Chemexfoliation agents are broadly classified into superficial, medium, and deep peeling agents according to their depth of penetration and histologic injury.
Preoperative evaluation of skin type, degree of photoaging, and underlying skin disorders is critical in safeguarding against potential complications.
Appropriate patient selection and choice of procedure are critical to success.
Keratocoagulation, evidenced by a white frosting of the skin, is generally regarded as the desired clinical end point of chemical peeling with trichloroacetic acid.
Mechanical resurfacing, which includes microdermabrasion, manual dermasanding, and motorized dermabrasion, is an effective method for treatment of scars.
Infection, prolonged erythema, pigmentary alterations, and scarring are potential complications of resurfacing procedures.
Resurfacing procedures, including chemical, mechanical, and laser resurfacing, wound the skin in a controlled and predictable manner so as to promote the growth of new skin with improved texture and quality. The art of chemical peeling dates back to ancient Egyptian times when the use of animal oils, salt, and lactic acid in sour milk were used to cosmetically enhance the appearance of skin. Mechanical exfoliation was first described in Greek and Roman literature using compounds containing mustard, sulfur, and limestone. In the mid-1800s, Viennese dermatologist Ferdinand Hebra used various peeling agents to treat pigmentary abnormalities. These early exfoliative agents included tinctures of iodine and lead, croton oil, cantharides, and various acids, including sulfuric, acetic, hydrochloric, and nitric acids. Tilbury Fox first introduced phenol to the topical dermatology arena in 1871. A decade later, P. G. Unna reported on the use of salicylic acid, resorcinol, phenol, and trichloroacetic acid (TCA) as peeling agents. Over the next century, several physicians worked to modify peeling agent formulations, combinations, and procedures. In the 1980s, Samuel Stegman identified the depth of injury associated with various peeling agents, which enabled later categorization into superficial, medium, and deep chemical peels. Today, chemexfoliation, or chemical peeling, involves the application of a chemical exfoliant aimed to wound and subsequently regenerate the epidermis and/or dermis to remove superficial skin lesions, improve pigmentary abnormalities and photodamage, and address textural concerns (Table 213-1).1
Table 213-1Resurfacing Procedures |Favorite Table|Download (.pdf) Table 213-1 Resurfacing Procedures
| ||PEELING ||DERMABRASION ||LASER |
|Superficial || |
|Microdermabrasion ||– |
|Medium depth ||Jessner solution + 35% trichloroacetic acid ||Manual dermasanding ||Erbium laser |
|Deep ||Baker phenol peel ||Mechanical dermabrasion ||CO2 laser |
The perioperative evaluation is a critical component of every chemical resurfacing procedure. The physician should seek a thorough understanding of patient treatment goals, expectations, and allotted down time prior to initiation of the procedure. The physician should also assess the patient’s level of compliance and need for preprocedural and/or postprocedural adjuvant treatments.2 Patients should be instructed to avoid depilatory procedures, such as waxing and shaving, prior to the procedure, as well as ultraviolet light exposure before and ...