Sách Giáo Khoa Về Lột Da Hóa Học (Chemical Peels – Ấn Bản 2)

142      Textbook of Chemical Peels
(b)
(a)
(c)
Figure 19.10  Figure 19.10  (a) A hyperkeratotic lesion less than 1 cm in diameter, with a dry and atrophic epidermis. (b) After one local
application of Only Touch combined with two ETCA sessions. (c) Dramatic improvement after two applications of Only Touch and three of
ETCA. An extra session of Only Touch would be necessary to treat the problem completely.

Treating aging skin of the hands and forearms      143
NOTES

1. I shall make no comment on the validity of this type of replace-
ment therapy.

2. See Chapter 3. DHEA-Phyto cream (in the morning) and Renutriv
ACE Lipoic Complex (in the evening) are particularly effective
on the hands. Please see on page 141, “note 2.”
(a)
(b)
(c)
(d)
Figure 19.11  (a) Before application of Only Touch and Easy TCA. (b) Day 8 after application of Only Touch and Easy TCA: scabs are visible;
the patient should not scratch them. (c) Day 30 after Only Touch and Easy TCA treatment, just before fat graft. (d) Day 30 after fat graft.
(b)
(a)
Figure 19.12  (a) Flat warts after treatment with Only Touch. (b) Uneven but sufficient frosting achieved after local applications of Only Touch.

20
Treating the neck and décolletage
CONSIDERATIONS IN TREATMENT
Peeling or Surgery
The neck is a difficult area to treat, and results vary widely.
Essentially, the sagging neck remains a surgical indication.
Peelings can improve the neck skin quality, but they can-
not tense sagging skin. It is dangerous to think that applying
a larger quantity of acids on the neck will tense the skin. If
enough acid is applied on the neck to tense the skin, it will be
because of the scars that the acid induced.
Décolletage usually is not an indication for surgery;
­peelings are superior to surgical methods for improving décol-
letage skin quality.
Specific Risks of Peeling Neck/Décolletage
Even if this area presents a low appendage density, the skin
on the décolletage remains a good candidate for careful chemi-
cal peelings. Nevertheless, it responds all too readily to serious
injury (peeling procedures that are too deep) by forming scars
that are often hypertrophic.
Décolletage peeling should never be too deep; it should
never surpass the low capacity of this skin to regenerate.
Peeling Selection
Trichloroacetic acid (TCA) is a good choice as long as its con-
centration does not surpass 25%. The author prefers using Easy
TCA (ETCA), Easy TCA Pain Control, or Unideep peels for the
neck and décolletage.
Deep focal application is possible, as long as the diam-
eter of focal application is less than 1 cm. For small areas, a soft
touch with Only Touch peel is safe, even if the concentration
surpasses 45% w/w.
Peeling Application
When applying the peeling solution, the doctor must be patient
Do not apply quickly the successive layers; carefully wait for each
layer to dry completely before applying solution to the next one.
If the solution is applied to many layers without waiting
for it to dry, too much acid will interact with skin and an over-
peeling could result.
The details of treatments are outlined in Table 20.1.
Figure  20.6(a) shows the presence of numerous, large
lentigines on the décolletage. The average diameter of the
­lentigines is larger than 1 cm, and many lesions are confluent.
This ­contraindicates the use of Only Touch peel. The selected
alternative is a focal touch with Easy Phen Light on a cotton
bud (30% oil of phenol + 15% TCA + 4 alpha hydroxy acids)
combined with a full area application of ETCA after obtain-
ing the end point frosting with Easy Phen Light. An immedi-
ate ­erythema appears; it will be controlled in 5–10 minutes by
applying the Skin Tech postpeel mask (Figure 20.6[b]).
After the postpeel mask has been applied, a protec-
tive layer of Yellskreen powder is applied to the treated area.
Yellskreen contains bismuth subgallate powder, which forms a
protective crust (Figure 20.6[c]). This crust is not water soluble,
but natural moisture is present under the crust, which helps
achieve perfect healing. Moreover, the powder is antiseptic.
Because of the Yellskreen application, no special care is needed
for the next 8 days, which makes the postpeel period as simple
as possible. There will be no chance of self-infection by the
patient’s hands.
On postpeel day 8, white petrolatum jelly is applied on
the Yellskreen. It will form an impermeable coating over the
yellow crust, which will block the natural transepidermal
water loss into the crust and make the scab unstuck, because it
is not water soluble (Figure 20.6[d]). On day 10, focal erythema
is visible on the points that had been the most deeply touched
by the phenol. The rest of the skin is no longer red.
The most important step is to apply IPLase to block
further inflammation and free radical production, and sun
protection 50+ to prevent melanocyte stimulation by UVs.
Blending Bleaching Cream also should be used to prevent PIH
development.
On postpeel day 30, some erythema is still visible, but it
will progressively fade when following the same postpeel care
regimen (Figure 20.6[e]).
Acne Scars
Acne scars may be visible (Figure 20.7[a]); the presternal area
is known for its capacity of developing hypertrophic scarring.
The patient illustrated also presented facial vitiligo and vitiligo
spots on the area to be treated.
The aim of the treatment was to improve the appearance
of the acne scars without inducing hypertrophic scars and lim-
iting the risk of the Koebner phenomenon that could “import”
vitiligo to the treated area.
The treatment plan was as follows:
•
After careful disinfection, perform a superficial abrasion:
very first pinpoints of blood (Figure 20.7[b]). Sand paper
P220 wet or dry, gamma ray sterilized, has been used for
abrasion.
•
Do not apply acid after the abrasion.
•
Apply the Skin Tech postpeel mask under occlusion for
24 hours. The treatment team came to this decision after
discovering the postpeel mask under occlusion deepens a
peeling.
The postpeel mask is applied to the skin after sandpaper
abrasion; the mask is then covered by an alcohol disinfected

Treating the neck and décolletage      145
Table 20.1  Treatments for Décolletage and Neck
Indications
Protocol and repetition
Remarks
Slightly sun-damaged neck and/
or décolletage (Figure 20.1)
The basic protocol for Easy TCA (ETCA) should be used1 on
décolletage.
End point: Frosting points
Depth: 3/7
Postpeel mask applied at the end of peel
Then face is treated to the desired depth.
The décolletage could be treated as
a separate area but is usually
treated at the same time as the
face and neck.
The order in which these areas are
treated does not matter.
Nevertheless, for the patient’s
comfort, take into consideration
that treating the décolletage is
usually less painful than treating
the face.
To be repeated:
• Four times at weekly intervals on the face
• Four times once every 2 weeks on the neck and
décolletage, which take twice as long to flake as the face.
Moderately sun-damaged neck
and/or décolletage (Figure 20.2;
also see Chapter 15)
Deeper protocol of application is used.
End point: Cloudy-white frosting Depth: 4/7
Postpeel mask applied at the end of peel
Then face is treated to the desired depth.
A moderately damaged décolletage
presents deeper damage and
should be treated more
aggressively than a slightly
damaged décolletage.
To be repeated:
• Four times at weekly intervals on the face
• Two times once every 2 weeks on the neck and
décolletage, which take twice as long to flake as the face.
Lentiginosis of the décolletage
(Figure 20.3; also see Chapters
19, 22, and 38)
“Mosaic peel” technique is recommended.
Only Touch peel is applied focally on easily visible lentigines.
End point: White frosting.
This is treated with a combination of
Only Touch and ETCA.
Regular maintenance treatment and
sun protection are essential to
avoid recurrence or the
appearance of new lentigines.
Note: For more information on face
lentigines, see Chapter 22. Only
Touch is not intended for a facial
application because it could
induce scarring and long-term
redness/pigment problems.
Easy TCA is applied after Only Touch, up to the desired
depth: 3/7 or 4/7.
Postpeel mask is applied immediately at the end of the
procedure.
To be repeated:
• Only Touch to be applied immediately before the first and
eventually before the fourth ETCA.
• ETCA to be repeated an average two times once every 2
to 3 weeks on the neck and décolletage, which take
twice as long to flake as the face.
Moderate photoaging and acne
scars on the décolletage
(Figure 20.4; also see
Chapter 21)
If photoaging is widespread, a specific ETCA abrasive
protocol can be used: the décolletage is abraded with
sandpaper abrasion up to the very first bleeding pinpoints.
No acid is applied in this protocol, to prevent the acid from
penetrating too deeply and potentially causing scars, but
the area is covered with postpeel mask cream and left
under occlusion for 24 hours.
Such abrasive protocol, without acid, can be repeated after 1
month’s rest.
Severe photoaging of the
décolletage (Figure 20.5; also
see Chapter 23)
Deeper procedures could be considered:
1. Unideep, a papillary dermis TCA peel, can peel the
décolletage area more deeply.

Depth: 5/7

Unideep can be repeated 1 month after the first
procedure.
For more information about Unideep,
see Chapter 23.
Easy TCA Pain Control contains
phenol, but no toxicity is to be
feared as long as one dose only
(2.7 ml of reconstituted solution) is
used.
2. Easy TCA Pain Control can induce a deeper peeling than
ETCA and could be used for the décolletage area.

Depth: 5/7

Easy TCA Pain Control can be repeated 1 month after
the first procedure.
3. Easy Phen Light also can be used as a touch procedure
for treating numerous large décolletage lentigines.

Depth: focal 6/7

ETCA is applied after Easy Phen Light to the entire area.

146      Textbook of Chemical Peels
(b)
(a)
Figure 20.1  (a, b) Improvement only in the quality of the skin on the neck after two series of four ETCA peels according to the basic
protocol (frosting points).
Figure 20.2  Only the top part of the décolletage has been
treated with two sessions of four ETCA peels: there is a noticeable
improvement in the texture of the skin in the treated area.
Figure 20.3  Treatment of lentigines on the hands and décolle-
tage with Only Touch plus ETCA.
(a)
(b)
Figure 20.4  (a) Postpeel mask cream (only postpeel mask, without application of acid solution) under occlusion after sandpaper abra-
sion. (b) Appearance of the skin on the third day, just before flaking begins.

Treating the neck and décolletage      147
(a)
(c)
(d)
(e)
(b)
(f)
(g)
Figure 20.5  (a) Typical photoaging of the décolletage. (b) Treatment of décolletage photoaging with Unideep (TCA peel to the papillary
dermis). There is pink-white even frosting and “sliding” sign. (c) Cold packs (3M) can alleviate the burning sensation of acids. (d) Treatment
of décolletage photoaging with Unideep (TCA peel to the papillary dermis). Endpoint of the treatment and application of the postpeel mask.
(e) Skin desquamation of décolletage at day 3 after papillary dermis peeling with Unideep. (f) Daily care is as follows: on days 1–6, Nutritive
Cream Vit. A-C-E Lipoic Complex; on days 6 and 7, sterile white Vaseline. The photograph shows the results after 8 days. (g) Unideep:
results after 12 days. Sun protection of SPF 50+ and daily care are essential to maintain the results in the long term.

148      Textbook of Chemical Peels
cling film for 24 hours. Figure  20.7(c) shows a few bleeding
points. After 24 hours, the cling film is removed. The skin
appears uniformly red and without epidermis (Figure 20.7[d]);
some focal infection points are visible, and the patient will be
given antibiotic therapy for 5 days.
Yellskreen powder is applied to the desepidermized skin,
to protect the skin, and allow a natural healing under the crust
(Figure 20.7[e]).
An appreciable result typically is obtained after only one
session (Figure 20.8[a,b]).
(a)
(b)
(d)
(e)
(c)
Figure 20.6  (a) Numerous large lentigines on décolletage. (b) Erythema appears immediately after focal treatment with Easy Phen light.
(c) A protective layer of Yellskreen powder is applied. (d) White petrolatum jelly forms an impermeable coat over the yellow crust. (e) Result
at day 30.

Treating the neck and décolletage      149
(a)
(c)
(e)
(d)
(b)
Figure 20.7  (a) Acne scars on presternal area. (b) Appearance after superficial abrasion. (c) Postpeel mask and alcohol-disinfected cling
film. (d) Appearance after 24 hours. (e) Yellskreen powder is applied on the desepidermized skin.

150      Textbook of Chemical Peels
(a)
(b)
Figure 20.8  Acne scars (a) before and (b) after one session.
(a)
(c)
(b)
Figure 20.9  (a) Neck aging. (b) Result after one Easy TCA Pain Control (papillary dermis level). (c) Result after 2nd Easy TCA Pain
Control (papillary dermis level).

