The Role of Priming the Skin for Peels

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3 The Role of Priming the Skin for Peels

Barry I. Resnik

Introduction

Foundation: That upon which anything is founded; that on which anything stands, and by which it is supported; the lowest and supporting layer of a superstructure; groundwork; basis (Webster’s Revised Unabridged Dictionary 1998).

The art of chemical peeling has been a constant in dermatologic surgery for many years. From the use of phenol in the treatment of acne scars in the early 1950s through the delineation of trichloroacetic acid (TCA) as treatment for photodamage, and on to the use of high percentages of TCA in the treatment of acne scars and benign lesions, the chemical peel has been the ‘slow and steady’ performer for a variety of conditions. Regardless of the indication, to ensure the best results, skin priming is a required first step. The various factors involved in skin priming will be examined here.

The foundation of an effective chemical peel is skin preparation. This begins in the weeks leading up to the peel, and also includes the actual preoperative steps before the peel. With adequate priming, the skin will frost rapidly and more uniformly than unprimed skin. TCA in particular is usually applied expeditiously to minimize discomfort; a more rapid and complete frost will enhance the patient’s experience. Although relatively uncommon, adverse effects such as hypo- or hyperpigmentation, delayed reepithelialization and prolonged erythema may also be minimized because skip areas are usually minimized as well. Finally, the postoperative phase can be shortened as a result of more rapid healing in primed skin.

Skin priming can be divided into two phases: (1) pretreatment and (2) preparation. These two phases are differentiated and determined by timing and the agents used. The pretreatment phase consists of topical agents applied in the days or weeks preceding the peel. The preparation phase encompasses those steps taken directly before the peel is performed. These include patient degreasing and cleansing just before and upon arrival at the office. The goal of both phases is to thin the epidermal barrier, enhance uniform active agent penetration, accelerate healing, and reduce postoperative side effects and complications, most importantly postinflammatory hyperpigmentation. See Box 3.1.

Box 3.1

Key features

• Pretreatment with 0.05% tretinoin cream for 2 weeks has been shown to significantly accelerate healing, regardless of body region
• In patients with keratotic lesions like actinic keratoses, AHAs help thin the hyperkeratotic tissue, increasing the penetration of the peeling agent

Pretreatment

Pretreatment refers to the 2 to 4-week period prior to the actual peel. A well-planned and executed regimen will enhance any chemical peel. The two major goals are thinning of the stratum corneum and reduction of post-inflammatory hyperpigmentation. A valuable but less tangible goal is the ability to assess patient compliance and tolerance to the pre and post peel regimen, including sunscreens, moisturizers and other antiaging products. Agents used during the pretreatment phase can include lactic acid, salicylic acid, kojic acid, hydroquinone, tretinoin, retinol, glycolic acid, and azelaic acid. A broad-spectrum UVA/UVB sunscreen with a minimum SPF 30 should accompany any regimen. Sunscreens act to reduce background hyperpigmentation prior to peeling. If dyschromias are being treated, it is particularly important to have adequate UVA coverage either with photostable chemical ingredients (mexoryl or helioplex (parsol 1789)) or physical blocking agents (zinc oxide or titanium dioxide).

Tretinoin, or all-trans retinoic acid, is probably the most popular pretreatment agent. Many studies have supported tretinoin’s beneficial effects in wound healing. Pretreatment with 0.05% tretinoin cream for 2 weeks has been shown to significantly accelerate healing, regardless of body region. A more rapid and even frost in the pretreated areas has also been noted, regardless of location. Tretinoin pretreatment in dermabrasion cases has also been shown to enhance healing. In a study evaluating the effectiveness of hydroquinone and tretinoin as adjunctive therapy with TCA peels in the treatment of melasma in Indian skin, it was shown that although hydroquinone and tretinoin functioned equally well as adjunctive agents to TCA in the treatment of melasma, only hydroquinone showed a significant decrease in postinflammatory pigment deposition. However, in carbon dioxide (CO2) resurfacing patients, no significant difference in the incidence of postprocedural hyperpigmentation was found in skin pretreated with 10% glycolic acid, 4% hydroquinone or 0.025% tretinoin.

The alpha-hydroxy acids (AHAs) have been used in all three phases: pretreatment, preparation, and as a superficial peeling agent. Its utility is dependent on the concentration used. At low percentages, keratinocyte adhesion is reduced, while at high percentages, superficial-to-deep peeling can occur. A 2 to 3-week pretreatment period is sufficient to thin the epidermis and prepare the skin for the peel. In patients with keratotic lesions like actinic keratoses, AHAs help thin the hyperkeratotic tissue, increasing the penetration of the peeling agent. Glycolic acid does not have much effect on the incidence of postinflammatory hyperpigmentation. There have been no studies on whether glycolic acid has the same effect on postprocedural healing as tretinoin, but anecdotal experience has shown it to be beneficial in the postprocedural period as well.

