Trichloroacetic acid is a topical cauterizing agent recommended for the treatment of condylomata acuminata, including warts found in the external genital/perianal areas. It has also been used as a chemical peel in the treatment of actinic keratoses and other signs of photoaging, including melasma and lentigines. Trichloroacetic acid rapidly penetrates and causes protein denaturing and cell death when applied to skin. As a chemical peel, the depth of the protein destruction of skin layers (i.e., epidermis or dermis) depends on the concentration. For condylomas, a single application will usually not produce successful clearance and repeated applications are required. In comparative studies, trichloroacetic acid was associated with condyloma clearance rates of 70% to 80% after six applications. Recurrence rates at 2 months are still relatively high at 36%. Investigators have found that trichloroacetic acid has resulted in the eradication and/or improvement of actinic keratosis and other visible effects of photoaging, including melasma and lentigines.
General Administration Information
For storage information, see the specific product information within the How Supplied section.
NOTE: If patient develops intense pain at the application site or if an excessive amount of acid is applied, guidelines recommend the affected area be covered with sodium bicarbonate (i.e., backing soda), washed with liquid soap, or powdered with talc to neutralize and remove the acid.
Route-Specific Administration
Topical Administration
Other Topical Formulations
Liquid Solution
-Trichloroacetic acid can be used at a concentration of 50% to 90% for the treatment of condyloma acuminata. Guidelines recommend using a concentration of 80% to 90%.
-Trichloroacetic acid should be applied with a plastic-tip probe or a cotton tip applicator in a small amount directly to the condyloma by the provider once per week up to 3 times weekly.
-The affected area can also be covered with a dressing for 4 to 5 days. Do not use excessive amounts that would cause the liquid to spread to adjacent skin areas. This may result in scarring.
-Patients should be instructed not to sit or stand until the acid dries. As the acid dries, a white frosting will develop.
-The treatment may be reapplied if necessary for an average of 6 to 10 consecutive weeks.
-Skin areas around the condyloma may be protected with petroleum jelly.
Topical Peel
-Trichloroacetic acid can be used for a superficial, medium-depth or deep peel, depending on the concentration and time of application. Superficial peel uses a trichloroacetic acid concentration between 10% and 30%. Medium-deep peels are at a concentration above 30% to 50% or in combination (e.g. Jessner's solution and trichloroacetic acid 35%). Deep peels have a concentration of more than 50%. A variety of concentrations can be made. For example, trichloroacetic acid 35% is developed by mixing 35 grams of trichloroacetic acid in enough water to make 100 mL.
-After preparation, which includes priming and cleansing, apply the trichloroacetic acid using compresses, cotton, an applicator, or a brush.
-Contact time depends on the desired depth of peeling.
-Trichloroacetic acid can be neutralized with sodium bicarbonate or water, if necessary.
-Medium-depth and deep peels are applied only once. Superficial peels may be repeated if necessary.
-Hydrating and healing creams are applied after the session, and then followed by post-peeling care if needed.
-For medium-depth and deep peels, the use of sunscreen with an SPF 15 or higher with UVA/UVB for 6 to 12 months is recommended Antiviral therapy is required pre- and post-treatment for deep peels. It is optional for medium-depth peels.
Chemical peels are classified as superficial, medium-depth, or deep peels based on the depth of destruction caused by trichloroacetic acid. The depth of peeling with trichloroacetic acid depends on the concentration, pH, and the time of application. Adverse reactions vary based on the depth of treatment.
Mild skin irritation, including burning, stinging, inflammation, and tenderness occur commonly. Moderate adverse effects, including scabbing and skin ulcer at the site of application, have been reported in 26% to 30% of patients receiving treatment of condylomata acuminata. Scarring has been infrequently reported. For intense pain, the acid can be neutralized with soap or sodium bicarbonate (baking soda). When used as a chemical peel, skin hyperpigmentation, skin hypopigmentation, redness, and desquamation are expected.
Infection occurs rarely after trichloroacetic acid deep peels, and can be prevented and/or treated with topical antiinfectives or systemic antiviral agents and proper wound care.
The use of trichloroacetic acid in the treatment of condylomata acuminata in pregnancy is reported to be safe. There are no data evaluating the safety of using trichloroacetic acid on larger surface areas (e.g. chemical peel) in pregnant patients.
There are no data available evaluating the safety of trichloroacetic acid during breast-feeding. Because trichloroacetic acid is used in small amounts and applied topically and infrequently for the treatment of condyloma acuminata, it is expected that systemic exposure would not occur. The clinician should use with caution in breast-feeding females when treating condyloma acuminata. When used in larger amounts (e.g. chemical peels) as a single application, it is unknown whether systemic exposure would occur.
