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DM|MD Skin Care FAQ’s

Dr. Man Answers many of the questions that are on our minds! Please read the actual FAQ’s from Dr. Man.

In the many years of examining patients, I have seen, just as I’m sure you have, all types of skin. Patients present themselves with mild to advanced sun damaged skin, early to advanced lentigens, small to large keratoses, fine wrinkling, melasma, dark circles to the lower eyelid skin, and mild to moderate acne with minimal or moderate scarring.

How can we help many of these conditions?

The skin conditions I describe above are results of problems in different layers of the skin, therefore the repair must be one that addresses the upper, the middle and the deep dermis.

The Fitzpatrick skin types 1-6 can serve as a good scale to predict what are the specific needs of each patient:

Types 1-3 can be treated with various types of superficial and medium depth peels with not much of a pigment (melasma) issues.

Types 4-6 have more at stake as they these may develop PIH (post inflammatory hyper pigmentation).

One has to examine the degree of inflammatory skin disorder. Is there sebaceous gland Hyper activity?
How will their skin respond to topical retinoids?
Will these patients’ skin be exposed to severe sun conditions? Will they agree to a use of broad spectrum sun screen?
Will they be able to tolerate 6 to 8 hours of cream on their face? Do these patients have realistic expectations?
Will they return for the second stage two weeks after the first application?

My plan was to design a superficial and medium depth peel which will cause exfoliation of the skin, thereby achieving a better skin texture.
Simultaneously, I would like the application to increase the skin thickness and decrease the chances of acne brake outs. This peel needs to alleviate the conditions leading to already clogged pores.

Treating actinic keratoses with medium depth peel makes much more sense than using agents like SFU or resurfacing with lasers as the recovery with these is much longer.

In using medium depth peels there should be noticeable thickening of the skin by increasing the amounts of glycosaminoglycans, collagen and elastin fibers in the deeper reticular layer.

By using agents of superficial level peel and agents of medium and deep level peel we are able to improve many of the above conditions without causing delay in healing and achieving the above with a short recovery time.

Chemical peels have been used for over 120 years and remain a significant tool.
In contrast, other resurfacing procedures associated with modern instrumentation technologies have come and gone.

We have seen emergence of various tools like dermabrasions, micro-dermabrasions, light sources, ablative and non-ablative laser methods, radio frequencies and ultrasound. Neurotoxins and various fillers become popular sometimes taking away the popularity from some of these peels.

It also became clear that combining various modalities to treat the skin was changed the sum of
1+1+1=3 to 1+1+1= 10.

My idea to use various agents of superficial, medium and deep peels is no different. I was able to do this as certain chemical agents were found reliable for ablative resurfacing of the superficial (epidermal), medium level (upper reticular) and deep level (reticular) skin.


Why is the combination of peels so unique?

When evaluating various chemical peel agents, it become clear that there are advantages and shortcomings in each of them.

Learning the pros and cons gives us a better understanding of each.
When using these agents, we try to maximize their good affects and minimizing their side effects, so that the patient will get the best peel with the shortest healing time. The shorter the healing time, the less complication occur.
For deep wrinkles, or when different angles exist between one wrinkle to another, we need to
use a deeper chemical peel and or some of the newer lasers Less affected skin areas can be treated with lesser ablative methods such as Jessner peel, TCA peel or AHA, and TCA peel.
Adding facial volume with fat or fillers and using neurotoxins alongside the peel improves the
overall appearance.

Again, one can see that adding 1+1+1 is no longer 3 rather a “10”.


What is our skin made of?

Most of our skin is made of water (70%). 25% is made of proteins and the rest of the 5% is make of lipids and minerals.

The epidermis is mainly built out of Keratin which is a protein produced by the keratinocytes.

The Dermis is made of collagen fibers, Elastin fibers and Glycosaminoglycans. The Collagen fibers are mostly responsible for the strength of our skin.

The Elastin fibres gives our skin it’s elasticity.

The Glycosaminoglycans are responsible for retaining the water.

The Hypodermis or the sub cutaneous tissue is mostly made up of lipids (fat). Different components of the skin interact contrarily with various peeling agents. The PH of the Epidermis is slightly acidic (PH 4.2 to 5.6)

The Dermis is less acidic than the Epidermis as it contains more fluid and blood vessels. It is
therefore important to know the PH and the PK of the agents in the cream and how they will interact with the skin.

How does a combination of Light, Medium and deep chemical peel agents affect our skin?

Monheit has popularized a combination of superficial (Jessner’s) and medium (35% TCA) peel agents in arriving with a deeper than a superficial peel.

Several agents can be used in a light peel:
1) Jessner’s solution
2) glycolic acid 40-70%
3) TCA 10-20%
4) Salicylic acid
5) Retin-A

Coleman has recommended
1) TCA 35%
2) Glycolic acid 70%

Brody has recommended
1) TCA 35%
2) Co2 solid

Obagi has recommended
15,20 and 25% TCA peel
Blue color