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.

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