Hydroquinone is a fading agent used to treat conditions of pigmentation, including melasma and postinflammatory pigmentation. It is available commercially in 2% and 4% forms, and is compounded in higher percentages. This agent, when used as a priming ingredient in both TCA and glycolic acid peels for melasma, was more effective than retinoic acid 0.025% in reducing this difficult-to-treat condition. The author prefers to use a combination hydroquinone (8%), tretinoin (0.025%) and hydrocortisone (1%) product (modified Kligman’s formula) at night for the entire pretreatment period. Aberrant pigmentation and irradiation have not been noted with this formula.

Preparation

Preparation encompasses those steps that occur directly before, and sometimes those leading into the peel itself. Uniformity of depth, as well as ease of application and enhanced healing, all figure into this phase of the peel. Degreasers, ‘depth-enhancing’ agents such as Jessner’s solution, glycolic acid, and solid CO2, fluorescing agents, and applications of topical anesthetics all fall into this time period.

Most dermatologic surgeons will use alcohol, acetone, or a combination of both, to degrease the skin before the peel. Chlorhexidine gluconate (Hibiclens), a popular antibacterial scrub, is also utilized in this manner. It should be noted that chlorhexidine gluconate can cause keratitis and therefore may not be the best choice for facial procedures. The amount of material used, as well as the force and time of application, will have an impact on the depth and uniformity of the peel. The search for the ideal degreasing agent prompted an examination of alcohol, acetone, chlorhexidine gluconate and Freon Degreaser (trichlorotrifluoroethane) in 35% TCA peeling of the scalp. No differences between the various compounds were found, but the authors cautioned against the use of acetone in conjunction with possible igniters such as electrosurgical units.

Topical anesthetic preparations have been used as both preparatory and postprocedural agents. All of them are combinations of ‘caine’ anesthetics in differing vehicles. They offer pain control as well as skin hydration. The initial formulations required occlusion, but there are multiple commercial and proprietary versions now available that are effective without occlusion. In the author’s hands, a combination anesthetic gel obtained from a local compounding pharmacy (20% benzocaine; 6% lidocaine; 4% tetracaine) has proved to be very effective at pain control. The enhanced skin hydration usually combines with the other preparatory steps to deliver a more uniform peel. Differing results were reported with another proprietary formulation compounded in a methylcellulose base. Frosting occurred less rapidly, tended to be patchy, and went deeper than desired. Delayed stinging and discomfort occurred as well. These issues may have been due to the nature of the vehicle as well as to the topical anesthetic itself, and do provide a cautionary note. This author has not encountered these issues when using the newer preparations and has determined that their use can be a valuable adjunct to the procedure. Acids with fluorescent additives such as fluorescein sodium or salicylic acid with Wood’s lamp visualization can help ensure even coverage of treated areas during chemical peels. Although not as popular in recent years, this technique furthers the goal of even application and avoidance of skip areas. Glycolic acid compounded with fluorescein sodium is commercially available in various concentrations and can be invaluable to both dermatologic surgeons experienced in peeling and to those just adding chemical peels to their armamentarium. (Fluoro/Gly Pads and Gel, Topix Pharmaceuticals, North Amityville, N.Y.) It requires more time and a windowless or tightly shuttered room in order to be of value, but the even coverage can help produce a superior peel in the hands of all dermatologic surgeons.

Jessner’s solution, consisting of lactic acid, salicylic acid and resorcinol, is a mild peeling agent in its own right. However, it can serve as cleanser, degreaser and peel in one step. In this capacity, it is combined with TCA in a combination peel.

Glycolic acid in 70% strength was shown to promote even penetration of acid and facilitate uniformity of depth. This was also accomplished without the use of a degreaser. Eliminating a step in the process allows for a simpler and more reproducible peel. Jessner’s solution and solid CO2 have also been utilized in this manner, and have both proved to be effective preparatory agents in combination with TCA 35% in both the aqueous and clay-chelated forms.

