31 - 213 - CHEMICAL PEELS AND DERMABRASION Flashcards
generally regarded as the desired clinical end point of chemical peeling with trichloroacetic acid
Keratocoagulation, evidenced by a white frosting of the skin
IDENTIFY THE DEPTH OF PEEL (Superficial, Medium or Deep Peel)
Glycolic acid
Superficial
IDENTIFY THE DEPTH OF PEEL (Superficial, Medium or Deep Peel)
Jessner solution
Superficial
IDENTIFY THE DEPTH OF PEEL (Superficial, Medium or Deep Peel)
Baker Phenol Peel
Deep
IDENTIFY THE DEPTH OF PEEL (Superficial, Medium or Deep Peel)
CO2 laser
Deep
IDENTIFY THE DEPTH OF PEEL (Superficial, Medium or Deep Peel)
Manual dermasanding
Medium
IDENTIFY THE DEPTH OF PEEL (Superficial, Medium or Deep Peel)
Erbium Laser
Medium
IDENTIFY THE DEPTH OF PEEL (Superficial, Medium or Deep Peel)
Jessner + 35% TCA
Medium
IDENTIFY THE DEPTH OF PEEL (Superficial, Medium or Deep Peel)
Mechanical Dermabrasion
Deep
IDENTIFY THE DEPTH OF PEEL (Superficial, Medium or Deep Peel)
Salicylic acid
Superficial
IDENTIFY THE DEPTH OF PEEL (Superficial, Medium or Deep Peel)
Microdermabrasion
Superficial
classifies patients into categories I through IV based on whether the patient has mild, moderate, advanced, or severe photodamage, is a useful categorization tool for this purpose
Glogau system
In general, both category I and category II photodamage will improve with what type of peel
Superficial peel
Glogau Category III will respond to what type of peel
Medium depth peel
Glogau catergory IV will respond to what ype of peel
Deep peel
Pretreatment prophylaxis for patients with history of recurrent herpes simplex infection
Common pretreatment regimens include acyclovir 400 mg thrice daily and valacyclovir 500 mg twice daily starting on the day of the peel and continued until reepithelialization has occurred
wound the skin in a controlled and predictable manner so as to promote the growth of new skin with improved texture and quality
Resurfacing procedures, including chemical, mechanical, and laser resurfacing
deep peels are commonly avoided in patients with what skin types?
**SPT IV to SPT VI **skin because of the higher risks of postprocedural pigmentary change and scarring
Identify the skin phototype
Always burn, never tan
SPT I
Identify the skin phototype
Never burn, always tan
SPT IV
Identify the skin phototype
Always burn, sometimes tan
SPT II
Identify the skin phototype
Sometimes burn, always tan
SPT III
Identify the skin phototype
Darkly pigmented skin
SPT VI
Identify the skin phototype
Moderate pigmented skin
SPT V
physician should inquire about a history of what disorders prior to chemical resurfacing?
**atopy, rosacea, isotretinoin therapy, poor wound healing, connective tissue disease, and hypertrophic or keloid scar formation **as chemical resurfacing may be contraindicated in these patients
Additionally, a history of recurrent infections, including bacterial, fungal, and viral, should be elicited in the preoperative consultation.
Expected intraoperative side effects of chemical peeling
stinging, burning, and/or itching
In the immediate postoperative period, erythema, edema, and desquamation may be experienced
Pretreatment should begin how many weeks before the procedure?
2 to 4 weeks before the procedure and be discontinued approximately 2 to 3 days prior to the peel date
- topical pretreatment with retinoic, glycolic, or lactic acid alone, or in combination, will increase the absorption of the wounding agent and promote a more even penetration of the peel
- Topical medications such as 2% to 5% hydroquinone may be applied to the skin preoperatively and postoperatively to minimize the risk of postinflammatory hyperpigmentation.
Application of hydroquinone, in addition to a ultraviolet A/ ultraviolet B protective sunscreen (sun protection factor 30 or higher), should be initiated how many weeks before the peel?
2 to 4 weeks prior to the date of the peel and resumed once reepithelialization has occurred postoperatively
what are the relative contraindications to Medium and Deep Peels?
what are the absolute contraindications to Medium and Deep Peels?
