Chapter 19
Management of the Patient
Maria Pia De Padova, Antonella Tosti
The author has no financial interest in any of the products or equipment mentioned in this chapter.
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Contents
19.1 Patient Selection . . . . 209
19.2 Patient Evaluation . . . . 209
19.3 Instructions . . . . 209
19.3.1 Pre-operative Phase . . . . 209
19.3.2 Post-operative Phase . . . . 210
19.4 Photographs . . . . 210
19.1 Patient Selection
쐽
Identify and exclude patients with body dysmorphic disorders.
쐽
Obtain medical history and exclude patients with specific contraindications (Table 19.1).
쐽
Discuss patient’s expectations and clarify.
쐽
Discuss alternative procedures.
쐽
Explain procedure and discuss pain during procedure and post-operative morbidity complications (Table 19.2). Don’t minimize the severity of the post-peeling phase, which may preclude social activities for several days.
쐽
Obtain informed consent (see related chapters).
19.2 Patient Evaluation
쐽
Assess phototype, degree of sebaceous activity, skin thickness, and pigmentary abnormalities (Wood’s light).
쐽
Exclude viral or bacterial infections and inflammatory dermatosis including retinoid dermatitis and skin irritation (shaving, use of facial scrubs) in the area that should be treated.
Photographic documentation permits the eval- uation of results and programming of future procedures.
19.3 Instructions
19.3.1 Pre-operative Phase
쐽
Topical 0.025–0.1% retinoic acid:
– Favors homogeneous penetration of the peelings
– Accelerates post-peeling healing
쐽Topical 1–2% salicylic acid:
– Favors homogeneous penetration of the peelings
– Reduces risks of the post-peeling
pigmentation
19.3.2 Post-operative Phase
쐽
Absolute sun protection (SPF of 30 and above + UVA filters)
쐽
Topical medication:
– Topical moisturizer (three to four times daily) – Antibiotic ointment
(medium/deep three to five times a day)
쐽
Ice packs in case of burning
쐽Avoid excessive activity
(medium/deep)
쐽
Sleep with the head elevated (medium/deep)
쐽
Topical tretinoin α-hydroxy acid when reepithelialization is complete
19.4 Photographs
Photographic documentation is important for:
쐽
Medicological purposes. Polaroid photographs are recommended for this purpose.
쐽
Evaluation of cosmetic benefits with the patient. Digital photographs are the best, permit easy comparison and are inexpensive. It is helpful to show the patient the necessity
of photoprotection, to inform the patient about the procedure and to show the post-peeling course.
쐽
Scientific documentation. Comparable high quality digital photographs are necessary.
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Table 19.1Specific contraindications
Active labial HSV infection. Prescribe prophylaxis with oral antivirals in patients with relapsing HSV (2 days pre- and 5 days post-operatively)
Phototype IV and VI except for salicylic acid and TCA <than 25%
Recent plastic surgery procedures, wait at least 6 months Drugs:
Aspirin allergy Salicylic peeling
Isotretinoin, wait at least: 6/12 months for medium-deep peels 3/6 months superficial peels
Anticoagulants Medium-deep
History of local radiotherapy
History of Keloid formation Medium-deep
Pregnancy/breast-feeding
Heavy smokers Medium-deep
Occupations associated with heavy sun exposure Inflammatory dermatoses in the area of the peels:
Eczema Urticaria
Seborrheic dermatitis Psoriasis
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Management of the Patient 211
Table 19.2Complications Local
Transitory Infections
Pigmentary changes (Fig. 19.1, 19.2) Ecchymoses Subjective skin
hyperreactivity (Fig. 19.3, 19.4) Contact allergy Contact urticaria Acneiform eruption
Persistent Pigmentary changes
Scarring
Persistent erythema Sensitive skin Textural changes Skin thinning Milia
Systemic
Cardiac arrhythmias Laryngeal edema Toxic Shock Syndrome Salicylism
Ochronosis Myxedema
Methaemoglobinaemia Hypotension
Collapse
Fig. 19.1.Pigmentary changes after a contained peel
Fig. 19.2.Pigmentary changes after a contained peel
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Fig. 19.3.Subjective skin hyperreactivity after salicylic acid peel
Fig. 19.4.Subjective skin hyperreactivity after salicylic acid peel
