Anatomy of Skin

 

Epidermis Stratum Disjunctum

            S. Corneum

            S. Lucidum

            S. Filamentosum

            S. Germinativum basal layer

 

Dermis Papillary layer ; 모세혈관망

         Reticular layer ; 콜라겐 & 엘라스틴들의 섬유조직

 

Subcutaneou Fat

 

 

Classification of Peel Depth

 

Very superficial(exfoliation)

destruction of stratum corneum, not stratum granulosum

 

Superficial(epidermal)

destruction of part or all of the epidermis

 

Medium(papillary dermal)

destruction of the epidermis & part or all of the papillary dermis

 

Deep(reticular dermis)

-          destruction of the epidermis and papillary dermis that extends onto the reticular dermis

 

 

 

Peeling Agent의 종류

 

Inorganic Agent Phenol

TCA

Organic Agent

    AHA (Alpha Hydroxy Acid)

-Glycolic acid, Lactic acid, Malic Acid, Tartaric acid, Citric acid

-보습작용 / 수용성

 

    BHA ( Beta Hydroxy Acid )

-Salicylic Acid

-항염작용 / 지용성

 

    AFA ( Amino Fruit Acid )

-피부자극이 적으며 보습력이 좋다.

 

Classification of Peeling Agents

 

Very superficial

  -Glycolic acid 30% to 50% applied briefly ( 1~2 minutes)

-Jessner’s solution applied in 1 ~ 3 coats

-TCA 10% applied 1 coat

 

Superficial

-GA 50% ~ 70% applied ( 2~ 20 minutes )

-Jessner’s solution applied in 4 ~ 10 coats

-TCA 10% ~ 30%

 

Medium Depth

-GA 70% applied ( 3 ~ 30 minutes)

-TCA 35% ~ 50%

 

Deep

-Phenol 88% - 심혈관계 독성

-Obagi blue peel 눈으로 확인 가능

-Exoderm  -- 심부피부재생술

 

 

 

Fitzpatrick Classification System

 

Type I    white   always burn, never tans

II   white   Usually burns,  tans less than average

III   white   Sometimes mild burns, tans about average

IV   white   Rarely burns, tans more than average

V   brown   Rarely burns, tans profusely

VI   black   Never nurns, deeply pigmented

 

 

Repeeling

 

Very superficial (strastum corneum) peel  -  1 week

 

Superficial (intraepidermal) peel 2 ~ 6 week

Fullthickness epidermal peel  à at least 6 week

 

Medium depth ( papillary dermis ) peel 3 to 6 month

 

Never repeel a patient who has sensitivity or erythema persisting from a prvious peel

 

 

Safety Precaution of Peel

1.   Always check the label on the bottle of any chemical you applying to patient’s skin

2.   Never pass an open container of acid ( or an applicator wet with acid) over the patient’s face. It’s possible to accidentally drip acid onto the skin.

3.  Never perform a peel with the patient lying completely flat. Always elevate the head.

4.  Always have water nearby to flush the eyes in case acid get into them.

5.   Water for tears with all peels. A tear running down the cheek onto the neck can create an area of peeling on the neck.

6.   If you change brands of peeling agents, always be sure you know whether the preparation is made by the same measurement.

7.   Before peels, always ask patients whether fascial waxing, head & neck surgery, isotretinoin(로아큐텐) within past 1 to 2 years, using retinoic acid or AHA

8.   Any peel patients with a history of herpes simplex should use oral acyclovir(even with light peels)

9.   All patients undergoing any type of treatment for photodamage must a broad-spectrum sunscreen daily.

 

 

 

Jessner’s Solution

 

Formula

Salicylic acid    14g

Resorcinol   14g

Lactic acid(85%)  14g

Ethanol  to make  100ml

 

Stability

-          retain strength for up to 2 years if container is 5 minutes a month

-          light-and air- sensitive ;  stored in a dark amber bottlee with a tight cap

 

장점

 

1.  They are very superficial and rarely go deeper than you expect.(a safe choice fo sensitive skin)

2.  They create a fairly uniform depth peel (unlike AHAs).

3.  They create a good deal of exfoliation. This is helpful in treating dyschromias when you are trying to decrease the number of melanin-containing keratinocytes.

4.  Since the concentration of resorcinol in Jessner’s solution is low there is less risk of toxicity than a regular-strength resorcinol peel.

 

 

 

 

 

Glycolic Acid

 

Stability

-          not light-sensitive

-          very stable ( more than 2 year )

-          Deliquescent ( absorbs moisture from air ), so it must be kept tightly capped.

 

특징

1.   tremendous variability from patient in reactivity and efficacy

2.   not always create actual peeling of the skin ( not always necessary for result)

3.   has to be neutralized .  ( sodium bicarbonate solution )

4.  has a tendency to penetrate unevenly.

 

Caution

 

GA 70% cancreate an uneven peel, a dermal wound, scarring.

 

Key Points For Glycolic Acid Peels

 

1.  GA can create dermal wounds. ( Don’t ever tell a patient it is a risk-free peel )

2.  GA peels usually need to be repeated several times for their best effect.

3.  Some patients get significant effects from glycolic acid peel, other patients do not.

4.  GA peels always need to be neutralized to terminate their action.

5.  They can create significant inflammation in some patients and can induce postinflammatory hyperpigmentation.

 

 

Trichloroacetic acd(TCA) peel

 

-          not light-sensitive

-          stable for at least 23 weeks in an opened container.

-           

 

장점

-          no systemic toxicity

-          can be used to create superficial, medium or deep peels

-          inexpensive

-          stble

-          peel depth correlates with intensity of skin frost.

-          No need to neutralized a TCA peel

 

 

Complication of Peeling

1.  tears drriping onto the neck

2.  Premature peeling

3.  Infection

4.  acneform eruption

5.  echymosis

6.  postinflammatory hyperpigmentation

7.  hypopigmentation

8.  allergic reaction

9.

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