Deep peels scarring

Thick male skin is usually less responsive to deep peel, but men with severe actinic damage or acne scarring benefit significantly from the procedure. 

Perioral wrinkles (around the upper lip and chin) only respond to very deep peels (Figure 5.10). Many different agents have been tried e.g. pyruvic acid, that has a high potential for scarring, and this particular agent, which is difficult to control in concentrated solutions, is very rarely used. 

Scars that are in the same area treated for stretch marks by abrasion and ETCA respond well to this technique if they are stable and permanent. It is out of the question to use this deep peel on recent scars, as there is a risk that the scars will open. 

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. 

Phenol is applied up to the lower limits set before the start of the peel this forms the demarcation line (Figure 34.14). The skin on the neck is structurally different to that on the face it has fewer appendages and pilosebaceous imits. After a deep peel, the skin regenerates from these appendages. A phenol peel on the neck carries an increased risk of scarring. What is more, the usual post-peel facial edema tends to extend downwards to the neck, and if the neck is treated... 

The deeper the peel, the more effective it is, but also the more dangerous. A deep peel, when performed correctly, produces exceptional results in the majority of cases. I have never come across any report of complete facial necrosis after a peel. Fortunately therefore, the problem remains localized. Scarring can be atrophic, hypertrophic or retractile, depending on the depth of the burn and the area treated. To have a better understanding of the risk of post-peel scarring, we must take another look at the physiology of skin healing. 

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. 

Deep peels TCA (30%), salicylic acid (50%). These peels cause a deep frosting phenomena and they require home postpeeling management for the intense erythema. These peels are used in medium and deep acne scars. Ice-pick and boxcar scars can be treated with TCA 30% application all over the face when they are diffuse. When they are isolated, TCA cross 50-90% using cotton tips is the gold standard [15] (Fig. 13.13a. b). In Table 13.5, we sununarize the principal chenucal peels and their indication in acne. 

For medium-depth and deep peels any history of abnormal scarring or keloids. 

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]. 

Skin Side effects during deep peeling using phenol in treating atrophic post-acne scars were transient acneiform eruptions, transient erythema and hyperpigmentation, which resolved within 3-4 months. Two out of ten patients developed persistent erythema for 6 months, which had to be cured using topical pimecrolimus [81 ]. 

Leheta TM, Abdel Hay RM, El Garem YF. Deep peeling using phenol versus percutaneous collagen induction combined with trichloroacetic acid 20% in atrophic post-acne scars a randomized controlled IriaL J Dermatolog Treat 2014 25(2) 130-6. 

Medium-depth chemical peels include combinatian peels such as solid CO2 plus TCA or Jessner s solution plus TCA. Some authors also include 88% phenol as a medium-depth peeling agent, but others classily it as a deep peel. Historically, 50% TCA was used as a medium-depth peel, but the development of many complications such as scarring and PIH limited its use, although the use of 50% TCA is quite effective in the treatment of isolated lesions such as xanthelasma. 

Deep peels are not typically performed in Fitzpatrick skin types IV-VI, but can be done successfully by experienced physicians. Rullan Karam found deep peels to be particularly effective for the treatment of challenging acne scars. These require taping the face for 24 hours, removal, debridement of the coagulum, and application of a bismuth subgallate powder mask. This mask is left in place for about 7 days and then is carefully removed. The vast majority (99%) of patients are over 95% reepithehalized by the 8 day following the peel. 

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. 

The TCA CROSS (chemical restructuring of skin scars) technique should be performed sequentially over months prior to the definitive procedure, usually a combination of a medium deep peel with fractional laser resurfacing over the remaining superficial scars. 

Scarring is very rare follo wing superficial and medium peels and uncommon follo wing properly performed deep peels (Fig. 15.18). It can occur months after an uneventful deep peel, but quite often there will be signs or symptoms, most commonly in specific areas, which allow the practitioner to detect and treat these potential scars before they become hypertrophic. 

---