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Standard guidelines of care for chemical peels Standard guidelines of care for chemical peels Member, IADVL Task Force*, Department of Dermatology, Safdarjung Hospital, New Delhi, India or correspondence: Dr. Niti Khunger, Department of Dermatology, Safdarjung Hospital, New Delhi, India. Chemical peeling is the application of a chemical agent to the skin, which causes controlled destruction of a part of or the
entire epidermis, with or without the dermis, leading to exfoliation and removal of superfi cial lesions, followed by regeneration
of new epidermal and dermal tissues. Indications for chemical peeling include pigmentary disorders, superfi cial acne scars,
ageing skin changes, and benign epidermal growths. Contraindications include patients with active bacterial, viral or fungal
infection, tendency to keloid formation, facial dermatitis, taking photosensitizing medications and unrealistic expectations.
Physicians’ qualifi cations: The physician performing chemical peeling should have completed postgraduate training in
dermatology. The training for chemical peeling may be acquired during post graduation or later at a center that provides
education and training in cutaneous surgery or in focused workshops providing such training. The physician should have
adequate knowledge of the different peeling agents used, the process of wound healing, the technique as well as the
identifi cation and management of complications. Facility: Chemical peeling can be performed safely in any clinic/outpatient
day care dermatosurgical facility. Preoperative counseling and Informed consent: A detailed consent form listing details
about the procedure and possible complications should be signed by the patient. The consent form should specifi cally
state the limitations of the procedure and should clearly mention if more procedures are needed for proper results. The
patient should be provided with adequate opportunity to seek information through brochures, presentations, and personal
discussions. The need for postoperative medical therapy should be emphasized. Superfi cial peels are considered safe in
Indian patients. Medium depth peels should be performed with great caution, especially in dark skinned patients. Deep
peels
are not recommended for Indian skin. It is essential to do prepeel priming of the patient’s skin with sunscreens,
hydroquinone and tretinoin for 2-4 weeks. Endpoints in peels: For glycolic acid peels: The peel is neutralized after a
predetermined duration of time (usually three minutes). However, if erythema or epidermolysis occurs, seen as grayish
white appearance of the epidermis or as small blisters, the peel must be immediately neutralized with 10-15% sodium
bicarbonate solution, regardless of the duration of application of the peel. The end-point is frosting for TCA peels, which are
neutralized either with a neutralizing agent or cold water, starting from the eyelids and then the entire face. For salicylic acid
peels, the end point is the pseudofrost formed when the salicylic acid crystallizes. Generally, 1-3 coats are applied to get
an even frost; it is then washed with water after 3-5 minutes, after the burning has subsided. Jessner’s solution is applied
in 1-3 coats until even frosting is achieved or erythema is seen. Postoperative care includes sunscreens and moisturizers
Peels may be repeated weekly, fortnightly or monthly, depending on the type and depth of the peel.
Key Words: Glycolic acid, Trichloroacetic acid, Salicylic acid
*The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) Dermatosurgery Task Force consisted of the following members: Dr. Venkataram Mysore (co-
ordinator), Dr. Satish Savant, Dr. Niti Khunger, Dr. Narendra Patwardhan, Dr. Davinder Prasad, Dr. Rajesh Buddhadev, Lt. Col. Dr. Manas Chatterjee, Dr. Somesh Gupta, Dr. MK Shetty,
Dr. Krupashankar DS, Dr. KHS Rao, Dr. Maya Vedamurthy, Ex offi -cio members: Dr. Chetan Oberai, President IADVL (2007-2008), Dr. Koushik Lahiri, Secretary IADVL, Dr. Sachidanand S,
President IADVL (2008-2009), and Dr. Suresh Joshipura, Immediate Past president IADVL (2007-2008).
Evidence - Level A- Strong research-based evidence- Multiple relevant, high-quality scientifi c studies with homogeneous results, Level B- Moderate research-based evidence- At least one
relevant, high-quality study or multiple adequate studies, Level C- Limited research-based evidence- At least one adequate scientifi c study, Level D- No research-based evidence- Based on
expert panel evaluation of other information
For Disclaimers and Disclosures, please refer to the table of contents page (page 1) of this supplement.
The printing of this document was funded by the IADVL.
How to cite this article: Khunger N. Standard guidelines of care for chemical peels. Indian J Dermatol Venereol Leprol 2008;74:S5-S12.
