Introduction

In our evolution of chemical peeling for all skin types we have developed the progressive peel. This is a multiple coat peel in four steps, allowing the operator to watch the skin and adjust the peel to the skin’s reaction. Some patients will require three or four coats of each progressive peel solution I, II, III and IV. Other patients will develop the end point of the rosy red hue with a white frost with several coats of progressive peel I or II. This gradual progression of the peel allows the operator to stop at a safe end point. The step-by-step process avoids alabaster white, yellow or grey frost that may occur with high concentrations of TCA (45–55%) applied in one or two coats. Historically, the suggestions of other progressive peelers still apply (Box 6.1).

This chapter will be an overview of this progressive peel. We outline the step-by-step skin rejuvenation program (Box 6.2) for the improvement of complexion problems, fine lines and/or blotchy dyspigmentations in 155 patients. This illustrates what types of patients will benefit from the progressive peel. Afterwards, you will be able to conduct your patients through this step-by-step program to a freshened complexion. Previous authors in this textbook have also discussed skin preconditioning before the peel and more penetrating peels are covered in later chapters (see Box 6.3).

Box 6.3

Key features

• The more coats that are used the deeper the peel, so multiple coats of a 15% TCA can mimic the results of one or two coats of 30% TCA

• If too much surface area (face, arms and chest – 20% of the body’s surface area) is exposed to several coats of salicylic acid (14% in ethanol) that is left on the skin (as in the classic Jessner peel) eight to twelve hours later the patient can develop severe nausea, vomiting, dizziness and tinnitus from salicylism.

Method

• Patient selection

Skin Analysis

The skin analysis is the starting point for this rejuvenation process. The patient is classified by their Fitzpatrick skin type, plus, the extent of wrinkling, blotchy dyspigmention, sallow color, telangiectasia, pebbly appearance and the presence of skin lesions such as actinic keratoses. The overall score dictates the extent of skin rejuvenation required (Box 6.4). These findings correlate with the Rubin photo aging index. Rubin Level I is characterized by epidermal findings that maybe corrected with an aggressive topical skin care program alone. Rubin Level II is associated with papillary dermal findings which require a daily skin care program plus the progressive peel. Ruben Level III is with reticular dermal level changes which may require deeper rejuvenations such as laser resurfacing, dermabrasions or phenol peels. These will be covered in later chapters.

Box 6.4

Skin aging index

Informed Consent

The risks and benefits of this step-by-step skin rejuvenation program and the risks and benefits of alternative treatments including no treatment at all are discussed with the patient. All their questions are answered. These peels are contraindicated in some patients (Box 6.5). The degree of skin damage is determined and further documented with digital photography. Each patient signs the informed consent.

Box 6.5

Contraindications to the progressive peel

• The step-by-step skin rejuvenation program (Box 6.2)

There are five steps in the rejuvenation program. Step I of the rejuvenation process must be accomplished by the patient themselves. Free-radical generators such as sun worship, cigarette smoking and excessive refined carbohydrates in their diet must be avoided. If the patient plays golf or tennis in the sun every day or continues to smoke, the program will not work. The results will not last. If the patient continues to smoke, the collagen will be destroyed faster than it can be rebuilt. The ingestion of excessive sugars speeds up the glycosylation process in the dermis and makes the collagen more susceptible to hydrolysis.

Step II is the daily skin care program using cleansing granules, alpha hydroxyl acid toners and vitamin A conditioning lotions to accelerate the production of new skin cells. These three skin care formulations are used daily. However, patients with dry skin or who live in a dry climate start slowly, skipping days as needed to avoid retinoid dermatitis.

Step III is glycolic acid peels combined with microdermabrasions. This abrasion keeps the skin moving so it will not accommodate to step II. This step can be repeated every 2 to 4 weeks.

Steps II and III will continue for 4 to 16 weeks depending upon the skin type (Box 6.6) For example, the skin conditioning must be longer in the darker skin types to reduce the possibility of dyschromias.

Box 6.6

Length of preconditioning before the peel

• Caucasian: 4–6 weeks

• Mediterranean: 8–10 weeks

• Asian/Indian: 12–14 weeks

• Afro/American: 16–20 weeks

Step IV will be the application of the progressive peel. This will be adequate rejuvenation for the patients with a moderate skin aging index.

Step V, the phenol peel or equivalent may be required by some patients with a higher skin aging index. These procedures are covered in later chapters.

• The progressive peel

As a continuum of the skin rejuvenation process, the progressive peel is added after the skin has adjusted or accommodated to the initial two steps of the five-step program. The acute phase of retinoid dermatitis with the excessive peeling has passed. Although the skin may still be mildly flaking it will accept the peel safely; whereas, the resting untreated skin may not peel or the dermatitic skin seen during the initial phase of topical treatment with corrective skin care products is so raw that burning may develop. This process of preconditioning has been discussed in more detail in previous chapters.

Step IV: The Progressive Peel

After completing steps I, II, III of their skin care program the patient is ready for step IV, the progressive peel. They wash their face to remove any residual make-up, remove contact lenses and ear rings. Again, the peel program is outlined for them.

Tray Setup

A standard tray set up is important so nothing will be missed (Figure 6.1). Well-marked containers are used for the four peel solutions. Folded 3″ × 3″ cotton gauze is used to scrub in the chemical solutions. Five or six mL of each solution is poured onto the gauze which is rung out before the application begins sp the solution does not drip, cotton tipped applicators are available for small areas that require touch-ups or for around the eyes or temple areas. An eye wash solution is always on the tray to irrigate the eyes, if necessary. A bottle of water is on the tray to remind the patient to drink 4 or 5 glasses during the day to flush out any penetrating chemicals.