Treating the neck and décolletage      151
Neck Rejuvenation after One Application of Easy
TCA Pain Control, Depth 5/7 (Papillary Dermis)
Neck aging (Figure 20.9[a]) is treated separately with Easy TCA
pain control.
•
Depth 5/7: white frosting.
•
One session.
•
Postpeel care: Atrofillin cream and DHEA-Phyto cream.
After 3 months, a good result is obtained for the skin
structure of the neck (Figure 20.9[b]).
CARE AFTER PEELS
Usually, the postpeel period after neck/décolletage TCA peels
is characterized by redness and an inflammatory reaction
that appears quite soon after the peel and lasts for 2–3 days.
Fortunately, the postpeel mask stops this reaction immedi-
ately. The immediate postpeel period, after a peeling depth of
4/7, followed by the Skin Tech postpeel mask, is usually very
uneventful and without redness or pain. The post peel mask
ensures there is little skin edema.
Head movements and friction clothing can cause more
trauma to the neck skin than to the face. A neck peeling is often
more uncomfortable for a patient than a face peeling.
Patients should be informed that picking at flaking skin,
especially on the décolletage, will induce redness that could
become pigment issues or scars. Postpeel care is essential to
maintain the peel results for the long term.
On the day after the first peel, patients should start using
the following:
•
IPLase cream to reduce inflammation and redness.
•
Sun protection of SPF 50+.
•
Daily care cream appropriate for the patient’s condition
(see Chapter 3).
Follow-up peeling sessions could be planned for once a
year, for example.

21
Stretch marks, scars, and pilar keratosis
Anterior chemabrasion
GENERAL REMARKS
Stretch marks, acne scars, and pilar keratosis are three common
problems for which treatment results were disappointing in
the past. Doctors frequently had to refuse treatment and admit
to being powerless to help patients with these conditions. In
cases where the doctor did not refuse treatment, he or she often
regretted having used inappropriate techniques and having to
deal with the resulting complications.
Patients would suffer from their doctor’s refusal to treat
them, which meant having to delay indefinitely the blessed day
when their problems might improve. They also suffered side
effects caused by inappropriate treatments.
ORIGINS OF “ANTERIOR” CHEMABRASION
The high level of safety and effectiveness obtained when first
using the Easy TCA (ETCA) peel led the author to develop
complex but effective application protocols for the treatment
of stretch marks and scars. ETCA had proved effective for a
range of problems, including acne, pigment problems, and
skin aging, both on the face and on other parts of the body.
ETCA consists of an acid solution and an active postpeel cream
that the doctor applies to the treated area immediately after
the acid solution has produced pinpoint or cloudy-white frost-
ing and that is then left to work until the following morning.
The ETCA basic protocol provides a peel to the basal layer of
the epidermis or the Grenz zone but also can be used up to
the papillary dermis, simply by adding more coats, one at a
time, to achieve a pink-white frosting. The postpeel cream has
to be applied once by the doctor, immediately at the end of
the peeling. It is not a neutralizing cream, but an active cream
with a high concentration of vitamins C, E, and H; tretinoin
precursors; phytic acid; anti-free-radical agents; selenium;
methionine; tyrosinase inhibitors; trace elements; fatty acids;
and other actives. This cream is used to block unnecessary and
self-maintained immediate postpeel inflammatory reactions;
to provide a strong stimulus to the dermis, epidermis, and
regeneration processes; and to protect against complications.
Unlike a conventional trichloroacetic acid (TCA) peel, the post-
peel cream is responsible for a large part of the results and the
low level of side effects.
The cosmetic problems dealt with in this chapter, how-
ever, do not respond well to any chemical peels, even when they
reach the papillary dermis. In fact, publications about peelings
do not cover stretch mark treatments except for recognizing
their inefficacy. In an attempt to achieve better results, deeper
peel procedures were tried that went as far as the reticular der-
mis. However, peels are dangerous at this depth; the complica-
tions are discussed in Chapter 37.
Other authors have suggested a combined technique of
a chemical peeling and dermabrasion, but always in the order
of a peel followed by dermabrasion. This technique is known
as chemabrasion. For a better understanding and to distinguish
between the two techniques, we could use the term posterior
chemabrasion for a peel followed by dermabrasion and anterior
chemabrasion for the technique described in this chapter—
dermabrasion followed by a peel.
The treatment the author has developed consists of using
sandpaper dermabrasion followed by ETCA acid solution and
postpeel mask cream. Applying the postpeel mask cream,
after the peeling and under occlusion, deepens the treatment:
the longer the occlusion is left, the deeper the treatment will
be. Repeating the peels allows the epidermis to renew itself
gradually (a chemical resurfacing effect) while “filling” the
dermis with fibroblast products, the fibroblasts having been
stimulated by the treatment. Internal and gradual retraction
reduces the width of the stretch marks (a filling-shrinking
effect).
The combination of sandpaper abrasion, with or without
the application of the acid solution and occlusion of the ETCA
postpeel cream,1 allows a range of depths of action.
TREATING STRETCH MARKS
Table 21.1 outlines details of the treatments for stretch marks.
Classification of Stretch Marks
The Deprez–Adato classification2 is based on the clinical appear-
ance of the stretch marks (Table 21.2). Stretch marks in stages 2B
to 4 seem to respond best to this treatment. The best indications
are old and deep stretch marks, which respond much better
than recent and superficial ones (Figures 21.1 and 21.2).
Equipment Needed for the Abrasive Protocol
The sandpaper abrasion kit consists of 10 sheets of single-use
sandpaper (3M Wet-or-Dry P220) sterilized3 with gamma rays,
and a yellow disinfecting and healing powder: Yellskreen, con-
taining bismuth subgallate (BSG).
Mechanisms of Action of the Technique
The mechanisms of action are shown in Table 21.3.
Abrasion
The entire area—not only the atrophic base of the stretch
marks—must be abraded. Other techniques (laser and micro-
dermabrasion) have failed because they tend to stimulate only
the atrophic base of the stretch marks, where there are very
few keratinocytes capable of proliferating and very few fibro-
blasts available to fill the dermis. Sandpaper abrasion produces
even, physical resurfacing, leveling the skin and stimulating
the healthy skin between the stretch marks to regenerate. The
inflammatory reaction caused by the treatment stimulates
the growth of healthy keratinocytes on the edge of the stretch

Stretch marks, scars, and pilar keratosis: Anterior chemabrasion      153
marks. As these keratinocytes are stimulated, the epidermis
can gradually rebuild in a clinically visible way.
The abrasion procedure is summarized in Box 21.1.
Peel Solution
With the help of prepeel abrasion, the ETCA solution rapidly
penetrates to the reticular dermis and provides a deep chemi-
cal resurfacing. The combined physical and chemical effect
accelerates stimulation of keratinocyte growth on the edges of
the stretch marks. The subsequent occlusion does not deepen
the action of the ETCA. As mentioned elsewhere in this book,
occluding TCA tends instead to soften the effect of the TCA.
The subsequent occlusion seems to allow a specific activity of
the postpeel mask cream.
Note:  Easy TCA Pain Control (ETCA PC) contains phenol and
is not intended to be applied after abrasion. Its use is contrain-
dicated for anterior chemabrasion techniques.
Postpeel Cream under Occlusion
The mechanism of action of the postpeel mask cream, under
occlusion, is more difficult to understand. This antioxidant
and anti-inflammatory cream4 immediately stops the burning
sensation and the inflammation caused by the acid during an
Table 21.1  Evaluation of Treatment of Stretch Marks
Techniques for stretch
mark treatment
Efficacy
Remarks
Linear microdermabrasion
(corindon crystals)
Low
Do not apply acids after
such
microdermabrasion:
the acids will
penetrate only in the
lines of skin abrasion
drawn by the method.
Linear diamond drill
abrasion
Low
Dangerous, high risk of
scarring
Linear application of 25%
TCA
Low
Pigment problems
Linear application of 50%
TCA
Low
Pigment problems, risk
of scarring
Linear application of
phenol
Low
Pigment problems, risk
of scarring,
risk of toxicity
Linear sandpaper
dermabrasion
Low
Pigment problems
Microneedling
Low
Use a 2.5 mm needle.
Microneedling followed by
peeling
Medium
Use a 2.5 mm needle,
ETCA, and postpeel
mask.
Full abdomen application
of TCA 25%
Low
Pigment problems
Full area application of
TCA 40%
Low
Very high risk of
scarring and pigment
problems, infection
Full abdomen application
of phenol light or deep
Low
Do not do it; this
treatment is
dangerous with a very
high risk of toxicity.
Full abdomen sandpaper
dermabrasion
Low
Pigment problems, risk
of scarring
Posterior chemabrasion
Medium
Pigment problems, risk
of scarring
Anterior chemabrasion
with ETCA
Visible
results
Pigment problems, risk
of scarring
Table 21.2  Deprez–Adato Classification of Stretch Marks
Stage 1
Inflammatory
New, developing
stretch marks
Stage 2A
Ladder rungs
(–)
Nonpalpable
depression
Superficial, white
stretch marks
Stage 2B
Palpable
depression
Stage 3A
Ladder rungs
(+)
<1 cm wide
Atrophic stretch
marks
Stage 3B
<1 cm wide
Atrophic pearly white
stretch marks
Stage 4
Ladder rungs
(++)
>1 cm wide
Atrophic pearly white
stretch marks
Figure 21.1  Correct indications for anterior chemabrasion and
ETCA.
Figure 21.2  Correct indications for anterior chemabrasion and
ETCA.

154      Textbook of Chemical Peels
ETCA peel (standard use as a peel to the basal layer or Grenz
zone5), but when it is used under occlusion in the treatment of
stretch marks, it appears to be responsible for the depth of the
treatment. Clinically, it is plain to see that the longer the occlu-
sion is left in place,6 the deeper is the treatment.2 Also, as men-
tioned earlier, the postpeel mask cream can be applied without
the acid solution after sandpaper abrasion and can deepen the
treatment significantly, liquefying the skin under occlusion in
the same way as phenol does. (See Chapter 20 for information
on treating the décolletage.)
Sequenced photographs of the treatment show that the
postpeel mask cream penetrates more readily through the atro-
phic base of the stretch marks after abrasion and application of
the ETCA acid solution. Here, it causes inflammation, which
triggers regeneration, and it appears to be limited to this area.
The large majority of signs of active inflammation disappear
very quickly, in around 2–3 days, but a non-irritative edema can
persist for around 15 days at the base of the stretch marks.
Bismuth Subgallate
BSG is a yellow powder that makes postpeel care easier and
spares patients from having to apply complicated localized
treatments themselves, which could cause infection (see also
Chapter 34). A generous amount of BSG is sprinkled directly
onto the moist areas of skin where the epidermis has been
destroyed. The powder can also be spread on with a gloved
hand or sterile swab.
The BSG is covered with a silicone sheet, such as Mepitel,
which is in turn coated with a thin layer of neutral, sterile
Vaseline and protected by a thick absorbent dressing that is
held in place in a way that is comfortable for the patient. On
the third day, the silicone sheet is carefully replaced. It is again
coated in a thin layer of Vaseline to prevent it from sticking to
the outer, absorbent dressing. The dressing is removed for the
BOX 21.1  Summary of Abrasion Procedure
The abrasion is conducted with 3M Wet-or-Dry sandpa-
per, P220, sterilized with gamma rays. It should be gentle,
steady, careful, and even (intersecting each pass, as abra-
sion is more uniform when done in little circles), and should
be stopped as soon as the patient feels pain.
The keratinocyte touch should be positive: a gloved
­finger slides easily over the corneocytes (dead cells) that are
still present in the area surrounding the abraded zone, but
“brakes” on the hydrated keratinocytes (stratum spinosum)
that have been laid bare by the sandpaper. The first appear-
ance of pinpoint bleeding signals that the sandpaper has
reached the basal layer. Abrasion that goes any deeper can
cause permanent complications.
Table 21.3  Stretch Mark Treatments: Mechanisms of Action
Action on epidermis
(Figure 21.3)
The sandpaper abrasion and acid have a
synergistic effect of physical and
chemical resurfacing that improves the
quality of the entire epidermis.
Action on dermis
(Figure 21.4)
ETCA solution is directly applied to the
papillary dermis, after the epidermis has
been removed by sandabrasion. It directly
works on the reticular dermis.
When the postpeel cream penetrates the
atrophic base of the stretch marks, it
causes inflammation (controlled by the
antioxidants) that stimulates fibroblast
proliferation and metabolic production of
the noncellular components of the
dermis.
(See also inflammation visible in
Figures 21.11(b), 21.12, and 21.13.)
Potential action on
myofibroblasts
At the same time, the depth of injury to the
skin could stimulate deep myofibroblast
contraction and improve skin tension, as
has been observed clinically after
treatment.
Figure 21.3  The abrasion and acid resurface the normal skin sur-
rounding the atrophic base of the stretch marks, both physically
and chemically.
Figure 21.4  Occlusion of the postpeel mask cream, on the other
hand, causes severe inflammation of the dermis at the atrophic
base of the stretch marks.

