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Chemical peels offer versatile resurfacing tool

Article-Chemical peels offer versatile resurfacing tool

Dr Neil S. Sadick, M.D.
New York — Chemical peels continue to play an important role in the dermatologic surgeon's armamentarium for treating a spectrum of conditions that can benefit from resurfacing, says Neil S. Sadick, M.D.

"Used alone or in combination with other modalities, chemical peels offer a safe, effective and cost-effective approach for rejuvenating the aging face as well as for the treatment of actinic keratoses, pigmentary dyschromias, superficial scarring, acne and rosacea," says Dr. Sadick, clinical professor of dermatology, Weill Medical College, Cornell University, New York.

While chemical peels can be used to address actinic damage across its entire spectrum of severity from very mild to severe, the less-aggressive superficial peels and medium-depth techniques combining trichloroacetic acid (TCA) with CO2 or Jessner's remain the most widely used.

Superficial peeling removes the outermost layers of skin to the stratum granulosum and granular layer of the epidermis, and is most useful for treating acne, melasma or very minimal photodamage. A variety of different chemicals can be used. The alpha-hydroxy acids (AHAs), including lactic acid, glycolic acid, tartaric acid and pyruvic acid, help to decrease keratinocyte adhesion, improve epidermal maturation and stabilize dermal ground substance, and so are a good choice for early photoaged skin.

On the other hand, the beta-hydroxy acid salicylic acid is keratolytic, which makes it particularly useful in acne patients. Both Jessner's solution, because of its resorcinol content, and salicylic acid cause keratolysis, which is desirable for treating pilosebaceous skin, while superficial peeling with TCA is useful in patients with actinic keratoses because the TCA causes protein precipitation.

All patients undergoing superficial peels are started with an at-home regimen consisting of an AHA plus 4 percent hydroquinone. The AHA treatment begins with concentration of 5 percent to 10 percent and the strength is increased in increments of 5 percent monthly, as tolerated, up to a maximum of 40 percent.

"If excessive inflammation develops, short rest periods are allowed for resolution," Dr. Sadick says.

For all superficial peels, the skin must first be degreased with alcohol and wiped with acetone to strip the stratum corneum. The endpoint of treatment varies depending on the peeling agent.

"Using alpha or beta hydroxy acids, the goal is to achieve blotchy frosting, whereas with TCA, solid whitening is the endpoint," Dr. Sadick says.

Dual treatment with a salicylic acid peel plus microdermabrasion is a useful combination for treatment of melasma. For that indication, the procedures are alternated at two-week intervals while patients continue to use an at-home photobleaching peeling formula of AHA plus hydroquinone. These two modalities act synergistically in this setting, Dr. Sadick says.

"A small study of this combination approach is now in progress, but based on initial experience, it has been very effective in reducing the hyperpigmentation," he reports.

Medium-depth peels cause wounding up to the upper reticular dermis and can be used to treat mild-to-moderate photodamage, although they are best limited to patients with lighter skin (Fitzpatrick phototypes I to III) to minimize the risk for pigmentary changes.

Combinations best Modalities for medium-depth peeling include solid CO2 plus TCA 35 percent, Jessner's solution plus 35 percent TCA, TCA 50 percent alone and full-strength phenol 88 percent.

"However, the combinations using the lower strength of TCA may be preferred, as they offer similar efficacy compared to 50 percent TCA with less chance of scarring and pigmentary changes, and the eyelids should never be peeled with anything more than 35 percent TCA," Dr. Sadick says.

Patients undergoing medium-depth peeling should receive aspirin pretreatment to block the nerve fibers and reduce procedural pain. Application of cool compresses or dry cold packs immediately after treatment provides useful pain relief, and frequent moisture application postpeel is also recommended.

Deep peeling with Baker Gordon solution or modifications of that phenol mixture offers an alternative to treat severe photodamage. This approach is particularly helpful for treating deep perioral and periorbital rhytides, but it involves a significant recovery period and carries a number of intraoperative and postoperative risks.

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