Chemical peels (incl JAAD CME Aug 2019) Flashcards
In chemical peels, the agent used is usually an acidic solution.
T
For patients with extensive AKs, superficial peels should be used.
F Medium-depth peels.
Pre-treatment with tretinoin or AHAs is contraindicated prior to chemical peels.
F
recommended for 4-6 wks prior
Superficial peels penetrate to the epidermis/papillary dermis.
T
Medium peels can penetrate to the mid-reticular dermis.
F
Upper reticular dermis.
Deep peels can penetrate to the deep-reticular dermis.
F
mid-reticular dermis.
UVA radiation penetrates deeper in the skin than UVB
T
Topical tretinoin pre-treatment prolongs wound healing after medium-depth and deep-depth chemical peels.
F
Accelerates wound healing.
AHAs exert their epidermal effect at the level of the stratum corneum and granulosum junction.
T
AHAs can reverse the histologic signs of photoageing.
T
Sunscreens should be used regularly for 3 months prior to a chemical peel and continued indefinitely after the peel.
T
Hydroquinone should not be used prior to chemical peels.
F
Prophylactic antivirals are not needed prior to chemical peels.
F
Start day prior to peel, continue 10-14days.
Risks of chemical peels include stinging, burning sensation, visible peeling, scaling, milia formation, pigmentary changes, persistent erythema, infections and rarely scarring.
T
Persistent erythema is a sign of impending scarring
T
The use of AHAs has been shown to reverse histologic signs of photoaging
T
Used regularly for 3/12 AHAs showed a 25% increase in epidermal and papillary thickness, increase in mucopolyaccharides, improved quality of elastic fibres and increased collagen density
F
6/12
Active viral, bacterial or fungal infection preclude chemical peeling until there is complete resolution.
T
It is safe to perform a chemical peel if isotretinoin has been taken anytime prior to the procedure.
F
Must wait 6-12 months (impaired wound healing, increased risk of scarring).
The AHAs have been used as an adjunct to tretinoin therapy without increasing adverse sequelae
T
Patients who’ve had prior facial XRT are at higher risk for scarring after chemical peels.
T
Due to diminished adnexal structures (from where re-epithelialisation originates).
There is no need to delay chemical peels after facial surgery.
F
Should wait 6 months or more.
Smokers have increased rates of infection after chemical peels.
T
Superficial chemical peels work by exfoliating all or part of the epidermis, which leads to mild stimulation of collagen formation in the superficial papillary dermis.
T
Melasma, ephelides and post-inflammatory hyperpigmentation are not indications for superficial peeling.
F
Acne vulgaris is an indication for superficial chemical peel
T
Photoaging and fine rhytides are an indication for superficial chemical peel.
T
There is usually a significant effect noted after one superficial chemical peel.
F
Usually need 3-6 peels, in conjunction with topical home regimen
Multiple superficial peels will produce the same result as one deeper chemical peel.
F
Tretinoin should not be used topically for 2-4 days prior to a superficial chemical peel
T
To ensure intact epidermis
A bleaching agent should not be used in patients with darker skin types or pigmentary disorders until after the chemical peel.
F
Best to start prior to peeling.
Without topical agents, the skin will return to before-peel condition within 2 years.
T
Superficial chemical peels can be used on all Fitzpatrick skin types.
T
Glogau’s classification is a measure of photoageing.
T
Sebaceous gland density does not effect the depth of a peel.
F
The area treated does not effect the depth of a peel
F
The technique of application is a significant determinant of the depth of a peel
T
The sable brush has been shown to deliver the greatest quantity of solution when used as a peel applicator.
T
The response to a chemical peel is not affected by pressure or rubbing during application
F
The condition of the skin and the skin preparation technique can influence the depth of peeling
T
Seborrhoeic dermatitis may cause a peeling solution to penetrate less deeply
F
More deeply
Thicker and more sebaceous skin is less susceptible to the peeling agent.
T
Non-facial areas can be treated with peeling agents of any depth
F
Should only use superficial peeling agents
When peeling with AHA agents, the concentration of the solution is increased and the length of time that the acid is left on is reduced
T
Hand-held fans can be utilised effectively to minimise discomfort during a chemical peel.
T
Trichoroacetic acid 10-50% is a commonly used superficial peeling agent.
F
10-25%.
If the frost from TCA is unexpectedly rapid or intense water neutralization may dilute the effect if applied within 1 minute
F
Within 30 seconds
A solution of TCA 25% consists of 25g in 100mL of normal saline
F
Distilled water
With lower concentrations of TCA, mild erythema or whitish speckling may be evident
T
Repeated applications of TCA may be made to areas that don’t frost.