Stretch marks, scars, and pilar keratosis: Anterior chemabrasion      155
last time around 6 days after the treatment (see the following
sections for details).
The abrasion procedure is summarized in Box 21.1.
Three Treatment Possibilities after Abrasion
There are three possibilities for treatment after abrasion,
depending on the depth of action required (Table 21.4).
Origin of Stretch Marks
Stretch marks may result from the following, among other
factors:
•
Pregnancy: first or subsequent.
•
Breastfeeding: of first or later children.
•
Growth: at varying ages.
•
Sport: a variety of sports may be responsible.
•
Significant weight change.
Record of Stretch Marks to Be Treated, for Medical File
Figure 21.5 is a schematic illustration allowing the physician to
draw the locations of stretch marks and the areas treated with
ETCA/abrasion.
Summary of Stretch Mark Treatments
Table 21.5 provides a summary of treatments for stretch marks
to be included in the patient’s file; Table 21.6 summarizes prepa-
ration of the patient.
Determining the Ideal Depth of Abrasion
Wearing gloves, the doctor rolls a sheet of sandpaper around
a round object (e.g., a bottle of prepeel cleanser). The skin is
held taut with one hand, and intersecting, careful, gentle, and
repeated passes are made with the sandpaper. Pressure must be
firm and even. If the pressure is too light,8 the skin will not be
abraded properly. On the other hand, if the pressure is too firm,
it will take off more skin and make it too permeable.
When done correctly, the sandpaper abrasion gradually
permeabilizes the skin, is not painful at first, and is therefore
done without anesthetic. The depth can be classified in four
­different grades (Table 21.7 and Figure 21.6).
Other Abrasion Techniques
Other abrasion techniques have been tried, depending on the
doctor’s experience and the equipment available:
•
Microdermabrasion: It is impossible to get the microscopi-
cally even abrasion obtained with sandpaper; the corun-
dum crystals also have to be cleaned after abrasion.
•
Erbium laser: It is also possible to use laser abrasion after a
local anesthetic, but this technique takes much longer and
is more difficult and more expensive; it has no additional
advantages.
The sandpaper abrasion technique has the advantage of
being even over the whole area and is fast and inexpensive.
Table  21.8 details the three signs that guide abrasion:
pain, keratinocyte touch, and bleeding.
Topical Surface Anesthesia
Applying ETCA solution immediately after abrasion would be
extremely painful without an anesthetic. There are several dif-
ferent types of anesthesia to be considered (Table 21.9).
Effectiveness of the Topical Anesthetic:  After 10–15 minutes’ occlu-
sion, the lidocaine–adrenaline solution has penetrated the
skin and reached the epidermis: the adrenaline induces vaso-
constriction. Uniform vasoconstriction is a sign that the local
anesthetic has worked. Applying a single 5 cm “line” of ETCA
peel solution with a cotton bud is enough to test the patient’s
Figure 21.5  Picture used to take note of the general position of
stretch marks and the areas treated with ETCA/abrasion.
Table 21.4  Three Types of Treatment after Abrasion
Abrasion
No ETCA
solution
Postpeel
mask cream
is applied,
under
occlusion.
This protocol is
deeper than the
previous one and is
used in
rejuvenation
treatments and in
the treatment of
acne scars on the
décolletage (see
Chapter 20).
Abrasion
+ ETCA
solution
Postpeel
mask cream
is applied,
without
occlusion.
This is the protocol for
acne scars on the
face or back.
Abrasion
+ ETCA
solution
Postpeel
mask cream
is applied,
under
occlusion.
This is the protocol
used to treat stretch
marks and surgical
scars, when the
skin needs
tightening.

156      Textbook of Chemical Peels
Table 21.5  Summary of Stretch Mark Treatments
Prepeel
• Phototype I–III: Blending Bleaching Cream 1 week
before
30–60 min. before abrasion
• Phototype IV: Blending Bleaching Cream 3 weeks
before
• Give the patient an acetaminophen + codeine tablet
• Disinfect and degrease the skin
Abrasion (depth?)
• Too superficial: no pinpoint bleeding—no pain
The sandpaper can be found in Skin Tech’s
Abrasion kit.
• Right depth: first pinpoint bleeding—first pain—
keratinocyte touch
• Too deep: a lot of bleeding—very painful
Abrasion depth check: pain + pinpoint bleeding + keratinocyte touch (K touch)
Anesthetic
2% lidocaine with adrenaline (epinephrine) on gauze pad
+ plastic film, 15 min.
No eutectic mixture of local anesthetics
(EMLA) cream
ETCA solution
• Right depth: even pink-white frosting
Acid or no acid? (décolletage, breast, etc.)
(how many coats?)
• Too deep: pure white frosting
Post-peel mask
0.5 g/10 cm × 10 cm area
Occlusion duration
• Superficial treatment: 6–8 hours
Occlusion or no occlusion? (back, breast, etc.)
• Medium treatment: 8–16 hours
• Deep treatment: 16–24 hours
Occlusion check: skin liquefaction or not
Postpeel care
To be done by the doctor
To be done by the patient
+24 hours:
• Remove occlusive film
• Gently cleanse with a dry gauze
• Apply BSG: thick coat to dry the skin (BSG powder
can be found in Skin Tech’s Abrasion kit)
• Apply a silicone sheet or gauze coated in Vaseline to
cover the BSG
• Protect with a thick gauze
• Take acetaminophen if painful
• No showers, no baths, no scratching
• No sports, no swimming
• Keep out of the sun (be careful; the sun
can filter through clothes)
• Between days 1 and 2: take
acetaminophen if painful
Day 3:
• Change dressing
• Change the silicone sheet and reapply the dressing
as on day 1, without adding more BSG
• Avoid infection; administer antibiotics if necessary
• No showers, no baths, no scratching
• No sports, no swimming
• Keep out of the sun (be careful; the sun
can filter through clothes)
Day 6:
Same as day 3
Same as day 3
Days 7–8:
Skin is pink but usually healing well
If slow healing: prevention of problems
Weeks 1–5/6:
• Moisturize, protect, prevent PIH
• Prevent prolonged erythema: IPLase cream if
erythema + 2
• weeks, treatment with 1 week fluorinated
corticosteroid
• Prevent PIH: Blending Bleaching Cream should be
used before PIH begins, from day 8 Melablock-HSP®
• SPF50+ (sun protection cream)
• Prevent infection: administer antibiotics if necessary
• Prevent scratching:
• if skin is very dry: Vaseline
• If skin is dry: Vit E Antioxidant cream
• Check patient every week:
• If PIH begins, even out with Blending Bleaching
Cream and Melablock-HSP, SPF 50+
• If necessary add hydroquinone 6% to the Blending
Bleaching Cream (mixture 50/50)
• Maybe do ETCA peel on area with PIH
• 8 p.m. Blending Bleaching Cream followed
by
• Melablock-HSP 50+ or 30 (even if no sun
exposure)
• 12.00 p.m. Blending Bleaching Cream
followed by
• Melablock HSP®, SPF 50+ or 30 (even if
no sun exposure)
• 5 p.m. Nutritive ACE Lipoic Complex
• 8 p.m. Nutritive ACE Lipoic Complex +
DHEA Phyto cream
• Call the doctor with any questions or
problems such as pain, fever, itching,
redness
• Baths/showers are not allowed until the
skin is completely healed (average day
7–8)
• Sports allowed from day 10–15
• Sun not allowed for 3 months: sun
protection for 3 months (Melablock-HSP,
SPF 50+ or 30)
Repeat treatment after a minimum of 5 weeks or, if results are definitive, after 5 months or 5 years.
PIH: use Blending Bleaching Cream and Melablock-HSP® 50+ or 30 as soon as possible.
Treat with ETCA basic protocol 1–2 weeks + Blending Bleaching Cream and Melablock-HSP 50+ or 30.

Stretch marks, scars, and pilar keratosis: Anterior chemabrasion      157
Table 21.6  Preparing the Patient
Previous
consultation
Patient is prepared
psychologically
Patient is informed in detail about the treatment, developments, and possible risks.
Pictures of immediate postpeel period are shown.
Patient’s file is filled: Box 21.2
Patient’s stretch marks are drawn on the picture (Figure 21.5)
3–4 weeks before
treatment
Prevention of PIH
Preparing the skin tends to limit the risk of PIH, which is common after this
treatment. The stretch mark treatment causes severe inflammation and tends to
stimulate melanocytes, albeit only temporarily.
Phototype I–III patients can be treated without preparation, but patients of phototype
IV must apply effective sun protection and Blending Bleaching Cream twice a day,
especially if they live in a country with a very sunny climate (see Chapter 2).
Phototype V and VI patients are not candidates for this procedure.
Heat-shock proteins
stimulation
Applying products that stimulate synthesis of heat-shock proteins (HSPs) helps all
cells to resist this type of stress (see Chapter 2).
Sign informed consent
Preparing patients also involves getting them to sign an informed consent form,
explaining how the treatment and postpeel care will proceed.
Immediate prepeel
preparation
Acetaminophen plus codeine
tablet 30 minutes before
treatment and 2–3 hours
after treatment.
Disinfection and degreasing
The doctor should wash his or her hands surgically or wear sterile gloves.
The patient’s skin is disinfected with alcohol (75% alcohol and sterile gauze; firm
pressure should be applied on the gauze) and degreased with acetone (pure
acetone and sterile gauze; firm pressure should be applied on the gauze).
The acetone starts to break down the membrane phospholipids. The order in which
the alcohol and acetone are applied makes no difference clinically, but both
products must be applied several times.
Sandpaper must be sterilized, ideally with gamma rays.7
Table 21.7  Grades of Abrasion
Grade 0 sandpaper abrasion
This depth of abrasion provides only
low-quality topical anesthesia, and
the peel itself will be painful and too
superficial.
Subjectively:
The patient feels almost nothing.
Objectively:
The fingers slide easily (slip) over the superficial layers of
corneocytes: the keratinocyte touch is said to be negative,
because the fingers still are touching corneocytes.
Grade I sandpaper abrasion
Subjectively:
Abrasion feels unpleasant but still painless to the patient, as
the sandpaper is still a long way from the free nerve
endings that are in the lower part of the epidermis.
Objectively:
The keratinocyte touch is still negative. Although the fingers
can be felt to brake slightly as they slide from the healthy
zone to the abraded zone, they still slide easily over the
skin. Grade 1 sandpaper abrasion does not provide
adequate topical anesthesia, and the peel is still painful
and too superficial.
Grade II sandpaper abrasion
This is the correct level for effective
abrasion combined with this peel.
Topical anesthesia will be of good
quality, and the peel will reach the
required depth.
Subjectively:
The patient starts to feel pain from the sandpaper abrasion.
Usually the abrasion should be stopped here, but pain
thresholds vary from patient to patient. It is therefore
essential to look for the objective signs.
Objectively:
Note: the keratinocyte touch is
obtained by softly sliding the
fingers on the surface that
has been treated, as if softly
caressing the skin. The touch
should start outside of the
treated area and go toward
the center of it.
The keratinocyte touch is positive; the finger feels a marked
braking sensation as it passes from the slippery
dehydrated corneocytes of the nonabraded surrounding
skin to the living, well-hydrated keratinocytes exposed by
the abrasion. The first pinpoint bleeding appears on the
skin as the “highest” dermal papillae, where the blood
vessels of the papillary dermis are located, are abraded
(Figure 21.7).
Grade III sandpaper abrasion
Topical anesthesia under these
conditions would be rapid and of
good quality, but the peel would be
too deep and trigger permanent side
effects such as definitive
depigmentaion and/or
hyperpigmentation and/or scarring.
Subjectively:
The patient usually finds the abrasion very painful, even
unbearable, and will let the doctor know this. The abrasion
is going into the papillary dermis, and care must be taken.
Objectively:
There is a lot of bleeding as the loops of blood vessels in the
dermal papillae are now being abraded (Figure 21.8).
Abrasion must be stopped. If it were to continue, the
pinpoint bleeding would increase rapidly and appear as
extensive surface bleeding.

158      Textbook of Chemical Peels
sensitivity. If the patient feels no pain where the acid has been
applied, the ETCA solution can be applied to the whole area to
be treated. If the patient still feels some pain, the doctor should
replace the occlusion for another 5 minutes.
CASE STUDY 1 (PHOTOTYPE IV)
Applying the ETCA Solution
The plastic film from the anesthesia is gradually lifted, the skin
is dried, and the ETCA solution is applied with a double cotton
bud until pink-white frosting, never pure white frosting, occurs
(Figure 21.10).
The first coat of ETCA solution may cause linear and
uneven frosting, as can be seen in Figure 21.11. This applica-
tion is not perfect, and more ETCA solution should be applied
between the lines of frosting to even it out. In some cases, the
first coat of ETCA solution does not trigger any frosting, so
another coat must be applied perpendicular to the first.
Epidermal sliding is easy to recognize, as the dermal
and epidermal proteins have been coagulated by the TCA. The
BOX 21.2  Patient’s File
DATE OF TREATMENT
PREPEEL
Type of stretch marks: I □ IIa □ IIb □ IIIa □ IIIb □ IV
Age of stretch marks treated: 1 month □ 1 year □ 5 years □ 10 years □ 20 years or + _
The pretreatment photo is good quality: Yes/No
Blending Bleaching Cream 2 weeks prepeel: Yes/No
Prepeel painkiller: Yes/No
PEEL
• Disinfect with alcohol and degrease with acetone, leave to dry, mark out areas to be treated with marker pen
• Gentle sand abrasion of whole area to be treated:
•
Sandpaper from Skin Tech’s abrasion kit:
Yes/No
•
Other sandpaper: Which:
Sterilized/Not sterilized

Type of sterilization used:
•
Abrasion: Grade 1, Grade 2, Grade 3
• Photograph the abraded zones before applying the peel solution
• Gauze soaked in 2% lidocaine with adrenaline (epinephrine) – Occlusion for...... minutes (10–15); dry the lidocaine
• With two cotton buds, apply a vertical coat eventually followed by a horizontal coat of Easy TCA solution on each area:
•
Intensity of pain: 0 | ––––––––––––––– | ––––––––––––––– | +++
•
Intensity of frosting: (Cloudy) – Even pink-white – (Pure white – Gray/white)
• Apply the postpeel cream (0.5 g/10 cm × 10 cm surface area); plastic occlusion
POSTPEEL
• Removal of the plastic dressing after____ hours
•
Photograph 24 hours before application of bismuth subgallate (BSG)
•
Application of BSG: Yes/No
•
Application of silicone sheet: Yes/No
•
Thin layer of Vaseline on BSG, protect with thick sterile gauze pad
• Examination of skin on 3rd day:
•
Photograph – application of Vaseline – protective dressing
• Examination of skin on 6th day:
•
Photograph – application of Vaseline – light protective dressing 24 hours
• Postpeel care from 8th day:
•
Leave the skin to regenerate for 3 weeks at least
•
Blending Bleaching Cream and Melablock-HSP® 50+
•
If atrophic stretch marks: DHEA-Phyto once a day
•
If inflammation: Renutriv ACE Lipoic Complex
Improvement in stretch marks since previous treatment:
0 | ––––––––––––––– | ––––––––––––––– | completely gone
Improvement in stretch marks since start of treatment:
0 | ––––––––––––––– | ––––––––––––––– | completely gone
0
I
II
III
Figure 21.6  Sandpaper abrasion: grades 0–III.

