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Chemical Peels
Niti Khunger
CHAPTER ONE:
Why do We Use Chemical Peels?
INTRODUCTION
THE POWER OF PEELING
DOWNSIDE TO PEELING
WHERE DO PEELS STAND TODAY?
WHY DO WE USE CHEMICAL PEELS?
CONCLUSION
KEY POINTS
CHAPTER TWO:
Basics of Chemical Peeling
INTRODUCTION
ACIDS AND BASES1
BASIC CHEMISTRY OF SKIN1
Approximate Composition of Skin
MECHANISM OF ACTION OF PEELING AGENTS1–4
Metabolic Action
Alpha Hydroxy Acids
Azelaic Acid
Retinoic Acid
Caustic Action
Trichloroacetic Acid
Toxic Action
Phenol
Resorcinol
Salicylic Acid
WOUND HEALING3,5–7
Coagulation and Inflammation
Tissue Proliferation
Tissue Remodeling
CONCLUSION
KEY POINTS
CHAPTER THREE:
Types of Peels
INTRODUCTION
PEELING AGENTS
HISTOLOGICAL CLASSIFICATION OF PEELS1 (TABLE 3.1)
FACTORS MODIFYING DEPTH OF PEELS
Peeling Agent
Availability of Free Acid
Duration of Contact
Technique of Application
Method of Priming the Patient
Method of Degreasing the Skin
Characteristics of Patient's Skin
Location of Peel
FACIAL AND NONFACIAL PEELS
REGIONAL PEELS
COMBINATION PEELS
SEQUENTIAL PEELS
SEGMENTAL PEELS
SWITCH PEELS
CONCLUSION
KEY POINTS
CHAPTER FOUR:
Patient Selection
INTRODUCTION
INDICATIONS1–4
CONTRAINDICATIONS
PATIENT ASSESSMENT (TABLE 4.1)
COUNSELING
SKIN TYPES
EXPECTED OUTCOMES IN CHEMICAL PEELING
Epidermal Peels
Excellent results
Variable Results
Poor Results
Medium Peels
Excellent Results
Variable Results
Poor Results
CONCLUSION
KEY POINTS
CHAPTER FIVE:
Getting Started
INTRODUCTION
EQUIPMENT AND REAGENTS (FIGURE 5.1)
Basic Facility
Reagents
Equipment
CONSENT FORM (APPENDIX III)
DOCUMENTATION AND PHOTOGRAPHS1,2 (FIGURES 5.2)
PATIENT HANDOUTS AND INSTRUCTIONS (APPENDIX IV)
Choice of Sunscreen
Choice of Cleanser
Choice of Moisturizer
Choice of Retinoid
Choice of Hypopigmenting Agent
CHECKLIST
BASIC PROCEDURE (FIGURES 5.3 TO 5.5)
CONCLUSION
KEY POINTS
CHAPTER SIX:
Priming and Skin Preparation
INTRODUCTION
IMPORTANCE OF PRIMING1–3
PRIMING AGENTS
PRIMING REGIMEN
SKIN PREPARATION
CONCLUSION
KEY POINTS
CHAPTER SEVEN:
Glycolic Acid Peels
INTRODUCTION
MECHANISM OF ACTION1
CHOOSING A PEEL FORMULATION2–4
EQUIPMENT AND REAGENTS
INDICATIONS5–11
CONTRAINDICATIONS
PREPEEL ASSESSMENT
PRIMING AND PREPEEL PREPARATION
PROCEDURE
PEELING ENDPOINT
Timing with Glycolic Acid Peeling (Table 7.1)
POSTPEEL CARE
MAINTENANCE PEELS
COMPLICATIONS
BOTTOMLINE
Advantages
Disadvantages
CONCLUSION
KEY POINTS
CHAPTER EIGHT:
Trichloroacetic Acid Peels
INTRODUCTION
MECHANISM OF ACTION2
PEEL FORMULATION
EQUIPMENT AND REAGENTS
SUPERFICIAL PEELS
Indications3–6
Photoaging
Textural Changes
Hyperpigmentation
Acne
Contraindications
PRIMING AND PREPEEL PREPARATION
PROCEDURE FOR SUPERFICIAL PEELS
Peeling End Point
Postpeel Care
Medium Peels7–9
Indications
Contraindications
