Papillary dermis peel

Jessner s Solution has been used for over 100 years as a therapeutic agent to treat hyperkera-totic epidermal lesions [1]. This superficial peeling agent constitutes a mixture of salicylic acid, resorcinol, and lactic acid in 95% ethanol. Jessner s solution causes loss of corneocyte cohesion and induces intercellular and intracellular edema. Jessner s typically induces wounding to the level of the papillary dermis. Historically, resorcinol (a key component of Jessner s peels) was used in concentrations of 10-50% in the early twentieth century. High concentrations of resorcinol were associated with side effects such as allergic contact dermatitis, irritant contact... 

Level 2 White frosting with areas of erythema showing through.This level of peel is indicative of a full-thickness epidermal peel to the papillary dermis and can be achieved with TCA concentration of >30%.This peel will result in full exfoliation of the epidermis (Fig. 4). 

Salicylic acid has a keratolytic effect, thus eliminating superficial pigmented keratinocytes and stimulating cells turnover. This superficial peeling allows TCA to act a low concentration to remove pigmented keratinocytes through papillary dermis (see Fig. 14.12). 

Superficial chemical peels, including salicylic and glycolic acids, and Jessner s peels target the stratum corneum to the papillary dermis. These agents can be safely used to facilitate the resolution of PIH (Figs. 16.2,16.3,16.4 and 16.5). To assess for variability in response and limit further PIH, when possible, chemical peels should be initiated at the lower concentrations and titrated to higher concentrations if necessary to increase efficacy while minimizing side effects (see Darker Skin Section). 

There is one basic principle to be respected a peel should not be unnecessarily deep or unnecessarily superficial. There is no point completely destroying the papillary dermis when treating a purely epidermal problem, and it is pointless and ineffective to use an intraepidermal peel, even repeatedly, to treat a dermal problem. 

Prevention of the herpes simplex virus is essential for patients who have a history of the infection (a single incidence of herpes is enough). Herpes prevention is necessary with a peel to the papillary dermis. It is also worthwhile when a more superficial peel is usually accompanied by a severe inflammatory reaction, as is the case with resorcinol, classic AHAs and TCA-SAS. It is not necessary when using Easy TCA imder its basic protocol or Easy Phytic . General infection prevention measures should be taken, depending on the depth of the peel. For more information, see the discussion of infections in Chapter 37. 

Trichloroacetic acid in simple aqueous solution (TCA-SAS) involves pre-peel preparation, application of the TCA-SAS solution to the required depth (usually the papillary dermis), flaking, natural skin regeneration and post-peel care. 

This must be taken into account when choosing a peel Fitzpatrick skin phototypes I-III can tolerate any kind of peel. Patients of type IV with light-colored eyes have fewer problems with dyschromia after a peel than dark-eyed patients of the same type. Type V and VI patients are at most risk with peels, and it is recommended not to go beyond the papillary dermis with these patients to avoid hypochromia. Type V patients are also quick to develop hyperpigmentation. Special care should be taken with patients who have prolonged hyperpigmentation with mosquito bites or small wounds. 

Localized phenol peels should only be carried out on patients with a skin phototype lower than IV, so that the area treated with phenol is not left lighter than the surrounding skin, even if it has been treated with a medium peel to even out the color. The same applies to patients with many freckles, which mostly disappear after a peel to the papillary dermis. 

Solar or senile lentigines respond partially to peels to the Grenz zone and the papillary dermis. They sometimes require a peel to the reticular dermis to get rid of them completely. This deep peeling can be local. 

A deep peel would not be the best way to treat this patient, as the ratio of results to complexity -i- complications + downtime -I- cost would not be favorable. The possibility of a medium peel to the papillary dermis could be discussed, if the patient wanted fairly quick results or if she did not have enough time for a series of lighter peels. She could also be advised to have a series of peels, either intraepidermal (to remove the epidermis) or dovm to the basal layer, combined with appropriate daily care. 

Lip Eyelid formula was originally developed to treat only the lips and eyelids before its indications were extended to the full face. It can be applied locally without nerve blocks or any kind of anesthetic (see Chapter 36). A TCA Unideep peel (to the papillary dermis) is applied to the rest of the face immediately after the phenol peel has been applied locally (Figure 5.11). The Unideep must not come into contact with the skin that has been treated with phenol. 

Botulinum toxin, used alone, would only partially improve the areas around the eyes, lips and cheeks. A surgical facelift would tighten the neck and the cheeks, but it would not treat the crow s feet satisfactorily and would have no effect at all on the wrinkles on the lips and the overall skin quality. A light peel would only improve skin quality and even out skin tone, but would not get rid of the wrinkles. A peel to the papillary dermis would have a similar and more noticeable effect, but would not get rid of these deep and long-standing wrinkles. An experienced... 

For the same reasons outlined above, the risk of secondary bacterial infection is considerably lower with ETCA than with TCA-SAS. Systematic prevention of infection is not necessary with ETCA no antibiotics, no disinfectants. The Langerhans cells (LCs) in the epidermis and papillary dermis are not destroyed, nor are the other antigen-presenting cells, and they continue to prepare the body s defenses against microscopic predators. The lymphocytes, macrophages and other defense cells remain present in the dermis. The post-peel cream , applied as soon as the first... 

TCA-SAS is applied with a view to destroying damaged (usually sim-damaged) skin structures and benefiting from the skin regeneration that naturally follows a peel. It is really effective when it destroys the papillary dermis. 

Applying a TCA-SAS peel, usually to the papillary dermis, takes a lot longer at least an hour should be allowed for settling the patient in, disinfection, make-up removal, setting up the monitoring equipment, FNB or sedation, a series of applications and letting the patient rest after the peel. 

Post-ETCA care consists simply of asking patients to protect their skin from the sun (Melablock -HSP) and to apply the most suitable cosmeceutical for their particular problem (see Chapter 3). They should start the very day after the first of the four peels and continue until the end of the 6th week after the last peel. The post-treatment care after a TCA-SAS peel is more complex and needs much closer monitoring, as the risk of complications is much higher. Follow-up monitoring after a TCA peel to the papillary dermis is described in Chapter 23. 

During the post-peel period after a TCA peel to the papillary dermis, the patient has to put up with a week of edema, scabbing, erythema, pain and other inconveniences. Any form of social life is out of the question, and the patient can only return to normal social activities, with the help of make-up, after the 8th day. It is several weeks before the skin returns to normal. With ETCA (basic protocol), on the other hand, the patient can lead an almost perfectly normal social life, as the flaking is no more serious than with sunburn and only lasts for 48-72 hours. 

Either four Easy TCA peels to the basal layer or a Unideep peel to the papillary dermis. 

See Chapter 34 for application of the Lip Eyelid formula. Although it must be taken into account that four peels to the Grenz zone are not necessarily as efficient as one peel to the papillary dermis. The latter can destroy a large number of lesions that peels to the Grenz zone do not always reach. Some studies suggest that DMAE can eliminate the lipo-fuchsin in lentigines. 

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