Stretch marks, scars, and pilar keratosis: Anterior chemabrasion      159
ETCA solution should not be neutralized or removed. It stays
where it is and will be covered with the postpeel mask cream
(Figure 21.12).
Applying the Postpeel Mask Cream and Occlusion
As soon as frosting occurs, 0.5 g of postpeel mask cream should
be applied per 10 cm x 10 cm surface area. The dosage card in
the ETCA kit can be used to determine the correct quantity.
After the postpeel mask cream has been applied over the whole
area that has been abraded and coated in ETCA solution, it
should be covered with an impermeable, occlusive plastic film
(Figure 21.13). The plastic film is secured with a hypoallergenic
Table 21.9  Anesthesia Considerations
EMLA cream or
other topical
anesthetic
cream
As pointed out in Chapter 33, EMLA cream
should not be applied before a peel. For the
same reasons, topical anesthetic creams
should not be used before applying ETCA
for stretch marks. Moreover, they are not
efficient enough for preventing the pain of
this kind of treatment.
Anesthesia with
lidocaine spray
Lidocaine spray contains alcohol and is very
painful when applied to abraded skin.
Klein solution
injection
Injections of Klein solution have been tested,
but the results are unsatisfactory: it
anesthetizes the deeper layers not reached
by the acid, but the surface anesthetic
effect remains largely inadequate.
Topical
application of
2% lidocaine
solution with
adrenaline
(epinephrine)
Lidocaine, poured directly onto sterile gauze
pads on the skin, provides an excellent
anesthetic (Figure 21.9a). One percent
lidocaine is not effective enough. Lidocaine
without adrenaline is rapidly reabsorbed,
and its effect is too short-lived after
epidermal abrasion. Two percent lidocaine
with adrenaline should be covered with an
impermeable plastic film for 10–15 minutes
to prevent it from evaporating too quickly
and to enhance its effect (Figure 21.9b).
Table 21.8  Three Signs that Guide Abrasion
1. Pain
Completely painless abrasion:
It has only reached the stratum corneum.
Uncomfortable but not yet really painful: The
sandpaper comes into contact with the
keratinocytes. The upper layers of
keratinocytes are not directly innervated. When
the patient says that the abrasion feels
uncomfortable but not painful, the doctor must
pay very careful attention, as it will become
painful at any moment when the sandpaper
gets closer to the free sensitive nerve endings
in the deeper layers of the epidermis.
Abrasion becomes painful:
It reaches the area next to the basal layer of the
epidermis. Sensitivity varies from patient to
patient, and other objective signs, discussed
below, must be taken into account. When the
first pain is felt, that is the right time to stop
abrasion.
Abrasion is very painful: Abrasion is definitely too
deep or the patient is squeamish.
With a squeamish patient, before applying the
acid, the doctor must check the anesthetic for
effectiveness. When the abrasion is too deep
(grade III), the doctor must monitor carefully how
much acid is applied to the skin so as not to go
beyond even pink-white frosting (see below).
2. Keratinocyte
touch
Negative: Fingers easily slide over corneocytes;
abrasion did not reach the keratinocytes.
Positive: When sliding the fingers (even with
gloves on) from a nonabraded area to an area
that has been abraded, a braking sensation is
felt if the abrasion passed through the stratum
corneum.
3. Bleeding
No pinpoint bleeding = grade I abrasion:
The treatment is not deep enough.
Very first pinpoints of bleeding: grade II abrasion,
which is the right depth.
Too many pinpoints bleeding or surface
bleeding = grade III abrasion: There is a risk
that the peel will be too deep and cause
permanent complications.
Figure 21.7  Pinpoint bleeding—grade II abrasion. The arrows
indicate the first pinpoint bleeding. This depth of abrasion is ideal
for this treatment: it gives the right anesthesia and depth of action.
Figure 21.8  Pinpoint bleeding—grade III abrasion. Contact
anesthesia will be just right, but there is a risk that the peel will be
too deep. Care must be taken regarding how much acid is applied
to the skin, to avoid complications such as scarring and/or pigmen-
tary changes.

160      Textbook of Chemical Peels
dressing and held in place for 24 hours. The actual depth of
the peel and the amount of “phenol-like” skin liquefaction
depend on how long the post-peel cream is occluded. From 8
to 12 hours’ occlusion does not liquefy the skin, and the results
are often inadequate. More than 24 hours’ occlusion carries a
higher risk of infection.
Removal of the Occlusion
How long the occlusion is left in place depends on the depth of
action desired. Twenty-four hours seems to be a good compro-
mise between effectiveness and the risk of complications. The
occlusive plastic film is removed and reveals skin that is extremely
inflamed and covered in a liquid that can be thick and runny,
and have an unpleasant odor (Figure 21.14). This liquid consists of
the remnants of the cream, inflammatory serous fluids, and dead
cells. The odor, which can be unpleasant even for people standing
close by, is usually the same for all patients. It is the same as the
odor that follows occlusion of a full-face phenol peel.
Close-up of the Skin after Occlusion
The treated area is severely inflamed. The atrophic base of the
stretch marks stands out and signals the extent of the dermal
reaction (Figure 21.15). The controlled inflammation caused by
the treatment is essential, as it triggers the skin regeneration
processes. In short, abrasion and the application of acid appear
to stimulate the regeneration of normal keratinocytes on the
edge of the stretch marks, and occlusion of the postpeel mask
cream strongly stimulates the fibroblasts.
Applying Bismuth Subgallate
Any excess liquid is mopped up with sterile gauze, although
the skin is not dried completely. Some liquid is needed for the
Yellskreen to stick. Skin Tech’s Stretch Mark kit contains P220
sandpaper as well as a shaker of BSG.9 A generous amount of
the powder should be sprinkled directly onto the skin, leaving
a thick layer (Figure 21.16). Gently passing a sterile gauze pad
over the powder evens it out and makes it stick to the liquid left
on the skin.
Protecting the Skin
Different types of dressing have been tried to protect the BSG.
Melolin (Smith & Nephew) is an excellent sterile dressing that
has one “normal” side and one side covered in a transparent
plastic film that does not stick to wounds. The plastic is applied
on top of the powder and the Melolin is secured on the healthy
surrounding skin. The author used this method for many years
until I could no longer get a supply of Melolin. I then used
Mölnlicke’s silicone or absorbent dressings (Mepilex, Mepitel,
etc.) to good effect.
Mepilex and Melolin are not always easy to find. The
author therefore had to look for another type of cheap and read-
ily available protective dressing and went back to using sterile
white Vaseline. Applying a thin coat of sterile white Vaseline to
the BSG turns it into a paste that is easily spread with a tongue
depressor and sticks to the skin (Figure 21.17). The Vaseline and
BSG paste is then covered with a thick and absorbent sterile
gauze that is secured to the healthy surrounding skin, as can be
seen in Figure 21.18. In some patients, the BSG and Vaseline can
(b)
(a)
Figure 21.9  (a) Topical application of 2% lidocaine with adrenaline (epinephrine): the lidocaine is poured over the gauze. (b) Occlusion
of the lidocaine for 10–15 minutes.
Figure 21.10  Starting application of the ETCA solution.

Stretch marks, scars, and pilar keratosis: Anterior chemabrasion      161
act as an occlusion and unexpectedly deepen the action of the
peel. Any overpeeling can lead to complications with scarring
or dyschromia.
Checking the Dressing at Day 3
The sterile gauze does not stick to the skin too much and usu-
ally can be removed easily by drawing it back smoothly and
carefully. If the dressing sticks in places, it should not be pulled
off; instead, the doctor should cut around the part that is stuck
to the skin and leave it in place (Figure 21.19). Vaseline can be
applied to this area to help the dressing come away naturally
and quickly. The skin may look rather gruesome, as can be seen
in Figure 21.20. The use of a silicone sheet coated in a thin layer
of Vaseline to cover the BSG, as described earlier, drastically
reduces the risk of the dressing sticking to the skin and causing
lesions.
On the third day, the skin will be dry and flaking
(Figure 21.21). To help the flaking proceed, a thick layer of ster-
ile white Vaseline can be applied (Figure 21.22) and the skin
protected with a new gauze dressing (similar to that shown in
Figure 21.18).
Care on Day 5 or 6
The doctor sees the patient one last time to evaluate the con-
dition of the skin and apply another thick layer of Vaseline
(Figure 21.23) and one last dry dressing (as in Figure 21.18).
It is common to see lines of depigmentation on phototype
IV patients (Figure 21.24). This depigmentation tends to return
naturally to the original skin color within a few weeks, even
without applying Blending Bleaching Cream (Figure  21.25),
which reduces the risk of postinflammatory hyperpigmenta-
tion (PIH).
Protecting the Skin
At the end of the first week after the peel, the skin is thin and
delicate, quick to hyperpigment, slightly itchy, and swollen.
(b)
(a)
Figure 21.11  (a) Linear and uneven frosting following application of a first coat of ETCA solution. (b) Uniformization of the frosting after
applying a second careful coat of ETCA solution between the lines of frosting.
Figure 21.12  Application of the postpeel mask cream on the first
quadrant to be treated.
Figure 21.13  Occlusion with impermeable plastic film.

162      Textbook of Chemical Peels
(c)
(a)
(b)
Figure 21.14  (a) The occlusive plastic film is left in place for 24 hours. After it has been removed, the skin appears inflamed (b) and
­covered in a thick, runny, foul-smelling liquid. Softly remove this liquid before applying the BSG powder (c).
Figure 21.15  Severe inflammatory edema at the base of the
stretch marks and in the surrounding skin.
Figure 21.16  Application of BSG to the left half of the abdomen.

Stretch marks, scars, and pilar keratosis: Anterior chemabrasion      163
The edema can persist for more than 2 weeks at the base of the
stretch marks.
It is essential to apply appropriate care creams to the
skin.
•
Hydration: Vit. E Antioxidant cream (see Chapters 2
and 3) or a thin layer of sterile white Vaseline should be
applied.
•
Prevention of pigmentary changes: Blending Bleaching
Cream and Melablock-HSP 50+ or 30 should be applied
until the following treatment or for at least 6 weeks.
•
Prevention of infection: The doctor should check for infec-
tion and prescribe antibiotics as necessary (the first week
after the procedure is the most critical).
•
Prevention of oxidation: The patient can apply an anti-
oxidant cream if the extent of the inflammatory reaction
­warrants it.
•
Stimulation of the skin’s metabolism: The patient can
apply DHEA-Phyto cream if the extent of atrophy war-
rants it.
CASE STUDY 2 (PHOTOTYPE II)
The patient has postpregnancy stretch marks (Stage 3B stretch
marks with skin laxity; Figure 21.26).
Sandpaper for abrasion is rolled over a rigid tube for an
easier use (Figure 21.27). Sandpaper abrasion should be stopped
when pain occurs and the first bleeding pinpoints appear. The
doctor applies 2% adrenalinated lidocaine to sterile gauzes.
The gauzes are covered by a plastic film to avoid evaporation
(Figure 21.28). After 10 minutes, on average, the plastic film is
Figure 21.17  The BSG is covered with sterile white Vaseline and
protective gauze.
Figure 21.18  Wide, thick gauze secured on the surrounding
healthy skin.
Figure 21.19  The dressing is sticking slightly. It should not be
pulled off; rather, the doctor should cut around the part that is
sticking.
Figure 21.20  Appearance of the skin after 72 hours, following
removal of the dressing.

