Medium-Depth Peels and Trichloroacetic Acid Blue Peel Flashcards
1
Q
when does “intrinsic aging” starts?
A
- Starting around the age of 18 years
- there is a natural decline in fibroblast function resulting in decreased collagen and
elastin production - referred to as “intrinsic aging”
- This reduction is on the order of ~1% per year starting at the age of 18 years
2
Q
external factors that are known to accelerate aging process?
A
- ultraviolet radiation (UVR)
- high-energy visible light
- infrared light
- known as “extrinsic aging”
3
Q
changes at epidermal level from “intrinsic” vs “extrinsic” aging
A
- normal cycling of the keratinocytes slows with age
- with extrinsic aging, epidermis begins to show roughness, dyschromia, keratinocyte atypia
4
Q
important steps to be taken before peel
A
- evaluate the patient for skin flaws & scars
- document skin imperfections at the time
of consultation - take high-quality before-and-after photographs for each procedure
5
Q
advantage of taking high-quality before-and-after photographs
A
- allows the patient to gauge whether this treatment is giving the amount of improvement they seek
- helps the physician to identify patients with unrealistic expectations
6
Q
how should photos be taken?
A
- Patients should be examined with no makeup on in a well-lit room
- Acne scar patients should be examined with indirect overhead light to allow shadows to be cast on the skin to better delineate scar morphology
- skin conditions that can Koebnerize to areas that are resurfaced should be identified as well (flat warts, vitiligo, psoriasis)
7
Q
Patients being treated for melasma should be questioned about…?
A
- use of hormone intrauterine devices
(IUDs), hormone cervical rings, or OCPs - use of hormone contraceptives will continue to stimulate the melasma and may lead to treatment failure or worsening of the condition
8
Q
Clinical Indications for Skin Resurfacing
A
9
Q
Patient Social & Medical History
- questions to be asked ?
- relative contraindications ?
- absolute contraindications ?
A
10
Q
Anatomical Areas Safe for
Light & Medium-Depth Peels
A
11
Q
- who are at greater risk for PIH & permanent hypopigmentation ?
- what can be done to reduce the risk ?
A
- Patients with darker complexions
- risk of PIH in a darker-skinned patient can be reduced by extending the length of skin preconditioning to 3 months rather than the usual 6 weeks
12
Q
Chemical Peel Formulas
- name some keratolytic formulas
- name some protein denaturants
A
13
Q
Keratolytic agents
A
- keratolytic agents disrupt the adhesion of the keratinocyte cells to one another
- can be used to break up the stratum corneum & various levels into the epidermis to allow for a light chemical exfoliation to occur
- can help enhance the depth of penetration of TCA peels when used in combination
14
Q
two main acids used for combination peels
A
- glycolic acid
- Jessner’s solution
- Jessner’s solution is composed of 14%
each of resorcinol, salicylic acid, and lactic acid mixed in ethanol
15
Q
Advantages of Jessner vs glycolic ?
A
- Jessner has salicylic acid, that is lipophilic
- Therefore Jessner’s solution can penetrate acne lesions or oily skin better than a hydrophilic agent such as glycolic acid
- physician does not have to monitor the skin contact time closely as one would with a glycolic acid solution
16
Q
name the 2 protein denaturant peeling agents
A
- Phenol
- TCA
17
Q
TCA & phenol work by causing…?
A
- protein coagulation & denaturation as they penetrate skin
- TCA & phenol coagulate proteins that make up the cells of the epidermis and dermis as well as the blood vessels
- Once a certain amount of the acids have been applied, they will continue to coagulate proteins until they are used up
- They cannot be neutralized once they begin to be absorbed into the skin
18
Q
- how long should we wait to evaluate the depth of TCA or phenol penetration ?
A
- After about 2 minutes, the depth of TCA penetration can be observed and a decision can be made if more acid is needed to drive the peel deeper
- Phenol is a lot more rapid in its penetration, and the depth is apparent almost immediately
- Subsequent application of acid will continue to drive the peel deeper until it is used up by coagulating proteins deeper in the skin
19
Q
safest & most agreed-upon method of TCA concentration ?
A
weight-to-volume (W:V) calculation
20
Q
it is correct to refer to TCA peels as light, medium, or deep solely based on TCA concentration
T/F ?
