Topical Treatments and Adjuncts to Peels

Considerable improvements in sun-damaged skin can be achieved with topical therapy alone if the patient is willing to be consistent and compliant with a skin care program. Topical retinoids, such as tretinoin (Retin-A), have been shown to clinically and histologically reverse sun damage. In fact, the more severely damaged the skin, the better the response. Newer tretinoin products have gained popularity owing to advances in their delivery systems geared toward reducing the common side effects of dryness and irritation. For example, Renova (Ortho Dermatologics, Skillman, NJ) is delivered in an emollient base. Retin-A-Micro (Ortho Dermatologics) has a patented microsphere delivery system, and Atralin (Valeant Pharmaceuticals, Aliso Viejo, Calif) is delivered in a water-base, alcohol-free vehicle, with added hydrating and moisturizing ingredients. Compliance and consistency with topical therapy are much greater when dryness and skin irritation are decreased. After the use of topical retinoids, biopsies demonstrate deposition of new dermal collagen, formation of new blood vessels, and normalization of epidermal atypia. Accumulated melanin in the basal layer is transported to the surface and shed, improving pigmentation. Epidermal cell turnover is stimulated, producing a proliferation of new cells and improving skin texture. Improved blood supply to the dermis enhances both skin color and the transportation of nutrients to the skin. However, a minimum of 24 weeks is necessary to manifest visible signs of improvement. Unfortunately, topical treatments must continually be used to maintain improvements. When topical treatments are discontinued, the skin gradually returns to its previous condition.

Fortunately, retinoids are now available generically, so their cost has decreased; however, some dermatologists insist that the generic preparations have a higher risk of skin irritation because of their preservatives. Those likely to benefit the most from retinoids are fair-skinned individuals in their 30s and 40s who have blotchy pigmentation, sunspots, or fine lines around their eyes.

Lustra (Medicis Pharmaceuticals, Phoenix, Ariz) is an antiaging cream that contains 2% glycolic acid, antioxidants, and 4% hydroquinone. Hydroquinone, a tyrosinase inhibitor, disrupts the synthesis of melanin, thus lightening the skin or pigmented areas. It is also available in a preparation that contains a complete sunblock (Lustra AF). This type of preparation can be used in combination with topical retinoids to treat areas of hyperpigmentation, such as melasma. Use of a combination of topical preparations is likely to be slightly irritating to the skin. To avoid irritation that may cause patients to discontinue their regimen, it is wise to start with every-other-day application for the first 2 weeks, and then daily.

If skin irritation occurs and becomes problematic, a mild steroid cream or ointment (triamcinolone 0.1%), applied sparingly and concomitantly once a day, may reduce the associated erythema and flaking.

α-Hydroxy acids (AHAs) can be applied at low strength (2% to 20%) by patients as part of their daily skin care regimen to improve collagen and elastin synthesis and promote protein regeneration. AHA is a “blanket” term for a variety of fruit acids. Studies have indicated that both the papillary dermis and the epidermis can be thickened, elastic fibers improved, and melanin dispersed with the use of AHAs. Benefits visible to the patient include the reduction of fine lines and wrinkles along with improved skin color, tone, and texture. At low doses these occur without inflammation. Because AHAs do not cause angiogenesis (as opposed to retinoids), they are the preferred treatment for patients with telangiectases from rosacea. In addition, because AHAs work by a different mechanism, they can be used concurrently with retinoids.

The following is a list of some of more commonly used AHAs or ones you may see as ingredients in skin care products:

Because of increased sun sensitivity, retinoids are usually applied at night, whereas AHAs are most often applied during the day, along with the recommendation of a sun protection product with an SPF of 15 or greater. Skin texture, and to some degree skin pigmentation, may benefit at any age from retinoids, AHAs, or both. If irregular or abnormal pigmentation is persistent, consider incorporating hydroquinone, a tyrosinase inhibitor, or kojic acid, a melanin inhibitor, to the patient’s treatment program.

There are many AHA preparations available, buffered to various pH levels. It has been theorized that the beneficial or antiaging effects of AHAs are due to activation of transforming growth factor-β, which is increasingly activated at cutaneous pH levels below 5. The prolonged application of “acid” AHAs may reduce the cutaneous pH and thus activate this growth factor. Most unbuffered AHAs have a low pH; however, a low pH also increases the risk of local skin irritation. Buffered preparations with pH levels above 2 are available and may be preferred if skin irritation occurs. In addition, using a low-strength AHA before a chemical peel not only will allow the clinician to judge patient tolerance, but will enhance the penetration of the peel.

Alternative Procedures to Chemical Peels

Alternatives to chemical peels include the following:

Of the alternatives to chemical peels, cryopeels are the most similar in effect (see Chapter 14, Cryosurgery). Many primary care clinicians already use liquid nitrogen for freezing pigmented spots (lentigines), warts, actinic keratoses, seborrheic keratoses, and angiomas. With considerable experience, and often aided by a special attachment, the clinician can treat the entire face with cryotherapy to produce a cryopeel. It is less expensive for the patient than having a deep chemical peel, and with proper patient selection results may last up to 1 to 2 years. Although a cryopeel may result in more swelling initially, results are often comparable with those of a medium-depth chemical peel.