Trichloroacetic acid has a viscosity comparable to water and can spread rapidly if excessive amounts are applied. Accidental exposure may result in damaged tissue in surrounding areas; scarring has been reported. If patient develops intense pain at the application site or if an excessive amount of acid is applied, guidelines recommend the affected area be covered with sodium bicarbonate (i.e., backing soda), washed with liquid soap, or powdered with talc to neutralize and remove the acid.
For the treatment of condylomata acuminata due to human papillomavirus (HPV) infection:
Topical dosage:
Adults: Apply a small amount topically to the wart(s) once weekly until complete clearance of all warts or for a maximum of 6 weeks.
Adolescents: Apply a small amount topically to the wart(s) once weekly until complete clearance of all warts or for a maximum of 6 weeks.
Children weighing 45 kg or more: Apply a small amount topically to the wart(s) once weekly until complete clearance of all warts or for a maximum of 3 to 6 weeks.
For the treatment of photoaging* including actinic keratosis*, facial wrinkles*, lentigines (freckles)*, and melasma* using a medium-depth peel:
NOTE: Use is recommended only by experienced clinicians. For deep peels, consult standard dermatology references.
Topical dosage:
Adults: Apply trichloracetic acid 30% after thorough cleansing with acetone-soaked sponges. Discontinue application when an even frosting develops. Apply sunscreen daily and 0.05% tretinoin cream to the face and scalp nightly. In a prospective, randomized study, treatment with 30% trichloroacetic acid resulted in an 89% reduction in mean actinic keratosis count 3 months after facial resurfacing when compared with the control group (p = 0.004). A decrease in cancer incidence (i.e. new non melanoma skin cancers) was also reported. As a combination treatment, trichloroacetic acid 35% is used with Jessner's solution as a medium-depth chemical peel for actinic keratosis. Pretreat both sides of face with 0.025% tretinoin cream every night for 2 weeks. For patients with a history of labial herpes simplex infection, give prophylactic acyclovir for 2 days before and 4 days after the procedure. Clean skin thoroughly with acetone-soaked guaze pads prior to application. Protect eyes with saline-soaked eye pads. Apply Jessner's solution with cotton applicator and apply firm pressure until a pink color (i.e. mild erythema) and a frosting appear. Then, apply 35% trichloroacetic acid evenly to 2 cm2 at a time with a cotton applicator and apply firm pressure until a frost appears, feathering the solution into the hairline and jawline to avoid lines of demarcation. Apply trichloroacetic acid alone to lower eyelids and below the eyebrows. Immediately after frosting, apply an ice-water soaked guaze until burning subsides. After treatment, apply Bacitracin 3 times per day during the first week, avoid sun exposure for at least 1 week, and use a protective hat with broad-brim. In a small comparison study, patients that were treated with the combination regimen had a 75% reduction actinic damage after 1 month. The depth of the trichloroacetic acid chemical peel depends on concentration and length of application. Success in the treatment of actinic keratosis requires considerable experience and is operator-dependent.
Maximum Dosage Limits:
Maximum dosage information is not available. It is recommended that trichloroacetic acid be applied no more than 3 times/week for up to 10 weeks for condyloma acuminata. Topical peels are applied once.
Patients with Hepatic Impairment Dosing
Specific guidelines for dosage adjustments in hepatic impairment are not available; it appears that no dosage adjustments are needed.
Patients with Renal Impairment Dosing
Specific guidelines for dosage adjustments in renal impairment are not available; it appears that no dosage adjustments are needed.
*non-FDA-approved indication
There are no drug interactions associated with Trichloroacetic Acid products.
Trichloroacetic acid is a keratolytic agent that rapidly penetrates and chemically causes protein denaturing and cell death when applied to skin. When used in the treatment of condyloma acuminata, the area will turn white or "frost", indicating precipitation of denatured protein.
When used in the treatment of actinic keratosis and other physical signs of photoaging, trichloroacetic acid is used as a superficial, medium-depth or deep peel, depending on the concentration. When used at a medium-deep peeling level (35% concentration), new and healthy keratinocytes will be produced to replace damaged cells and collagen production is stimulated. Deep peels (more than 50% concentration) will cause coagulation of membrane protein and destruction of cells in the reticular dermis, which produces frosting and complete epidermolysis. This results in the restoration of dermal architecture.
Data on the pharmacokinetics of trichloroacetic acid have not been described by the manufacturer.