As a practicing aesthetician, how do you determine the need for a light to mid-depth peel like trichloroacetic acid (TCA) or Jessner solutions? In some states, these peel treatments may not be permitted by stand-alone aestheticians – even then, it may not be the State, but an insurance carrier preventing the treatment in a facility. Once eligibility is determined, there is the wide-ranging availability of the peel in many solutions, protocols to be followed per the manufacturer, and training that may be required.
Although TCA and Jessner solutions are not commonplace peel treatments in skin care facilities, there are medical aestheticians that use these peel solutions on a daily basis for nearly every client that steps foot through the door. However, the widespread availability of both TCA and Jessner solutions introduces a degree of confusion and misconception on the uses of these "advanced" peel treatments, what skin types they may benefit, when they can be applied, and how to apply them.
Both Jessner and TCA solutions have undergone a significant evolution in formulation from the peels we have available today. In the early 1900s, Phenol peels were formulated with resorcinol for skin use. This combination resulted in facial scarring and introduced toxins into the bloodstream, killing people. The dire need for an alternative led scientists to experiment with many different solution combinations in the 1940s: resorcinol, sulfur, salicylic acid, and solid carbon dioxide (CO2). These solutions would later create the peel we now know as a Jessner solution. TCA was not widely used until the 1950s when Harold Brody, M.D. formulated a beneficial solution of 35 percent TCA and solid CO2, whereas Gary Monheit, M.D. formulated a Jessner solution with a 35 percent TCA for skin rejuvenation. Modern Jessner solutions contain salicylic acid, resorcinol and lactic acid at a seven or 14 percent concentration, with or without added antioxidants or bleaching ingredients. A seven percent Jessner solution is a very superficial to light superficial peel solution that aids in controlling excess sebum on the skin surface, whereas the 14 percent solution can be layered for a superficial peel treatment. TCA formulations, on the other hand, contain a 10 to 70 percent TCA with added phenol, acetone, glycolic acid, or solid CO2. Aestheticians who are qualified by insurance carriers and State Boards may perform a 20 percent TCA-AHA blended peel treatment. Anything higher is reserved for medical use. However, how do professionals justify these guidelines set by higher authorities when a variety of peels, including TCA and Jessner solutions can be purchased over the internet without a license? A fairly safe generalization to make regarding chemical peel ingredients are – the more ingredients listed, the less potent the peel. Nonetheless, any peel that is labeled for professional use can inflict damage to the skin that may result in scarring, lines of demarcation, hyperpigmentation, or hypopigmentation.
Superficial to mid-depth peels, like the TCA and Jessner, are not suitable for every skin type. Consideration should be taken to the melanin content of the skin, skin thickness, and problems or conditions that are present. The main goal behind any skin care treatment is to deliver the best results with little downtime, irritation, or injury. Using the Glogau Classification of Photo aging and the Fitzpatrick Scale together can aid in determining if a client's skin is suitable for this treatment, but not provide you with a rate of tolerance for pain or sensitivity or determine patient allergies. A chart of the Glogau Classification can be seen in this article. For example, if your client is in phase II to III of the Glogau Chart, she is a candidate for a TCA and/or Jessner peel. However, if the client is a phase II to III on Glogau, but a Fitzpatrick V, then you may want to assess the pre-peel treatment regimen and the amount of layers/time you leave the peel on the skin, or stick to a 15 to 30 percent glycolic, salicylic, or lactic acid peel. Clients who may not be a candidate per the Glogau or Fitzpatrick range, but present common skin conditions in the form of non-inflamed acne, acne scarring, post-inflammatory hyperpigmentation, or sun damage may be treated with a modified TCA or Jessner solution to aid in reducing hyper sebaceous activity, minimize pore appearance and promote an even skin tone. When addressing specific skin issues, these peel solutions can be applied lightly to the entire facial area, or specifically to the problem areas.
Before performing a TCA and/or Jessner chemical peel treatment, skin preparation – pre- and post-peeling – is by far the most important factor to consider next to client qualification for the treatment. Clientele and skin care professionals must understand that these peel treatments are not a part of routine maintenance. Clients must understand that there is up to two weeks’ worth of downtime associated with a TCA or Jessner treatment, and a specific skin regimen must be followed. Professionals conducting this peel treatment must understand that the client will require some "hand-holding" through the peeling process. Performing a Jessner or TCA peel may only take 30 minutes in the treatment room, but follow-up visits and phone calls should be conducted by the skin care professional to the client to allow for a proper recovery. Any individual undergoing these specific peel treatments should be on a preparatory skin care regimen two weeks prior to the treatment. Preparing the skin involves essentially two steps: First, home exfoliation, and then performing a pre-peel. At least two weeks prior to the peel, the client should be using a topical vitamin A, melanin suppressing cleanser or serum, vitamin C, and sun protection. The purpose of these ingredients is to remove surface dead skin and debris that cleansers and topical scrubs cannot penetrate, prevent trauma-induced hyperpigmentation, and prevent further sun damage (the main reason the client is receiving this peel). Once the client is in the treatment room, the second goal (for TCA peeling) is to further remove surface epidermal layers and squamous cells of the stratum corneum to reveal the absorbing cells of the stratum lucidum and granulosum. This process may be achieved by performing a standard cleansing and toning the skin, then drying the skin completely for maximum absorption of a hydroxy acid or Jessner solution. When treating oily skin, the use of a salicylic acid or Jessner solution is preferred to aid in controlling the amount and production of sebum on the skin surface and allowing the TCA solution to penetrate into the skin evenly. Excess sebum aids in inhibiting acid penetration through the superficial layers of the epidermis.
