Deep peels infections

Special care should be taken with patients who have extremely thin, dry or sun-damaged skin, as the acids penetrate this very permeable skin more quickly and more deeply and the skin can sometimes overreact. Careful anamnesis will reveal any personal or family history of keloids or any tendency to scar hypertrophy. Insulin-dependent diabetics should be ruled out from a peel to the reticular dermis (because of the increased risk of scarring and infection), whereas diabetic patients (type 2, noninsulin-dependent) who are stabilized on oral antidiabetic drugs can have a deep peel on condition that they are monitored more closely than usual. 

Pruritus must be treated rapidly to prevent infections. Deep peels, to the reticular dermis, obviously pose a particular risk of secondary infection during the first week after treatment. 

An infection can be assumed to be herpes if the patient has a personal history of herpes. If pain is felt on the upper lip first, this also suggests herpes, while pain felt on the cheek would rather suggest a bacterial infection, especially if there are scratch lesions and pus. Given that the epidermis has been exfoliated by the medium or deep peel, the doctor should not expect to see herpes blisters. 

Active acne must be treated in the weeks before a peel to the papillary or reticular dermis, and the medium or deep peel can only be started once the infection has completely cleared. The increased epidermal permeability resulting from prescription treatments must be taken into account. 

It is common for acneiform dermatitis to develop under greasy dressings (see also the section above on microbial infections) after deep peels treated with the moist technique. Vaseline in fact creates an impermeable layer that acts as total occlusion. It is known that bacterial proliferation is much more rapid under occlusion than in the open air. Antibiotics and standard local treatments are used to treat post-peel acne. 

Superficial peels are usually safe and well tolerated, with such undesirable effects as burning, irritation, and erythema [281]. With superficial peels, scarring and infection are rare. With medium and deep peels, demarcation lines (technique-related) may occur [281]. Deeper peels may have adverse effects of postinflammatory hyperpigmentation (PIH in dark-skinned individuals), infections, allergic reactions, improper healing, disease exacerbation, and complications secondary to improper application [281]. Chemical injuries may occur when glacial acetic acid is not properly used for chemical peeling [341]. 

The healing process after a chemical peel must be as rapid as possible so as to avoid infections. While uncommon, infections may deepen the wounds irregularly, converting an anticipated superficial peel into a deep peel and increasing the chance of scarring. If excessive crusting occurs, topical and/or oral antibiotics should be prescribed to treat presumed bacterial infection. 

While infection is rare after any type of peel, it tends to result more frequently after medium and deep peels. It is not the infection per se that is problematic, but rather the associated scarring that can ensue. If bacterial, fungal or viral infection is suspected, empiric therapy should be started after a culture is taken. Infections can be bacterial (most commonly staphylococci and streptococci), viral (herpes simplex) and fungal (Candida). Patients with positive history of herpes simplex infection should be treated prophylacticaUy with acyclovir or valacyclovir until full reepithehalization is achieved. 

Although serious infections have been reported following deep peels, including bacterial pyodermas, toxic shock syndromes and Epstein Barr virus keratitis, I have to date only observed two types of infectious complication (1) Herpes simplex, which has been virtually eradicated by the use of prophylactic antiviral medications. The onset of herpes is often heralded by increasing pain, and (2) superficial pyoderma, which is often associated with poor postoperative wound care. 

Infections other than the activation of herpes are quite rare when the light peels are employed. Medium peels and deep peels can tii er herpetic infection so it is important to determine in advance whether patients are exposed to anyone with cold sores or fever blisters. Even if they deny ever having had herpetic infections, patients are advised... 

The majority of the skin s immune defenses are found in the deep layers of the epidermis and dermis. An intraepi-dermal peel lets in many xenobiotic microorganisms, but all of the skin s defenses remain viable and usually stop any local infection from developing. After an intraepidermal peel, skin regeneration is very rapid and there is not really enough time for infection to set it. Intraepidermal peels are usually repeated once a week or every 2 weeks. Each intraepidermal peel stimulates the skin s regenerative capacities, and the skin finds it more and more easy to resist infection. Therefore, these peels do not increase the risk of infection (or only very little). The risk of herpes is not increased. 

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