Original Contribution

Journal of Cosmetic Dermatology, 12, 204--209

Chemical peeling with trichloroacetic acid and lactic acid for

infraorbital dark circles
Charitomeni Vavouli, MD,1 Andreas Katsambas, MD, PhD,2 Stamatis Gregoriou, MD, PhD,3 Anca
Teodor, MD, PhD,4 Carmen Salavastru, MD, PhD,4 Adina Alexandru, MD, PhD,4 & George
Kontochristopoulos, MD, PhD1
1
2nd Dermatology Department, Andreas Sygros Hospital, Athens, Greece
2
Department of Dermatology, University of Athens, Andreas Sygros Hospital, Athens, Greece
3
Department of Dermatology, University of Athens, Attikon Hospital, Athens, Greece
4
Second Clinic of Dermatology, Colentina Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania

Summary Background Periorbital dark circles are relatively common, affecting individuals
regardless of age, sex, and race. Available treatment includes bleaching creams,
topical retinoid acid, chemical peels, laser therapy, autologous fat transplantation –
injectable fillers, surgery (blepharoplasty), and chemical peeling.
Objective To evaluate the efficacy of a combination of trichloroacetic TCA 3.75% and
lactic acid 15% on improving the periorbital hyperpigmentation.
Patients/Methods Thirty patients with periorbital dark circles and skin types II, III, or
IV were included in the study. Chemical peeling was performed every week for a
series of four treatments. The effect was photo-documented, and a patient’s and
physician’s global assessment was evaluated.
Results Almost all the patients showed significant esthetic improvement. Physicians
assessed a fair, good, or excellent improvement in 93.3% of the patients. Patient’s
global assessment rated a fair, good, or excellent response in 96.7% of the patients.
The procedure itself had only mild and temporary adverse effects, such as erythema,
edema, frosting, dryness, and telangiectasias. The effects of treatment remained for at
least 4–6 months in the majority of patients with appropriate sun protection.
Conclusion The combination of trichloroacetic TCA 3.75% and lactic acid 15%
showed encouraging results on improving periorbital hyperpigmentation.
Keywords: dark circles, infraorbital hyperpigmentation, chemical peeling, trichlo-
roacetic acid, lactic acid

a significant cosmetic concern especially for female

Introduction
Dark circles (DC) under the eyes are defined as bilat-
eral, round, homogenous pigment macules on the
infraorbital regions.1 The condition is relatively com-
mon affecting individuals regardless of age, sex, and
race. It worsens with the aging process, and it can be
Correspondence: S Gregoriou, 2nd Dermatology Department, Andreas
Sygros Hospital, I. Dragoumi 5, Athens 16121, Greece. E-mail:
stamgreg@yahoo.gr
Accepted for publication March 12, 2013
patients.2 DC interfere with the face appearance, giving
the patient a tired, sad, or hung-over look.1 Hyper-
chromia of the orbital region can be subdivided into
primary or idiopathic and secondary type which is
associated with systemic or local diseases of a known
cause.3 DC are caused by multiple etiologic factors that
include dermal melanin deposition (nevus of Ota),
familiar or ethnic tendency, specific anatomic formali-
ties, postinflammatory hyperpigmentation secondary to
atopic or allergic contact dermatitis, periorbital edema,
superficial location of vasculature and shadowing due

204 © 2013 Wiley Periodicals, Inc.