Preparation (Weeks to Days Before Peel)
■ Topical pretreatment with a retinoid, glycolic or lactic acid solution (begin 2 to 4 weeks prior, discontinue 2 to 3 days before peel date)
■ Consider topical 2% to 5% hydroquinone preoperatively and postoperatively, if postinflammatory hyperpigmentation is a concern (2 to 4 weeks prior)
■ Sun avoidance, especially in individuals at risk for dyschromias
■ Consider pretreatment with acyclovir 400 mg thrice daily or valacyclovir 500 mg twice daily on the day of peel and until reepithelialization
Preprocedural Care (Immediately Prior to Peel)
■ Cleanse skin with gentle facial cleanser
■ Position patient with head up at a 30-degree angle
■ Consider sedative/pain medications or local nerve blocks for medium to deep peels
■ Degrease skin with acetone, hexachlorophene, rubbing alcohol, or chlorhexidine
■ Rinse and dry skin prior to application of chemexfoliant
Degreasing the skin prior to peel can be done by using what solutions?
acetone, hexachlorophene, rubbing alcohol, or chlorhexidine
This cleansing regimen will remove all oil and debris and promote even penetration of the wounding agent while minimizing the risk of a spotty or ineffective peel.
Postprocedural Care
■ Cleanse skin up to 4 times/day
■ Dilute 0.25% acetic acid (1 tbsp vinegar in 1 pint water) as cleansing agent
■ Pat dry, apply bland emollient
■ Daily sunscreen use
■ Avoidance of excessive sun exposure
Brody Peel
solid carbon dioxide (CO2) + 35% TCA
- In 1986, Brody and Hailey applied solid carbon dioxide (CO2 ) in combination with acetone prior to application of 35% TCA to disrupt the epidermal barrier and achieve a more even peel at a greater histologic depth
Monheit Peel
Jessner solution + 35% TCA
Acting as an absorbing agent, Jessner solution removes the stratum corneum allowing for deeper penetration of TCA.
Coleman Peel
70% glycolic acid + 35% TCA
The peeling agent is then applied. This is commonly done with what materials?
cotton-tipped applicators or 4-inch × 4-inch/2-inch × 2-inch gauze
representative of underlying keratocoagulation, or denaturation of epidermal keratin proteins.
Frosting
Identify the level of frosting
erythema with blotchy or spotty frosting
Level I
This is often seen with light chemical peel
Identify the level of frosting
achieved when a white coating is evident with a slight erythematous background showing through
Level II frosting
commonly seen in medium-depth chemical peels
Identify the level of frosting
solid white enamel-like frosting is demonstrated on the skin
Level III
This is seen in deeper chemical peels and is indicative of peel penetration into the papillary dermis
This is the only peel the requires neutralization.
glycolic acid
depth of superficial peels
entire epidermis
depth of medium depth peels
Medium-depth peels penetrate through the papillary dermis to the upper reticular dermis
depth of deep peels
Deep peeling agents wound a greater portion of the **reticular dermis **resulting in production of new collagen and ground substances
examples of superficial peels
10% to 20% TCA (20% to 35% TCA achieves a complete epidermal peel), Jessner solution (14% salicylic acid, 14% lactic acid, and 14% resorcinol in ethanol), resorcinol, salicylic acid, and α-hydroxy acids such as glycolic acid
naturally occurring β-hydroxy acid derived from the bark of the willow tree
Salicylic acid
t is regarded as a safe peel in all skin types for the treatment of acne, melasma, and postinflammatory hyperpigmentation.
