Superficial to Medium-Depth Peels: A Personal Experience

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13 Superficial to Medium-Depth Peels

A Personal Experience


Chemical peeling is the process of applying chemicals to the skin to destroy the outer damaged layers, thus accelerating the normal process of exfoliation. With respect to the depth of penetration and histological level of necrosis, chemical peels can be divided into:

Chemical peelings are used to reverse the signs of skin aging and to treat certain epidermal skin lesions as well as scars, particularly acne scars. Dyschromias, wrinkles and acne scars are the major clinical indications for facial chemical peeling. Dyschromias include ephelides (freckles), lentigo simplex, senile lentigo, melasma, and post-inflammatory hyperpigmentation. The efficacy of chemical peels depends mostly on the histological depth of the lesions. For instance, in a patient with epidermal dyschromia and fine wrinkling due to papillary dermal atrophy and damage, a medium deep peel can restore the papillary and epidermal damage ; this is because an epidermal peel can only improve the dyschromia and has little or no effect on wrinkling.

Chemical peeling as a therapeutic modality for acne has many benefits:

The Problem Being Treated

The main aim of this chapter is to provide our practical treatment guidelines for various cutaneous indications.

Proper patient selection along with determination of the most appropriate type of peeling agent, concentration and the time of application required to treat a specific disorder will optimize benefits and minimize potential side effects.

Patient selection

The success of a chemical peel depends on careful selection of patient and individualization of treatment. Patients with mild facial rhytides and/or minimal dyschromias are the best candidates for superficial to medium-depth chemical peels. Deep rhytides and excessive facial laxity are likely to best respond to traditional rhytidectomy as the primary procedure and chemical peeling as an adjunct. Careful evaluation of skin type and complexion is the first step. The Fitzpatrick classification of skin types (I–VI) is often used to help stratify a patient’s risk for pigmentary complications. Darker phototypes are at higher risk for developing postpeel hyperpigmentation especially after more aggressive peels, while lighter phototypes seem to be more susceptible to excessive penetration of the peeling agent. In all cases, careful monitoring during the procedure is prudent (Boxes 13.1, 13.2, Table 13.1).

Box 13.2

Wrinkle severity rating scale (WSRS)

Score Description
1 Absent: No visible fold; continuous skin line. Amelioration with TCA peels
2 Mild: Shallow but visible fold with a slight indentation; minor facial feature; improvement in skin texture with TCA peels
3 Moderate: Moderately deep folds; clear facial feature visible at normal appearance but not when stretched. Excellent correction with phenol peels
4 Severe: Very long and deep folds; prominent facial feature; less than 2 mm visible fold when stretched. Significant improvement expected with combined peels
5 Extreme: Extremely deep and long folds detrimental to facial appearance; 2–4 mm visible V-shaped fold when stretched. Unlikely to have satisfactory correction with medium and deep peelings alone

Table 13.1 Correlation among skin diseases and suggested peeling approach

Skin disease Diagnostic method Suggested approach
Comedonal Acne-papulo-pustular Global scorea

Melasma MASI scoreb

Photoaging Wrinkle severity indexc Xantelasma Clinical evaluation Acne scars
Box scar Goodman & Barron classificationd Rosacea Clinical evaluation Lentigo simplex Clinical evaluation Actinic keratosis Clinical evaluation Chicken pox Goodman & Barron classificationd

a Doshi A, Zaheer A, Stiller MJ 1997 A comparison of current acne grading systems and proposal of a novel system. International Journal of Dermatology 38:416–418

b See Box 13.1

c Day DJ, Littler CM, Swift RW, Gottlieb S 2004 The wrinkle severity rating scale: a validation study. American Journal of Clinical Dermatology 5(1):49–52

d Goodman GJ, Baron JA 2006 Postacne scarring: a qualitative global scarring grading system. Dermatologic Surgery 32:1458–1466

Patient expectations and lifestyle must also be evaluated. During the consultation, if it is evident that the patient overestimates the benefits that can be achieved or cannot tolerate long post peeling care and recovery time (as with medium-depth TCA peels), the physician must recommend an alternative treatment. Numerous skin disorders can be improved with chemical peeling.



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