Upon achieving skin preparation, the TCA or Jessner solution may be applied in layers and monitored. Not all TCA or Jessner manufacturers may follow this protocol for skin peeling. Always consult the manufacturer for a protocol and State Board and insurance provider for the ability to conduct this peel treatment. There are several misconceptions about qualification and application that demand a need for education prior to practice on skin. First and foremost, do you know how many layers of skin can be removed with a layered superficial or mid-depth peel? As a mid-depth peel, layers from the stratum lucidum down to the papillary dermis can be removed with a TCA. Can you visibly gauge how many layers are being exfoliated during the peel treatment? Probably not. This is why looking for the visible signs of exfoliation (erythema, frosting, or pinpoint bleeding) are important. In addition to the problem of gauging the layers of skin that are in the process of removal, how do you prevent lines of demarcation or blistering of the skin? Normally when there is the possibility of over-exfoliation, spot neutralization is achieved with lotion, water, or baking soda and water solution. This brings another question to consider, how do you know if this completely neutralizes peel and how will it affect the overall results? The questions proposed above are listed to give a generic insight into the complications that may occur. Physical application on the appropriate candidate for a layered peel should be controlled and monitored. Without increased awareness and education on consultation and skin analysis, a TCA or Jessner peel can provide undesirable results.
Once the peel treatment has been performed, client care and consultation is still a priority. The client should experience peeling and sloughing of the skin for up to 10 days. While the skin is making this transformation by regenerating and peeling, home care and ingredient precautions must be mandated and followed for optimal results. First and foremost, the client must leave his/her skin completely dry for at least 24 hours for proper peel penetration. Humidity, steam, sweat, tears, rain, and any other water-based products on the skin can cause premature neutralization and affect the peeling process. After the first 24 hours of the peel treatment, client's home care should be restricted to a mild cleanser and sun protection. It may take up to four days for the dehydrated superficial layers of skin to lift, "crack," and begin to peel. A petrolatum based healing balm can help promote healing and sloughing of dead skin. Hydroxy acid and/or retinol products should not be used for at least two weeks after the peeling has completed. In addition, exposure to heat and sun exposure (ultraviolet irradiation) must be monitored. Heat exposure can be in the form of outdoor recreation or saunas, but also internal as a result from physical exertion and exercise. Care for the skin must be a high priority for clientele. Without proper care and precaution, skin damage is inevitable. Home care and a dedication to skin care should be part of the initial consultation and qualification process.
TCA and Jessner peels are not acceptable chemical peels to use for monthly maintenance. They are specialty peels that should be performed only one to two times per year. It has taken doctors and skin professional’s decades to create, master, and control chemical peels to provide optimal results with minimal irritation to the skin. Even modern peel solutions do not come without their risks. Without proper education, skin analysis, and client qualification, these treatments can be damaging. Even modern peel solutions can introduce a degree of toxicity to the body when not used properly. Skin care professionals must not use expired or old solutions as toxicity and penetration increases with age. On the other hand, TCA and Jessner solutions can provide optimal results for photo aged skin when used properly and the pre- and post-peel care has been followed. Ultimately, it is the responsibility of the skin care professional and the client to maintain everlasting treatments and home care.
Brannon, Heather, M.D. Glogau Classification of Photoaging: Classifying the Severity of Wrinkles. December 29, 2006. (http://dermatology.about.com/od/wrinkles/a/glogau.htm)
Rigel, D.S., Weiss, R.A., Lim, H.W., Dover, J.S. (Eds.). 2004. Photoaging. New York: Informa Health Care
Tina Zillmann is a paramedical aesthetician, having a focus in acne care and light-peeling treatments. She is also the owner of the Skin Rejuvenation Clinique, Inc., a facility that services to pre- and post-operative patients. Zillmann also acts as a national educator for Advanced Rejuvenating Concepts™. Recently, she was the recipient of the Entrepreneur Spirit Award from the National Association of Women Business Owners. She is also the President of Aesthetics International Association (AIA)