Salicylic acid
- salicylic acid exhibits a lipophilic nature that allows for effective dissolution of the stratum corneum as well as comedolysis
- proves beneficial in the treatment of comedonal and papular/pustular acne.
preferential peeling agent for dyschromia as it is the least inflammatory of peeling agents
Salicylic acid
the action of this peel is time dependent and must be neutralized with normal saline, water, or sodium bicarbonate
glycolic acid
It has the least risk of producing postinflammatory hyperpigmentation
Salicylic acid
Medium-depth chemical peels indications
mild to moderate photoaging, pigmentary disorders, lentigines, epidermal growths, rhytides, and actinic keratoses
examples of medium depth peels
- 45% to 60% TCA
- Jessner solution with 35% TCA (Monheit peel),
- 70% glycolic acid with 35% TCA (Coleman peel)
- solid CO 2with 35% TCA (Brody peel)
- Liquified phenol USP (U.S. Pharmacopoeia) 88%
- Combination peels are the preferred medium-depth peels because of their lower risk of postprocedural dyschromias and scarring
crystalline inorganic compound that results in keratocoagulation, or protein denaturation, and resultant cell death, as indicated by a white frosting on the skin
TCA
characterize the healing process of TCA
- As the skin heals, erythema intensifies as desquamation comes to an end within **3 to 4 days. **
- New skin is evident within 6 to 7 days, and healing is complete within **7 to 10 days. **
- At this point, the erythema is reminiscent of a sunburn and is expected to resolve within** 3 to 4 weeks**
examples of deep peel
- Baker phenol
- phenol is diluted to a concentration of 45% to 55% with croton oil, hexachlorophene, and water, and is referred to as the Baker-Gordon phenol peel.
most permanent skin rejuvenation of all resurfacing procedures
Baker-Gordon deep chemical peeling
% of TCA used for TCA cross
(70% to 100%) of TCA
Medium-depth and deep peeling agents result in significant inflammation and wounding within the deep reticular dermis and heal with 4 characteristic stages
What are these stages?
1/2. Inflammation and coagulation - occur** within hours of application** of the peeling agent.
3. Reepithelialization - begins on day 3 and continues through days 10 to 14
4. Fibroplasia - the last stage of the healing process and persists for 3 to 4 months; This stage includes neoangiogenesis and collagen proliferation
possible Postoperative complications of chemical peels
(bacterial, viral, fungal), prolonged erythema, pruritus, pigmentary alterations, contact dermatitis, milia/ acne, exacerbation of an underlying skin disease, and scarring
signs that skin is not healing normally and are indicative of scarring potential
Delayed wound healing and persistent erythema
- Delayed healing is evident with the appearance of friable, stellate erosions on the skin at the time reepithelialization is expected
define persistent erythema depending on the depth of peel
- > 3 to 5 days - superficial peel,
- 15 to 30 days - medium-depth peel
- 60 to 90 days - deep chemical peel
- Persistent erythema is defined as erythema lasting longer than 3 to 5 days for a superficial peel, 15 to 30 days for a medium-depth peel, and 60 to 90 days for a deep chemical peel
- Etiologies include underlying skin disorders such as rosacea and atopy, contact dermatitis or sensitivity to the peeling agent, and aggressive peeling techniques.
- Persistent erythema should be treated promptly with topical and/ or systemic corticosteroids
Hypopigmentation, on the other hand, can be a complication associated with what peel?
phenol peels.
uses sterile sandpaper of varying grades to ablate the epidermis and portions of the dermis
Manual dermabrasion
- Two hundred or 400 grit-grade sandpaper wrapped around gauze or a cotton-tipped applicator is used to abrade the skin until punctate bleeding is evident.
mechanical resurfacing technique in which handheld devices using burrs of varying degrees of coarseness are used to remove layers of the epidermis and/or dermis.
Motorized dermabrasion
- Motorized dermabrasion is indicated for moderate to severe photodamage, including textural changes, rhinophyma, and scar revision.
Punctate bleeding is indicative of wounding to what level on the skin?
papillary dermis
more confluent bleeding is seen with wounding to what level of the skin?
reticular dermis
To minimize the risk of adverse events including scarring, treatment should never extend below what layer?
mid-reticular dermis
identify the depth reached after dermabrasion
- Small red dots-fraise
- Corn rows of bleeding-brush
Papillary dermis/capillary loops
identify the depth reached after dermabrasion
- Yellow globules-sebaceous glands
- Frayed collagen bundles
Mid-deep reticular dermis
identify the depth reached after dermabrasion
- Large red dots-fraise
- White parallel lines in collagen-brush
Upper reticular dermis
