Reversing Photoaging by Facial Skin Resurfacing
Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Answers
1. The explosion of interest in chemical peeling and laser resurfacing, on the part of physicians has paralleled the general public’s interest in acquiring a youthful appearance by rehabilitating the photoaging skin. The public’s interest has been furthered heightened by advertisements for cosmetic agents, over-the-counter chemicals, and treatment programs that have entered the general market of products meant to rejuvenate skin and erase the marks of sun damage and age. Most of these over-the-counter, home, do-it-yourself programs have been tried by patients, and by the time they consult their dermatologist or cosmetic surgeon, they are ready for more definitive procedures performed with either chemical peeling or laser resurfacing. It is the obligation of the physician to analyze the patient’s skin type, the degree of photoaging skin and thus prescribe the correct facial rejuvenation procedure that will give the greatest benefit with the least risk factors and morbidity. Major indications when the patient requests improvement include photoaging skin for the correction of rhytides, lentigines, actinic keratoses, and age-related chronological changes of the skin that alter texture and color.

2. Pre-cancerous lesions have been defined as early epidermal changes that are
predecessors to skin cancer. These include actinic keratoses, bowenoid keratoses, and even Bowen’s disease. Actinic keratoses can be treated by many different modalities including cryosurgery and topical 5-fluorouracil. Medium depth chemical peeling is well suited for these epidermal lesions as the entire face or a particular subunit of the face, such as the forehead, temples and cheeks can be treated fully within a week to ten days. Active lesions can be removed as well as incipient growths as yet undetected will be removed as the epidermis is sloughed. Advantages for the male patient include a limited recovery time – seven to ten days, with little post-operative erythema after healing. There is little risk of pigmentary change with either hypo or hyperpigmentation. Thus, the patient can return to work rather quickly after healing. There is a long remission period where the patient can expect few if no actinic keratoses to recur.
Deep chemical peels or laser resurfacing will produce a wound deeper than needed for the removal of epidermal lesions; thus, the physician should choose medium depth injury. This includes erbium:YAG laser resurfacing or medium depth chemical peel.
3. In reference to pre-cancerous skin growths such as actinic keratoses, the methods in use today include:
a. Topical chemotherapy – 5-fluorouracil
b. Cryosurgery
c. Electrosurgery
d. Retinoic acid – there are no definitive studies that demonstrate the production of
actinic keratoses with the use of tretinoin.

4. Analyzing the patient with photoaging skin must take into account skin color and skin type as well as degree of photoaging. Various classification systems have been available and I would like to present a combination of three systems that would simplify and help the physician to find the right program or therapeutic procedure for his patient. The Fitzpatrick skin type system classifies degree of pigmentation and ability to tan. Graded I through VI, it prognosticates sun sensitivity, susceptibility to photodamage and ability for facultative melanogenesis (one’s intrinsic ability to tan). In addition, this system classifies skin as to its risk factors for complications during chemical peeling. Fitzpatrick divides skin types I through VI, taking into account both color and reaction to the sun. Skin type I and II are pale, white and freckled with a high degree for potential to burn with sun exposure. Three and IV can burn but instead usually tan to an olive or brown coloration. Five and six are dark brown/black skin that rarely ever burns and usually does not need sunscreen protection. The patient with skin type I or II skin with significant photodamage needs regular sunscreen protection prior to and after resurfacing procedures. He, though, has little risks for reactive hyperpigmentation after a chemical peel. The patient, though, with type III through VI skin has a greater risk for pigmentary dyschromia – hyper or hypopigmentation after a chemical peel and may need pre and post-treatment with both sunscreen and bleaching to prevent these complications.

The Glogau system classifies severity of photodamage taking into account the degree of epidermal and dermal degenerative effects. The categorization is I through IV, ranging from mild, moderate, advanced and severe photodamaged skin. These categories are devised for therapeutic intervention in that category I with minimal degree of photodamage can be treated with light chemical peeling and medical treatment. Category II and III would entail medium depth chemical peeling or erbium:YAG laser resurfacing or dermabrasion, while category IV would require deep chemical peeling or laser resurfacing and may need those other cosmetic surgical interventions for gravitational changes.

