Basal layer peel

Preparation with AHAs or tretinoin reduces the thickness of the stratum corneum, the skin s natural barrier. As the barrier is not as thick, it is easier for the products applied to the skin to penetrate to the basal layer of the epidermis and more deeply into the dermis. It should be noted that not aU peels require this kind of preparation. ... 

At the other end of the scale, what is the minimum age for having a chemical peel The answer is simple in the majority of cases, a peel is only necessary for young patients if they have acne. Acne responds extremely well to intraepidermal peels or peels to the basal layer of the epidermis. Deeper peels are not recommended when the skin is infected. Very young patients benefit from relatively superficial techniques... 

The fact that in most cases they cannot use camouflage make-up makes it difticult to carry out a local or full phenol peel. Moreover, phenol peels produce less spectacular results on thick skins than on thin skins. Shaving does not pose a problem, as a peel to the basal layer of the epidermis does not rule out shaving, even with a blade. For a peel to the papillary or reticular dermis, it is best not to shave while the skin is flaking. It is usually possible to shave after the 8th day. Alcohol-based aftershaves should be avoided, and a hydrating, anti-oxidant or firming cream should be used instead, followed by effective sun protection. 

Patients often ask about make-up. The general principle is that it is possible to wear make-up, even when the skin is flaking, after an epidermal peel or a peel to the basal layer, but it is unlikely to look good. After a peel to the papillary or reticular dermis, make-up is usually allowed, and even recommended, on the 8th day. Patients who do not like wearing make-up should be warned of the likelihood of post-peel erythema, depending on the depth of the treatment. Some patients are thus ruled out, as their professional lives do not allow any visible erythema or they cannot stand the idea of wearing make-up. In these cases, it is recommended to repeat an Easy TCA peel four times rather than use Unideep . ... 

A deep peel would not be the best way to treat this patient, as the ratio of results to complexity -i- complications + downtime -I- cost would not be favorable. The possibility of a medium peel to the papillary dermis could be discussed, if the patient wanted fairly quick results or if she did not have enough time for a series of lighter peels. She could also be advised to have a series of peels, either intraepidermal (to remove the epidermis) or dovm to the basal layer, combined with appropriate daily care. 

Comedonal acne (Figure 5.5) can be treated with an intraepidermal peel or a peel to the basal layer. A trichloroacetic acid (TCA) peel to the papillary or reticular dermis could be considered, but such a deep treatment would be pointless for this type of disorder, which can be treated with a lighter peel and, in any case, requires longterm maintenance treatment. 

The basic protocol for ETCA is intended to reach the basal layer of the epidermis or the Grenz zone. There are (many) other deeper protocols but they are not as straightforward as ETCA and the risk of complications is relatively much higher. ETCA is not necessarily a light peel it can be used to reach all depths, from the basal layer of the epidermis to the reticular dermis, depending on the protocol used. The relatively superficial action of the ETCA solution (basic protocol) strongly stimulates the skin regeneration... 

Either four Easy TCA peels to the basal layer or a Unideep peel to the papillary dermis. 

Awareness of this problem led to the rapid development of new TCA peel formulas between 1990 and 2000. One of the first solutions put forward was the New Peel combination of TCA and Mikuda complex. The soft Peel formulation used asiaticosides and ginsenoids, glycerol, urea (carbamide), sorbitan monolaurate and methyldibromo-glutaronitrile, among other ingredients. Easy TCA , Unideep and Only Touch Peel (OTP) provided another answer to the problem these stabilized solutions consist of a base solution to which a determined quantity of 50% m/m TCA is added. There are no complicated calculations to be performed, the directions for use state precisely what volume of 50% m/m TCA solution should be added to the base solution to make up the Easy TCA , Unideep and OTP solutions, which provide peels to the basal layer, the papillary dermis and the reticular dermis, respectively. 

A peel to the basal layer lightens the freckles, sometimes only temporarily. A peel to the Grenz zone removes many freckles and lightens others. A peel to the papillary or reticular dermis gets rid of freckles altogether (Figure 13.11). 

Here too a combination of techniques proves worthwhile. Acne responds well to a TCA peel to the basal layer or the Grenz zone, whether it is comedonal, microcystic (Figure 13.16), papular or papulopustular. Deeper peels, to the papillary dermis, should not be used when acne is still active, because of the increased risk of infection (see Chapter 37). The number of open or closed comedones can be expected to decrease after several TCA peels. We shall see how the Easy TCA technique allows comedones and microcysts to be opened immediately before the peel, which gives faster and better results. Seborrhea is often reduced after TCA... 

