Body Peeling

12 Body Peeling

Rebecca Tung, Mauricio Sato, Natalie Kim, Fabiane M. Brenner

When discussing the approach to chemical peeling off the face, adjectives such as conservative and gradual should come to mind. Common indications are much the same as their facial counterparts and can be grouped into those that would be best treated with superficial peels and those that would benefit from medium-depth peels (see Table 12.1).

Table 12.1 Indications for superficial and medium-depth peels

Superficial peels	Medium-depth peels
Acne Superficial dyschromias Keratosis pilaris Mild photodamage	Moderate photodamage Textural abnormalities including mild scarring Deeper dyschromias Lentigines Melasma Postinflammatory hyperpigmentation Poikiloderma of Civatte Striae alba

• Patient selection

All skin types may undergo body peeling but extra caution should be employed in darker skin (III–VI) types since there is increased risk of unwanted pigmentation changes. Skin types I and II can easily undergo medium-depth peels with little risk of untoward effects. Appropriate patient expectations should be established from the start.

While medium-depth peels on the face can be considered one-stage procedures, this is often not the case on the body. Due to increased potential for adverse events such as scarring off the face, similar peels are done in a series and at lower concentrations. Results are seen after a few sessions and should be accompanied by a regular topical maintenance program to prolong the benefits. Additionally, for specific indications, body peels can be combined with other minimally invasive procedures including lasers, light sources, electrodessication, cryosurgery to expedite resolution while minimizing complications and downtime.

While all superficial peels are virtually pain-free, a few patients may opt for a sedative (like diazepam) prior to a medium-depth body peel. Overall, the skin on the body is much less sensitive than the face. Even our most anxious patients find the nonfacial medium-depth chemical peeling experience to be ‘easy and quick’ and prefer to avoid an anxiolytic so that they can drive themselves to and from the procedure.

Whether peeling in facial or nonfacial locations, similar background medical and surgical history should be collected. Waiting periods of greater than 6–12 months after isotretinoin and greater than 6 months after invasive surgery may be observed due to potential for delayed wound healing and abnormal scarring.

Past exposure to radiation in the neck, chest or other proposed site to be peeled is also relevant. Radiation diminishes the number of pilosebaceous units in treated areas and places these patients at an increased risk for development of postoperative scarring. Presence of adnexal structures can be assessed clinically by observation of vellus hairs or microscopically by performing a small punch biopsy as Brody describes. Similarly, a history of hypertrophic scar or keloid formation is also relevant especially if peeling will take place in high risk areas such as the chest, back shoulders and junction of the jaw and neck.

Common medications such as oral contraceptives, hormone replacement, and minocyclines can predispose to postinflammatory hyperpigmentation after a peel. Patients taking these medications should be warned of this possibility and advised on sun avoidance after the peel and regular usage of broad-spectrum sun protection.

Vasoconstriction due to smoking can create delayed wound healing and predispose to infections. Additionally, smoking also impairs existing collagen and elastic fiber. While chemical peeling can be performed in smokers, benefits may not be as pronounced.

Peeling in patients with active inflammatory conditions such as dermatitis and acne should be carefully undertaken. Likewise, if an individual has open excoriations, one may wish to delay a peeling until these areas are healed.

When peeling off the face, herpes simplex reactivation is less likely and antiviral prophylaxis is not required. Due to the fact that all of the peeling agents have some degree of bacteriostatic activity, postprocedural antibiotics are not routinely prescribed.

All patients undergoing medium or deeper peels should have preoperative and postoperative photographs to document the baseline extent of solar damage, scarring, and/or other conditions and to demonstrate the degree of improvement after the peeling process.

A signed informed consent form should outline the risks, benefits, alternatives and limitations associated with chemical peeling. Expected responses to peels include burning and stinging sensations, redness, and peeling. Less common effects following medium and deep peels include prolonged erythema, and abnormal pigmentation. Rarely, infection, delayed healing or scarring may result. Alternative resurfacing procedures such as microdermabrasion, dermabrasion, nonablative, fractional and ablative resurfacing lasers should also be mentioned.

Once a patient decides to pursue chemical peeling, we also like to give them a written information sheet which details what to expect (specific information regarding downtime limits future phone calls), what they will need to do or purchase for after care, and contact phone numbers if questions or problems arise in the postpeel period.

• Preconditioning the skin

As might be expected, preparing the skin of the body is similar to what is done to the face prior to chemical peeling . For the sake of ease, only specific differences will be highlighted in the text while common preparations are listed in Table 12.2.

Table 12.2 Preconditioning the skin: selected priming regimen components

Daily broad spectrum sunscreen application is important in all conditions prior to peeling. It functions to reduce background pigmentation and potentially reduce the likelihood of postpeel hyperpigmentation.

In nonfacial acne, peels improve acne and mild scarring indirectly by improving the absorption of topical preparations and directly through the comedolytic and neo-collagenesis effects. While tretinoin is the most studied and commonly used retinoid for other indications such as photodamage and dyschromias, many acne patients may be on other products such as adapalene and tazorotene depending on tolerability. The purpose of starting topical retinoids ideally at least 14 days in advance of a peel is to harness their ability to promote an even, uniform peel and expedite time to healing. Patients may continue on their oral antibiotics throughout the process. Other topical therapies like benzoyl peroxide containing leave-on preparations should be discontinued a few days before the peel and restarted once the skin inflammation has subsided.

Of note, in patients who are being treated for abnormal pigment conditions or have a greater amount of background pigmentation in their skin, application of bleaching agents both before and after the peel can minimize the occurrence of postinflammatory hyperpigmentation. While hydroquinones (2–10%) are the most commonly used bleaching agents, other agents include, azelaic acid, aloesin, vitamin C, arbutin, licorice extract, or glabridin (licorice extract), mequinol (4-hydroxyanisol), melatonin, peptides (Lumixyl), niacinamide, and paper mulberry, soy, vitamin E, kojic acid, alpha and beta hydroxy acids, and retinoids. Alternating usage of hydroquinone in 3 to 4 month cycles with one of the natural depigmenting agents may prevent or reduce the possibility of side effects such as irritation or even exogenous ochronosis.

The Procedures on Location

• Chest and neck

For treatment of photodamage and dyschromias alone or associated with Poikiloderma of Civatte, we find that the Jessner’s + TCA (20–25%) combination peel produces good improvement in a safe and reproducible manner. Common locations where this type of peel would be performed include the neck, chest, back, hands, arms and legs. Depending on the sebaceous quality of the skin and overall skin sensitivity, the skin may be degreased fully with alcohol and acetone (sebaceous, non-atopic skin) or minimally with alcohol or simply with a mild cleanser and water (translucent, paper-thin skin or dermatographic atopic skin). Specific locations such as the neck also warrant a more gentle approach (generally no need for degreasing with alcohol or acetone) since the neck has fewer adnexal structures and is more prone to scarring. Compared to the face, the degreasing process when performed on the body is much lighter, in order to reduce the chance of the peel penetrating more deeply than anticipated.

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Tags: Procedures in Cosmetic Dermatology Series Chemical Peels

Mar 12, 2016 | Posted by admin in General Surgery | Comments Off

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