA did not cause dryness, edema, or intensive lysis of the epidermis, and the frequency of peel-induced erythema did not increase with the addition of glycolic acid, but with higher concentration of the TCA solution. However, subject-perceived improvements of the 35% TCA peel did not differ significantly from subject-perceived improvements of combination peel treatment. Adverse events requiring intervention or discontinuing treatment were not observed in either group. CONCLUSION: The addition of glycolic acid before 15% TCA chemical peel application significantly enhanced TCA-induced improvement in photoaging parameters (increase in skin elasticity and hydration; reduction in melanin index and erythema index), and subject-perceived improvements. However, 35% TCA peel is more effective in reducing wrinkles, despite a lower tolerability. Both medium-depth chemical peels including 15% TCA in combination with 70% GA and 35% TCA alone proved to be useful for the removal of epidermal or superficial lesions and to improve the texture of photodamaged facial skin (grade II-III Glogau photoaged skin).

Filling Up the Valleys

Man has tried and sought to erase wrinkles and scars for millennia. Sadly, however, the most effective and permanent techniques have fallen into disuse and neglect due to lack of training in universities, lack of awareness on the part of both physicians and patients, and heavy mass marketing of injectable fillers. Dermal grafting is a standard, time honored method for permanent correction of deep facial defects. Our goal as dermatologists is to generate the best results for our patients, and also to develop our personal skills and talents to the utmost.

Comparative Efficacy of a 35% Glycolic Acid Peel Alone or in Combination With a 10% and 20% Trichloroacetic Acid Spot Peel for Melasma: A Randomized Control Trial.

BACKGROUND: To study and compare the therapeutic efficacy and side effects of a 35% glycolic acid (GA) full face peel alone or in combination with a 10% or 20% trichloroacetic acid (TCA) spot peel for facial melasma. METHODS: Thirty patients with facial melasma were randomly divided into 3 equal Groups A, B, and C. Group A was treated with a 35% GA full-face peel, Group B and C with 35% GA full-face peel followed by a 10% and 20% TCA spot peel respectively once every 15 days. Four peels were performed once every 15 days. The response to the treatment was evaluated by the percentage reduction in melasma area severity index (MASI) scoring. RESULTS: All 3 groups had significant reduction of MASI, but there was no significant difference between the groups. Group A had minimum side effects. CONCLUSION: Chemical peels with GA alone or in combination with TCA do result in a significant improvement in melasma, but the combination of the peels in the same sitting does not seem to have any additive or synergistic effect while they may increase the side effects.

Efficacy and tolerability of using platelet-rich plasma versus chemical peeling in periorbital hyperpigmentation.

BACKGROUND: Various therapeutic modalities for periorbital hyperpigmentation (POH) have been proposed. OBJECTIVE: This study was designed to compare the efficacy and tolerability of autologous platelet-rich plasma (PRP) and chemical peeling in POH. SUBJECTS AND METHODS: Forty-two patients were enrolled in this study and randomly subdivided into two groups. Group A patients were assigned to receive four sessions of chemical peeling using trichloroacetic acid and lactic acid, while group B was assigned to patients who received four sessions of PRP injection with 2 weeks of intervals. Patients were assessed by digital photographs. The degree of improvement included four degrees from poor to excellent, and side effects were reported. RESULTS: Females constituted 38 out of 42 patients (mean age, 28.14 ± 3.47 years). There was a significant improvement in favor of chemical peeling over PRP. Good improvement occurred in 47.6% in the group A versus 4.8% in group B (P < 0.001). None of the PRP group had excellent improvement, while 38% of chemical peeling group did. Most of group A patients reported very pleased (47.6%) to excellent (38%) degree, in contrast to group B where 52.5% were just pleased (P < 0.001). Some of group A patients experienced itching (14.3%) and redness (14.3%), while in group B, they experienced pain (23.8%) and edema (14.3%) with nonsignificant difference between both groups (P = 0.07). CONCLUSIONS: Both PRP and chemical peeling are effective for treatment of POH; however, chemical peeling is much more effective, tolerable, and satisfying procedure than PRP.

Radio Peel-Synergism Between Nano-fractional Radiofrequency and 20% Trichloroacetic Acid Chemical Peeling.

BACKGROUND: Microneedling fractional radiofrequency (FRF) and chemical peels are widely used for skin rejuvenation. OBJECTIVE: The authors aimed at evaluating the efficacy and safety of FRF and trichloroacetic acid 20% (TCA20%) peel in different combinations for determining the optimal treatment protocol. METHODS: In this prospective clinical comparison of 4 protocols (FRF alone, TCA20% alone, TCA20% before FRF [TCA→FRF], and TCA20% following FRF [FRF→TCA]), the patients underwent 3.8 ± 1.2 successive treatments of one protocol at 4- to 6-week intervals. The patients and 2 dermatologists evaluated improvement of pigmentation and dyschromia, erythema and blood vessels, laxity and wrinkling, and skin imperfections using a global aesthetic improvement scale (GAIS) and a 1 to 5 scoring system. The patients rated their satisfaction and reported adverse effects and reduced activity. Skin impedance and histological changes following the different protocols were also evaluated on 3 additional volunteers. RESULTS: Sixty-seven patients (age range 22-80 years) were studied. TCA→FRF caused skin impedance to decrease, yielding a more superficial and less-efficient penetration of FRF energy. FRF→TCA produced more significant improvement in overall facial skin appearance (GAIS) and most evaluated skin parameters. Adverse effects and satisfaction rates were similar for all approaches. CONCLUSION: FRF→TCA had the best synergistic effect on skin rejuvenation compared with FRF or TCA20% alone and TCA→FRF.