164      Textbook of Chemical Peels
lifted to check for the presence of vasoconstriction (adrenalin
effect) that appears together with anesthesia (lidocaine effect;
Figure 21.29). Anesthesia is effective at the same place as vaso-
constriction. Erythematous areas are affected to a lesser extent
by anesthesia. Uniform ETCA application induces uniform
pink-white frosting (Figure 21.30). The peeling depth is to the
papillary dermis.
A postpeel mask is applied—one line/10 cm x 10 cm
surface (Figure  21.31)—and covered with a plastic film to
allow maceration for 24 hours (Figure 21.32). After 24 hours,
the plastic film is removed and Yellskreen is applied (BSG;
Figure  21.33). BSG is protected by a bandage that will not
stick to it, such as a multiperforated silicone sheet, Melolin,
Melipex, Mepiform, and so forth. The protective bandage
is protected by an abdominal gauze that stays in place for 2
more days, up to day 3 (Figure 21.34). On day 3 all bandages
should be carefully removed. Never stretch the bandages,
as this can damage the skin and induce scarring or pigment
problems. Should the protective bandage stick to the skin,
spray thermal water on the bandage, cover it with a thick coat
of Vaseline, and allow it to sit for 30–45 minutes. The bandage
will become easy to remove without damaging the skin. After
examination, the skin is coated with a thick coat of Vaseline
and protected again with abdominal gauze (Figure  21.35).
By day 7, desquamation begins and the skin is reepithelized
(Figure 21.36).
Figure 21.21  Dryness and flaking on the third day.
Figure 21.22  Application of Vaseline on the third day.
Figure 21.23  A thick layer of Vaseline is applied.
Figure 21.24  On the sixth day, areas of depigmentation are com-
mon in patients with dark skin phototypes.

Stretch marks, scars, and pilar keratosis: Anterior chemabrasion      165
Postpeel details are given in Table 21.10 and Figure 21.37.
Patient information is shown in Figure 21.38.
RESULTS OF TREATMENT
Although results appear gradually after stretch mark treat-
ment, they are permanent (Figures 21.39–21.44).
Progressive Results
Stretch marks are the result of severe dermal and epidermal
atrophy, lack of appendages, and an extreme paucity of cells. It
is impossible to eliminate stretch marks in a single treatment
session. With each treatment, the quality of the skin improves
visibly, and patients themselves can see this. Photographs
do not do justice to the improvement in skin quality, and to
understand how this treatment works, detailed studies are
necessary.
The first treatment usually brings great satisfaction to
the patient in terms of how the stretch marks feel: they do
not feel as deep, and the depressed atrophic base starts to
fill out. Gradually, the atrophic base becomes level with the
(b)
(a)
Figure 21.25  (a) Depigmentation on the sixth day after the peel. (b) The pigmentation returns almost to normal 30 days after the first peel,
after treatment with tyrosinase inhibitors.
Figure 21.26  Stretch marks with skin laxity.
Figure 21.27  Sandpaper for abrasion is rolled over a rigid tube
for easier application.

166      Textbook of Chemical Peels
Figure 21.28  Gauze is covered by plastic film.
Figure 21.29  The plastic film is lifted up.
Figure 21.30  Pink-white frosting.
Figure 21.31  Postpeel mask.
Figure 21.32  Postpeel film.
Figure 21.33  Yellskreen.

Stretch marks, scars, and pilar keratosis: Anterior chemabrasion      167
surrounding skin, and in places its structure returns com-
pletely to normal. Regeneration continues throughout the
­following treatments.
In one published study,2 69 patients of all phototypes
between ages 14 and 63 were treated for stretch marks in dif-
ferent places: abdomen, breasts, back, hips, and so forth. The
patients were followed up for an average of 18 months, and the
stretch marks treated ranged from light/recent to very deep/
old. An average improvement of 70% in the appearance of the
stretch marks was observed after an average of four treatments
(4.2 exactly), and the results have been published.
Table 21.10  Postpeel Details
Easy or difficult
technique?
Anterior chemabrasion is one of the most
difficult peeling techniques. It requires sound
experience in postpeel care and should not
be the first peel that a doctor performs.
Those used to using ablative lasers should
not face technical problems in dealing with
anterior abrasion for stretch marks.
Control of the
patient at
days 1, 3, 6
Postpeel monitoring is critical, and the follow-up
care during the first week after the peel must
be rigorous. The doctor should see the
patient several times during these first
8 days.
Procedure at
risk of
infection
If there is any doubt about the possibility of
infection, oral antibiotics should be
administered immediately.
Bath or shower
during the
first 8 days
Contact between the abraded skin and water is
very painful and increases the risk of
infection. The patient obviously cannot take a
bath during the first week until the skin has
completely restructured and is impermeable
again. The patient can take a quick shower if
an impermeable plastic covering is placed
over the protective dressing.
Pain
management
Oral painkillers make both the patient and the
doctor feel more at ease: a 500 or 1000 mg
tablet of acetaminophen or acetaminophen
plus codeine taken half an hour before the
peel and 2 hours after allows the patient to
carry on as normal. The patient can take
another painkiller before going to bed if need
be. There should be no pain the following
morning, only a feeling of slight discomfort.
If pain disappears and appears again over
the next few days, a possible complication
could be developing.
Sun protection
The patient should keep out of the sun for 3
months after the treatment. Effective sun
protection is essential, even under clothing.
Risk of
isomorphic
response
There is a risk of an isomorphic response,
especially in patients with progressive vitiligo
or psoriasis and in patients where a minor
trauma such as friction from clothing has
induced the Köbner phenomenon in the past.
The Köbner phenomenon can be induced by
other disorders: reactive perforating
collagenosis (transepidermal elimination of
collagen), eruptive xanthoma (e.g., in cases
of secondary hypertriglyceridemia), erythema
multiforme, macular or maculopapular
exanthema associated with juvenile arthritis,
and various types of lichen (e.g., planus or
sclerosus). Caution should be exercised in all
cases.
Figure 21.34  Protective bandage and abdominal gauzes.
Figure 21.35  Vaseline and protective gauze.
Figure 21.36  Desquamation and reepithelization of the skin.

168      Textbook of Chemical Peels
Day 0:
Day 1
Remove
cling
film
Apply
Yellskreen
Days 3
Check if
infection
Apply
vaseline
& protect
Days 6
Check if
infection
Apply
vaseline
& protect
Days 7–8
No
bandage
– 2 Weeks
Protective Home care
IPLASE (reduces erythema) 3x/d
Skin Tech Cleanser (Cleanse skin)
Blending Bleaching (Pigment control) 2x/d - at least 2 months
Atrofillin
09 am–12 pm, 03 pm
DO NOT REMOVE YELLSKREEN
Skin is regenerating under the crust
Melablock HSP 30
09 am–12 pm, 03 pm
Melablock HSP, SFP 30
0
SMT
1
1
2
4
5
3
6
7
8 to 15
After day 15
Specific Home care
if PIH risk, give the patient Blending Bleaching 3 x/day 2 weeks before Unideep
SMT = Stretch marks treatment
ETCA = Easy TCA
YELLSKREEN: Protective yellow powder
ETCA
Postpeel
mask
Cling
film
occlusion
24h
Figure 21.37  Postpeel care of stretch marks.
Generally:
STRETCH MARKS : Postpeel care — Patient Information
D 0:
Do not scratch, do not moisten (no shower, no bath) or remove or peel away the yellow powder.
Contact your doctor for any question, any doubt.
Take a painkiller tablet if necessary (afternoon and/or before sleep)
Do not remove plastic film.
See the doctor.
He will remove the plastic film and apply a yellow powder.
See the doctor, he will apply vaseline, protect and control your skin.
See the doctor, he will apply vaseline, protect and control your skin.
NO bandage needed.
Protective home care
Apply IPLASE Mask 3 x/day; it helps to reduce redness.
Cleanse the skin, using Skin Tech Cleanser only.
Apply Blending Bleaching Cream 2x/day.
Specific home care
1- Cleanse the skin, using Skin Tech Cleanser only.
2- Atrofillin (refills dermis, tenses the skin, uniformizes skin color).
3- Pigment control: Blending Bleaching Cream morning and evening.
Sun Protection:
Days 1 to 15: NO sun exposure and use Melablock HSP, SPF 50+ (9 am, 12 pm, 3 pm).
Days 15 to 90: Be careful with sun exposure and use Melablock HSP, spf 30 (9 am, 12 pm, 3 pm).
D 1:
D 3:
D 6:
D 7:
D 8–15:
After D 15:
Figure 21.38  Patient information.

Stretch marks, scars, and pilar keratosis: Anterior chemabrasion      169
(b)
(a)
Figure 21.39  Before (a) and after (b) two treatments on day 30 in a phototype V patient.
(b)
(a)
Figure 21.40  Before (a) and after (b) two ETCA abrasive protocols.
Figure 21.41  Two treatment sessions on a phototype V patient: anterior chemabrasion as described in this chapter.

170      Textbook of Chemical Peels
Duration of Results
It is commonly acknowledged that the histological changes that
take place in the deep dermis should be considered permanent.
We can therefore assume that the results achieved are also per-
manent, and this corresponds to current clinical experience.
The first treatments were conducted in 1996, and the results
achieved then were still completely stable in 2014, even if other
signs of skin aging appeared during this period.
Complications
Complications from this deep peel are relatively common but
can be prevented or treated. Caution and adherence to strict
Figure 21.42  Before anterior chemabrasion, two sessions.
Figure 21.43  After anterior chemabrasion, two sessions.
Figure 21.44  Before and after one session of anterior chemabrasion.

Stretch marks, scars, and pilar keratosis: Anterior chemabrasion      171
methodology should ensure safe treatment. The deeper the
peel, the higher the risk of complications.
Complications include hyperpigmentation (Figures 21.45–
21.47), depigmentation, or scarring, depending on how serious
the cause is:
•
Uneven abrasion: If abrasion is too deep, the acid penetrates
too deeply and there is a risk of scarring. Even abrasion
produces even results.
•
Uneven application of the peel solution: The solution must
be applied evenly to achieve even results. It is especially
important that the cotton buds be squeezed out properly,
as the ETCA solution penetrates very quickly through the
abraded skin.
•
Pulling off a dressing: If a dressing is stuck to the skin, it
must not be pulled off; this would pull off the regenerat-
ing epidermis, and the skin would have to start the heal-
ing process again, leaving a hyperpigmented area. The
dressing should be cut off around the area that is sticking
to the skin, and a coat of Vaseline should be applied to
help the dressing come away without causing injury to
the skin.
•
Pruritus: This causes scratch lesions.
•
Infections: These can result from not cleaning hands and
equipment properly, inadequate prepeel disinfection, or
overlong occlusion (more than 24 hours’ occlusion usually
causes infection). A preexisting skin infection can also be
the cause, for example when treating a patient with acne
scars who has active lesions.
•
Technical error.
See Chapter 37 for more information.
TREATING SCARS
Treating surgical scars and acne scars is never easy. A scar is
the tip of a fibrotic iceberg buried deep under the skin; effective
treatment is therefore by definition a deep treatment. Postacne
pigmentation scars are easy to treat (Figure 21.48).
Facial Scars
Phenol
Along with laser and abrasion treatment, a full-face phenol peel
is considered one of the best options for treating facial scars.
It is not completely effective, however, and it is often neces-
sary to use chemabrasion—that is, a combination of a phenol
peel followed (immediately or the next day) by abrasion with a
­diamond fraise or sandpaper.
Several cases of insufficient results in deep acne scar
treatment (Figures  21.49–21.53) made the author search for
another option for treating pike acne scars, applying the stretch
marks technique to the face. Compared to the abdomen or
thighs, the face has numerous appendages, allowing a deeper
Figure 21.45  The first of two cases of PIH linked to the lack of
postpeel use of antityrosinase/antioxidant cream and sun protec-
tion. The treatment used Blending Bleaching Cream and two ETCA
peels without sandabrasion, using the “base protocol.”
Figure 21.46  The second case of PIH linked to the lack of post-
peel use of antityrosinase/antioxidant cream and sun protection.
The treatment used Blending Bleaching Cream and two ETCA
peels without sandabrasion, using the “base protocol.”
Figure 21.47  Scarring after anterior chemabrasion, resulting
from an irregular abrasion and supposed poor follow-up. The treat-
ment used topical and injected corticosteroids, antityrosinase and
antioxidant cream, and silicone sheet compression.

172      Textbook of Chemical Peels
(b)
(a)
Figure 21.48  (a, b) PIH (acne) treated with ETCA (nonabrasive, basic protocol) combined with daily depigmenting treatment and
sunblock.
Figure 21.49  Typical acne scars, representing a classic good
indication for a deep phenol peel.
Figure 21.50  During application of phenol. Gray frosting and yel-
lowish spots are the symptoms of the deepest possible depth of the
phenol peel: 7/7. A good result was anticipated.