A
False
- Acid concentration is only one variable affecting peel depth
- For example, 1 mL of 40% TCA applied to the face will result in penetration to the basal layer, whereas 6 mL of 40% TCA applied over the same body surface area will result in penetration to the mid-dermis or deeper
21
Q
Features of TCA 10% to 50%
A
- can be used as a sole peeling agent
- It is hydrophilic by nature
- thus it may have patchy absorption through the lipid-containing & thickened
stratum corneum - higher doses of TCA are harder to work with
- It is tough to reapply TCA at high concentrations in areas that need it without risking too deep of a peel. To facilitate even TCA penetration, the skin should be prepared in advance with a skincare regimen geared at making the stratum corneum more even & compact
- Oily skin needs to have adequate oil control before performing the peel. This can be achieved with a short course of isotretinoin for a few months, ending about 3 to 6 months before the peel
22
Q
what can be done to reduce risks ass/w high-concentration TCA peels ?
A
- use of combination peels
- These peels help to facilitate the penetration of TCA solution, allowing for a lower concentration of TCA to be used while still allowing a medium-depth peel to be achieved
23
Q
3 MCy used modified TCA peels
A
- Jessner’s solution–TCA peel
- glycolic acid–TCA peel
- Blue Peel
24
Q
modified TCA peels
* penetration depth ?
* main indications ?
A
- these peels are designed to peel to a depth of the papillary dermis
and at most to the most superficial aspect of the reticular dermis - main indications for TCA & modified TCA peels are for epidermal & upper dermal pathology: photodamage, actinic keratoses, lentigines,
ephelides, fine rhytides, very superficial, nonfibrotic (stretchable) scars - These peels are not suited for fibrotic scars, deep nonstretchable rhytides, or extensive laxity
25
how can you clinically evaluate if a rhytid or scar can be improved with a medium-depth peel?
* **If a rhytid or scar improves with stretching the skin, a medium-depth peel can help improve it**
* However, **if the scar or rhytid is etched into the skin or is fibrotic, the tightening effect of the peel may not be enough** to give adequate clinical improvement
26
It is easiest to think of the combination TCA peels as being...?
* **accelerated or decelerated**
27
name **2 accelerated combination TCA peels**
* **Jessner + TCA**
* **glycolic + TCA**
28
**decelerated combination TCA peel**
**Blue Peel**
29
Jessner’s–TCA peel features
* **uses Jessner’s solution (keratolytic), applied before the application of TCA**
* Application of Jessner’s solution allows for faster & deeper penetration of the subsequently applied 35% TCA
30
**glycolic acid–TCA peel features**
* **uses 70% glycolic acid (keratolytic) before application of 35% TCA**
31
decelerated peel , Obagi blue peel
* allows the entire peeling process to be slowed down so that one has greater control over the depth of penetration of the peel
* The Blue Peel incorporates a nonionic blue dye, glycerin, and a saponin with a specific volume of 30% TCA to yield a 15%, 20%, 22.5%, or 24% TCA–Blue Peel solution
* The blue coloring, which stains the stratum
corneum, allows the physician to see where the solution has been applied while still allowing the signs of depth penetration, such as frosting & erythema, to be visualized
32
Phenol exerts its actions by...?
* **protein denaturation & coagulation**
33
**Phenol peels features**
* metabolized , excreted by ?
* any toxicities ?
* The **rapid speed** by which phenol **penetrates** the skin requires **careful application & constant vigilance by the physician**
* when treating a large area such as the face, serum phenol levels can quickly become elevated, resulting in **systemic toxicity & cardiac arrhythmias**
* **Once absorbed, phenol is partially detoxified in the liver and excreted by the kidneys**
* Therefore **all patients must be cleared from a cardiac,renal, and hepatic standpoint preoperatively**
* Intraoperative cardiac monitoring & high-volume IV fluid hydration are imperative to avoid cardiac issues
34
**2 instances where we can use phenol without cardiac monitoring or IV hydration**
* using **lower-concentration formulas** such as **Hetter VL**
* **limiting phenol peel to one cosmetic unit (perioral or periorbital)**
35
systemic absorption of phenol is related to...?
* **body surface area treated** more so than the concentration used
36
what can be done to minimize phenol toxocity in peels?
