Photoaging severity

The success of a chemical peel depends on a careful selection of patients and individualization of the treatment. Skin texture, thickness, degree of photoaging, severity of facial rhytids and scars, and age-related gravitational changes must all be considered. It is very important to choose chemical peels that are safe and effective in darker skinned patients since these individuals are at greater risk of pigmentation abnormalities or other complications after peels. 

Fig. 15.3c, d. Series of patients showing Glogau s four photoaging groups, c Advanced photodamage, d Severe photodamage... 

The more severe the photoaging, the more important it is to consider the depth of the peel. The patient shown in Figure 5.7 has a light skin type that is sensitive to the sun s rays. She has developed a number of solar lentigines and fine wrinkles caused by UV rays. The eyelids are very wrinkled and the nasolabial folds and marionette lines are slack. 

Patients with skin phototype above IV are therefore ruled out from this treatment, as are patients with a light skin phototype but a lot of freckles, and patients whose skin is severely photoaged. Phototype IV patients should make a choice between deep wrinkles and a possible depigmentation. 

A young, healthy and hydrated skin is less permeable than skin treated with tretinoin or skin with seborrheic dermatitis, severe photoaging or acne. 

As a precaution, the initial concentration of glycolic acid should not be more than 8% and the gel should be applied every other day at first. The concentration and frequency of application can be increased, depending on the skin s response and tolerance. When treating severe photoaging, the concentration of the glycolic acid should be gradually increased from 8% to 12%, 15% or possibly 20%. 

When phenol is dumped into river water, it is very toxic to aquatic fauna and lethal at a concentration of 1 ppm. The genuine toxicity of phenol and the almost apocalyptic descriptions of its side-effects, which can even lead to death by cardiovascular collapse, severely limited its cosmetic use imtil the second half of the 1990s, especially in Europe. English-language publications, for their part, state that, even so, a phenol peel is one of the most frequently used techniques in the treatment of photoaging . ... 

A phenol peel is mainly indicated to treat facial skin for severe photoaging. It is the only type of peel that can get rid of deep wrinkles and regenerate elasticity and firmness in... 

The patient in Figure 29.9 is a typical case where the facial photoaging would benefit far more from a full-face phenol peel than from a neck- and face-lift. Nevertheless, phenol, with difficulty, tightens and rejuvenates the neck, which will only benefit from surgery followed by a peel to the papillary dermis or several peels to the Grenz zone (with ETCA) to improve the quality and the color of the skin after the surgical face-lift. 

For example, when the patient presents with severe photoaging and sagging skin at the same time. 

A phenol peel is the deepest type of peel, the one that gives the most dramatic results but that is also the most dangerous. Its indications are precise and limited to cases that cannot be treated by other peels. If an alpha-hydroxy acid (AHA) or trichloroacetic acid (TCA) peel can solve a skin problem, it will be chosen over a phenol peel without hesitation. The main indication for a phenol peel is severe photoaging. 

Lentigo maligna combined with severe photoaging (a) before and (b) after a full-face phenol peel. 

Fig. 10.1 Severe hand photoaging before (a), after 1 week (b), and after four sessions (c) of bio-rejuvenation followed by combination 25% salicylic acid and 25% TCA. Note crusting (b) on the hyperpigmented lesions treated with spot TCA...

A number of small studies have indicated that the amelioration of more severe acne scars, moderately deep rhytides, and the effects of photoaging, which are often recalcitrant to standard treatment regimens, can be improved by combining microdermabrasion and super-hcial chemical peels in one treatment session. While more published data to support the use of this combined technique would be welcome, the data that are available indicate that it is highly effective, well tolerated, and more convenient for patients. 

Need for heavy makeup Type IV Severe photoaging... 

Uses Despite frequent adverse reactions, many off-label uses of isotretinoin, or 13-c/s retinoic acid, have been reported, the most promising of which are seborrhea, seborrheic dermatitis, severe rosacea, advanced photoageing with multiple actinic keratoses, and prevention of non-melanoma skin cancer in at-iisk patients [67 ]. 

---