Stretch marks, scars, and pilar keratosis: Anterior chemabrasion      173
peel. Finally, the cause the acne gives us options for treating
acne scars: strong and numerous pilo sebaceous units allow fast
skin regeneration after anterior chemabrasion.
Different treatment possibilities were examined:
1.
Posterior chemabrasion: Sandpaper abrasion could be care-
fully done immediately after a phenol peel.
2.
Anterior chemabrasion with ETCA peeling.
Considering the technique of posterior chemabrasion
after phenol as an efficient but difficult and dangerous one and
weighing that against the good results obtained with stretch
mark treatment, the option of anterior chemabrasion with
ETCA was the best choice. Sandabrasion followed by ETCA is
illustrated in Figure 21.54.
A specific anterior chemabrasion technique has been
developed for the treatment of facial acne scars. The results are
very good, and are better compared to those achieved with a
full-face phenol peel. The technique is the same as for stretch
marks, except from the points in Table 21.11.
Figures 21.55 and 21.56 summarize the postpeel care regi-
men; Figure 21.57 shows the patient information.
Results of Anterior Chemabrasion with ETCA on Facial Acne Scars
Anterior chemabrasion using ETCA showed good results with
an easy and safe post-peel period (Figure 21.58). Patients did
not experience any major side effects. Figure 21.59 summarizes
the treatment algorithm.
Double Anterior Chemabrasion
Some acne cases present a challenge: acne scars are large
and deep, and the skin is thick (Figure 21.60). At first sight,
Figure 21.51  Occlusion was implemented for 24 hours imme-
diately after the phenol peel. The next day, the patient came for
removal of the occlusion. Strong edema appeared during the phe-
nol peel application, which is a positive sign of deep activity.
Figure 21.52  At day 10, the results of this deep phenol peel were
deceptive; the acne scars were barely affected.
Figure 21.53  This picture taken during the peeling applica-
tion gives a clear indication of the lack of activity: The phenol
application induced immediate edema, with an orange skin
effect that deepened the pike scars. The phenol therefore did
not correctly penetrate into the bottoms of the deep pike acne
scars. This problem was apparent during the application, and
the phenol solution was selectively introduced into each scar,
using a wooden pike. This selective treatment induced the area
of re-frosting seen here, but this was ineffective in the end, as
seen in Figure 21.52.

174      Textbook of Chemical Peels
Day 7–8
Makeup allowed
if PIH risk, give the patient Blending Bleaching 3 x/day 2 before treatment
Protective Home care
Skin Tech Cleanser (cleanse skin)
IPLASE (reduces erythema) 3x/d
Melablock HSP 50 09–12 am, 03 pm
Blending Bleaching (pigment control) 2x/d – at least 2 months
09–12 am, 03 pm
Melablock HSP, SFP 30
Specific Home care
Day 6
Check if infection
Vaseline everywhere
ST = Scar treatment
ETCA = Easy TCA
YELLSKREEN: Protective yellow powder
Day 3
Check if infection
Vaseline on the edges
–2 Weeks
3
6
0
1
2
4
5
7
8 to 15
After day 15
DO NOT REMOVE YELLSKREEN
Skin is regenerating under the crust
ST
Day 0:
ETCA postpeel mask
YELLSKREEN
Figure 21.55  Postpeel care summary: anterior chemabrasion treatment for scars.
(a)
(b)
(c)
Figure 21.54  (a) Facial abrasion with 3M Wet-or-Dry sandpaper, P220. (b) End of abrasion: confluent bleeding. (c) After application of the
ETCA solution, there is pure white or gray-white frosting. The postpeel mask cream is applied as soon as frosting occurs.

Stretch marks, scars, and pilar keratosis: Anterior chemabrasion      175
we would tell this patient that peeling is not an option and
that several surgical procedures should be used for softening
the aspect of the skin: fat transfer, punch-and-lift, and more.
For this patient we used another deeper technique consist-
ing of “classical” anterior chemabrasion followed by local
diamond drill abrasion for deeper and larger acne scars. A
gauze soaked in adrenalinated 2% lidocaine was applied after
the sandpaper abrasion and after the diamond drill abrasion,
before the ETCA application. The double chemabrasion tech-
nique was performed twice on this patient, at a 1-year interval
(for personal reasons; the minimal interval between two ses-
sions is 6 weeks). Figure 21.61 shows an interesting result 15
days after the ­second double chemabrasion with ETCA. There
is still edema and slight erythema, but no sign of unstable
scarring. Note that the results are visible not only on the acne
scars, but also on the skin structure and on signs of aging (see,
for example, the enhancement of the pre-auricular folds and
deep wrinkles). Double anterior chemabrasion is therefore
worth additional technical commentaries.
The patient in Figure  21.62 presented with pike acne
scars on left and right sides of the face sides, which were
treated with double anterior chemabrasion. The patient
underwent a total of two sessions of anterior chemabrasions,
with a 1-year ­interval, for personal reasons. Note that the
physician and assistant should wear protective equipment
on their clothes, hands, face, and eyes when performing this
technique. A mask is necessary as diamond drill abrasion
sprays blood.
After disinfection (alcohol or chlorexidine) and degreas-
ing (acetone), abrasion is performed using sandpaper (P220,
Wet-or-Dry). Such abrasion is not painful as long as the area
around the basal layer of the epidermis is not touched.
The patient typically begins to feel pain as the first pin-
points of bleeding appear. A gauze soaked in 2% adrenali-
nated lidocaine is applied to the abraded area and covered by
a cling film to prevent evaporation. Anesthesia occurs when
the bleeding stops. Sandpaper abrasion can then continue up
to the end point: surface bleeding. Then, another topical anes-
thetic is applied. After the second anesthetic is considered
effective, the diamond drill abrasion is carefully performed on
the deeper scars. The end point of the abrasion is shown in
Figure 21.63.
At the end of the diamond drill abrasion, a gauze soaked
in 2% adrenalinated lidocaine is again applied to the abraded
area, to stop the pain and bleeding and to prepare for the ETCA
application.
When the anesthesia is effective, one coat only of
ETCA  is uniformly applied to the full face. When pass-
ing over  the  recently abraded areas, a gray frosting appears
immediately.
When abrasion and ETCA application are complete,
a thick coat of postpeel mask cream is applied on the skin.
Yellskreen (BSG) powder is applied directly over the postpeel
mask (Figure 21.64). It will build a protective crust that will stay
in place for 7 days. The patient leaves the clinic wearing the
powder. Under the Yellskreen non-water-soluble crust, healing
typically takes place very quickly.
•
On day 2, surprisingly, the skin is already in the healing
phase. There is no peripheral inflammation (postpeel mask
action) and the healing looks to be perfectly sane.
•
On days 3 and 6, the patient is examined for any signs
of infection. If infection is present, oral antibiotics are
given, but the yellow crust cannot be removed for any
reason.
•
On day 7, a thick coat of Vaseline will allow the crust to be
easily removed, without traction. The skin already appears
reepithelized (Figure 21.65).
Table 21.11  Information about Chemabrasion
Sandpaper
abrasion end
point
The sandpaper abrasion must be taken a step
further (grade III) on the face: confluent
pinpoint bleeding appears on the abraded
area of the scars. This physical resurfacing
makes the skin appear smoother after
abrasion (Figure 21.55b)
The abrasion should be totally uniform because
irregularities would allow a differential acids
penetration and irregular results of side
effects.
Topical
anesthetic
A gauze soaked in 2% adrenalinated lidocaine
is applied on the abraded area, after the
patient claims that treatment becomes
painful. Lidocaine application directly on the
dermis might be felt as a slight burning for
few seconds. The topical anesthetic dries up
the blood and anesthetizes the whole area
before the acid is applied. The anesthetic is
applied after abrasion and before application
of the ETCA solution. It can be covered with a
cling film to prevent evaporation and allow
better efficacy.
Peeling end
point
Application of the ETCA solution triggers pure
white or even gray-white frosting. The solution
penetrates to the reticular dermis.
Nonocclusive
technique
Occlusion is not necessary; the abrasion is
deeper than in the case of stretch mark
treatment.
Immediate
postpeel care
After obtaining the desired frosting, postpeel
mask cream is generously applied. BSG
powder is applied on the postpeel mask; it will
adhere to form a protective crust. It should be
left in place for 7 days.
Day 0: bismuth subgallate
Day 3: check if infection
Vaseline on the edges
Day 6: check if infection
Vaseline everywhere
Days 8–15: IPLASE 1 tube
Blending Bleaching
Melablock HSP 50
Days 15–90:
Blending Bleaching
Melablock HSP 50
Figure 21.56  Timeline for postpeel care.

176      Textbook of Chemical Peels
Generally:
SCARS : Postpeel care— Patient Information
D 0–1 :
Do not scratch, do not moist or remove or peel away the yellow powder.
Contact your doctor for any question, any doubt.
Apply YELLSKREEN powder if it becomes wet.
Take a painkiller tablet if necessary (afternoon and/or before sleep).
See the doctor, he will apply vaseline on the edges of the treated area and control your skin.
See the doctor, he will apply vaseline on the whole area to help to remove YELLSKREEN.
Makeup allowed.
Protective home care
Apply IPLASE Mask 3 x/day : helps to reducing redness.
Cleanse the skin, using Skin Tech Cleanser only. (Cleanses and balances skin pH.)
Apply Blending Bleaching Cream 2x/day.
Specific Home Care
- If pigmentary risk: Pigment control : Blending Bleaching Cream 2x/d during 3 months.
- if no pigment risk: subcutaneous tissues filling : Atrofillin 2x/day during 6 months.
Sun Protection:
Days 1 to 15: Avoid any sun exposure and use Melablock HSP, SPF 50 (9 am, 12 am, 3 pm).
Days 16 to 90: Avoid sun exposure; use Melablock HSP 30.
(or 50+ depending on the sun and the phototype) at 9 am, 12 am, 3 pm.
D 3:
D 6:
D 7:
D 8–15:
D 16–90:
Figure 21.57  Scars—patient information.
(a)
(b)
Figure 21.58  (a) and (b) Result of anterior chemo-abrasion with Easy TCA.

Stretch marks, scars, and pilar keratosis: Anterior chemabrasion      177
•
Diamond drill abrasion can be performed without ­general
anesthesia. Sequential topical anesthesia is absolutely
effective.
•
On day 7, the skin has healed and the inflammation level is
very low. This is much faster than could be foreseen with
such a deep treatment.
Nevertheless, double anterior chemabrasion is a poten-
tially dangerous technique if the physician does not fully
understand the postpeel events. The technique itself is not very
difficult; the only real concerns are to perform a uniform abra-
sion and not to apply too much acid. Uniformity is key.
The result obtained after two sessions of double anterior
chemabrasion is evident (Figures  21.66 and 21.67). Also note
the global enhancement of skin quality—wrinkles, lentigines,
­tension—of the nonabraded skin, which is related to the con-
comitant application of two ETCA peelings.
Body Scars
The treatment of body scars is more complex than that of facial
scars. The same technique described for stretch marks is used:
abrasion plus ETCA peel plus postpeel mask cream plus occlu-
sion. The results, although not exceptional, are quite good, as
evident in Figures 21.68 and 21.69.
Scars that are in the same area treated for stretch marks
by abrasion and ETCA respond well to this technique if they
are stable and permanent. It is out of the question to use this
deep peel on recent scars, as there is a risk that the scars will
open.
(c)
(d)
Figure 21.58 (Continued)  (c) and (d) Result of anterior chemo-abrasion with Easy TCA: note that deep wrinkles disappeared in the same
time as acne scars.
Superficial acne scars
Single anterior
chemabrasion
Deep acne scars
Double anterior
chemabrasion
Diamond drill abrasion
Andrenalinated lidocaine
Sand abrasion
Adrenalinated 2% lidocaine topical
Easy TCA peeling solution
Postpeel mask
Bismuth subgallate
Acne scars
Figure 21.59  Treatment algorithm.
Figure 21.60  Acne scars in thick skin.

178      Textbook of Chemical Peels
Acne Scars on the Back (Figure 21.70)
Technique
An intraepidermal abrasion is performed with positive kera-
tinocyte touch. Applying an acid solution immediately after
abrasion would be very painful, and a surface anesthetic
must be applied with gauze pads soaked in 2% lidocaine with
adrenaline (epinephrine) (allowing 10–15 minutes under plastic
film to prevent evaporation). The anesthetic can be seen to be
working as the adrenaline penetrates and causes vasoconstric-
tion. The ETCA solution is applied carefully, and cloudy-white
frosting may appear with the first coat of acid solution. As soon
as cloudy-white frosting occurs, 0.5 g of postpeel mask cream
should be applied per 10 cm × 10 cm of surface area treated10
and the skin massaged.
Figure 21.61  Clinical result 15 days after the second double
chemabrasion with ETCA.
Figure 21.62  Patient with pike acne scars.
Figure 21.63  The endpoint of abrasion.
Figure 21.64  Postpeel mask and Yellskreen.
Figure 21.65  Reepithelization of the skin.

Stretch marks, scars, and pilar keratosis: Anterior chemabrasion      179
Figure 21.66  Before double anterior chemabrasion.
Figure 21.67  After two sessions of double anterior chemabrasion.
(c)
(b)
(a)
Figure 21.68  (a) Abdominal scar before the first stretch mark treatment. (b) Appearance of the scar 30 days after the first stretch mark
treatment: the quality of the skin has improved significantly, the small scars left on the sides by the stitches have disappeared/diminished,
and the scar is flatter. (c) Improvement in the appearance of the scar and skin tension after the second stretch mark treatment (abrasive-
occlusive ETCA).