T
If frosting is rapid or intense after TCA application, the effect can be diluted if water is applied within 2 minutes.
F
Within 30 seconds
If stinging occurs after TCA application, it tends to crescendo for 2 minutes, then subside.
T
White frosting produced by TCA resolves within 1-2 days.
F
1-2 hours
Light peels can be performed weekly for acne vulgaris at concentrations of 10-15% TCA with minimal downtime.
T
Applications of 25-35% TCA may take 14 days to heal within darkening of the face for 5-7 days and fine desquamation on days 3-6.
F
5-7 days to heal, darkening for 2-3 days.
Jessner’s solution consists of: resorcinol 14g, salicylic acid 14g, lactic acid 14g, and ethanol 95% per 100ml.
T
The salicylic acid in Jessners solution fluoresces under the woods light, which is another method that can be used to ensure even cover
T
Frosting usually occurs with Jessner’s solution application.
F
Just erythema and white speckling.
Jessner’s peels are usually followed by 2-3 days of light white desquamation.
T
AHAs are naturally occurring organic acids extracted from fruit, sugar cane, and other foods.
T
Glycolic acid is the most commonly used AHA in superficial peeling.
T
AHAs cannot be used on Fitzpatrick skin type IV-VI.
F
Glycolic acid 70% peels have been shown to be equivalent to Jessner’s solution for efficacy in active acne.
T
For AHA peels, low pH solutions (pH2) create more necrosis and improve efficacy
F
More necorsis without improving efficacy.
70% glycolic acid can be used unbuffered and unneutralised.
T
An abrasive skin cleansing regimen should be used prior to AHA peels in order to de-grease the skin.
F
Should avoid – can increase depth of penetration.
Glyocolic acid should be applied with cotton balls rather than gauze to avoid abrasive effects of rubbing.
T
It is unnecessary for the physician to stay in the room during an AHA peel
F
Need to observe for ‘hot spot’ erythema.
AHA can be neutralised with a 5% sodium bicarbonate solution with multiple rinses.
T
Indicators to neutralise the AHA solution include unusual degree of patient discomfort, mild erythema, or adequate time interval.
T
Time dependency is not a factor in glycolic acid peeling.
F
Unique factor must time and neutralise this peel
Salicylic acid can be used solo in 20-30% solutions for superficial peeling.
T
Salicylic acid peels can cause white precipitation within 2-3 days.
F
White precipitation occurs immediately.
Salicylic acid peels are self-limiting and there is no need for timing or neutralisation
T
There is a tendency for great discomfort immediately following salicylic acid chemical peels
F
There is very little discomfort due to the anaesthetic properties of SA
SA peels may benefit acne more than other peels.
T
Because it is also comedolytic.
SA peels cannot be used in Fitzpatrick V and VI skin types.
F
Can be. Start with 20%, use hydroquinone post Rx
SA peels often are prepared with ethanol as a vehicle, which causes redness, stinging and burning.
T
Newer polyethylene glycol base less irritant.
Solid carbon dioxide can be used as a superficial peel.
T
Tretinoin cannot be used as a superficial peel.
F
Can use 1-5% concentration.
Resurfacing techniques are ineffective for the treatment of AKs.
F
A thin coat of petrolatum or antibiotic ointment should be applied after most peels.
T
Topical steroid ointment should not be applied after a chemical peel.
F
Use if reaction brisk, or type IV/greater skin.
Patients should cleanse their face twice daily after a chemical peel and resume their normal skin-care regimen as soon as the skin returns to normal.
T
A combination of Q-switched alexandrite laser with concomitant superficial TCA peeling can be used for recalcitrant pigmentary disorders.
T
Apply peel before laser.
Medium-depth peeling is defined as the application of a wounding agent to the skin, producing a wound at or through the level of the papillary dermis.
T
The injury of medium-depth peeling is associated with coagulation necrosis of the epidermis only.
F
Also papillary dermis + inflammation to the reticular dermis.
Medium-depth peels are indicated for AKs, superficial seborrhoeic keratoses, lentigines and other pigmentary dyschromia.
T
TCA with concentrations above 50% is used to achieve a medium-depth peel to the skin.
F
35-50% (although 45-50% can have unpredictable effect so rarely used now)
35% TCA can be combined with solid CO2, Jessner’s solution or 70% glycolic acid to achieve a medium-depth chemical peel.
T
88% phenol and pyruvic acid are medium-depth peeling agents.
