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Fig. 13.2b-d. Hematoxylin/eosin stains of biopsies of c Twenty-five percent TCA induced mid-epidermal back skin taken 24 h post-chemical peeling. b Salicylic wounding/separation. d Thirty percent TCA peel caused acid 30%. Note mild lymphohistiocytic infiltrate. deep epidermal separation

peeling agent to assess the patient's sensitivity and reactivity. The author's standard protocol involves initial pretreatment for 2—4 weeks with 4% hydroquinone formulations. Higher strength formulations (5-10%) can be compounded for recalcitrant hyperpigmentation. Azelaic acid or kojic acid formulations are used if patients are experiencing irritation or hypersensitivity to hydroquinone. Tretinoin, tazarotene and retin-ol are often used to treat acne, hyperpigmenta-tion or photodamage in darker skin types. However, these agents should be discontinued 1-2 weeks prior to peeling to avoid post-peel complications in dark skin. Retinoids increase epidermal turnover and they increase the depth of the peeling agent. This may be a desired effect in skin types I—III; however, in dark skin increasing the depth of the peel may result in excessive erythema, crusting, desquamation, and post-inflammatory hyperpigmentation. Topical bleaching agents, which do not contain retinoids, lower strength alpha hydroxy acids, polyhydroxy acids, and beta-hydroxy acids can be continued up to 1 or 2 days prior to peeling. These are less aggressive agents compared with retinoids. Superficial peels are performed at 2-to 4-week intervals and a series of three to six are routinely performed.

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