180      Textbook of Chemical Peels
The doctor will decide if he wants to deepen the action of
the peel with 24 hours’ occlusion, as with stretch marks, or to
end the peel here, without occlusion.
Postpeel Care
Postpeel care is the same as for the stretch mark treatment. The
peel should be repeated several times at 3- to 5-week intervals if
necessary. Repeated epidermal repair and dermal stimulation
gradually improve acne scars on the back.
TREATING KERATOSIS PILARIS
Keratosis pilaris is an abnormal keratinization of the hair folli-
cles that makes the skin feel rough. It occurs mainly on the arms
(especially the back of the upper arms) and thighs, but it can
also develop on the cheeks of young children. A red, inflamed
ring eventually surrounds the cone formed by the keratosis.
After light sandpaper abrasion followed by application of
ETCA peeling solution, white-gray frosting is seen, localized at
the level of keratosis pilaris (Figures 21.71 and 72).
Table 21.12 summarizes the treatment options.
(b)
(a)
Figure 21.69  (a) Before stretch mark treatment. (b) Before the third abrasive ETCA treatment. In spite of the poor quality of the photo-
graphs (due to the large pixel size of the first generation of digital cameras), it is easy to see the improvement in the scar across the abdo-
men as well as in the stretch marks.
(a)
(b)
Figure 21.70  (a, b) Treatment of pigmentary changes from acne scars on the back (without occlusion).

Stretch marks, scars, and pilar keratosis: Anterior chemabrasion      181
NOTES
1. The length of occlusion varies, as discussed later in this chapter.
2. Adato M, Deprez P. Striae treated by a novel combination treat-
ment—Sand abrasion and a patent mixture containing 15% tri-
chloracetic acid followed by 6–24 hrs of a patent cream under
plastic occlusion. Journal of Cosmetic Dermatology. 2004; 2: 61–70.
3. Sterilizing sandpaper for dermabrasion poses certain problems
that are discussed later in this chapter.
4. See the detailed formula of this cream in Chapter 15.
5. As mentioned earlier in this chapter, the postpeel mask is a
slightly acidic cream and cannot therefore be considered as a
simple “neutralizer.”
6. Although there is no point in going beyond 24 hours of occlusion.
Table 21.12  Treatment of Keratosis Pilaris
Classic medical
treatments:
Simple glycolic or lactic acid peel gives no
interesting result.
Dermatologists typically prescribe creams
that combat uncomfortable chronic skin
disease: moisturizers to soften the skin; and
urea, lactic acid, glycolic acid, salicylic acid,
tretinoin, vitamin D, or steroids if
inflammatory pilar keratoses are present.
Enhancement usually begins after a long
period of time, and results are not definitive.
Alpha hydroxy
acid (AHA)
peels
(glycolic, lactic,
etc.)
Usually, AHA peels do not show decisive
results, perhaps because AHA should be
neutralized quickly after application; acids
do not have much time to work on
keratoses.
AHAs partially neutralized only need a rinsing
with water and are not neutralized.
Nevertheless, partial neutralization makes
these peeling solutions less active on pilar
keratosis.
Easy Phytic
Solution (EPS)
(See Chapter 11
for more
information)
EPS is an interesting alternative because it
should not be neutralized, even if the pH of
the solution is +/–1. It offers much more
time for the acids to dissolve keratosis.
Application of EPS allows a better result. EPS
is not neutralized and acts longer on
keratosis, obtaining a better result than
other AHA peels. A simple occlusive
technique is used for 15 minutes, which
deepens the efficacy of EPS. Results are
obtained immediately after the first session:
application of EPS gives an immediate
sensation of soft skin. Side effects have not
been described.
As is the case with other treatments, it does
not modify the genetic base of the pilar
keratosis and recurrence is of high
probability. A maintenance treatment
extends the duration of the results:
moisturizers, antioxidant and vitamin
creams (Vitamin E antioxidant, Nutritive
ACE lipoic complex).
Application of EPS can be repeated on a
monthly basis
Abrasive
treatment
After disinfection, light abrasion (grade I) with
sandpaper should be performed. After
abrasion, a topical anesthetic is applied as
described in the protocol for stretch marks,
followed by ETCA solution. Pinpoint or
cloudy white frosting appears, especially on
the keratoses that take the brunt of the
abrasion. The postpeel cream is applied
and left to act until the next day. This
procedure is repeated four or five times, at
2-week intervals.
To maintain results, the peels are repeated,
and from time to time a simple, superficial
abrasion is performed.
Figure 21.71  Treatment of pilar keratosis: aspect of the skin after
sandpaper abrasion and application of ETCA solution. Points of
frosting can be seen.
Figure 21.72  White-gray frosting.

182      Textbook of Chemical Peels
7. Dry heat burns the sandpaper, damp heat twists it, and in both
cases the sandpaper’s silicone grains might come away from the
paper and be “grafted onto” the patient’s skin. With chemical
disinfection, there is a risk of toxic molecules being imported
into the patient’s skin.
8. If the pressure is too light, too many passes are needed, which
irritates and heats the skin more than abrading it. The risk of
postinflammatory hyperpigmentation is then higher.
9. See Chapter 35 for more information on bismuth.
10. The 0.5 g of postpeel mask can be measured out using the dosage
card in the kit. This corresponds to “one line of cream.”

22
Face and hands
Actinic keratoses and lentigines
Keratoses and lentigines need relatively deep treatment, but the
whole face does not need a full deep treatment when there are
only a limited number of lesions. A local application of Only
Touch peel (OTP), combined with a full-face, more superficial
application of Easy TCA (ETCA) or Easy TCA Pain Control
(ETCA PC) is sufficient.
DESCRIPTION
OTP is a CE-certified medical device whose formula is derived
from the ETCA and Unideep formulas.
The OTP kit contains a vial of base solution and a vial of
Aktivator TCA 80%, which contains trichloroacetic acid (TCA)
concentrated to 80% w/w. After mixing, the final concentration
of TCA is 43% w/w. After the doctor has reconstituted OTP by
adding TCA, the solution can be used to treat the skin focally to
the reticular dermis. Its pH is less than 1. It is therefore a very
strong peel, to be used only for limited indications. Table 22.1
lists the contents of the OTP kit.
INDICATIONS
Indications are restricted to the treatment of small benign
lesions less than 1 cm in diameter. Ideally, the treatment is lim-
ited to the hands, forearms, or décolletage, but in precise condi-
tions, OTP can also be applied on the face, neck, or body. OTP is
used to treat localized and benign solar lentigines (SLs) and/or
actinic keratoses (AKs) in patients with skin phototypes I to III,
or sometimes IV1 (Figures 22.1–22.3).
OTP must not be used on surface areas larger than 1
cm in diameter—not even partially. Nor should it be used on
lesions unless it is certain that they are benign. Nevi are not
an indication for OTP. Some doctors, by pushing the diam-
eter limits, have tried to use OTP to treat melasma. Melasmas
were partially treated in this way by gradually applying OTP
to small areas. However, this technique has proved ineffec-
tive, and there is a high risk of stimulating melanogenesis in
the melasma, breaking the basal membrane and encouraging
the development of dermal melasma. Under no circumstances
should OTP be considered as a treatment for standard or resis-
tant melasma.
CONTRAINDICATIONS
Phototypes FZ 5–6 are at high risk of postpeel pigment problem.
Avoid applying OTP on facial skin as it may result in persistent
red or pink marks for several weeks or months, and in the case
of postinflammatory hyperpigmentation (PIH). In particular,
do not apply OTP to patients who have had or are undergoing
treatment that might increase skin permeability.
Do not apply Aktivator TCA 80% without diluting it to
the recommended concentration, as this could cause perma-
nent scarring (see Figures 22.28 and 22.30).
To treat facial lentigines, a focal or local ETCA application
can be used (see Figure 22.8).
APPLICATION TIPS
Preparing the Skin
Weeks before Peel
OTP is a deep TCA peel and therefore tends to cause pigmentary
changes. The patient should apply Blending Bleaching Cream
(see Chapter 2) twice a day2 for 2–3 weeks before treatment
to reduce melanocyte activity. After the Blending Bleaching
Cream, sun protection cream (Melablock-HSP 50+ or 30) should
be applied and then reapplied every 2–3 hours, depending on
the amount of time the patient is exposed to sunlight. This prep-
aration reduces the risk of pigmentary changes after the OTP.
Immediately before Peel
Clean the skin with Skin Tech Cleanser, rinse and dry the skin,
and then disinfect and degrease it with a 50% alcohol/50% ace-
tone preparation.
Peeling Procedure
Inject the entire contents of the Aktivator TCA 80% vial into the
base solution vial to obtain a concentration of TCA 43% w/w.
Pay special attention to the manipulation of these products.
TCA 80% is extremely corrosive and should not come into
unwanted contact with the skin. Remember that injecting any
volume into a container that is hermetically closed will induce
pressure that could spray the acid on yourself or on your patient
when removing the needle from the vial. Furthermore, TCA
solutions, stored at room temperature, can release gas over time
and induce pressure in the absence of any previous manipu-
lation. Therefore, it is essential to release any excess pressure
from the bottle before inserting the needle into the liquid.
Using a 1 cm3 syringe, draw out the required quantity of
80% m/m TCA3 and inject it into the bottle of OTP base solu-
tion. Remember that 80% m/m means 80 g of TCA crystals with
an added 20 g of distilled water.
After making up the OTP solution, between 0.2 and 0.5
cm3 (the amount depends on the number of lesions to be treated)
are drawn up. This solution is put in a small glass or ceramic
bowl (under no circumstances should a metal container be
used).4 A cotton bud is then soaked in this solution and partly
squeezed out to make sure that there is no excess solution. Any
“drips” of OTP on the face can lead to cosmetically disastrous
results (see Figure 22.30).

184      Textbook of Chemical Peels
Prepare Cotton Bud for Application
Draw out 0.3 ml of the OTP solution using a 1 ml syringe Nokor
and a needle. The product could be tested on a small area of
skin before the first application to check the skin’s reaction to it.
OTP is applied with a cotton bud or, for very small lesions, with
a wooden pick soaked in the solution.5
Directly from the needle, soak a cotton bud, drop by drop,
until it is damp but not dripping. Usually, 0.15 ml is enough for
doing this. The solution left over in the syringe will be needed
to progressively soak the cotton bud again when it dries.
Focal Application of OTP Solution
Touch the lesion quickly and lightly, leaving the skin moist
without an excess of acid solution. Then let the skin dry. If
necessary, reapply OTP after it has completely dried to obtain
locally pure white or white-gray frosting, in keratosis or len-
tigo. The skin with white frosting must remain flexible and
elastic. In case of excess peeling solution, the appearance of a
hardening similar to a freeze must be anticipated to prevent a
potential complication of scarring.
The number of touches needed to induce the desired
frosting depends on the skin’s permeability. The important
point is to treat the skin progressively, which allows the physi-
cian to stop application before burning the skin.
The contact time between the cotton bud soaked in OTP
solution and the skin should be as brief as a finger touch on a
keyboard, a fraction of a second. If the time is any longer (≥1 sec-
ond), too much acid will be left on the skin. The frosting then
turns gray or even yellow and signals prolonged sequelae (see
Chapter 37). Prolonged contact or possibly repeated applications
make the skin appear “frozen” and indicates prolonged conse-
quences. The scabbing can last for more than 3 weeks in this case,
Table 22.1  Content of Only Touch Peel Kit
Base solution
One 5 ml vial containing a solution of
four alpha hydroxy acids, antioxidants,
trace elements, and saponines
Aktivator TCA 80%
One 3.8 ml vial containing a 80% w/w
TCA solution
Various
A small container for mixing the TCA
with the base solution, cotton buds,
and instructions for use.
(a)
(b)
Figure 22.2  Solar lentigines on the hands (a) before and (b)
after combined OTP and ETCA treatment. Daily care consisted of
DHEA-Phyto and Blending Bleaching Cream.
(a)
(b)
Figure 22.1  Solar lentigines (a) before and (b) after treatment with a combination of OTP and ETCA.

