The Role of Priming the Skin for Peels

Introduction

Foundation: That upon which anything is founded; that on which anything stands, and by which it is supported; the lowest and supporting layer of a superstructure; groundwork; basis Webster’s Revised Unabridged Dictionary 1998.

The art of chemical peeling has been a constant in dermatologic surgery for many years. From the use of phenol in the treatment of acne scars in the early 1950s through the delineation of trichloroacetic acid (TCA) as treatment for photodamage, through the use of high percentages of TCA in the treatment of acne scars and benign lesions to the advent of alpha-hydroxy acid (AHA) and beta-hydroxy acids and others, the chemical peel has been the “slow and steady” performer for a variety of conditions. Regardless of the indication, skin priming is a required first step to ensuring the best results. It may be the most valuable step in the peeling treatment of melasma, second only to aggressive sun protection. The various factors involved in skin priming are examined here.

The foundation of an effective chemical peel is skin preparation. This begins in the weeks leading up to the peel and also includes the actual preoperative steps before the peel. With adequate priming, the skin will frost rapidly and more uniformly than unprimed skin. TCA in particular is usually applied expeditiously to minimize discomfort; a more rapid and complete frost will enhance the patient’s experience. Although relatively uncommon, adverse effects such as hypopigmentation or hyperpigmentation, delayed reepithelialization, and prolonged erythema may also be minimized, because skip areas are usually minimized as well. Finally, the postoperative phase can be shortened as a result of more rapid healing in primed skin.

Skin priming can be divided into two phases: (1) pretreatment and (2) preparation. These two phases are differentiated and determined by timing and the agents used. The pretreatment phase consists of topical agents applied in the days or weeks preceding the peel. The preparation phase encompasses those steps taken directly before the peel is performed. These include patient degreasing and cleansing just before and upon arrival at the office. The goal of both phases is to thin the epidermal barrier, enhance uniform active agent penetration, accelerate healing, and reduce postoperative side effects and complications, most importantly postinflammatory hyperpigmentation.