Monheit and Fulton have devised a system of quantitating photodamage, helping numerical scores that would fit into corresponding rejuvenation programs. In analyzing photodamage, the major categories include dermal changes with texture and epidermal with skin lesions. Dermal changes include wrinkles, cross-hatched lines, sallow color, weathery appearance, crinkly-think parchment skin, and pebbly white nodules of milia. Each of these is evaluated and given a point score one through four. In addition, the number and extent of epidermal lesions are evaluated from freckles, lentigines, telangiectasias, actinic and seborrheic keratoses, skin cancers and senile comedones. These are also added in the classification system one through four and a final scoring result is tabulated. The patient then can see which treatment is necessary by the height of score produced. A total score 1-4 would indicate mild damage and the patient would adequately respond to a five-step skin care program including sunscreen protection, retinoic acid, glycolic acid, and selective lesional removal. A score of 5-9 would include all of the above plus repetitive superficial peeling programs. A score of 10-14 would include medium depth chemical peeling, and a score of 15 or above would include deep chemical peeling or laser resurfacing.

5. See question 4. Dermabrasion, medium and deep chemical peeling and laser resurfacing are the modalities used for Glogau III and IV. The Monheit-Fulton system, a score of 10-14 and above.

6. Dermabrasion is the treatment of choice for acne scars, traumatic scars and dermal contour changes. Best results are for the above. It also will remove epidermal growths and have an effect on wrinkles but this effect is not as long-lasting as deep chemical peeling or laser resurfacing. This may be because of the thermal heat effect in collagen contraction in laser resurfacing has a greater effect for deep wrinkles. There, though is less prolonged erythema than found in the resurfacing and less chance for pigmentary dyschromias. The degree of complexity is equal to that of laser resurfacing and more difficult than chemical peeling.

7. Drawbacks of dermabrasion include the necessity for general anesthesia or circumferential local anesthesia. Healing time ten days to two weeks with erythema lasting four to six weeks, risks of herpes simplex, milia formation and potential scarring. There is little indication for repeat treatments except of deeper scars where dermabrasion may be repeated after a year.

8. Dermabrasion is my primary treatment of choice for scars. It is my third treatment choice following chemical peeling and then laser resurfacing for epidermal growths, actinic keratoses and photodamaged skin. Rhytides and photodamage with dermal changes require either laser resurfacing or a second choice, dermabrasion.

9. Superficial chemical peeling is an exfoliation of the stratum corneum or the entire epidermis to encourage regrowth with less photodamage and a more youthful appearance. It usually takes repetitive peeling sessions to obtain maximal results. These agents have been broken down into very superficial chemical peels which will remove the stratum corneum only, and superficial chemical peels which will remove the stratum corneum and damaged epidermis also. It is to be noted that the effects of superficial peeling on photoaging skin are subtle and will not produced prolonged or very noticeable effect on dermal lesions such as wrinkles and furrows. Agents used include: trichloracetic acid 10-20%, Jessner’s solution, glycolic acid 40-70%, salicylic acid – beta hydroxy acid, and tretinoin. Each of these agents has its own characteristics and the physician must be thoroughly familiar with the chemicals, methods of application and the nature of healing. The usual time for healing is for one to four days, depending on the chemical and its strength.

10 /11. The advantages of superficial chemical peeling are the simplicity of the procedure, quick healing time, fewer complications and lack of need for anesthesia. The very superficial chemical peel has been called the “lunchtime peel” because it can be fit into a busy schedule with no downtime. One can though take into account what patient expectations and needs are because in many instances, this peel will not accomplish the results that an individual requires.