* phenol peels are **usually performed in small anatomical sections of the face with a
15-minute break before the application of the acid to the next anatomical unit**
* This allows the body to metabolize phenol that is absorbed before the reapplication of the solution
* **face is usually treated in sections** such as the forehead, right cheek, left cheek, nose, perioral, periorbital region
37
Peel tips
38
**TCA peels features**
* goal is to reach ?
* what does the patient feel once applied ?
* usually used to peel to a medium-depth peel
* **goal is to reach papillary dermis with the peel solution**
* Once applied to the skin, the TCA solution generates a **stinging & burning sensation that builds up & peaks then subsides**
* Until the desired depth of penetration is
achieved, more coats of TCA solution are applied, resulting in the cycle of burning/stinging then resolution
* once the patient finishes the peel, there should only be little to no discomfort left
39
peel setup
* TCA, 70%
* alcohol and/or acetone
* electrodessication tip
* tissue (to blot tears or acid run off)
* cotton-tipped applicators (for eyelids & nose)
* sponge to apply the acid
* Nearby there should be water or saline to
flush the eyes if needed
40
endpoint of TCA application ?
**frost**
41
**Levels of frost**
* how many ?
* what is their meaning ?
42
* meaning of **pink sign vs**
* **loss of pink sign**
43
Peel Depth Signs
44
Epidermal sliding sign
* Once peel penetrates the epidermis but has **not coagulated dermal proteins**
* there is a transient time **when pinching the skin shows exaggerated wrinkling or epidermal sliding**
* Continued peel application results in a loss of
this sign as the epidermis and dermis become coagulated to one another
* **Once this sign appears then disappears, it is the maximum recommended peel application for a medium-depth peel**
* May be **difficult to assess in thick skin**
45
meaning of edema in peel
* As the peel penetrates into the dermis, edema is noted upon pinching the skin. This sign takes some practice to pick up on
* **Once edema is felt upon pinching the skin, this is the endpoint of a medium-depth peel**
46
definition & meaning of level 1 frost
* penetration of TCA in the skin **starts to coagulate epidermal proteins first**
* **resulting in a light, nonorganized frost**
47
definition & meaning of level 2 frost
* **solid frost with a reactive pink background**
* pink background of the frost is referred to as the “pink sign” and will be apparent as long as the blood vessels of the papillary dermis are still intact with normal blood flow
* **level 2 frost is the endpoint for standard, papillary dermis–level peel**
* There may be noticeable edema in the skin upon pinching it
48
definition & meaning of level 3 frost
* penetration of TCA to or into the **reticular dermis, resulting in a solid frost with a loss
of the pink background**
* level 3 frost implies that the **whole papillary dermis is involved with the peel and the upper reticular dermis has been reached**
* **This is the maximum recommended
level for a TCA peel**
49
what if we continue to apply TCA once level 3 frost has been observed?
* Continued TCA application **will drive the peel into the mid-reticular dermis**, resulting in a **“gray” appearance to the skin**
* Penetrating to this level correlates with an **increased risk of scarring & permanent hypopigmentation**
50
which sign should be used to evaluate peel depth on darker skin patient?
* **epidermal sliding**
* because "pink sign” may be difficult to visualize
51
* definition & meaning of epidermal sliding sign
* what does it disappear ?
* **transient sign that demonstrates exaggerated wrinkling of the skin**
* occurs before complete precipitation & coagulation of papillary dermis proteins
* **Papillary dermal edema & disruption of anchoring fibrils allows the epidermis to be more freely movable, resulting in exaggerated wrinkling when the skin is pinched**
* This sign **disappears when the papillary dermis proteins become coagulated and adherent to the epidermal coagulated proteins**, thus indicating that the peel depth has reached the superficial reticular dermis
* Once this is achieved, the pink background goes away and **edema sets in**
52
Glycolic Acid–TCA Peel
step by step
* skin is degreased by cleansing it with soap &
water
* Quickly and evenly, unbuffered 70% glycolic acid is applied
* **After 2 minutes of contact time, it is neutralized with a copious amount of water**
* small amount of 35% TCA is applied in even
strokes to the skin using gauze or a large cotton swab
* A 2 to 3 minute waiting time is given to allow the TCA to penetrate and to assess whether further application is indicated
53
Jessner-TCA peel
step by step
* **skin is adequately cleansed with soap (preferably a foaming cleanser) and water**
* face is then further degreased by acetone
* A 2-inch by 2-inch gauze or cotton-tipped applicators are used to **apply the Jessner’s solution evenly, just enough to cause a very light frost**
* After 6 minutes, this is followed by application of a small amount of 35% TCA in even strokes using either gauze or cotton-tipped applicators
* A 2- to 3-minute waiting time is given to allow the TCA to penetrate and to assess whether further application is indicated
54
what should be done to avoid lines of demarcation?
