13 Superficial to Medium-Depth Peels
A Personal Experience
Introduction
Chemical peeling as a therapeutic modality for acne has many benefits:
The Problem Being Treated
• Patient selection
The success of a chemical peel depends on careful selection of patient and individualization of treatment. Patients with mild facial rhytides and/or minimal dyschromias are the best candidates for superficial to medium-depth chemical peels. Deep rhytides and excessive facial laxity are likely to best respond to traditional rhytidectomy as the primary procedure and chemical peeling as an adjunct. Careful evaluation of skin type and complexion is the first step. The Fitzpatrick classification of skin types (I–VI) is often used to help stratify a patient’s risk for pigmentary complications. Darker phototypes are at higher risk for developing postpeel hyperpigmentation especially after more aggressive peels, while lighter phototypes seem to be more susceptible to excessive penetration of the peeling agent. In all cases, careful monitoring during the procedure is prudent (Boxes 13.1, 13.2, Table 13.1).
Box 13.1
An example of significant improvement in MASI score, after peeling treatment, from baseline to T3
| Facial Areas | TOTAL MASI SCORE |
|---|---|
| F + RM + LM | 12.6 |
| Facial Areas | TOTAL MASI SCORE |
|---|---|
| F + RM + LM | 3.6 |
Box 13.2
Wrinkle severity rating scale (WSRS)
| Score | Description |
|---|---|
| 1 | Absent: No visible fold; continuous skin line. Amelioration with TCA peels |
| 2 | Mild: Shallow but visible fold with a slight indentation; minor facial feature; improvement in skin texture with TCA peels |
| 3 | Moderate: Moderately deep folds; clear facial feature visible at normal appearance but not when stretched. Excellent correction with phenol peels |
| 4 | Severe: Very long and deep folds; prominent facial feature; less than 2 mm visible fold when stretched. Significant improvement expected with combined peels |
| 5 | Extreme: Extremely deep and long folds detrimental to facial appearance; 2–4 mm visible V-shaped fold when stretched. Unlikely to have satisfactory correction with medium and deep peelings alone |
Table 13.1 Correlation among skin diseases and suggested peeling approach
| Skin disease | Diagnostic method | Suggested approach |
|---|---|---|
| Comedonal Acne-papulo-pustular | Global scorea | |
| Melasma | MASI scoreb | |
| Photoaging | Wrinkle severity indexc | |
| Xantelasma | Clinical evaluation | |
| Acne scars Box scar | Goodman & Barron classificationd | |
| Rosacea | Clinical evaluation | |
| Lentigo simplex | Clinical evaluation | |
| Actinic keratosis | Clinical evaluation | |
| Chicken pox | Goodman & Barron classificationd |
a Doshi A, Zaheer A, Stiller MJ 1997 A comparison of current acne grading systems and proposal of a novel system. International Journal of Dermatology 38:416–418
c Day DJ, Littler CM, Swift RW, Gottlieb S 2004 The wrinkle severity rating scale: a validation study. American Journal of Clinical Dermatology 5(1):49–52
d Goodman GJ, Baron JA 2006 Postacne scarring: a qualitative global scarring grading system. Dermatologic Surgery 32:1458–1466