FACE AND HANDS: ACTINIC KERATOSES AND LENTIGINES      185
and hypochromic, achromic, or even hypertrophic scars may
develop (see the section on hyperpigmentation in Chapter 37).
Precise Application
AKs are less permeable to acid solutions than the normal skin
surrounding them, and the frosting on the hyperkeratinized
area appears (much) more slowly. OTP should therefore be
applied first only to the hyperkeratinized area and should not be
allowed to run over onto the neighboring skin. If too much OTP
is applied in an attempt to achieve frosting more quickly, the
neighboring skin may be damaged by the acid solution. Clinical
experience shows that it is preferable to have uneven frosting
on the AK during the first OTP session, as a second application
can be made a few weeks later, just before the fourth application
of Easy TCA that always accompanies the OTP (see discussion
below).
When treating the face, touch it once only. The applica-
tion of OTP should “moisten” the lesion. If the lesion still looks
dry immediately after one dab of OTP, more solution should be
applied. The OTP should be allowed to dry completely; frosting
should then be clearly visible. Frosting on the face appears far
more quickly than on the body (e.g., hands and forearms), and
with a smaller amount of the product. In most cases, a single
dab of OTP is enough to treat SLs on the face. However, three
or four dabs may be necessary to treat AKs on the body. Excess
solution and any unnecessary drips or runs should be avoided.
Uniformization of Results by Combination
with Easy TCA
After touching all lesions to be treated and obtaining the
desired frosting, apply ETCA 15% on the entire area (hand or
forearm, as described earlier). At the end of the ETCA appli-
cation, uniformly apply the Skin Tech postpeel mask (see the
package’s dosing card) and leave it on for at least 8 hours with-
out washing the skin.
Why Is It Wise to Combine?
Concentrated TCA has a strong potential to stimulate melano-
cytes, and PIH is common when OTP is used as monotherapy
without the blocking action of ETCA and without reducing
melanocyte activity beforehand. PIH can also occur when the
contact time between the cotton bud soaked in OTP solution
and the skin is too long—although not long enough to trig-
ger scarring. Unlike ETCA solution, OTP does not protect the
patient’s skin against inflammatory and free-radical attacks
after the peel.
Applying OTP correctly and combining it with ETCA
helps to avoid almost all pigmentary changes, whereas apply-
ing OTP on its own causes them in more than 60% of cases.
Easy TCA First, or OTP First?
The method for combined application is simple: OTP is applied
as described earlier; ETCA is applied to the whole area, includ-
ing the lesions that have just been treated with OTP, as soon as
there is sufficient frosting from the OTP. The protein coagula-
tion caused by the OTP does not allow the less concentrated
ETCA to penetrate.
It is unadvisable to apply ETCA before OTP, as ETCA
permeabilizes the epidermis and the OTP would penetrate too
deeply.
The two peels are repeated at different intervals: ETCA is
repeated once a week on the face and once every 2 weeks on the
body; OTP is repeated once every 3 weeks on the face and once
every 6 weeks on the body.
Figures  22.4 and 22.5 show how the two peels work
together and how often they should be repeated.
TREATMENT OF SOLAR LENTIGINES
SLs are brown macules 1–3 cm in diameter that tend to con-
verge and are found on 90% of Caucasians over 60 years old
(Figure 22.6). They are often seen on people of Asian origin as
well. They can, however, appear on the skin of much younger
subjects after acute or chronic UV exposure. They can disap-
pear partially or appear more diffuse when UV exposure stops.
Melanocyte proliferation varies, but sometimes the melano-
cytes in the basal layer of the epidermis can increase to such
an extent that the keratinocytes in the same layer seem to be
replaced by melanocytes. The structure of the epidermis is
(b)
(a)
Figure 22.3  (a, b) An excellent indication for OTP: the patient has a few scattered lentigines that do not justify a peel to the papillary
dermis; a combination of OTP and ETCA is ideal.

186      Textbook of Chemical Peels
hyperplastic and less permeable to the acids. Melanocyte
abnormalities have been detected, and this suggests a poten-
tial relationship between SLs and lentigo maligna, but to date
no clear link has been established between the two disorders.
They are difficult to treat unless all the melanocytes involved
are destroyed. Theoretically, this is an epidermal problem, but
the treatment has to go deeper, as the basal layer does not form
the classic, perfect sine wave that we see in the books. The basal
layer of an SL typically takes on the form of a “golf club” buried
deep in the dermis; it merges with other “golf clubs” and even-
tually creates a deep network. Conventionally, SLs are treated
with cryotherapy or laser (Q-switched ruby laser), but it is pref-
erable to treat them with deep and very localized6 peels, which
give excellent long-term results. Effective daily sun protection
is essential.
Before any treatment, a differential diagnosis should be
made between SLs and freckles, certain types of flat seborrheic
keratoses, early pigmented AKs, lentigo maligna, junctional
nevus, and some acanthomas. There are different ways to treat
SLs on the face, hands, neck, and décolletage, from laser to
pulsed light, cryotherapy, dermabrasion, and peels.
Applying a combination of OTP and ETCA to SLs on
the face is a simple, inexpensive, and effective option (see
Figure 22.16).
On the face, just a single dab of OTP is enough to coagu-
late the skin locally to the reticular dermis. ETCA is applied
immediately after OTP, over the whole face, following the basic
protocol (pinpoint frosting).
The epidermis is more impermeable on the décolle-
tage, and sometimes two dabs of OTP are needed to obtain
frosting. ETCA is applied over all of the neck and décolletage
immediately after OTP until pinpoint or cloudy white frost-
ing occurs.
Sometimes, SLs on the hands and forearms do not frost
until after three or four applications of OT. When the frost-
ing from the OTP is satisfactory, three successive coats of
ETCA are applied on the hands and forearms; there should be
no further frosting from the ETCA, however. If any frosting
starts with the second coat of ETCA, a third coat should not
be applied.
CASE STUDY 1: SOLAR LENTIGINES
TREATED WITH ETCA FULL-FACE
APPLICATION, DEPTH 3/7
Indication
The patient is a young female living in a sunny country and
suffering from early photoaging with SLs. After summer, her
SLs become darker and she suffers postsummer acne resur-
gence (Figure 22.7).
Treatment
ETCA is applied uniformly on the entire face until the end
point: frosting points. The peeling is repeated four times, at
1-week intervals.
Daily Care
The patient is instructed to apply Blending Bleaching Cream
twice a day and Melablock-HSP, SPF 50+, daily at 9 a.m., 12 p.m.
and 3 p.m.
6 weeks’ care
1st OT
before
1st
ETCA
2nd
ETCA
3rd
ETCA
2nd OT
before
4th
ETCA
2 weeks
2 weeks
2 weeks
Figure 22.5  OTP combined with ETCA on the body.
Figure 22.6  Solar lentigines.
1 week
1 week
1 week
6 weeks’ care
1st OT
before
1st
ETCA
2nd
ETCA
3rd
ETCA
2nd OT
before
4th
ETCA
Figure 22.4  OTP combined with ETCA on the face.

FACE AND HANDS: ACTINIC KERATOSES AND LENTIGINES      187
CASE STUDY 2: SOLAR LENTIGINES
TREATED WITH ETCA REGIONAL
APPLICATION + FULL-FACE APPLICATION
(ISO-MOSAIC TECHNIQUE)
Figure  22.8 demonstrates SLs and photo aging treated with
ETCA. The areas most affected by SLs are treated more deeply:
pink-white (5/7) or pure white (6/7) frosting is reached on
the regional area with lentigines. The rest of the face is treated
up to depth 3/7 (basal layer peel). As with the OTP protocol,
the regional 5/7 or 6/7 peel is to be done before the first and
eventually before the fourth ETCA. Daily care should include
­application of Blending Bleaching Cream, DHEA-Phyto cream,
and Melablock-HSP, SPF 50+.
Figure  22.9 shows the penetration of a regional appli-
cation of ETCA. Acid penetration cannot be uniform because
there is a large permeability difference between the SLs
and surrounding skin. The SLs present hyperkeratiniza-
tion that could slow down the acid penetration. The physi-
cian is advised to be patient: do not apply more acid, just let
the acid  you already applied penetrate. Waiting a few min-
utes  more will  prevent spending hours later treating side
effects.
CASE STUDY 3: SOLAR LENTIGINES
TREATED WITH ETCA FOCAL APPLICATION
+ ETCA FULL-FACE APPLICATION
(ISO-MOSAIC TECHNIQUE)
The patient shows general photoaging of the face and SLs
(Figure 22.10).
Peelings options include the following:
•
Deep full-face phenol peel (Lip & Eyelid Formula).
•
Light full-face phenol peel (Easy Phen Light).
•
Medium-depth TCA peel (Unideep).
•
Focal reticular dermis peel (OTP).
•
Regional deep ETCA peel.
•
Focal deep ETCA peel.
•
Full-face papillary dermis peel (ETCA PC).
•
Full-face basal layer peel (ETCA).
The best choice is always the least traumatic and least
dangerous technique that could be effective for the patient,
depending on analysis of his or her skin. This patient does not
need a deep phenol peel. OTP comes with the risks of PIH and
depigmentation of the face. Papillary dermis peels (Unideep,
(a)
(b)
Figure 22.7  (a) Young female patient living in a sunny country and suffering from early photoaging with lentigines. (b) After ETCA
treatment.

188      Textbook of Chemical Peels
ETCA PC) are other options, but there is no need for a peel of
such depth on the whole face for this patient. Therefore, prefer-
ence is given to an “iso-mosaic technique” using ETCA.
Figure 22.11 shows the patient at “day 0” of the selected
treatment. Treatment consists of a focal deep touch with ETCA;
the end point was focal pink-white frosting limited to the exact
level of SLs. ETCA Pain Control could also have been used.
After getting the pink-white focal frosting, ETCA is
applied on the whole face to treat general photoaging. ETCA
is also passed over the focal application of ETCA, which
is already pink-white. Application of more ETCA will evi-
dently deepen the focal peeling. This is why the end point of
focal application is voluntarily limited to pink-white color,
which indicates focal papillary dermis activity. At the end of
(b)
(a)
(c)
Figure 22.8  (a–c) Solar lentigines and photoaging treated with ETCA. The areas with lentigines are treated more deeply (pink-white or
even pure white frosting) than other areas (pinpoint frosting). Daily care comprised Blending Bleaching Cream and DHEA-Phyto.

FACE AND HANDS: ACTINIC KERATOSES AND LENTIGINES      189
the peel, the postpeel mask is applied on the whole area to
treat inflammation.
The patient’s daily home care consists of applying
Blending Bleaching Cream in the morning, DHEA-Phyto cream
in the evening; and Melablock-HSP 50+ as sun protection at
9 a.m., 12 p.m., and 3 p.m.
Figure 22.12 shows the evolution at day 7. The entire face
is treated with ETCA up to the basal layer (depth 3/7; end point:
(a)
(b)
Figure 22.9  There is a large permeability difference for acids between lentigines and surrounding skin.
Figure 22.10  General photoaging of the face and lentigines.
Figure 22.11  Patient about to undergo ETCA.

190      Textbook of Chemical Peels
frosting points); desquamation is over on day 7. Areas deeply
touched with ETCA are depth 5 or 6/7; the end point is pure
white or gray-white frosting. The average patient is still in the
desquamation phase up to day 10.
No further peels are possible as long as desquamation is
visible. The next peel should be scheduled on day 15 after first
application. The daily home care is to be continued as described
earlier.
Figure  22.13 shows the patient at day 15 after the first
application. A second ETCA is applied; the end frosting point
is depth 3/7 (basal layer peel). At day 21 after the first applica-
tion, a third ETCA is applied; the end frosting point is depth
3/7 (basal layer peel). At day 28 after the first application, after
examination, the decision is made to use the same iso-mosaic
technique again, as done during the first session: focal deep
application of ETCA (depth 5/7) followed by full-face applica-
tion of E TCA (depth 3/7).
Areas needing a second focal deep application of Easy TCA
are drawn as shown in Figure 22.13; note the already dramatic
enhancement of general skin quality obtained by the treatment.
Figure  22.14 shows the patient at day 28 after the first
application: repeat the treatment done at “day 0.”
Figure 22.15 shows the patient at 4 weeks after the first
treatment. SLs and global sun aging have been dramatically
enhanced. The face is globally rejuvenated and the skin qual-
ity recuperated. Daily care should be continued for at least 6
weeks—for 6 months if possible. Sun protection and avoidance
are necessary every day.
CASE STUDY 4: SOLAR LENTIGINES
TREATED WITH OTP FOCAL APPLICATION
+ ETCA FULL-FACE APPLICATION
(HETERO-MOSAIC TECHNIQUE)
Figure 22.16 shows a patient suffering from photoaging and a
few SLs on the face. The decision is made to treat the patient
with a hetero-mosaic technique. OTP will first be applied on
the SLs. After obtaining a white elastic frosting, ETCA will
be applied on the entire face. The postpeel mask ends the
treatment.
The physician should touch the lesion quickly and lightly,
leaving the skin moist without an excess of acid solution; then
let it dry. The skin with white frosting must remain flexible
and elastic. If there is excess peeling solution, the appearance
of hardening similar to a freeze must be anticipated to pre-
vent a potential complication of scarring. The contact time
between the cotton bud soaked in OTP solution and the skin
should be as brief as a finger touch on a keyboard, a fraction
of a second. AKs are less permeable to acid solutions than the
normal skin surrounding them, and the frosting on the hyper-
keratinized area appears (much) more slowly. OTP should not
be allowed to run over onto the neighboring skin. If too much
OTP is applied in an attempt to achieve frosting more quickly,
the neighboring skin may be damaged by the acid solution.
Frosting on the face appears far more quickly than on the body
(e.g., hands and forearms), and with a smaller amount of the
product. In most cases, a single dab of OTP is enough to treat
SLs on the face.
Figure 22.12  Patient at day 7.
Figure 22.13  Patient at day 15.