to skin laxity, tear trough depression, medications,
systemic diseases, fatigue, smoking, excessive sun expo-
sure, etc.1,2 Periorbital pigmentation in actuality can be
a combination of the aforementioned factors.4 On the
other hand, it has been suggested that cutaneous hyper-
chromia of the orbital region is not necessarily associ-
ated with systemic diseases, as it also occurs in healthy
individuals.5 Available treatments for DC include bleach-
ing creams,6–9 topical retinoid acid,10 chemical peels,11
laser therapy,12–15 autologous fat transplantation –
injectable fillers,16–19 and surgery (blepharoplasty).20
None of the existing topical therapies for DC has been
found to be entirely satisfactory. Chemical peeling is a
medical procedure which constitutes controlled skin
damage, promoting regeneration and rejuvenation of
tissues. It can be classified into three basic categories
according to the histologic depth of injury, whether this
is superficial (effecting the horny layer and the vital por-
tion of the epidermis down to the basal layer), medium
(which effects the papillary portion of the dermis), or
deep (which can reach the reticular dermis).21 Chemical
peels are widely used for depigmentation in combination
with topical agents22,23 or as monotherapy.
The study evaluates the efficacy and safety of a new
superficial chemical peeling consisting of trichloroacetic
acid (TCA) and lactic acid (LA) (Enerpeel EL, Tebitech-
General Topics Lungolago Zanardelli, 32—25087 Sal
(BS) – Italy). This combination peel enhances the depth
without using high concentration of the agent. It does
not have the potential adverse effects of scarring and
permanent depigmentation.
Material and methods
Twenty-nine female and one male patient with an age
range 24–68 years (mean ~ 43) years with infraorbital
hyperpigmentation were included in the study. Patients
were all those presenting at the outpatient clinics of
our hospital and willing to have their periorbital
hyperpigmentation treated during a one-month period.
All were adult Mediterranean patients with skin types
II, III, or IV. Thirteen patients reported a positive fam-
ily history (43%). Eleven patients were not using sun-
screen and 22 were not applying it on the periorbital
region before the treatment. Two patients suffered also
from melasma. Prior consent was taken from each
patient after explanation of the procedure. A detailed
history was taken, and in some cases, a clinical and
laboratory testing was performed. Individuals were
excluded from the study if they presented inflamma-
tion, infectious, systemic diseases, or any other treat-
ment (dermabrasion, laser, radiation, surgery) on the
© 2013 Wiley Periodicals, Inc.
Chemical peeling for infraorbital dark circles . C Vavouli et al.
affected region performed <6 months prior to the
beginning of the study. Other exclusion criteria were
pregnancy, nursing, allergy, hypersensitivity to the
components, photosensitivity, and unrealistic expecta-
tion. Digital photographs were taken for every patient
at baseline and after the treatment. These photographs
were analyzed by three independent dermatologists.
Before therapy, a severity index score was performed
for each patient. The intensity of periorbital hyperpig-
mentation was evaluated as mild, moderate, advanced,
or severe, based on the color of the orbital region as
compared to the patient’s color according to the Fitzpa-
trick scale (Table 1).
Patient’s demographics and DC grading scale before
treatment are shown in Table 2. Seven subjects had
mild, 11 had moderate, eight had advanced, and four
had severe hyperpigmentation. The correlation of DC
with some factors which worsen the degree of hyper-
chromia in patients appears in Table 3.
Combination of peeling agents consisted of TCA in
concentration 3.75% and LA 15%. It was performed
using the basic guidelines for chemical peelings. A
degreasing wipe moistened with an acidified hydro-
alcoholic solution with citric acid was used to remove
any impurities and excess oil from the surface of the
eyelids. The texture of the peel was in a gel formula-
o tion. The device applicator was a rigid element cover
with a thin layer of spongy material which allowed the
precise application of the gel, so as to reduce the risk
of involuntary contact with the ocular conjunctiva to
a minimum. The patients were also instructed to keep
their eyes closed during the application. They were
subjected to peeling every week for a series of four
treatments. Four layers of the peel were applied to each
infraorbital area in the same session. The first layer of
the peel was applied starting from the area where
Table 1 DC classification according to the phototype
DC grading scale Subject’s phototype Color of the orbital region
Mild II Golden
III Fairly dark
IV Dark
Moderate II Fairly dark
III Dark
IV Chocolate
Advanced II Chocolate
III Very dark
IV Black
Severe II Very dark
III Black
IV Blue-black
DC, Dark circles.
205
Chemical peeling for infraorbital dark circles . C Vavouli et al.

