Scars patient selection

The risk of scarring after a TCA peel is also linked to the quality of the care surrounding it. Apart from some serious cases, scars do not form immediately, but are preceded by prolonged local erythema and/or infection that should be diagnosed and treated appropriately. Many problems (see below) can be avoided by proper patient selection, and post-peel monitoring can limit others. 

Since TCA in higher concentrations tends to produce increased scarring and hypopigmenta-tion, 70% glycolic acid solution was applied to the entire face of patients and diluted with water after 2 min. This was followed by the sequential application of EMLA cream (lidocaine 2.5% and prilocaine 2.5%) or ELA-Max cream (lidocaine 4%) to selected areas on the face for 30 min without occlusion. These agents were then removed and 35% TCA was applied to the entire face [10]. 

Practolol (Figure 8.13) was the prototype cardioselective p-adrenoceptor blocking agent. Selectivity was achieved by substitution in the para position with an acetyl anilino function. The similarity of this drug with those outlined above is obvious. Practolol caused severe skin and eye lesions in some patients which led to its withdrawal from the market [6]. These lesions manifested as a rash, hyperkeratosis, scarring, even perforation of the cornea and development of a fibrovascular mass in the conjunctiva, and sclerosing peritonitis. Some evidence is available that the drug is oxidatively metabolized to a reactive product that binds irreversibly to tissue pro-... 

Delayed enhancement MRI may prove to be a powerful noninvasive technique that based on quantification of scar burden can risk stratify patients for SCD and select patients who may need further therapy. Ongoing trials will clarify the role of MRI in risk stratification, and whether assessment of infarct mass will supplant LVEF as the best sole risk stratification tool. 

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. 

The level of improvement can vary with regard to different diseases and individual patients. With training and experience, one will be able to select the most apjjropniate peel type(s) to address a patient s specific skin condition. For example, a patient with ice-pick acne scars can expect only mild improvement in the scars even if skin texture is remodeled. Conversely, a patient with isolated box car scars can obtain a significant improvement with focal application of TCA at 50-90% to individual scars. This technique called TCA CROSS (chemical reconstruction of skin scars) can produce more than 70% improvement of visible scars with homogeneous tightening of the skin. 

To better select the right patient for the right peel it is important to obtain a detailed history that evaluates all potential risks linked to the peeling agents. It is important to identify all potential factors that may adversely affect the outcome of a peel and fully characterize a patient s skin type and jjropensity to scar and hyperpigment (see Table 13.3). 

---