T
Benefits of medium-depth peeling can be seen in patients with severe actinic damage and sallow discolouration of the skin with significant wrinkling.
F
Moderate actinic damage, without significant wrinkling.
Bichloroacetic acid can be used carefully as a spot treatment for conditions such as trichodiscomas, sebaceous hyperplasia, syringomas and trichoepitheliomas.
T
The uniformity of the application of a Jessner’s solution peel can be identified with a Wood’s lamp
T
SA in Jessner’s fluoresces.
It is unnecessary to extend a chemical peel into the hairline or below the jawline.
F
Feather into these areas to reduce noticeable lines of demarcation.
Coarser, more sundamaged skin reacts faster to TCA peels, thus requiring less heavily applied acid.
F
Reacts more slowly, requires more heavily applied acid.
TCA will penetrate deeper with a more heavily saturated applicator (eg cotton tip).
T
Two small dry cotton-tipped applicators should be held at the medial and lateral canthus of the eye to catch any tears that may develop during a chemical peel, preventing ‘wicking’ of the acid into the eye.
T
Once TCA has been applied, there is no period in which it can be diluted prior to keratocoagulation and the frosted appearance.
F
About 30 seconds
After a medium-depth peel, the skin should be kept greasy with appropriate ointments until desquamation is complete, generally within 5-7 days.
T
By 8 hours after a medium-depth peel, the skin has a light brown appearance.
F
24 hours.
Areas of pigmentary dyschromia and freckling appear darker after a medium-depth chemical peel.
T
After a medium-depth chemical peel, desquamation begins around the hairline.
F
Around mouth and central face. Hairline is last area to peel.
Peeling usually starts on day 3 after a medium-depth chemical peel and is complete within 1 week.
T
After a chemical peel, pts should facilitate the peeling process by gentle scrubbing the skin.
F
no scrubbing or picking allowed
Patients can wear make-up within 2 weeks post medium-depth chemical peel.
F
7-10 days.
Erythema usually fades within 1-2 weeks post medium-depth chemical peel.
F
2-4 weeks.
AHAs may be restarted on week 3 after a medium-depth chemical peel, and tretinoin 4-6 weeks after the peel.
T
Following an AHA peel a 10% sodium bicarbonate solution with multiple rinses is used to neutralize the AHA agent
F
5% in Robinson bt can actually use 5-16%
The use of botox 7-10 days before a medium-depth peel is prohibited.
F Enhances the results.
Laser resurfacing to the deeper perioral rhytides complements medium-depth peeling and should always be performed after the peeling, at the end of the procedure
T
The ideal patient for a deep chemical peel is a thin-skinned woman with fair complexion and generalised wrinkling.
T
If a deep phenol peel is being considered for the entire face, the patient must have normal hepatorenal and cardiovascular status.
T Due to cardiotoxicity of phenol.
Deep chemical peels are best suited for facial wrinkles (periocular and periorbital regions), pigmentary dyschromia, AKs and superficial acne scars.
T
It is not necessary to remove deep facial oils prior to a phenol peel.
F
A full-face phenol peel should extend over a 30 minute period to avoid cardiac arrhythmias.
F 60-90 minutes.
No more than 50% of the face should be treated during a 15 minute time period.
F 30 minute
Cardiac monitoring is not needed during and after a full-face phenol peel.
F
Upper eyelid peeling should not be carried down below the superior tarsal fold.
T
Lower eyelid peeling should be done with the patient gazing upward.
T
It is not necessary to stretch the skin during perioral peeling.
F
Allows peel solution to be applied evenly.
If deep wrinkles are treated, an open technique is generally better.
F
Closed technique of taping – remove at 24hrs.
Sun avoidance is recommended for up to 12 weeks after a deep chemical peel to prevent PIH
F
Up to 6 months.
Skin appears erythematous for up to 12 weeks after a deep chemical peel.
T
Non-facial skin has decreased adnexal structures, which impairs wound healing.
T
The ‘Cook total body peel’ consists of applying 70% glycolic acid gel combined with 35% or 40% salicylic acid
F
35% or 40% TCA.
NB this peel not in 3rd edition
Using the ‘Cook total body peel’ technique, there is no need for neutralisation.
F
Neutralise at desired depth with copious 10% sodium bicarbonate solution.
NB this peel not in 3rd edition
For the ‘Cook total body peel’, liquid glycolic acid could result in increased scarring.
T
Need to use gel – acts as partial barrier to TCA.
NB this peel not in 3rd edition
After the ‘Cook total body peel’, the skin flakes for 2-4 weeks.
