Trichloroacetic Acid Peels of the Neck, Chest, and Arms and Hands

Introduction

The face is frequently the focus of antiaging and skin rejuvenation interventions. It is important to remember, however, that there are other areas that should be targeted for rejuvenation efforts to avoid a discordant appearance between the face and other visible areas. As we age, both intrinsic and extrinsic factors affect the appearance of the dorsal hands, neck, and décolletage and can “give away” a person’s true age if care is not taken to treat them along with the face.

Typical signs of aging and sun damage include solar lentigines and other dyschromias. External factors, like ultraviolet light, smoking, and secondhand smoking, contribute to extrinsic aging of the skin. Extrinsic aging leads to skin changes that many patients find cosmetically unappealing and prompt them to seek evaluation and treatment. These include actinic keratoses, seborrheic keratoses, and tactile and visible roughness. Intrinsic aging that results from internal factors, such as dermal and fat atrophy, contribute to wrinkles, prominent tendon and vein visibility, and bony prominence. Procedures that target these common signs of aging will enhance a patient’s overall rejuvenation results. The most cosmetically pleasing results often come from a combination of modalities focused on addressing the internal and external factors that are contributing to the appearance of the aged hand, neck, and chest ( Figs. 6.1 and 6.2 ). Trichloroacetic acid (TCA) peels, when used appropriately, can be an important step in an overall rejuvenation plan.

Indications and Evaluation for Chemical Peels of the Hands, Neck, and Chest

Chemical peels can address the extrinsic signs of aging. Proper patient selection is paramount for a reproducibly good outcome. It is important in the preprocedure consultation to identify the role that chemical peeling may play in overall rejuvenation and to discuss realistic expectations for improvement and review that the procedure is likely just one part of a therapeutic plan.

Unrealistic expectations or an inability to follow through on pretreatment recommendations should be red flags. A thorough medical history is necessary for identifying those at risk for poor or delayed healing. Those with diabetes mellitus, immunodeficiency, chronic kidney or liver disease, or connective tissue disease, or those on chronic steroids or immunosuppressive or immunomodulatory medications, deserve special attention. A history of medications that can lead to pigment deposition in areas of trauma, like minocycline, should also be elicited. Any allergies or medication sensitivities should be recorded. A history of herpes simplex virus (HSV), varicella zoster virus (VZV), or methicillin-resistant Staphylococcus aureus (MRSA) would indicate the need for more stringent preoperative and postoperative prophylaxis and surveillance. Patients with skin disorders with risk of Koebnerization, like psoriasis and lichen planus, should also be counseled about potential increased risk from the procedure. It is important to solicit a social history as well. Smokers, including those who vape nicotine-containing solutions, due to reduced blood flow, are at increased risk for poor wound healing. Occupation would also be relevant due to potential exposures that may affect healing. Those who work outdoors may be expected to have increased risk of ultraviolet (UV)-induced side effects like postinflammatory hyperpigmentation and dyschromia. Those who work in the healthcare setting may have increased risk for infection depending on their exposure level.

A patient’s tendency to heal appropriately should be assessed and a history of poor healing, hypertrophic or keloidal scarring, or a tendency to postinflammatory hyperpigmentation should be elicited. Absolute contraindications to peels include pregnancy and active infection at the procedure site.