12. Medium depth chemical peeling is defined as controlled damage from a chemical agent to the papillary dermis resulting in specific changes that can be performed in a single setting. Agents currently used include combination products – Jessner’s solution, 70% glycolic acid, and solid carbon dioxide combined with 35% trichloracetic acid. The hallmark for this level peel was 50% trichloracetic acid. It has traditionally achieved acceptable results in ameliorating fine wrinkles, actinic changes and pre-neoplasia. However, since trichloracetic acid is an agent more likely to be fraught with complications, especially scarring in strengths of 50% or higher, it has fallen out of favor as a single agent chemical peel. It is for this reason that the combination products along with a 35% TCA formula have been found equally effective in producing this level of controlled damage without the risk of side effects.

13. The medium depth chemical peel has primary indications for the following conditions:
a. Removal of diffuse actinic keratoses as an alternative to chemical exfoliation with topical 5-fluorouracil chemotherapy.
b. Mild to moderate photoaging including pigmentary changes, lentigines, epidermal growths and rhytides.
c. Melasma and dyschromia
d. Used in combination with other modalities, i.e. dermabrasion and laser resurfacing – to blend areas of the face with mild to moderate photoaging changes.
14. This procedures requires mild pre-operative sedation and non-steroidal anti-inflammatory agents. The patient is told the peeling agent will sting and burn temporarily and aspirin is given before the peel and continued through the first twenty-four hours. I usually require sedation for my patients but when the peel is concluded, the discomfort has ended. The patient remains comfortable during healing.

On the downside, this is not a “lunchtime peel” and requires a week to ten days for healing. There is post-operative erythema, desquamation, drainage, and edema that may last seven to ten days. There are also risks for prolonged erythema, delay of healing, aggravation of herpes simplex, bacterial or fungal infection and even the possibility of scarring. In my fifteen years of using this procedure, I have yet to see true full thickness scars with medium depth combination peeling.

15. Level III-IV Glogau photodamage requires deep chemical peeling. This entails the use of either trichloracetic acid above 50% or Baker-Gordon phenol peel. Laser resurfacing can also be used to reliably reach this level of damage. Trichloracetic acid above 45% has been found to be unreliable with a high incidence of scarring and post-operative complications. For this reason, it is not included as standard treatment for deep chemical peeling. The Baker-Gordon phenol peel has been used successfully for over four years for deep chemical peeling and produces reliable results. It is a labor-intensive procedure that must be taken seriously as all major surgical procedures. The patient requires pre-operative sedation with an intravenous line and pre-operative IV hydration. Usually, a liter of fluid is given pre-operatively and in addition, a liter of fluid is given during the procedure. Phenol is both a cardiotoxin, hepatotoxin, and has nephrotoxicity. For this reason, one must be concerned with the serum concentration of phenol through cutaneous absorption. For that reason, all patients are given intravenous hydration prior to the procedure, patients are monitored for electrocardiographic abnormalities, and the procedure is spread out over a period of 1 ½ to 2 hours which decreases the amount of phenol absorbed at any one time, limiting serum phenol concentrations and, thus, toxicity. This is a tried and true technique for correction of deep rhytides and more severe photoaging changes. Crow’s feet, perioral rhytides and more severe facial changes respond dramatically to the phenol peel. It has been said that his peel is the most permanent procedure producing changes for photoaging skin. The immediate surgical drawbacks have already been discussed. Long-term side effects include hypopigmentation and textural changes. Deep chemical peels that are taped had given an alabaster or statuesque appearance to the skin. While this was acceptable twenty years ago, it is a trade-off for these changes in the skin, both the hypopigmentation and the alabaster skin is not acceptable today. The consumer today requires a natural look with less of a dramatic effect. This is a limiting factor for deep resurfacing, both peeling and laser, and the physician must take this into account.

16. The CO2 laser is a standard and the erbium:YAG laser also coming into use. The CO2 laser can selectively destroy thin layers of epidermis and dermis with little thermal effects to underlying tissue. Using the CO2 laser, the target chemical is water, the most common intracellular compound. The CO2 laser with a computer generated scanner (CPG) can efficiently accomplish deep resurfacing with three layers of the facial skin surface in the period time of one hour. Full face resurfacing, though, requires either general anesthesia or a full-face aesthetic blocks for local anesthesia. Post-operative side effects can be similar to those of deep chemical peeling including pre-operative erythema and even hypopigmentation with textural changes.