PRIMING AND PREPEEL PREPARATION
PROCEDURE FOR SUPERFICIAL PEELS
POSTPEEL CARE
Non-facial TCA Peels11
Combination Peels and Procedures
COMPLICATIONS19,20
Complications of Superficial Peels
Complications of Medium Peels
Bacterial Infection
Herpetic Infection
Candidial Infection
Hyperpigmentaton (Figure 8.8)
Hypopigmentation (Figure 8.9)
Lines of Demarcation (Figure 8.10)
Scarring
Milia
Delayed Healing
Textural Changes
Spot Peels21
TCA CROSS TECHNIQUE (CHEMICAL RECONSTRUCTION OF SKIN SCARS) FOR ICEPICK SCARS22,23
BOTTOM LINE
Advantages of TCA
Disadvantages of TCA
TCA WITH SANDABRASION FOR ACNE SCARS (SEE CHAPTER 16)
CONCLUSION
KEY POINTS
CHAPTER NINE:
Salicylic Acid Peels
INTRODUCTION
PEEL FORMULATIONS
EQUIPMENT AND REAGENTS
INDICATIONS3–6
CONTRAINDICATIONS
PRIMING AND PREPEEL PREPARATION
PROCEDURE
POSTPEEL CARE
COMPLICATIONS
BOTTOM LINE
Advantages
Disadvantages
CONCLUSION
KEY POINTS
CHAPTER TEN:
Tretinoin Peels
INTRODUCTION
CHOOSING A PEEL FORMULATION
EQUIPMENT AND REAGENTS
INDICATIONS
CONTRAINDICATIONS
PRIMING AND PREPEEL PREPARATION
PROCEDURE
POSTPEEL CARE
COMPLICATIONS
BOTTOM LINE
Advantages
Disadvantages
CONCLUSION
KEY POINTS
CHAPTER ELEVEN:
Jessner's Peel
INTRODUCTION
MECHANISM OF ACTION
CHOOSING A PEEL FORMULATION
EQUIPMENT AND REAGENTS
INDICATIONS
CONTRAINDICATIONS
Absolute
Relative
Priming and Prepeel Preparation
PROCEDURE
POSTPEEL CARE
COMPLICATIONS
COMBINATION PEELS
BOTTOM LINE
Advantages
Disadvantages
CONCLUSION
KEY POINTS
CHAPTER TWELVE:
Newer Peels
INTRODUCTION
MANDELIC ACID1
Mechanism of Action
Choosing a Peel Formulation
Procedure
BOTTOM LINE
Advantages
Disadvantages
CONCLUSION
LACTIC ACID PEELS2,3
Introduction
Mechanism of Action
Choosing a Peel Formulation
Procedure
BOTTOM LINE
Advantages
Disadvantages
Conclusion
PYRUVIC ACID PEELS4–6
Introduction
Mechanism of Action
Choosing a Peel Formulation
Procedure
BOTTOM LINE
Advantages
Disadvantages
Conclusion
POLYHYDROXY ACIDS7–9
Introduction
Mechanism of Action
Procedure
BOTTOM LINE
Advantages
Disadvantages
Conclusion
PHYTIC ACID10
Introduction
Procedure
BOTTOM LINE
Advantages
Disadvantages
Conclusion
CITRIC ACID11
Introduction
Mechanism of Action
Procedure
Miscellaneous Peeling Agents
CONCLUSION
KEY POINTS
CHAPTER THIRTEEN:
Phenol Peels
INTRODUCTION1
MECHANISM OF ACTION5
CHOOSING A PEEL FORMULATION
Baker-Gordon Formula2
Stone Venner-Kellson Formula
Stone II Formula
Exoderm Solution
EQUIPMENT AND REAGENTS
INDICATIONS
CONTRAINDICATIONS
PRIMING AND PREPEEL PREPARATION
PROCEDURE
PHENOL APPLICATION WITHOUT TAPING
POSTPEEL CARE
COMPLICATIONS
CONCLUSION
KEY POINTS
CHAPTER FOURTEEN:
Nonfacial Peels
INTRODUCTION
DIFFERENCE BETWEEN FACIAL AND NONFACIAL PEELS1,2
PATIENT ASSESSMENT
INDICATIONS
Contraindications
PRIMING
PROCEDURE
POSTPEEL CARE
COMPLICATIONS
CONCLUSION
KEY POINTS
CHAPTER FIFTEEN:
