Medium-Depth Peeling

Trichloroacetic acid and phenol peels (see peel sections) have been used extensively to treat photodamage [60, 61]. However, TCA peels in concentrations above 35% are unpredictable. Albeit efficacious for severe photodamage, phenol peels are associated with myriad side effects [61]. Hence, combination medium-depth peeling agents have become increasingly popu- 

Lawrence et al. [66] in a split face study, compared the efficacy and safety of Jessner s solution and 35% TCA with 5% fluorouracil in the treatment of widespread facial actinic keratoses. Fifteen patients were treated. Both treatments reduced the number of visible actinic keratoses by 75%. Similarly, both caused equivalent reductions in keratinocyte atypia, hyperkeratosis, and parakeratosis. Compared to fluorouracil, only one application of the peel was necessary. 

Bhawan J, Andersen W, Lee J, Labadie R, Solares G (1995) Photoaging versus intrinsic aging a morphologic assessment of facial skin. J Cutan Pathol 22 154-159 

Gilchrest BA (1996) A review of skin aging and its medical therapy. Br J Dermatol 135 867-875 

Lavker RM (1995) Cutaneous aging chronologic versus photoaging. In Gilchrest BA (ed) Photodamage. Blackwell Science, Cambridge, MA, PP 123-135 

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Glycolic acid can be applied simultaneously with TCA, which represents another technique for a medium-depth peel. Glycolic acid is also used in creams for self-treatment. Since complications such as hyperpigmentation, infection, irritation, and photosensitivity are very rare, it is well tolerated. 

Epidermal growths such as actinic keratosis, lentigines or thin seborrheic keratoses can all be treated effectively with 25-35% TCA peels. Thicker epidermal growths or growths involving the dermis will be more resistant to treatment such as hypertrophic actinic keratoses and thicker seborrheic keratoses and may even be resistant to a medium-depth peel. Resistant lesions many times are best treated with a combination of a medium-depth chemical peel and other modalities such as manual dermasanding or CO, laser. 

TCA in concentration of 10-25% can be used safely for superficial depth peels and in concentrations >30% can be used for medium-depth peels. However, multiple coats of even the lower concentrations of TCA can result in a deeper penetration of this agent, thus essentially resulting in a medium-depth peel. In general, use of TCA in concentrations >40% is not recom-... 

Phenol-based peel can be performed as a full-face or partial procedure. If only one cosmetic unit is peeled with phenol-based solution, it is strongly recommended to perform medium depth peel on the rest of the facial skin. Full-face peels should be carried out under full cardiopulmonary monitoring with intravenous... 

Jessner s solution contains 14% resorcinol, 14% salicylic acid and 14% lactic acid. Jessner s solution has been used alone for superficial peeling, or in combination with TCA 35% to achieve a medium-depth peel. Increasing the number of coats applied to the treated area increases the depth and reaction induced by the Jessner s peel. These peels are well tolerated with minimal side effects in the author s practice. As with glycolic acid and salicylic acid peels, Jessner s peels are most commonly used as adjimctive therapy for moderate to severe facial dyschromias, acne, oily skin, texturally rough skin, fine wrinkles, and pseudofolliculitis barbae. 

Microdermabrasion Superficial chemical peeling Medium-depth peeling Deep peeling Ablative laser resurfacing Nonablative laser resurfacing Radio frequency therapy Facial lifting procedures... 

Tse Y, Ostad A, Lee HS, Levine VJ, Koenig K, Kamino H, Ashinoff R (1996) A clinical and histologic evaluation of two medium-depth peels. Glycolic acid versus Jessner s trichloroacetic acid. Dermatol Surg 22 781-786... 

The risk of bacterial or viral complications with medium or deep peels could lead doctors to think that, in order to avoid these problems, only superficial peels should be performed and patients with active acne or herpes should not be treated at all. With a medium or deep peel, herpes prevention - as far as it goes - consists in a sandwich treatment with aciclovir, which is not well tolerated by patients with sensitive stomachs. With acne, caution limits the range of treatment choice to careftjl superficial peels (which have limited effectiveness even after repeated sessions). We are forced to put off, sometimes indefinitely, performing medium-depth peels on patients with acne or herpes that have not responded to preliminary medical treatment. 

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