Originally designed to remove acne scars, surgical skin planing, or dermaplaning, was soon found to be useful for scarring from other causes, such as photodamage. After freezing, the skin layers are removed mechanically. Although postoperative healing is slower with dermaplaning and the cost is much higher than for a peel (as much as $4000 for a full-face dermaplane), more severe lesions can be treated, and the results of the skin resurfacing last longer (5 years or more). A more common and less invasive dermaplaning procedure is accomplished by scraping the skin with a no. 12 blade. After cleansing the skin, a light coating of povidone–iodine (Betadine) is applied and allowed to dry. Visualizing the change of color while gently scraping the skin allows the clinician to carefully remove only the most superficial layers of the epidermis. Repeat treatments may be done every 4 to 6 weeks at a cost of $150 to $200 per treatment. Although chemical peels are the procedure of choice for fine wrinkles, dermaplaning has a more prolonged effect and is superior for deep acne scars. Dermabrasion is similar to dermaplaning (e.g., preparations, indications) and is most often used to improve the look of facial scars caused by accidents or previous surgery or to smooth out fine facial wrinkles. The patient should be aware that after dermaplaning or dermabrasion, the immedicate postprocedure effects on the face will be quite obvious to friends and colleagues, with an average downtime of at least 10 to 14 days or even longer.

Microdermabrasion (see Chapter 58, Microdermabrasion and Dermalinfusion) is a technique in which the skin is buffed with aluminum oxide crystals. This method has grown in popularity because there is virtually no downtime. It has been coined “the lunchtime peel” and it is much less expensive than dermabrasion (about $50 to $100 per treatment). Three to six treatments are needed at weekly intervals for significant results. Among aesthetic skin care providers, microdermabrasion is the closest equivalent to superficial facial chemical peels. A potential drawback for primary care clinicians is the initial cost of $3500 to $10,000 for equipment.

Carbon dioxide laser resurfacing is another option. Traditionally, lasers were used to obtain a deep resurfacing that often required general or tumescent anesthesia. The cost was as much as $3500 to $5000 per treatment. Although studies have not been published comparing laser surgery with dermabrasion, anecdotal evidence indicates it to be as effective as dermabrasion for removing deep wrinkles around the mouth. There have been no comparative studies showing advantages of laser resurfacing of the whole face over dermabrasion or chemical peeling.

Long-pulse (i.e., 1000 milliseconds) erbium-YAG lasers and CO₂ lasers are now being used to achieve results similar to superficial and medium-depth chemical peels. Using special techniques (fractional ablation techniques), islands of skin are left unaffected within the treated area. This leads to a more rapid recovery time (5 to 7 days) as opposed to previous laser therapy (6 weeks). These lasers can be used anywhere on the body with only topical anesthesia and some oral sedation (see Chapter 51, Lasers and Pulsed-Light Devices: Skin Tightening, and Chapter 53, Fractional Laser Skin Resurfacing). These units require a considerable investment ($70,000 to $140,000).

With the exception of ethnically darker skin types, IPL therapy works best for pigment reduction, redness, flushing, or dilated capillaries, and can also be used for overall skin rejuvenation. There is no downtime for patients and minimal discomfort during the four to six required treatments. Unfortunately, the cost of equipment ($40,000 to $80,000) again prevents many primary care clinicians from offering this procedure. Certain IPL technologies can also be successful for hair reduction. However, if using IPL therapy for hair reduction, Fitzpatrick skin types IV through VI will present a challenge in both treatment safety and efficacy (see Chapter 39, Epilation of Isolated Hairs [Including Trichiasis]).

Chemical Peels

If self-applied over-the-counter AHAs alone are unsatisfactory, they can be used at higher strengths (20% to 70%) or with other agents to cause an inflammatory response or a skin peel. Chemical peeling relies on penetration of an irritating exfoliant into the dermal level to produce a controlled-depth wound that results in sloughing of the superficial skin layers of the epidermis. The injury also evokes a nonspecific tissue regeneration that produces a smoother and more youthful-appearing skin. A peel can be used after the skin has been prepared over time with retinoids, AHAs, or both, or it can be used as an alternative to the continuous application of these topicals.

It is not surprising that AHAs improve the skin; fermented food products that contain them have long been used to exfoliate the skin. Ancient Egyptians used the “hemayet” fruit, Greeks used facial masks, and Romans applied various combinations of salts and plants for this purpose.

Four levels of chemical peels are available: (1) superficial, (2) superficial to medium, (3) medium, and (4) deep (Table 59-3). The deeper the peel, the higher the risk of complications, patient inconvenience, and discomfort. A downtime of 1 or 2 weeks is to be expected with medium-depth and deeper peels, and it is usually obvious to the patient’s friends and colleagues that a cosmetic procedure has been performed. On the other hand, most superficial peels can be performed on a Thursday with the patient able to return to work the following Monday with little noticeable skin damage.

TABLE 59-3 Levels of Chemical Peeling

Type of Peel	Chemical Formula	Indications
Superficial, stratum granulosum/papillary	AHA (GA 20%–70%)	Fine rhytides (wrinkles)
dermis (up to 0.06 mm)	BHA (SA 20%–30%)
	5-Fluorouracil	Bad skin texture
	TCA (10%–20%)
	Jessner solution:	Acne vulgaris (comedonal/inflammatory, papular-pustular)
	14 g resorcinol
	14 g SA
	14 g lactic acid
	95% ethanol (quantity sufficient to add up to 100 mL)	Acne rosacea (papular-pustular)
	Unna’s paste	Pigmentary changes (especially postinflammatory)
	Carbon dioxide (solid)	Superficial actinic keratoses
Superficial to medium (0.06–0.45 mm)	20%–30% TCA	Persistent fine rhytides or bad skin texture
	Series of AHA (GA 20%–70%) or BHA (SA 20%–30%) peels (see Table 53-4)	Persistent acne vulgaris or rosacea Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Like this: Like Loading... Related Related posts: Electrical Cardioversion Umbilical Vessel Catheterization Knee Braces Compartment Syndrome Evaluation Stay updated, free articles. Join our Telegram channel Join Tags: Pfenninger and Fowlers Procedures for Primary Care Expert Consult May 14, 2017 | Posted by admin in GENERAL & FAMILY MEDICINE | Comments Off on Skin Peels Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access %d