COSMETIC DERMATOLOGY: PRINCIPLES AND PRACTICE in VS .NET

Maker QR-Code in VS .NET COSMETIC DERMATOLOGY: PRINCIPLES AND PRACTICE

COSMETIC DERMATOLOGY: PRINCIPLES AND PRACTICE
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Postinflammatory hyperpigmentation is a rare complication in superficial chemical peels that are started at low strengths and titrated up very slowly Grimes followed 25 patients with Fitzpatrick skin types V and VI who were treated with 20% and 30% salicylic acid peels37 These patients were pretreated with hydroquinone 4% for 2 weeks prior to peeling Only three patients developed temporary postinflammatory hyperpigmentation No residual hyperpigmentation was seen Several studies have shown that superficial peels can also be used safely in Asian patients38,39 However, most dermatologists agree that these patients should be pretreated with a depigmenting agent and tretinoin and should be advised to use effective sun protection offering broad UVA and UVB coverage
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MEDIUM-DEPTH PEELS
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Trichloroacetic Acid 10% to 40%
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TCA became popular in the 1960s through the work of Ayres40 Lowstrength TCA (10% 15%) is used to ameliorate fine wrinkles and dyschromias and to provide the skin with a smooth, healthy appearance TCA, at these strengths, does not improve deeper wrinkles or scars41,42 Higher-strength TCA (35% 40%) produces epidermal and dermal necrosis without serious systemic toxicity It must be used with extreme caution, however, because hyperpigmentation and scarring can result Practitioners should carefully select patients, noting that patients with darker skin types should not be treated with TCA as they have an increased risk for postinflammatory hyperpigmentation TCA at 35% to 40% is the standard solution for medium-depth peels for the face and hands When discussing the strength of TCA peels, it is imperative to discuss the strength in weight per volume (wt/vol) measurements Unfortunately, not all authors use this form of measuring so one must take care when reading and basing a peel on the literature to know how the strength was calculated in order
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to avoid underestimating the strength of the peel This precaution reduces the risk of inducing scarring43 For instance, 25% TCA cannot be formed by diluting 50% TCA with an equal volume of water because this type of dilution is vol/vol and actually yields a solution stronger than 25% wt/vol TCA When following a protocol from the literature, the practitioner should calculate the TCA percentage by wt/vol measurements to avoid mistakes TCA can be purchased according to the desired wt/vol strength Following application of a TCA peel, denatured protein causes a frosting of the skin, signaling the completion of the peel The time lag between the application and the appearance of the frost varies according to the acid concentration The delay might last 5 to 7 seconds after application of 40% TCA, but can last as long as 15 to 20 minutes after application of a more dilute acid This is crucial for the practitioner to remember in order to avoid overtreatment TCA can be applied alone or after use of Jessner s solution or glycolic acid to achieve a deeper peel Healing time is usually between 5 and 7 days for patients treated only with TCA and between 7 and 10 days for patients treated with a combination of TCA and either Jessner s solution or glycolic acid41,42
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FIGURE 20-12 Delasco brand trichloroacetic acid in varying strengths These TCA peels may be used with a prep of glycolic acid (40% shown here) or Jessner s solution be applied to increase the peel to one of medium depth Other peels, such as the Obagi Blue Peel , contain only TCA (Figs 20-13 and 20-14) This peel is also applied in coats One or two coats produce a superficial peel while three to four coats produce a medium-depth peel
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CHAPTER 20 CHEMICAL PEELS
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Pyruvic Acid
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Pyruvic acid is an alpha ketoacid that is physiologically converted to lactic acid, thereby rendering it a chemical peeling agent while providing hydration to the skin Pyruvic acid penetrates down to the papillary dermis and results in increased production of collagen and elastic tissue44 It is important to note that pyruvic acid must not be used in high- or full-strength concentration since there is the potential for scarring45 The pyruvic acid peel has been used
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