For improvement of comedones, acne, and dilated pores, our preferred combo is SA-PEG (Dainichi et al. 2008a, b), left in the skin for 5–10 min, removed with a soft wet rayon tissue, followed by 5% tretinoin mask (solution or cream). This combination is particularly effective because SA-PEG does not evaporate and penetrates deeply in the follicles. After applying tretinoin, all-trans retinoic acid (ATRA), the residual intrafollicular peel blends with the mask, producing an occlusive intrafollicular effect of both agents.

When facing a patient with extensive facial palpable actinic keratosis (AKs), with the intent of treating the whole field of cancerization, many methods may be used, including photodynamic therapy (PDT), medium- or deep-depth chemical peeling, or dermabrasion. But those methods are usually performed after scheduling, and also, the patient has to plan for downtime. Less painful and no-downtime procedures include daylight PDT and superficial peels, followed by either localized cryotherapy on the thicker AKs or by a mask of Efudex^®, 5% 5-fluorouracil (5-FU) cream. The superficial peels of choice for these procedures are 30% SA-HA, Jessner’s solutio n, 70% glycolic acid , or 40–50% pyruvic acid . These procedures may be repeated every 7–14 days, until no residual AKs are palpable, usually after five sessions. The whole combo may be performed in the following way: 40% pyruvic acid peel for 5 min, neutralization with 10% sodium bicarbonate solution in a wet rayon soft tissue, removal of residual bicarbonate with a wet rayon soft tissue, and friction with gauze sponge on areas of AKs or soft curettage, application of Metvix^®, daylight procedure for 2 h, or exposure to 37 J/cm² red LED (about 7 min), cryotherapy on the thicker AKs, and 5% 5-FU mask for 4–6 h. This latter procedure is much more valuable, and may remove most palpable AKs in a single session.