Choosing the Correct Peel for the Appropriate Patient

Question 1

4 categories of chemical peels,
depending upon the depth of the wound created by the peel

Answer 1

• Very superficial peels: only penetrate through the stratum corneum and the uppermost portions of the epidermis
• Superficial: penetrate the epidermis but
  not more than the basal layer of the epidermis
• Medium-depth: penetrate entire epidermis plus papillary dermis
• Deep: create a wound to the level of the upper & mid-reticular dermis

Question 2

Questions during evaluation of a patient for a peel

Answer 2

• history & frequency of HSV infection
• HIV status (more so, viral load)
• keloid formation
• previous x-ray therapy of the skin
• nicotine use
• oral isotretinoin use
• history of a previous facelift or browlift

Question 3

Management of patient with a history of frequent HSV infections ( >1 every 6 months)

Answer 3

• prophylactic treatment to prevent an outbreak of herpes during the healing process
• This is most important during medium-depth & deep peels
• Typically patients having a medium-depth or deep peel are started on 500 mg valacyclovir twice a day for 7 to 14 days starting the day
  before the procedure
• If an HSV or VZV breakthrough is suspected
  during the healing process, the dose is increased to 1000 mg 3 times a day for 14 days

Question 4

management of patient with HIV (detectable viral load)

Answer 4

• poor candidates for a medium-depth or deep peel
• because their immunocompromised state delays wound healing and increases the risk of wound infection and subsequent scarring
• Transplant patients & patients on immunosuppressive medications for autoimmune diseases are similarly at risk for infection and poor wound healing

Question 5

Obagi Skin Classification

Answer 5

Question 6

most important discussion that a physician
must have with a patient preoperatively

Answer 6

• the one regarding realistic expectations
• physician should elicit the patient chief complaint
• physician should realistically describe the
  postoperative course, healing time, anticipated results, potential risks of the procedure

Question 7

very superficial peel features

Answer 7

• with a single treatment can induce exfoliation
• improvement of skin texture, through the removal of the stratum corneum
• induction of acanthosis
• increase in thickness of granular layer

Question 8

how common is PIH with superficial peels & why ?

Answer 8

• not common, because they create minimal inflammation

Question 9

superifical chemical peels

Answer 9

• more effective than very superficial peels for the treatment of AK, epidermal melasma, solar lentigines, epidermal growths such as thin seborrheic keratoses
• Skin texture may also be improved
• Erythema & scaling will occur postoperatively for 3 to 4 days
• healing time is faster if patients are pre
  treated with proper skin preconditioning

Question 10

Medium-depth peels

Answer 10

• reach papillary dermis level
• take about 7 days to heal
• With increased healing time comes an increased risk for complications such as scarring, hypopigmentation & PIH

Question 11

Deep peels are comparable to…?

Answer 11

• traditional ablative CO2 laser resurfacing
• most appropriate for patients with deep scars or deep wrinkles

Question 12

features of deep peels

Answer 12

• due to depth of penetration into the reticular dermis, textural change, permanent hypopigmentation, and scarring are real concerns
• recovery time ass/w deep peels is on the order of 10-12 days

Question 13

age related skin fragility is due to..?

Answer 13

• flattening of the Rete ridges between the epidermis & dermis (DEJ) and the loss of anchoring fibrils at the DEJ
• Patients usually present with easy bruising & delayed wound healing from minor wounds (mainly on the dorsal forearms)
• This is worsened with age, with long-term systemic prednisone use, and with taking
  blood-thinning medication
• Repeated papillary dermis–level peels can help reduce the fragility of the skin

Question 14

Skin laxity must be differentiated from…?

Answer 14

• muscle laxity
• Muscle laxity requires surgical intervention to help resuspend ptotic tissue
• However, skin laxity improves with repeated papillary dermis level resurfacing
  because it increases the amount of anchoring fibrils at the DEJ & the papillary dermis–level collagen and elastin thickness, which in turn firms up skin

Question 15

why are thinner-skin patients at risk during deep-skin resurfacing?

Answer 15

• due to a decrease in the amount of the adnexal structures that are required for
  reepithelialization

Question 16

• which patients are more prone to developing PIH ?
• which are less prone to PIH & why ?

Answer 16

• Patients with melasma and freckling are more likely to,develop PIH
• Patients without dyschromia tend to have more stable pigment cells
• Skin color alone does not help predict PIH