Combination peels indications

Given the inherent risks of this combination, its indications are restricted to the treatment of keratoses or depressed scars, in which the dry ice, applied locally and combined with TCA, produces very good results, comparable to those of a phenol or Only Touch peel. 

One Easy TCA peel per week for 4 weeks can restructure the skin and eliminate any abnormal sensitivity. In this indication, the cosmeceuticals that can be combined with it are restricted to Vit E Antioxidant cream in the morning and the more nourishing Renutriv ACE Lipoic Complex cream in the evening. 

These are very rarely indicated in combination with peels, and then only in the case of very specific problems (see Chapter 37). 

Peels are not indicated for hypertrophic scars. Some fine facial scars (from a face-Kft, for example) improve vastly after local application of some phenol peels others are improved by a combination of abrasion and peeling. Body peels produce fewer results and more problems that facial peels. 

With regard to acne, in 80% of cases, the first application of ETCA to active papulopustular facial lesions improves their number and severity by 50%, and the lesions seem to heal without scarring. ETCA is applied on the basis of one peel per week for 4 weeks that clear the lesions almost completely without having to resort to antibiotics. Deep wrinkles and acne scars do not disappear they lie deep under the skin and even phenol or carbon dioxide laser resurfacing cannot always treat them. A combination of several different techniques is clearly needed in these indications. 

Other peels can be used, depending on the case being treated. Unideep is also indicated for the treatment of keratoses on the scalp the Unideep solution produces even frosting more rapidly. Only Touch can be used in combination with a more superficial ETCA peel (cloudy-white frosting instead of even white frosting) on isolated keratoses on the scalp. 

This demarcation line (Figure 29.6) can be made less obvious both by a good peeling technique and by combination with other peels on the neck. Darker skin types are not such a good indication, because of the change in skin tone after the peel. Most patients with a lot of wrinkles, however, prefer to exchange their wrinkles for a difference in skin color that can easily be disguised with makeup. 

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. 

Effective sun protection is always indicated with erythema, as it tends to develop into hyperpigmentation after UV exposure. Antioxidant creams can limit the negative effects of free radicals and the damage they cause to the cells. Creams containing vitamins A, C and E and lipoic acid can be combined with an antioxidant cream. The Easy TCA post-peel mask provides effective protection against erythema. 

Using peels to different depths on the same patient is indicated when disorders of different depths coexist. Consider a patient who presents with early elastosis, a few lentigines and deep wrinkles on the upper lip only phenol can get rid of the wrinkles on the upper lip, but it would be unnecessarily deep to treat the early elastosis on the rest of the face. The phenol would of course get rid of the few senile lentigines, but a deep and very localized treatment with Only Touch can also get rid of them and with less risk. This patient would therefore benefit from the following combination (Figure 38.2) ... 

A number of small studies have indicated that the amelioration of more severe acne scars, moderately deep rhytides, and the effects of photoaging, which are often recalcitrant to standard treatment regimens, can be improved by combining microdermabrasion and super-hcial chemical peels in one treatment session. While more published data to support the use of this combined technique would be welcome, the data that are available indicate that it is highly effective, well tolerated, and more convenient for patients. 

Done for the right indication and chosen for the correct patient, chemical peeling remains as an alternative modality for patients with melasma. It becomes more effective when combined with medical therapy since the peels mechanically remove (he melanin while topical medications inhibit melanocytes or melanogenesis. 

The more general phenomenon of adhesion between a rubbery polymer and a different surface is frequently studied by tests of the force required to peel a thin layer of polymer from a rigid substrate. 2,53 at different peel rates and different temperatures can be combined by reduced variables with shift factors given by the WLF equation, indicating that here as in friction the process is controlled by rates... 

In many applications rubber is bonded to metal for fixing purposes or in order to alter the stiffness, and the integrity of the bond is often vital for maintenance of the required stiffness characteristics and to ensure adequate life. The mechanics of bond failure were studied for various types of deformation. Provided that the tests were carried out under suitable loading conditions, time-dependent failure with a similar locus was observed in peeling at 90 or 180 degrees, pure shear and various combinations of simple shear and compression. There were indications that an energetics approach could enable results from different geometries to be quantitatively interrelated. Cavitation-... 

While medium-depth peels on the face can be considered one-stage procedures, this is often not the case on the body. Due to increased potential for adverse events such as scarring off the face, similar peels are done in a series and at lower concentrations. Results are seen after a few sessions and should be accompanied by a regular topical maintenance program to prolong the benefits. Additionally, for specific indications, body peels can be combined with other minimally invasive procedures including lasers, light sources, electrodessication, cryosur-... 

The most common indications we use TCA peels to treat are solar lentigos and severe acne scars [Figure 13.3). TCA can also be combined with salicylic acid for treatment of solar lentigos. For the treatment of recalcitrant hyperpigmentation and melasma, TCA can be combined with salicylic acid or glycolic acid. 

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