Medium and Deep Peels

Medium and deep peels utilize TCA concentrations of 30-40% or greater or phenol combina- 

Clinicians should be acutely aware that deeper peels carry substantial risks of inducing scarring and hypopigmentation in darker-skinned racial-ethnic groups (Fig. 13.6). 

Montagna W, Prota G, Kenney JA (1993) Black skin structure and function. Academic Press, San Diego, PP 42-45 

Szabo G, Gerald AB, Patnak MA, Fitzpatrick TB (1969) Racial differences in the fate of melano-somes in hirnian epidermis. Nature 222 1081-1082 

Olson RL, Gaynor J, Everett MA (1973) Skin color, melanin, and erythema. Arch Dermatol 108 541-544 

---

Superficial, Medium and Deep Peels in Cosmetic Practice... 

Chemical skin peeling agents are usually classified as producing superficial, medium, and deep peels (see Table 4.21) [288-290]. 

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 usual classification of chemical peels comprises superficial, medium and deep peels. For superficial peels, AHA, Jessner s solution, tretinoin, TCA in concentrations of 10-30% and most recently hpo-hydroxy add are used to induce an exfoliation of the epidermis. Medium-depth agents such as TCA (30-50%) cause an epidermal to papillary dermal peel with subsequent regeneration. Deep peels using TCA (>50%) or phenol-based formulations penetrate the reticular dermis to induce dermal regeneration. The success of peeling in darker skin is crudally dependent on the physician s understanding of the chemical and biological processes, as well as of indications, clinical effectiveness and side effects of the procedure (see Box 9.1). 

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. 

Pruritus, which is a normal consequence of the healing jjrocess, often foUows medium and deep peels, although it can be associated with more important complications. Some authorities recommend the use of aspirin or propranolol, after eliminating infectious processes or sensitization as a cause of pruritus. I ordinarily use low-strength topical steroids, reassurance, oral antihistamines and a mild moisturizer such as Kinerase if the skin is very dry. 

SweUing is common following medium and deep peels. 

---