18.1 Safety Considerations

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  A careful history and physical examination allows for the clinician to determine the patient’s candidacy (▶ Table 18.2 ).

  
  
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  The senior author’s (R.J.R.) preference is to pretreat all patients for 4 to 6 weeks prior to chemical peeling. ^{1 , 2} This regimen includes topical tretinoin (0.05–0.1%), hydroquinone (2–4%), sunscreen, and alpha hydroxyl acid (4–10%). Pretreatment improves skin tolerance, regulates fibroblast and melanocyte function, improves dermal circulation, and allows for the treated skin to heal 3 to 4 days faster due to increased cellular division and new collagen formation. ^{1 , 3 , 4}

  
  
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  Safety and consistency are prioritized to ensure optimal results. In the case of 35% TCA peel combined with Jessner’s solution, this begins with a set-up of four clearly labeled glasses ordered from left to right in the appropriate sequence of usage.

  
  
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  The glasses are filled by the operating surgeon with:

  
  
  
  
  1. 
     

     70% ethyl alcohol (cleanser).

     
     
  2. 
     

     acetone (degreasing agent).

     
     
  3. 
     

     Jessner’s solution (provides a uniform superficial exfoliation).

     
     
  4. 
     

     35% TCA acid solution. ¹

  
  
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  The addition of Jessner’s solution prior to TCA peel application leads to partial removal of the epidermis, allowing for deeper penetration of the TCA. This combination is beneficial, as lower concentrations of TCA can be used for the same depth of peel, minimizing complications such as scarring. ⁴

  
  
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  All patients are given 24 hours of prophylactic antibiotics. Acyclovir is initiated 2 days prior to chemical peel and continued 5 days after the peel in patients with a prior history of herpetic lesions.