Pre-peel care is discussed in Chapter 2. Further information can be found in Chapter 12. The safety of peels employing trichloroacetic acid in simple aqueous solution (TCA-SAS) has been greatly improved by systematic preparation of the skin before peeling. Preparing the skin helps improve microcirculation, increase glycosaminogly-can synthesis, increase the number of mitoses in the basal layer keratinocytes, stimulate production of epidermal growth factors, deactivate melanocytes and even out and deepen the effect of the TCA. 

Scattered pinpoint frosting the peel is near the basal layer (Figure 14.1) Sunburn-type flaking (Figure 14.2)... 

The post-peel mask cream contains retinol microencapsulated in a cyclodextrin. Vitamin A is involved in the processes of cell division and differentiation that help the epidermis regenerate after the peel from the cells of the basal layer. 

Basic protocol removal of the epidermis. The peel reaches the basal layer Pinpoint frosting 4 peels 1 per week... 

After a resorcinol peel, the superficial stratum corneum comes away from the germinative layer in the stratum granulosum. The basal layer shows increased mitosis and accelerated turnover. The total thickness of the epidermis therefore increases, to the detriment of the stratum corneum, and the skin appears more hydrated. 

The epidermal layers are dissolved down to the basal layer in 24—36 hours under an occlusive mask. Thereafter, the architecture of the cells returns to normal and the histological coloring evens out. After a peel, the palisade structure of the keratinocytes is more even. 

Histologically, freckles are characterized by a normal number of melanocytes in the basal layer. The melanocytes are, however, larger and more dendritic , and give up their melanosomes more readily to the keratinocytes. Freckles disappear completely and definitively with phenol. A TCA peel to the papillary dermis will also get rid of freckles. A local phenol peel is contraindicated on light skin phototypes - which in principle are a good indication for phenol - with freckles, as they will disappear where the phenol has been applied and will persist in the surrounding areas. A combination of local Lip Eyelid and Unideep (TCA to the papillary dermis) is suitable to avoid this freckle demarcation Hne. 

Normal face-lift scars are not usually too unsightly, but some patients want a treatment to soften them or get rid of them completely. A full-face phenol peel is the best option (Figure 30.19), but a local application of phenol precisely on the scar is also a possibility, in combination with another more superficial peel (to the papillary dermis, the Grenz zone or the basal layer). Standard scars from an upper blepharoplasty do not seem to respond as well to a... 

After an intraepidermal peel, to the basal layer or the Grenz zone, the skin regenerates from leftover islets of ker-atinocytes. In the case of a deep peel, the skin regenerates from its appendages. The face has more pilosebaceous units than the neck, and facial skin regenerates more quickly, with less risk of scarring. 

Peels to the basal layer can be repeated four or five times (Easy TCA ) on an average of one session a week. The doctor should always wait for the skin to recover before re-peeling. Skin that is actively flaking should not have another peel applied to it. Some patients need a fifth peel (oily skins, resistant hyperchromia, squeamish patients who do not allow the doctor to apply the solution properly, etc.). 

Indurated erythema might lead to scarring, and preventive treatment should be started (see the section on scarring later in this chapter). When intraepidermal TCA peels or TCA peels to the basal layer are repeated too often," erythema can last even longer. Using tretinoin during the weeks before or after a TCA peel is also likely to trigger or exacerbate erythema. 

A peel to the basal layer (Figure 37.22) is characterized by erythema and the appearance of pinpoint frosting after TCA or generalized erythema after AHAs. Phenol is not indicated for this depth of peel. 

Even if the acid reaches the papillary dermis in places, a large number of keratinocytes survive, allowing the skin to regenerate very quickly. The process of re-epitheHalization is the same as for intraepidermal peels the basal layer keratinocytes are stimulated to grow. 

Skin repair after a peel to the reticular dermis is slower, as all the basal layer keratinocytes have been destroyed and the skin can only rely on the differentiated keratinocytes of the pilosebaceous units and the intradermal excretory ducts of the sweat glands. To repair the dermis, the sebocytes in the pilosebaceous units must dedifferentiate, and horizontal growth is required to close the skin quickly. Next comes a phase of vertical growth whose purpose is to regenerate a physiologically sound epidermis that will maintain homeostasis and restore the vital barrier function after the keratinocytes have differentiated into corneocytes. 

Whatever the case may be, my first choice of treatment for epidermal or dermal post-peel PIH is always four sessions of Easy TCA to the basal layer (pinpoint frosting) in combination with Blending Bleaching cream. Results can often be seen after the first re-peel. 

Peel to the epidermis and basal layer very low risk... 

Intraepidermal peels to the basal layer or the Grenz zone do not require such stringent precautions as deep peels, and... 

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