The patient’s skin color, skin type, and degree of photoaging must be taken into account. Three classification systems are available that can help to find the right therapeutic procedure for the individual.

The Fitzpatrick skin type system classifies degree of pigmentation and ability to tan. Types I and 11 are pale and have a high potential for sun burning; types III and IV can burn but usually tan, and V and VI are dark brown and black, tan easily and rarely or never burn. This system not only predicts sun sensitivity, tanning ability, and susceptibility to photodamage, but also classifies each skin type according to its risk factors for complications during chemical peeling. Individuals with Type I and 11 skin are at low risk for reactive hyperpigmentation (darkening of skin color) after a chemical peel. Those with types III through VI have a greater risk for either hyperpigmentation or hypopigmentation (fading of skin color) after a chemical peel. In order to prevent these complications, pre and post-treatment with both sunscreen and bleaching agents may be necessary.

The Glogau system classifies severity of photodamage into Categories I through IV. Patients in Category I with a minimal degree of photodamage can be treated with light chemical peeling and medical treatment with topical agents. Those in Categories II would receive medium-depth chemical peeling, erbium: YAG laser resurfacing, or dermabrasion, while category IV would require deep chemical peeling or laser resurfacing and may need the addition of filler substances to correct gravitational changes, i.e., sagging.

Dark-skinned patients have a greater incidence of post-inflammatory hypo and hyperpigmentation. The physician needs to be very careful in using either deep chemical peeling or laser resurfacing on dark skin. If these modalities are chosen, the patient must be prepared for the procedure with pre and postoperative bleaching agents, retinoic acid, and sunscreen. Medium-depth peeling requires the same preparation, but the risk is less.

The answer to this is yes. Actinic keratoses are sun-induced surface lesions that can develop into squamous cell carcinoma. When removed by resurfacing, they do not proceed to the next stage of development. Both active lesions and incipient growths as yet undetected will be sloughed off with the epidermis.

Actinic keratoses can be treated by many different modalities including cryosurgery, topical 5-fluorouracil, tretinoin (Retin AO), and the erbium:Yag laser. Medium-depth chemical peeling is well suited for these epidermal lesions, as the entire face or a particular sub-unit of the face, such as the forehead, temples, and cheeks can be treated fully within a week to ten days. Deep chemical peels will produce a wound deeper than needed for the removal of epidermal lesions.

Advantages include a limited recovery time of 7 to 10 days, with little postoperative erythema (reddening) after healing. Risk of pigmentary change with either hypo or hyperpigmentation is small. Thus, the patient can return to work rather quickly after healing. There is a long remission period when the patient can expect few or no actinic keratoses to recur.

Dermabrasion is my primary treatment of choice for scars. For actinic keratoses and photodamaged skin, I would make chemical peels my first selection, laser resurfacing second, and dermabrasion third. For wrinkles and photodamage reaching the dermal (second) skin layer, either dermabrasion or laser resurfacing is needed.

While dermabrasion improves wrinkles, the change is not as long-lasting as deep chemical peeling or laser resurfacing. This may be because heat produced by the laser has a greater thermal effect on collagen contraction and, therefore, on deep wrinkles. The degree of complexity for this procedure is greater than that for chemical peeling and is equal to that of laser resurfacing.

General anesthesia or circumferential local anesthesia to block the face is needed. Also, the healing time lasts 10 days to 2 weeks, with redness continuing for 4 to 6 weeks. There is also a risk of Herpes simplex infection, milia formation, and potential scarring. Repeat treatments are seldom needed, except in the case of deep scars where dermabrasion may be used again after a year.

Very superficial chemical peeling removes only the cell of the stratum corneum, a process known as exfoliation, while superficial chemical peeling removes the damaged epidermis as well. The new layer of cells that grows has less photodamage and so presents a more youthful appearance.

The very superficial chemical peel has been called the “lunchtime peel” because it can be fitted into a busy schedule with no downtime. The simplicity of the procedure, the quick healing time, few complications, and avoidance of anesthesia are advantages.

Medium-depth peeling is defined as controlled damage from a chemical agent to the papillary dermis, the upper portion of the second skin layer. It is effectively used for the following conditions:

Removal of diffuse actinic keratoses as an alternative to exfoliation with topical 5-fluorouracil chemotherapy.
Mild to moderate photoaging including pigmentary changes, lentigines, epidermal growths, and rhytides.
Melasma (a patchy discoloration of the skin) and dyschromia (abnormal skin color).
Used in combination with other modalities, i.e., dermabrasion and laser resurfacing, it can blend or unify areas of the face with mild to moderate photoaging changes.
Agents currently used include combination products-Jessner’s solution, 70% glycolic acid, and solid carbon dioxide combined with 35% trichloracetic acid.