The Erbium:YAG laser now has been used for facial resurfacing but I feel it will never replace CO2 laser resurfacing as a primary agent for advanced photoaging problems. Erbium:YAG laser can be used for medium depth resurfacing but is not reliable as a primary agent for deep resurfacing. Recently, it has been combined along with CO2 resurfacing with combination laser therapy to promote faster healing with less prolonged erythema.

17. CO2 laser resurfacing is the primary treatment modality for advanced photoaging, especially of the eyelids and perioral area. It eliminates many of the risk factors found with phenol peeling and performed conservatively, it will give reliable results in eradicating dermal changes such as rhytides of the eyelids and lips. There is still a place for medium depth and superficial chemical peeling as well as dermabrasion today. The laser is the latest tool in our armamateria in resurfacing but these other tried and true techniques should not be abandoned in the proper indications.

18. Advanced photodamage, especially dermal changes of the eyelids and lips (see question 17).

19. The major advantages are the safety of this procedure for advanced photoaging skin over deep chemical peeling. Long-term side effects, though, can be similar with specific patients and one must carefully gauge the level of laser penetration to the skin type.

20. Laser technology is expensive and that cost must be reflective on the patient’s costs. The same procedure can be performed simpler at less of a cost with similar or less potential side effects and the physician should choose the simplest procedure. There are, though, procedures today that lasers alone can accomplish.

21. The typical patient requiring a combination procedure would be those with advanced photodamage around the eyes and mouth with only moderate photodamage on the rest of the face. Those who treat the eyelids and lips alone with a laser would deliver noticeable pigmentary and textural changes to those areas which the rest of the face would still have dyschromic and textural photodamage. Using a medium depth chemical peel for those other areas of skin, i.e. forehead, cheeks and chin, find that laser resurfacing around the eyes and mouth blend those areas to a uniform facial texture and color. It also reduces laser risks as the areas with greatest tendency to scar are the malar eminences, the forehead, and the hairline (often called “keloid alley”) by using the medium depth peel on these high risk areas. I even use a superficial chemical peel on the neck so that further blending will allow a gradual transition from the face down to the chest. The distinctive lines found when a face is resurfaced at the jawline is a deformity patients resent.

22. Dark-skinned patients have a greater incidence of post-inflammatory hypo and hyperpigmentation. One 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 post-operative bleaching, retinoic acid and sunscreen. The same is true for medium depth peeling without quite this risk.
23. I use all three modalities: 1) chemical peeling, 2) dermabrasion, 3) laser resurfacing. Having all of these tools available allows me to pick the appropriate technique for each of my individual patients. This is a far superior choice than relying on one modality for all patients. In that case, some are under-treated, some are over-treated and some are not treated correctly. Primarily speaking, I divide the following criteria in my choice:
Dermabrasion – acne scars, contour defects
Chemical Peeling – superficial and medium depth – Glogau I through III skin, dyschromias, actinic keratoses
CO2 Laser Resurfacing – Glogau photoaging skin III and IV with distinctive dermal changes.
24. Therapeutic resurfacing for a lesion of skin cancer is a covered expense when it is not being performed for cosmetic reasons alone. I have found this true for patients who have diffuse actinic keratoses and are not amenable to simpler procedures such as topical 5-fluorouracil and cryosurgery alone. It usually takes a precertification letter along with photographs to demonstrate the extent and degree of precancerous changes as well as their recalcitrant nature.

25. All patients will need a full sun block six weeks to three months after a resurfacing procedure. I also implore my patients having these procedures performed for photoaging skin to use a sunscreen regularly from this point on. Patients need to understand that the approach to photoaging skin is not a one-stage procedure but includes post-treatment therapy including long-term photo protection.