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CHAPTER 20 CHEMICAL PEELS
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DEEP-DEPTH PEELS
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Laser surgery and dermabrasion have largely supplanted deep-depth peels, having shown superior results with fewer complications Currently, there
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FIGURE 20-16 Patient with photodamage prior to one coat of a Jessner s peel followed immediately by the Accupeel 16%
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pear and then return after the chemical peel This occurs because the melanocytes that are responsible for pigmentation reside below the level of the chemical peel (see 13) The results will be improved if patients use retinoids, sunscreen, and hydroquinone or other bleaching agents (Figs 20-16 to 20-18) Following medium peels, as with superficial ones, it is important for patients to use sunscreen and to practice sun avoidance Patients with darker skin types should use hydroquinone after the peel to lower the incidence of hyperpigmentation Practitioners should administer antiviral medication to patients with a history of herpes simplex infection Also, it is important for the practitioner to avoid overzealously applying TCA, which can cause scarring Patients recently treated with isotretinoin are also particularly vulnerable to scarring from medium peels
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COMBINATION OF SUPERFICIAL AND MEDIUM-DEPTH PEELS
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Many physicians use a superficial peeling method to decrease and even out the SC and follow that up with the applicaFIGURE 20-17 Same patient 4 days later The peeling has begun The solar lentigo on the right cheek is much inproved
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BOX 20-3
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Super cial Peel Indications
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FIGURE 20-18 Eight days later The solar lentigo on the right cheek is beginning to reappear, which is often the case with larger lesions
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are modified phenol peels such as the Stone Venner-Kellson peel (composed of phenol, croton oil, water, olive oil, and septisol solution) available, but they are rarely used by physicians in the United States The Stone Venner-Kellson peel can be ordered from Delasco and the ordering physician must specify the ingredients Since deep-depth peels are no longer popular and have been replaced by laser surgery, phenol peels and other deep-depth peels will not be discussed here
AT-HOME CHEMICAL PEELS
Chemical peels used to be offered by dermatologists or trained professionals at beauty salons Recently, many companies have developed at-home skin peel kits mostly using AHA as their main ingredient Considering the potential side effects, especially increased photosensitivity, the FDA s AHA Review Committee and the Cosmetic, Toiletry, and Fragrance Association s (CTFA) Cosmetic Ingredient Review (CIR) Expert Panel reviewed the use of
AHAs in cosmetic products57 In 1998, the CIR Expert Panel came to the following conclusion: Based on the available information included in this report, the CIR Expert Panel concludes that glycolic and lactic acid, their common salts and their simple esters, are safe for use in cosmetic products at concentrations 10%, at final formulation pH 35, when formulated to avoid increasing sun sensitivity or when directions for use include the daily use of sun protection These ingredients are safe for use in salon products at concentrations 30%, at final formulation pH 30, in products designed for brief, discontinuous use followed by thorough rinsing from the skin, when applied by trained professionals, and when application is accompanied by directions for the daily use of sun protection 58 There are several AHA products available as at-home peel kits Resurface Peel by Lanc me (8% glycolic acid and 5% Physio-Peel enhancer), Glytone Boost Mini Peel Gel (108% glycolic acid), and Dermo-Expertise ReNoviste Antiaging Glycolic Peel Kit by L Or al
Acne and Rosacea BHA peels can be used in all skin types Resorcinol can be used in Fitzpatrick skin types I and II and light type III skin Do not treat rosacea patients with AHAs and retinoids because it worsens the erythema Melasma Jessner s peels, modi ed Jessner s peels and resorcinol are rst-line choices here Resorcinol can be used in Fitzpatrick skin types I and II and light type III skin AHAs and BHA are also effective Photoaging and mild wrinkles All of the mentioned chemical peels have been shown to be useful for treatment of photoaging The choice of which to use should be based on patient history, other concurrent pathology, and the downtime that the patient can tolerate Pretreatment for a medium-depth peel One can condition the skin for a medium peel by pretreating with any of the super cial peels The likely method of action is the quickening of the cell cycle pace Most physicians pretreat with topical retinoids, bleaching agents, and three to four super cial peels prior to a medium-depth peel for patients with Fitzpatrick skin type III Medium-depth peel indications The indications are the same as those for super cial peels The pathology is more signi cant, though Therefore, severe acne and photoaging would respond better to mediumdepth peels Patients with a history of hyperpigmentation disorders or with Fitzpatrick skin type III or greater skin should be treated very cautiously with medium-depth peels
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