T
NB this peel not in 3rd edition
The ‘Cook total body peel’ cannot be used for AKs or DSAP.
F
NB this peel not in 3rd edition
For mid to deep peels, antiviral prophylaxis should be used in all immunosuppressed patients or those with a history of HSV.
T
The risks of complications from peels increase proportionately with the depth of the wound.
T
Lighter peels are more likely to be associated with hypopigmentation and deeper peels with hyperpigmentation.
F
Lighter with hyperpigmentation.
Deeper with hypopigmentation.
The risk of hyperpigmentation is increased by exogenous oestrogens, photosensitising medications and direct sun exposure during the first 6 weeks after a peel.
T
Hypopigmentation is an unexpected complication of phenol peels and deeper resurfacing procedures.
F
Normal sequela.
Accentuation of naevi can occur after peels.
T
Milia usually occur within the first 1-3 weeks after peels.
F
1-3 months.
Persistent erythema is closely associated with deeper peels, but may be seen after medium-depth peels and rarely after superficial peels.
T
Infection is common after chemical peels.
F
Rare. Both TCA and phenol are bactericidal.
Toxic shock syndrome has been reported in association with phenol-based peels.
T
Previous medium or deep peels, dermabrasion, or laser resurfacing without waiting 6-12 months can increase the risk of scarring after a chemical peel.
T
IV hydration during phenol peeling assists in clearing the phenol from the circulation and decreases the likelihood of toxicity.
T
50% TCA is a medium depth peeling agent
T
Solid Co2 +35% TCA is a superficial depth peeling agent
F
medium
Jessner’s solution + 35% TCA is a deep chemical peel
F
medium
70% glycolic acid +35% TCA is a medium depth peel
T
88% phenol is a deep chemical peel
F
medium
Pyruvic acid is a superficial chemical peel
F
medium
Hypopigmentation is a potential complication of deep peels only
T
Lighter peels are more commonly associated with hyperpigmentation
T
Depth of injury superficial vs med depth peel?
JAAD CME Aug 2019
Superficial: EpidermisMedium: Into/Through Papillary Dermis
List Common Superficial Peels
JAAD CME Aug 2019
Alpha hydroxy Acids (water soluble) - Glycolic Acid Beta hydroxy acids (lipid soluble) - Salicylic Acid Jessner Solution (14% Resorcinol, 14%SA, 14%LA in 95% EtOH) Retinoic Acid (all-trans retinoic/tretinoin) TCA (10-35%) Alpha-keto Acid - Pyruvic Acid
Which superficial peels require neutralisation (and with what)?
JAAD CME Aug 2019
Glycolic and Pyruvic Acid
Neutralise with water (ie to wash off), or with sodium bicarbonate
List common medium depth peels
JAAD CME Aug 2019
70% Glycolic + 35% TCA (Coleman)
Jessners + 35% TCA (Monheit)
Solid CO2 + 35% TCA (Brody)
88% Phenol
What is the specific systemic concern re phenol peels?
JAAD CME Aug 2019
Risk of cardiotoxicity.
<p>What is the depth of penetration of 50-100% TCA?
JAAD CME Aug 2019</p>
<p>Upper reticular dermis.Increased risk of complication (use for focal areas only)</p>
<p>T/F tretinoin peel solutions have no measurable pH
JAAD CME Aug 2019</p>
<p>T (non-acidic)</p>
Typical concentration for tretinoin peel?
5-10% eg leave on 6 hours
<p>T/F tretinoin peels are typically uncomfortable
JAAD CME Aug 2019</p>
<p>F (minimal discomfort during application)</p>
<p>Expected reaction of tretinoin peel?
JAAD CME Aug 2019</p>
<p>Mild erythema and desquamation approx day 2 postpeel</p>
Main indication tretinoin peel?
JAAD CME Aug 2019
Acne, though little supportive clinical trial data.(Article notes a study where 0.05% tretinoin cream daily for forearm rejuv was similar to a q2/52 5% peel)
T/F Salicylic Acid is an alpha hydroxy acid
JAAD CME Aug 2019
F beta (lipid soluble)
T/F Salicylic Acid peels are great for comedonal acne
JAAD CME Aug 2019
T (lipophilic and comedolytic)
T/F Salicylic Acid is ok to use in all Fitz skin types
T
What can Salicylic Acid be mixed with (typically 20-30%) to produce a pseudofrost on application?
Ethanol (hydroalcoholic vehicle)Pseudofrost crystals can be washed off -> cannot penetrate the skin -> self limiting peel
<p>What is a complication of Salicylic Acid/Ethanol peels?