Table 2 Patient’s demographics and DC grading scale before

(a)
treatment

No. of Gender/ DC grading scale

patients age(years) Phototype before treatment

1 F/24 III Moderate

2 F/30 II Moderate
3 F/33 II Mild
4 F/34 IV Moderate
5 F/35 II Moderate
6 F/36 II Mild
7 M/36 II Moderate
8 F/36 III Severe
9 F/37 III Moderate (b)
10 F/37 II Advanced
11 F/37 IV Moderate
12 F/39 II Moderate
13 F/39 II Advanced
14 F/39 III Moderate
15 F/39 III Severe
16 F/42 IV Advanced
17 F/42 IV Severe
18 F/44 III Mild
19 F/45 III Moderate
20 F/46 II Moderate
21 F/46 III Advanced Figure 1 Patient no 30. Infraorbital dark circles due to photoag-
22 F/47 III Mild ing. (a) Before treatment. (b) Improvement after peeling therapy.
23 F/49 III Mild
24 F/49 IV Advanced
25 F/50 III Advanced (a)
26 F/52 II Mild
27 F/54 II Mild
28 F/55 III Advanced
29 F/66 IV Severe
30 F/68 IV Advanced

DC, Dark circles.

Table 3 Factors worsening DC, incidence in the present study

No. of No. of
Adverse factors patients patients% (b)

Family history of DC 13 43
No use of sunscreen 11 36.7
No use of sunscreen on the eyelids 22 73.3
Smoking 10 33.3
Alcohol 8 26.6
No exercise 14 46.7

DC, Dark circles.

hyperpigmentation was more intense. The duration of

the 1st, 2nd, and penultimate layer ranged between 1
to 2 min and in the last layer, about 5 min. Total time
for a single session was 8–11 min. The peel was neu-
tralized with a wipe moistened with 12% solution of
arginine. Also, patients were advised to wash the
treated area with pure water after the neutralization.
Figure 2 Patient no 13. (a) Before and (b) after peel. Marked
improvement of dark circles.
All patients were instructed to avoid direct sunlight, to
apply a sunscreen (SPF 50+) before any sun exposure,
and to wear sunglasses (Figs 1–3).

206 © 2013 Wiley Periodicals, Inc.

 Chemical peeling for infraorbital dark circles . C Vavouli et al.

Table 4 Results of TCA–LA peel for the treatment of DC

(a)

Poor Fair Good Excellent

Physician’s global assessments

No. of patients 2 11 12 5
No. of patients% 6.7 36.7 40.0 16.6
Patient’s global assessments
No. of patients 1 8 14 7
No. of patients% 3.3 26.7 46.7 23.3

DC, Dark circles; TCA, trichloroacetic acid; LA, lactic acid.

(b) Table 5 Patient’s satisfaction

Not satisfied Slightly satisfied Very satisfied

No. of patients 4 7 19
No. of patients% 13.3 23.3 63.3

Table 6 Patient’s global tolerance

Poor Fair Good Excellent

No. of patients None 7 9 14

Figure 3 Patient no 11. Mother (Fig. 1) and daughter with the No. of patients% 0.0 23.3 30.0 46.7
same problem of dark circles. (a) During the 2nd peel (b) After
2nd peel.
categories: very satisfied, slightly satisfied, and not satis-
fied. Patient’s satisfaction is shown in Table 5.
Results
Safety was assessed by evaluating tolerance and
Skin lightening was observed in most patients from the adverse events. Most patients (76.7%) described a good
first peel with further improvement thereafter (Figs. 1– to excellent tolerability (patient’s global tolerance;
3). Among the three observers who examined the pho- Table 6) with only some mild discomfort (tingling,
tographs of each patient before and after the treatment, itching, burning sensations, or pain) during the ther-
none of them classified the patients as “worse” after the apy. Other irritating reactions of the treatment were
treatment. Medical observers performed clinical assess- the presence of erythema in 26.6% of the individuals,
ments using the following grading scale: 0–25% edema (6.6%), frosting (10%), dryness (6.6%), and the
improvement (poor), 26–50% improvement (fair), revelation of pre-existing telangiectasias (10%).
51–75% improvement (good), 76–100% improvement (Table 7). The most common adverse effect was
(excellent). They indicated an excellent improvement in
16.6%, a good in 40,0%, a fair in 36.7% and a poor in Table 7 Adverse events during and after the treatment, incidence
in this study
6.6% of the cases. Furthermore, 23.3% of the patients
assessed the efficiency of the treatment as excellent, Adverse events No. of patients No. of patients%
46.7% as good, 26.7% as fair and 3.3% as poor. The
results of global assessment among physicians and Tingling 7 23.3
patients presented differences without statistical signifi- Itching 1 3.3
Burning 4 13.3
cance. Both the patient’s and physicians’ global assess-
Pain 2 6.6
ments after the treatment are demonstrated in Table 4. Erythema 8 26.0
Most patients (86.6%) were satisfied with the outcome. Dryness 2 6.6
They were interviewed about their level of satisfaction Edema 2 6.6
Frosting 3 10.0
with the clinical results after the treatment. The patient
Telangiectasias 3 10.0
was requested to estimate the clinical results (patient’s Postoperatively hyperpigmentation None 0.0
global assessment; Table 5) and select one of three

