Medium-depth peels.

Treatment of melasma remains challenging due to frequent relapses and the occurrence of post-inflammatory hyperpigmentation (PIH) following many interventions. Treatment goals are inhibition of melanin synthesis and transfer by sunscreens, sun avoidance and the use of bleaching agents on one hand and removal of already present pigment by peeling, lasers and light on the other hand. Triple combination creams (TCC) (also known as Kligman’s formula utilizing hydroquinone and modifications of Kligman’s formula) remain the mainstay of treatment. Newer bleaching agents derived from plants and synthetic compounds have been introduced and many of them are promising safe substitutes for hydroquinone. Peeling agents especially superficial and medium depth peels are effective treatment modalities for melasma. Newer peeling agents are less irritating and may thus lead to fewer side effects. Q-switched lasers, which target melanin, have led to PIH until the innovation of “laser toning” and fractional Qswitched ruby, which have better outcomes. Fractional non-ablative and ablative lasers are useful at lower fluencies. Pulsed dye laser, which targets the vascular component in melasma, is promising with less melasma rebound. Combinations of the above-mentioned modalities usually have a better treatment outcome than either alone. This review will focus on the more recently introduced therapies.

Chemical peeling has become increasingly popular. Technique is more critical in medium depth peeling than with deeper peels because of variable penetration of the trichloroacetic acid. This article describes a novel use of two caustic agents, glycolic acid and trichloroacetic acid, to effect a predictable approach to medium depth peeling. Without other skin preparation, 70% glycolic acid was applied to the entire face and diluted with water after 2 minutes. Then, 35% trichloroacetic acid was applied over the same areas. Biopsies were done on selected patients after 24 hours and 30, 60, and 90 days. Both clinically and histologically the glycolic trichloroacetic acid peel resulted in medium depth injury. Improvement in pigmentary dyschromias and actinic damage was impressive. The GA-TCA peel provides a consistent approach to medium depth peeling to add to the armamentarium of the dermatologic surgeon.

We are currently in an era of rapid development of new techniques for skin enhancement and rehabilitation, some of which offer the possibilities of dramatic results, with minimized discomfort and diminished downtime. The goal of chemical peeling is to remove a controlled uniform thickness of damaged skin to improve and smooth the texture of the facial skin by removing the superficial layers and stimulate a wound healing response. In response to the chemical injury, fibroblasts in the papillary dermis increase production of collagen and growth factors. The collagen increase in turns thickens the dermis, which enhances the tensile strength of the skin and yields the clinical appearance of rejuvenation. Skin anatomy, technique of superficial and medium-depth peeling, postoperative care, and possible complications are discussed. Expertly performed chemical peels with healthy wound healing can achieve a significant reduction in facial rhytids, dyschromias, solar changes, acne, and superficial scarring.

The frequency of dermatological procedures is steadily increasing, accompanying a growing demand from patients. Chemical peels are a method of resurfacing in the treatment of various skin conditions. However, during the early healing process, patients may impose downtime on themselves. The erythema, pain and poor aesthetic appearance of the skin can lead to unwillingness to participate in social or professional activities. The objective of this study was to evaluate the tolerance and efficacy of a repair cream based on Rhealba Oat plantlets extract and active healing compounds after a peeling procedure. Men and women, aged 18-65years, with Fitzpatrick phototype I-IV, who had previously received a medium-depth chemical peel on the face (TCA 30%) entered with their consent a clinical study evaluating the new test product based on Rhealba Oat and active healing compounds. At the beginning of the study, the selected patients received a TCA 30% medium-depth peel. Afterwards, they were treated during 29days with the repair cream and evaluated for the benefits to downtime and pain. Significant reductions of pain (P<0.0114) and erythema (P<0.0001) were observed in the study. The downtime reduction with the tested cream was 92% - from 9days after the previous peeling procedure to 0.74days with application of the tested cream - a difference of 8.39days. In consequence, the tested repair cream based on Rhealba Oat plantlets extract and active healing compounds brings clinical benefit to patients who undergo peeling procedures. By reducing pain and downtime, it allows patients to get back to their daily life activities a week earlier than with previous peels.

Medium-depth chemical peels are an effective and popular treatment for actinic damage, fine wrinkles, and pigmentary dyschromias. However, they are also uncomfortable. A previous attempt to study the effectiveness of a topical anesthetic gel in 35% trichloroacetic acid (TCA) peeling found a reduction in discomfort but an increased depth of penetration and delayed healing. To evaluate both the efficacy of two topical anesthetic agents in medium-depth combination peeling as well as the histologic result from chemical peeling combined with topical anesthesia. Seventy percent glycolic acid (GA) was applied to the entire face of 10 patients and diluted with water after 2 minutes. This was followed by the sequential application of EMLA cream (lidocaine 2.5% and prilocaine 2.5%), ELA-Max cream (lidocaine 4%), and placebo to selected areas on the face for 30 minutes without occlusion. These agents were then removed and 35% TCA was applied to the entire face. The level of discomfort felt by the patients during the TCA peel was recorded, clinical photographs were taken, and bilateral preauricular biopsies were performed at baseline, 48 hours, and 90 days postoperatively. Clinically there was a statistically significant decrease in pain felt during the 70% GA-35% TCA peel with topical anesthesia when compared to the control. There was no statistically significant difference in efficacy between EMLA and ELA-Max. There was also no difference in either the clinical or the histopathologic appearance between the medium-depth peel combined with topical anesthesia and the medium-depth peel with control. Both EMLA and ELA-Max decrease the discomfort felt during medium-depth combination chemical peeling without influencing either the clinical or the histopathologic result.