Outcome

In most cases of actinic damage, the mediumdepth peel has been effective, as evidenced by a diminution of AK and lessening of fine lines and wrinkles. Tse et al. accepted the challenge of comparing two different medium-depth combination peels, 70% glycolic acid/35% TCA versus Jessner’s solution/35% TCA,with respect to clinical and histological effects on facial skin [66]. Thirteen patients with AK, fine wrinkling, and lentigines were treated prospectively with both combination peels, each one applied randomly to either the left or right side of the face. Patients were evaluated at postoperative intervals of 7, 30, and 60 days using photographs and preauricular skin biopsies taken at each of the three postoperative visits. Clinically, both peeling combinations were effective at treating solar lentigines and AK, with the glycolic acid/ TCA demonstrating a slight advantage in eliminating AK. Neither peel was significantly effective at treating fine wrinkles. Recovery time for both agents was comparable at 7–10 days, but the Jessner’s/TCA combination created more postoperative erythema (30–60 days). Additionally, discomfort with the glycolic combination was slightly greater. Histologically, a more prominent periappendageal infiltrate was detected on the Jessner/TCA side, but greater neoelastogenesis on the side treated with the glycolic/TCA sides. An increased thickness of the grenz zone was noted on the glycolic acid/ TCA side, a finding that was, however, statistically insignificant [66].

Advanced photoaging (Glogau level III) is characterized dyschromic skin with obvious keratoses and demonstrable wrinkles at rest (Table 4.3). These patients are thought to typically fall into the age range of 50–60 years, but there is variation based on history of sun exposure, ethnicity, and Fitzpatrick’s classification of skin types (Table 4.2). In a study evaluating these types of patients with severe facial actinic damage,Witheiler et al. demonstrated that medium- depth peels can be equal in efficacy to 5- FU chemexfoliation in the treatment of AK, but reappearance of these lesions in both groups during a 12–32 month follow-up confirmed the need for regular follow-up [67].


Pigmentary dyschromias, including postinflammatory hyperpigmentation, and melasma, have both been treated successfully with medium- depth peels. The epidermal component of these pigmentary aberrations is responsive to superficial and medium-depth chemical peels, topical bleaching agents, and laser therapy. The dermal component can also be responsive to medium-depth chemical peeling agents albeit the response is less. In addition to removing the epidermis (and offending pigment), mediumdepth peels also affect the melanocytes in the pilar apparatus during the process of re-epithelization [49]. This mechanism, along with pre/posttreatment regimens with retinoic acid and hydroquinone, allows for a reduction in the risk of rebound hyperpigmentation when treating these pigmentary problems in nonwhite skin.

A combination medium-depth peel using Jessner’s/35% TCA was used to treat 15 Iraqi brown-skinned patients with acne scars classified as “crater-like form” and “pitted (ice-pick),” with enhanced treatment around the edge of the scar with 50% TCA beginning at the time of the second of three total peels [68]. The interval between peels was 1 month, and clinical response was documented by serial photographs and patient self-assessments.At an evaluation 3 months following the final peel, moderate improvement was achieved in eight of the 15 patients (53.3%) and minimal to no response in one patient each. In spite of pretreatment with bleaching aids, posttreatment hyperpigmentation was recorded in nine patients (73.4%) but completely resolved by the 3-month follow-up. Patients with primarily atrophic scars faired better than those with predominantly pitted scars,but the overall level of patient satisfaction with the outcome of their treated acne scars was 80%.


Cook et al. reported that in their series of 3,100 patients treated with a 70% glycolic acid gel and 40% TCA combination peel, approximately 10% were treated on their abdomen. In many cases, they found that abdominal striae distensae can be greatly improved, even if hypopigmented and atrophic.Understanding that the appearance of striae distensae frequently improves with time, irrespective of treatment, the authors warn that in those patients who did not observe improvement after the first peel, subsequent peels would likely be of no benefit.

By focally applying TCA at concentrations ranging from 10% to 65%, Chun et al. safely treated a host of benign pigmented lesion in 106 dark-skinned patients. The chemical peeling agent was applied to the affected area with a sharpened wooden applicator and allowed to remain until frosting.The concentration selected was based on the desired depth of penetration required to target each given lesion. The results revealed that 42 of 49 (86%) patients with solar lentigines, 19 or 23 (83%) patients with seborrheic keratosis, eight of 14 (58%) patients with freckles, and 11 of 20 (55%) patient with melasma experienced a good clinical response without significant complications [56]. A study involving 20 patients with Fitzpatrick skin types II–III and mild to moderate photoaging were treated monthly with four pyruvic acid 50% facial peels. Postoperative evaluation was based on this agent’s ability to improve the classic signs of photoaging and revealed smoother skin texture, less-apparent fine wrinkles, and lightening of freckles and lentigines [48]. Patient acceptance was high overall for this procedure due not only to the success in clinical improvement but also the low risk of complications and limited postpeel discomfort.