* **TCA should be feathered down along the
jawline & should extend to the hairline**
55
Hetter VL Peel features
* light phenol peel
* can be used to treat a “single” cosmetic unit without the need for cardiac monitoring or IV hydration
* can reach reticular dermis level peel with fewer complications than the traditional Baker-Gordon peels
56
Hetter VL peel step by step
* Clean skin is further degreased by using 70% alcohol or acetone
* The bottle is shaken gently to mix the various components, and some of the solution is pulled into another bowl using a pipette
* While performing the peel and in between applications, the phenol mixture must be swirled, because the oil and water components of the solution have a tendency to separate
* The solution is applied to the skin with a cotton-tipped applicator
* Care must be taken not to let the solution drip or run down the face. The frost appears very quickly following the application of the peel solution
* The endpoint for deep wrinkles or redundant skin is an even white frost. The frost dissipates quickly, so one must pay close attention to make
sure that one does not apply more solution & peel the skin too deeply
57
**best method to plan out a combination procedure at the consultation**
* **notice which areas need a vascular laser, which need electrodessication of adnexal structures** (syringomas, sebaceous hyperplasia, cherry angiomas, seborrheic keratosis)
* **which need medium-depth resurfacing**
* which need deep resurfacing
* **The order of the procedures is critical**
* Preoperative markings should be made to help demarcate the areas that will be treated more deeply from those to be treated more lightly
58
why is neck & chest rejuvenation more challenging than facial skin rejuvenation?
* **because the neck has fewer adnexal structures, which are crucial to wound healing**
59
Algorithm for safely combining procedures
60
what should a patient expect after a medium-depth peel ?
* **usually take 6 to 7 days to heal fully**
* The first day patients are told to take it easy & apply frozen peas to the face 10 minutes per hour (**no ice to nonfacial skin**)
* **Patients are asked to sleep at a 45-degree angle the first couple of days to reduce facial
edema**
* **Facial edema, especially with phenol peels**, begins shortly after the procedure & **peaks at 24 to 48 hours**
* By 72 hours, most of the swelling has resolved,
but skin begins to look like a mask or a snake about to shed its skin
* **Patients will notice a progressive darkening & tightening of their skin into a mask-like appearance**
* Areas that have been treated with phenol or laser resurfacing will have a **fair amount of proteinaceous exudate that may look yellowish on appearance**
* This exudate **may look like pus to the patient**, so reassurance should be given that it is normal and will resolve
61
what can be done to reduce the risk
of postoperative staphylococcal infection?
* patients are instructed to **start applying mupirocin ointment to the nostrils 3 times a day starting 1 week before resurfacing & continuing until the skin has fully healed**
62
how should patients wash their face after peel ?
* Patients should **cleanse their skin twice a day using a gentle cleanser**
* **avoiding the use of a washcloth**
63
healing time in papillary vs superficial reticular dermis peels?
* Papillary: 7 days
* Reticular: 10 days
64
when are patients reseen after peeling?
* **midweek at day 3 or 4** to make sure
they are following instructions and to assess their level of compliance with the soaks and postoperative care
* Any early signs of infection or contact dermatitis can usually be picked up early at this point
* Patients are **seen again at day 7** to make sure that all areas have healed and that any remaining exudate is soaked off in the office & the underlying skin is assessed
65
During the entire healing process, patients are to avoid...?
* **exercise, heat exposure, bathtubs, swimming pools/Jacuzzis, sun**
* They are to wash their hands after using the restroom or petting their animals
* They are to keep their pets away from their faces and pillowcases
66
Absolute avoidance of sun exposure is recommended for...?
**the first 4 to 6 weeks postoperatively**
67
Skin firming can become apparent after ...?
* in as little as a few weeks and continue for up to 3 months afterward
