Application of the Wounding Agent

Before application of the peeling agent,patients are usually given a short, active sedative (i.e., Valium 5–10 mg) and a mild analgesia (meperidine and hydroxyzine hydrochloride). Frequently, aspirin is given before the peel and continued throughout the first 24 h, not only to relieve pain, but also to combat swelling. The area to be peeled is cleansed vigorously with an antiseptic cleanser using a 4 by 4 gauze pad, and residual facial oil is removed with acetone. The peeling agent is then applied with either cotton-tipped applicators or 2-inch by 2-inch gauze, usually with one or two coats to achieve a light frosting in the case of Jessner’s solution [49]. Once frosting is achieved, the Jessner’s solution is no longer active.

Upon complete drying, the skin is now ready for the 35% TCA peel. The depth of penetration can be influenced at this stage by the method of application. Using large cotton-tipped applicators allows for more solution application and, therefore, absorption. Repeat rubbing with 4- inch by 4-inch gauze or the application of multiple layers are two techniques for enhancing penetration.TCA is typically applied to one cosmetic unit, allowed to reach an end point, diluted with cool saline compresses, then applied to the next cosmetic unit. The activity of TCA ceases upon complete frosting, which is noticeable at 30 s to 2min. The sequence of application is typically from forehead, to temple, to cheeks, and lastly to lips and eyelids [49]. Judicious placement of the peeling agent to eyelids and lips in imperative, and having an assistant to protect the ocular canthi and stretch the skin over the lip along the vermillion is essential. The end point for medium-depth peels can be selected based on the level of actinic damage or lesion type being treated. Frosting represents keratocoagulation and may take several different forms as defined by Rubin (see below). It can serve as a guide, indicating areas not adequately covered, but it is advised that 3–4 min should pass before a second coating or “touchup” of TCA is applied to an area of uneven frosting [49]. Many still rely on the level of frosting to estimate the depth of penetration attained although this measure is thought by others to be unreliable and not supported scientifically [57]. Rubin’s level 0 frosting is described as pink or erythematous skin. During level 1 frosting, the skin is still pink,but white speckles have begun to appear. Level 2 frosting refers to skin that is frosted but with background pink skin intervening. Level 3 frosting is defined by opaque, solid-white skin that appears blanched and is thought to represent a depth of penetration in the reticular dermis [58]. This level of frosting is usually avoided, except in fair skin where blending of the upper neck may be desired [59].


Most people experience an intense burning during the peeling process, but this sensation subsides as the frosting is completed. [49] In a split-face study comparing the usefulness of topical anesthetic agents EMLA versus ELAMAX cream applied after 70% glycolic acid but before the application of 35% TCA, Koppel and colleagues demonstrated a significant reduction in pain between the anesthetized areas and the control side (unanesthetized). There was no difference, however, between the two types of topical anesthesia used or in the histology of the sides treated and untreated with anesthetic cream [60]. The activity of the TCA peel is completed once the frosting has occurred, but persistent mild discomfort is not unusual [61].Cool saline compresses can offer relief, as well as aspirin or other nonsteroidal anti-inflammatory agents in the immediate postoperative period

Similar steps are taken in the case of glycolic acid pretreatment, except in the case of glycolic acid peels there is no associated frosting to indicate reaction cessation. Glycolic acid peels need to be timed, and with longer duration of peel contact and higher concentration of glycolic acid, the operator can adjust the intensity of effect. Cook et al. reported the findings of high patient satisfaction and low rate of complications in a series of 3,100 patients treated with a combination of 70% glycolic acid gel with 40% TCA used on facial and nonfacial skin to treat photodamage, striae, and pigmentary abnormalities [59]. These clinicians used 70% glycolic acid gel instead of liquid to act as a partial barrier to the TCA solution, which was applied immediately after. The end point of this technique was a Rubin’s level I or II frosting, and the peeling agents were neutralized with 10% sodium bicarbonate solution [58]. Cook et al. coined the term “total body peel” for this type of peel, not because the peel is applied to the entire body, but because it can be used on most parts of the body.Accordingly, their most impressive results were seen on the hand, neck, and chest of patients with actinic damage.