Combination and Sequential Peels
INTRODUCTION
COMBINATION PEELS
Superficial Peels
SEQUENTIAL PEELS
SEGMENTAL PEELS
SWITCH PEELS
COMPLICATIONS
PHYTIC ACID PEELS7
Shehnaz Arsiwala
Introduction
Mechanism of Action
Indications
Procedure
CONCLUSION
KEY POINTS
CHAPTER SIXTEEN:
Combination Therapies
INTRODUCTION
PATIENT COUNSELING
CHEMICAL PEEL WITH MICRODERMABRASION1,2
CHEMICAL PEEL WITH DERMASANDING3–5
Procedure (Figures 16.1 to 16.9)
CHEMICAL PEEL WITH DERMABRASION6–8
CHEMICAL PEEL WITH LASERS4,9
CHEMICAL PEEL WITH BOTULINUM TOXIN10
CHEMICAL PEEL WITH FILLERS10
COMPLICATIONS
CONCLUSION
KEY POINTS
CHAPTER SEVENTEEN:
Chemical Peeling in Darker Skin
INTRODUCTION
DIFFERENCES1
PROBLEMS2
To Summarize
PATIENT ASSESSMENT
COUNSELING
PRIMING AND PREPARATION3,4
PRECAUTIONS
PEEL SELECTION
Safe Peels
High Risk Peels
Peels Better Avoided
PROCEDURE
POSTPEEL CARE
COMPLICATIONS
Hyperpigmentation
Hypopigmentation
Lines of Demarcation
CONCLUSION
KEY POINTS
CHAPTER EIGHTEEN:
Chemical Peeling in Sensitive Skin
INTRODUCTION
PROBLEMS
PATIENT ASSESSMENT
COUNSELING
PRIMING AND PREPARATION
PRECAUTIONS
PEEL SELECTION
PROCEDURE
POST PEEL CARE
COMPLICATIONS
CONCLUSION
KEY POINTS
CHAPTER NINETEEN:
Chemical Peeling in Aging Skin
INTRODUCTION
PROBLEMS
PATIENT ASSESSMENT
COUNSELING
PRIMING AND PREPARATION
PRECAUTIONS
PEEL SELECTION2–10
PROCEDURE
POST PEEL CARE
COMPLICATIONS
CONCLUSION
KEY POINTS
CHAPTER TWENTY:
Complications
INTRODUCTION
EVALUATING PATIENTS AT RISK
BASIC PRECAUTIONS
AVOIDING COMPLICATIONS1,2
Pre-peel
During the Peel
Postpeel
MANAGING COMPLICATIONS1–9 (TABLE 20.1 AND TABLE 20.2)
Edema
Blistering
Pain and Burning
Persistent Erythema
Pruritus
Infections
Hyperpigmentation
Hypopigmentation
Lines of Demarcation
Delayed Healing
Ocular Injuries7
Acneiform Eruptions
Allergic Reactions
Scarring
Toxicity
Complications of Medium and Deep Peels
Ectropion
TexturalChanges
Toxicity
Drug Interactions
CONCLUSION
CHAPTER TWENTY ONE:
Interesting Case Studies
CASE 1
Problem
Solution
CASE 2
Problem
Solution
CASE 3
Problem
Solution
CASE 4
Problem
Solution
CASE 5
Problem
Solution
CASE 6
Problem
Solution
CASE 7
Problem
Solution
CASE 8
Problem
Solution
CASE 9
Problem
Solution
CASE 10
Problem
Solution
CHAPTER TWENTY TWO:
Ten Golden Rules for Perfect Peeling
RULE 1: COUNSELING LIKE A PROFESSIONAL
RULE 2: ADEQUATE PRIMING
RULE 3: CHOOSING THE RIGHT PEEL
RULE 4: WHEN NOT TO PEEL
RULE 5: APPLYING THE PEEL
RULE 6: POSTPEEL CARE
RULE 7: DETECTING COMPLICATIONS EARLY
RULE 8: COMBINING PEELS
RULE 9: REPEATING PEELS
RULE 10: DON'T BE JACK OF ALL PEELS AND MASTER OF NONE
Appendices
APPENDIX I
Terminology in Chemical Peeling
APPENDIX II
Consent Form
APPENDIX III
Patient Handouts
APPENDIX IV
Ethical Aspects of Chemical Peels
INDEX
TOC
Index
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