Conclusion

The palette approach to chemical peeling begins with a solid foundation. The first stratum is the pretreatment regimen. Epidermal effacement, reduction of potential hyperpigmentation, and enhanced healing are the goals. A more intangible asset of the pretreatment period is the ability to prepare the patient mentally for the procedure. Regular daily application of pretreatment medications enforces the habits necessary for safer and more effective healing postprocedure. Although a poorly executed regimen is not a contraindication to performing the peel, the dermatologic surgeon can better gauge the patient’s commitment to treatment when assessing their adherence to the pretreatment regimen. The second stratum is the preparation period. The steps taken during this crucial time just before and during the peel itself are designed to ensure a more even application of agent, produce the desired depth of penetration, and reduce pain and discomfort. Combining a good foundation with excellent technique will help ensure an optimum result.

Further reading

Ayres SIII. Superficial chemosurgery in treating aging skin. Archives of Dermatology. 1962;85:578.

Brody HJ, Hailey CW. Medium-depth chemical peeling of the skin: a variation of superficial chemosurgery. Journal of Dermatologic Surgery and Oncology. 1986;12(12):1268-1275.

Chiarello SE, Resnik BI, Resnik SS. The TCA Masque: a new cream formulation used alone and in combination with Jessner’s solution. Dermatologic Surgery. 1996;8:687-690.

Chun EY, Lee JB, Lee KH. Focal trichloroacetic acid peel method for benign pigmented lesions in dark-skinned patients. Dermatologic Surgery. 2004;30(4):512-516. discussion 516

Coleman WPIII, Futrell JM. The glycolic acid trichloroacetic acid peel. Journal of Dermatologic Surgery and Oncology. 1994;20(1):76-80.

Garg VK, Sarkar R, Agarwal R. Comparative evaluation of beneficiary effects of priming agents (2% hydroquinone and 0.025% retinoic acid) in the treatment of melasma with glycolic acid peels. Dermatologic Surgery. 2008;34(8):1032-1040.

Hevia O, Nemeth AJ, Taylor JR. Tretinoin accelerates healing after trichloroacetic acid chemical peel. Archives of Dermatology. 1991;127(5):678-682.

Hung VC, Yu-yun Lee J, Zitelli JA, et al. Topical tretinoin and epithelial wound healing. Archives of Dermatology. 1989;125:65-69.

Koppel RA, Coleman KM, Coleman WPIII. The efficacy of EMLA versus ELA-Max for pain relief in medium-depth chemical peeling: a clinical and histopathologic evaluation. Dermatologic Surgery. 2000;26(1):61-64.

Lee JB, Chung WG, Kwahck H, et al. Focal treatment of acne scars with trichloroacetic acid: chemical reconstruction of skin scars method. Dermatologic Surgery. 2002;28(11):1017-1021. discussion 1021

MacKee GM, Karp FL. The treatment of post-acne scars with phenol. British Journal of Dermatology. 1952;64:456.

Mandy S. Tretinoin in the preoperative and postoperative management of dermabrasion. Journal of the American Academy of Dermatology. 1986;15(4):878-879. 888–889

Matarasso SL, Glogau RG, Markey AC. Wood’s lamp for superficial chemical peels. Journal of the American Academy of Dermatology. 1994;30(6):988-992.

Monheit GD. The Jessner’s + TCA Peel: a medium depth chemical peel. Journal of Dermatologic Surgery and Oncology. 1989;15:924-930.

Moy LS, Howe K, Moy RL. Glycolic acid modulation of collagen production in human skin fibroblast cultures in vitro. Dermatologic Surgery. 1996;22(5):439-441.

Nanda S, Grover C, Reddy BSN. Efficacy of hydroquinone (2%) versus tretinoin (0.025%) as adjunct topical agents for chemical peeling in patients of melasma. Dermatologic Surgery. 2004;30(3):385-389.

Peikert JM, Krywonis NA, Rest EB, et al. The efficacy of various degreasing agents used in trichloroacetic acid peels. Journal of Dermatology and Surgical Oncology. 1994;20(11):724-728.

Resnik SS, Lewis L. The cosmetic uses of trichloroacetic acid peeling in dermatology. Southern Medical Journal. 1973;66(2):225-227.

Rubin MG. The efficacy of a topical lidocaine/prilocaine anesthetic gel in 35% trichloroacetic acid peels. Dermatologic Surgery. 1995;21(3):223-225.

Van Scott EJ, Yu RJ. Alpha hydroxy acids: procedures for use in clinical practice. Cutis; cutaneous medicine for the practitioner. 1989;43(3):222-228.

West TB, Alster TS. Effect of pretreatment on the incidence of hyperpigmentation following cutaneous CO2 laser resurfacing. Dermatologic Surgery. 1999;25(1):15-17.

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