Superficial to Medium-Depth Peels: A Personal Experience

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13 Superficial to Medium-Depth Peels

A Personal Experience

Gabriella Fabbrocini, Maria P. De Padova, Antonella Tosti

Introduction

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:

1 Very superficial: destruction of the stratum corneum.

2 Superficial: destruction of part or all of the epidermis.

3 Medium: destruction of the epidermis and part or all of the papillary dermis.

4 Deep: destruction of the epidermis and papillary dermis, extending into the reticular dermis.

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:

1 Its ability to target the pathogenetic factors as well as to treat some of the existing primary and secondary lesions.

2 Augments delivery of topical antibiotics and keratolytics to targeted comedones, papules, and pustules.

3 Modifies the skin pH with improvement of acne lesions.

4 Expedites restoration of the skin back to its normal state.

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 13.1

An example of significant improvement in MASI score, after peeling treatment, from baseline to T3

Facial Areas	TOTAL MASI SCORE
F + RM + LM	12.6

Facial Areas	TOTAL MASI SCORE
F + RM + LM	3.6

F = Forehead

RM = right malar

LM = left malar

To calculate the MASI score, the sum of the severity grade for darkness (D) and homogeneity (H) is multiplied by the numerical value of the areas (A) involved and by the percentages of the four facial areas (10–30%).

Total MASI score: Forehead 0.3 (D+H)A + right malar 0.3 (D + H)A + left malar 0.3 (D + H)A + chin 0.1 (D + H)A

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 score^a	+++Salicylic acid +++Pyruvic acid +Glycolic acid +Mandelic acid

Melasma MASI score^b

+++Salicylic acid

+++Pyruvic acid

++Glycolic acid

+Kojic acid +Retinoic acid

Photoaging Wrinkle severity index^c

+++Retinoic acid

+++Trichloroacetic acid (TCA) 30%

++Glycolic acid

++Jessner’s solution

+Salicylic acid

Xantelasma Clinical evaluation

Acne scars
Box scar Goodman & Barron classification^d

+++TCA CROSS +++TCA 30%

++Glycolic acid ++Salicylic acid with TCA 25%

++Jessner’s solution

Rosacea Clinical evaluation

+++ Salicylic acid

+++Pyruvic acid

Lentigo simplex Clinical evaluation

++Salicylic acid

Actinic keratosis Clinical evaluation

+++TCA 10–30%

++Salicylic acid

++Glycolic acid 70%

Chicken pox Goodman & Barron classification^d

^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.

Indications

• Acne

In active acne, peels can be utilized due to their anti-inflammatory and keratolytic properties. These effects can enhance the efficacy of topical treatments and increase the patient’s compliance to therapeutic regimens. The keratolytic effect improves skin smoothness and promotes penetration of topical drugs by exfoliating the stratum cornuem. In this way it is possible to obtain a rapid improvement of comedonal and papulo-pustular lesions. However, patients with nodulocystic acne should be cautioned that only limited improvement with chemical peels is likely.

• Acne scars

The best results are achieved in macular scars. Ice pick and rolling scars cannot disappear completely and need sequential peelings combined with homecare treatment with topical retinoids and alpha hydroxy acids. For the deepest ice pick scars, phenol peels can be very useful but require monitoring.

• Melasma and hyperpigmentations

Chemical peels are very effective in treating melasma. To achieve optimal results, patients must adhere to home skin care regimens that include depigmentating topical agents and broad spectrum sunscreens. In dermal melasma or solar lentigines, peelings can be incompletely effective. Very circumscribed cryotherapy or intense pulsed light or laser can be employed to disperse residual pigmentation. Nevertheless, chemical peels can be utilized when lentigines are widespread and lightly pigmented to obtain an overall reduction in pigmentation prior to pulsed light or cryotherapy. In our hands, 30% salicylic acid is best suited for this indication.

• Xanthelasma

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