© 2013 Wiley Periodicals, Inc. 207

Chemical peeling for infraorbital dark circles . C Vavouli et al.
redness followed by tingling sensations and burning.
However, these were only temporary and did not
necessitate further treatment. The exfoliation was most
pronounced 24–48 h after the peel treatment. The
three patients, who had presented frosting, were trea-
ted with topical corticosteroids for a week. The other
participants were not asked to use any other topical
product before and after the sessions except sunscreen.
No hyper-or hypopigmentation or scarring was observed
post-treatment.
Discussion
There is no ideal treatment for DC. Little is published
in the literature regarding this subject. In the present
study, 30 healthy individuals with DC under the eyes
were treated with chemical peeling using a combina-
tion of two peeling agents (TCA, LA) at low concentra-
tions. According to the results of the study, this
combined peel is probably effective in the reduction of
the pigmentation in DC.
TCA applied to the skin produces modifications in
the epidermis and dispersion of melanin. It has been
used at different concentrations for superficial, med-
ium, and deep chemical peeling. It produces coagula-
tion of skin proteins and destruction of the epidermis
and the upper dermis, followed by epidermal and der-
mal regeneration with new collagen deposition and
increase in epidermal and dermal volume. The depth of
skin necrosis is directly proportional to the concentra-
tion of the TCA. It is possible to reach the dermis using
a low-concentration solution applied to an epidermis
that has been more permeable. It may become a med-
ium-depth peel depending on the number of layers
applied in the same session, the contact time, the num-
ber of treatment sessions previously performed, the
time interval between one treatment session and
another, the patient’s genetic-ethnic characteristics,
phototype and skin type. Also, the skin of the infraor-
bital eyelids is very thin (thickness of approximately
0.5 mm).
LA is an alpha hydroxy acid (AHA), the mechanism
of action of which is similar to glycolic acid. It facili-
tates dissociation of epidermal cells and promotes des-
quamation, dispersion of melanin, and increase in the
synthesis of collagen and glycosaminoglycans. In addi-
tion, it has also been described as having a tyrosinase-
inhibiting action and has been used in the treatment
of melasma.24,25
The skin-lightening effect and normalization of
hyperpigmentation can, in part, be explained by the
removal of melanosomes as the results of induced
208
keratinocyte removal (thinning melanin), by inhibition
of tyrosinase, and through thickening the epidermis
and the dermis (less visible vasculare).
Combination peels have many advantages: (i) They
allow us to exploit the different properties of each
agent for optimal results, (ii) minimize the risk of com-
plications by using low concentration, (iii) accelerate
tissue regeneration and the subsequent recovery time,
and (iv) broaden the range of applications of chemical
peeling methods.
With regard to complications that may appear dur-
ing, immediately after, or in the post phase, there does
not seem to be a restrictive factor, probably, due to
their transient nature.
Additionally, this chemical peel has the advantage of
well-homogenizing effect, thus combining convenience
and less expensive cost compared with other treat-
ments, but the applications must be repeated after a
certain time interval. The effects of treatment lasted for
at least 4–6 months in the majority of patients with
appropriate sun protection. Despite the many sessions,
this treatment poses a reliable therapeutic method for
the treatment of DC that appears to be effective, safe,
and well tolerated, achieving patient and physician
satisfaction.
Acknowledgments
This work was supported by the European Commission
under the 7th Framework Programme 2007–2013
through the Sectoral Operational Programmes focus on
human resource development and human resources,
Contract no. 2007RO051PO001, Educational Program:
POSDRU/63/3.2/5/318: International Training in
Dermato-cosmetics for Romanian Medics.
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