Are Trichloroacetic Acid Peels Safe?

Tamar K. Rawls, Mercer University College of Pharmacy

Chemical peeling exfoliates the top layer of skin, thereby removing superficial lesion and causing regeneration of new skin.  Indications for chemical peeling include pigmentary disorders, superficial acne scars, aging skin changes, and benign epidermal growths.  Contraindications include patients with active bacterial, viral, or fungal infection; tendency to keloid formation; facial dermatitis; taking photosensitizing medications; and unrealistic expectations. [1]

Universal Trichloroacetic Acid Peel Technique for Light and Dark Skin [2]
Design Case series; N= 923
Objective To clarify a practical approach to a universal trichloroacetic acid peel and to offer an organized, easy, and safe technique for medium and deep trichloroacetic acid peels by utilizing genetico-racial skin classification
Study Groups 1.    Northern Europeans (n= 46)

2.     Mid-Europeans (n= 332)

3.     Southern Europeans (n= 138)

4.     Southern Caucasians (n= 166)

5.     Africans (n= 46)

6.     Asians (n= 195)

Methods Candidates were placed in a genetico-racial skin classification category based on skin color and facial features.  The classification assisted in predicting the response to a peel.  The steps to a trichloroacetic acid (TCA) peel are as follows: 15 grams of prilocaine cream is spread on face and neck, then covered with saran wrap and left for 20 minutes.  .  The acid is applied on the left side of the face, the right side, the forehead, the eyelids, and then the neck.  Last, extra passes are added as needed to achieve a homogenous frost across the face.

The evaluation of the peel depth is based solely on the frost sign (the white color of the peeled skin).  The target frost for the three basic types of peels are: (1) light peel (the frost is light white, made of scattered white spots, like “white stars on pink skies”), (2) medium peel (the frost is medium white), and (3) deep peel (the frost is deep white).  The goal is to reach light white for a light peel, medium white for a medium peel, and deep white for a deep peel. The only exception is the neck area, which should be less white (more superficial) than the face due to skin sensitivity and slower recuperation.

Duration 01/01/1996 to 11/01/2015
Primary Outcome Measure Incidence of peeling complication per ethnic group
Baseline Characteristics Men (n= 120), women (n= 803); mean age 41.59 yrs

Category Complication Incidence of complication, %
Asian & Indo-Pakistani (southern Caucasian) Hyperpigmentation 5.9
Nordic (northern Europeans) Telangiectasia 0.3
African Hypopigmentation 0.1
Adverse Events Common Adverse Events: 5.9% hyperpigmentation
Serious Adverse Events: 0.2% acute herpesvirus infection
Percentage that Discontinued due to Adverse Events: not disclosed
Study Author Conclusions Trichloroacetic acid peels are efficient and safe for light and dark skin when properly applied. The technique can be an easily implementable addition to a physician’s cosmetic practice.


Mid-Europeans, a population which was known to have a favorable response to a peel, made up more than one-third of the population, thereby yielding more credible results to the study.  Furthermore, there was no comparative data to formulate if the universal TCA peel had less incidence of complications between genetico-racial groups.  Peels using TCA were claimed to be safe, but no safety endpoint or expectations were declared in the study.  Incidence of complications was reported during the investigation, but there was not a preset variable for the determination of safety.



  1. Khunger N. Standard guidelines of care for chemical peels. Indian J Dermatol Venereol Leprol. 2008;74 Suppl:S5-12.
  1. Fanous N, Zari S. Universal Trichloroacetic Acid Peel Technique for Light and Dark Skin. JAMA Facial Plast Surg. Published online January 12, 2017. doi:10.1001/jamafacial.2016.1666





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