JAAD CME Aug 2019</p>
<p>Hot spots/areas of overpenetration —> can lead to PIH.</p>
<p>What can Salicylic Acid be mixed with (instead of ethanol) to avoid hot spotting/overpenetration?
JAAD CME Aug 2019</p>
<p>Polyethylene Glycol (PEG) —> slows delivery and enhances follicular penetration. A study showed 30% SA/PEG to be superior to SA/HA(ethanol). SA/PEG does not give the day 2 desquamation.</p>
How is the SA/PEG solution applied?
JAAD CME Aug 2019
Left on skin >= 5mins and then washed off (primarily as the PEG is occlusive)
Any other rarer side effects/precautions for SA?
JAAD CME Aug 2019
SA can cause angioedema/urticaria in patients known to be sensitive to acetylsalicylic acid.
T/F TCA Crystallises >70% concentration
JAAD CME Aug 2019
F No crystallisation < 90%
Name the three levels of frosting assoc with TCA peels?
JAAD CME Aug 2019
- light reticular frost with background erythema
- confluent light white frost with background erythema
- solid white frost with no erythema
Name four indications for high concentration (>80%) TCA peels.
JAAD CME Aug 2019
Mild-Mod Rhinophyma (comparable to electrocoagulation)
CROSS (Chem Recon of Skin Scars - focal icepick/boxcar)
Earlobe Tears (90% TCA - Skin necrosis and secondary intention approximation
Xanthelasma (Macular lesions ~50%, papular lesions 70-100%)
At what concentration does TCA start to peel into the papillary dermis?
JAAD CME Aug 2019
~35% (Lower Concentrations Epidermal)
What is the formula for Jessners Solution?
JAAD CME Aug 2019
14% Resorcinol, 14% SA, 14% Lactic Acid in 95% Ethanol
What is resorcinol and are there any specific precautions to consider?
JAAD CME Aug 2019
Resorcinol is similar to Hydroquinone (meta- and para-dihydroxybenzene).
Risk of contact allergy and possible cross-sensitivity with hydroquinone.
T/F, JS + 20% TCA is more effective at Rx of melasma in darker skin types than 20% TCA alone?
JAAD CME Aug 2019
T, though with greater immediate discomfort. no difference in PIH.
What is the signal to neutralise glycolic or pyruvic acid?
JAAD CME Aug 2019
Clinical endpoint of erythema (or 5min if no erythema produced)
What can be used to neutralise glycolic or pyruvic acid?
JAAD CME Aug 2019
10% Sodium Bicarbonate, water, or wiping with a saline-dampened cloth
What is the risk of seeing frosting with a glycolic or pyruvic acid peel?
JAAD CME Aug 2019
PIH and scarring
What is the purpose of the CO2/Glycolic Acid/JS in the Brody/Coleman/Monheit medium depth peels?
JAAD CME Aug 2019
Induce epidermolysis to reduce the risk of uneven penetration, erosions and scarring.
What are the stages of histologic change for med depth peels?
JAAD CME Aug 2019
Day 3 - full thickness epidermal necrosis, dermal inflammation/oedema
Day 7 - epidermal reepithelialisation
Day 30 - regeneration of homogenised collagen
Day 90 - thickened collagen bundles in the dermis -> Grenz zone (thickness proportional to strength of peel)
Increased Type I Collagen
superficial peels have a significant risk of causing PIH in skin types III-VI
F
Sup peels had relatively low complication rate in this skin type group
JAAD Sep 18
Side effects from superficial peels are less frequent during winter months
T
JAAD Sep 18
The use of chemical peeling arose from ancient Egyptian traditions using AHAs in animal oils, salt + sour milk
T
JAAD Sep 18
Mandelic acid is the least ‘safe’ of the AHAs in terms of risk of AEs
F
Mandelic acid thought to be safest due to large molecular structure w uniform penetration
JAAD Sep 18
SA is lipophilic + has comedolytic effects
T
JAAD Sep 18
Glycolic acid 70% has been described as a treatment option for Becker’s naevus
T
70% applied for increasing time increments (15, 50, 60, 70 mins) with tx every 17-30 days
JAAD Jan 19
TCA 35% can be used in patients with active pemphigus vulgaris buccal mucosal lesions
F
Reported as option for stable, tx resistant buccal mucosal lesions though (!) - applied every month depending on response
chemical peel can be used as an alternative to filler injection for lip augmentation, though effects last < 6 months
F
Can be used (phenol 35% + croton oil 0.4-1.6%) as a peel with longlasting effects > 2 years
JAAD May 19