Received: August, 2007. Accepted: May 2008. Source of Support: Nil. Confl ict of Interest: Nil
Indian J Dermatol Venereol Leprol | Supplement 2008 Khunger N: Standard guidelines of care for chemical peels The concept of peeling the skin to improve the texture, smoothen and beautify it has been used since ancient times. In ancient Egypt, Cleopatra used sour milk, now known to contain lactic acid, an alpha hydroxy acid while French women used old wine containing tartaric acid, to enhance the appearance of the skin.[1, 2] Chemical peeling is a common office procedure that has evolved over the years, using the scientific knowledge of wound healing after controlled chemical skin injury.[3] In spite of the Active bacterial, viral, fungal or herpetic infection advent of newer techniques and lasers, peeling has stood the test of time as a simple procedure, requiring hardly any iii H/O (history of) drugs with photosensitizing iv. Preexisting inflammatory dermatoses such as Definition
Chemical peeling is the application of a chemical agent Uncooperative patient (patient is careless about sun to the skin, which causes controlled destruction of a part or entire epidermis, with or without the dermis, leading vi. Patient with unrealistic expectations.
to exfoliation, removal of superficial lesions, followed by vii. For medium depth and deep peels-history of regeneration of new epidermal and dermal tissues.
abnormal scarring, keloids, atrophic skin, and isotretinoin use in the last six months.[5] These guidelines identify the indications for chemical peels, various agents that can be utilized, methodology, pre- and 1. General
postpeel care, associated complications, and expected a. The physician should be a trained dermatologist.
b. The physician should have knowledge of the skin and subcutaneous tissue, including structural and functional differences and variations in skin anatomy of the facial cosmetic unit.
2. Specific
a. The physician should have appropriate training in chemical peeling either during postgraduation or later at a center that routinely provides education and training in cutaneous surgery. Such training may also be obtained in focused workshops providing b. The physician should have knowledge of the basic chemistry of peels, such as acids, bases, pH and pK a of peeling solutions and the mechanism of action of peels.[5] Familiarity with the properties of each Acne vulgaris-mild to moderately severe acne peeling agent to be used is critical for successful outcome.
The physician should know all aspects of mechanism of wound healing after chemical skin injury.
d. The physician should be well versed with all aspects of pathogenesis and the medical therapy of the condition to be peeled, such as melasma, acne, Indian J Dermatol Venereol Leprol | Supplement 2008 Khunger N: Standard guidelines of care for chemical peels iii Explanation about the nature of treatment, e. The physician should be well versed with expected outcome. It is advisable to downplay early recognition, prevention and treatment of postoperative complications such as prolonged iv Information about the time taken for recovery erythema, postinflammatory hyperpigmentation, of normal skin and importance of maintenance v Discussion of side effects, likely and unlikely complications, and particularly, pigmentation changes.
A. History should include general medical history, degree of sun exposure, occupation to judge the level Preprocedure treatment recommendations (Priming):[1,5,6]
of sun exposure, history of herpes simplex, recent Priming is essential for at least 2-4 weeks prior to the isotretinoin treatment in the last six months (for procedure. Priming helps to reduce wound healing time, medium depth and deep peels), keloidal tendency, facilitates uniform penetration of peeling agent, detects tendency for postinflammatory hyperpigmentation, intolerance to any agent, enforces patient compliance and current medications, any previous surgical treatment, immunocompromising conditions, and smoking (may delay healing in deep peels; this is not relevant for i Control any active infection or preexisting superficial peels). In patients in whom phenol peels are planned, history of systemic disease, particularly iii Hydroquinone (2-4%) in patients prone to B. Detailed medical examination should include general physical and cutaneous examination including skin Patients may also be primed at home by using type, degree of photoaging, degree of sebaceous mild topical peeling agents such as tretinoin activity (oily or dry skin), presence of postinflammatory 0.025%, adapalene 0.1%, Glycolic acid 6-12%, hyperpigmentation, keloid or hypertrophic scar, kojic acid, azelaic acid, etc (agents which are infection, and preexisting inflammation. likely to be used in postprocedure maintenance). Tretinoin is known to reduce healing time after resurfacing.[7] The choice of the priming agent to confirm diagnoses and see the level of pigmentation, e.g., mixed or dermal melasma, depends on the individual physician’s preference and individualized patient requirements. investigations are indicated for superficial peels. ii In patients with history of herpes simplex ii In patients in whom deep (phenol) peels are planned, hemogram, urinalysis, liver and renal antiviral therapy with acyclovir or famciclovir function tests and electrocardiograph may be is recommended, beginning two days prior to carried out as cardiac complications such as the procedure and continued for 7-10 days until life-threatening arrhythmia, are recognized as Informed consent after counseling as below i Correctly labeled peeling agents in various Counseling:
Evaluation of the psychological aspects to judge the motivation and expectations of the patient.
ii Explanation that patient should have realistic Syringes filled with normal saline for irrigation of expectations; this is particularly important the eyes, in case of accidental spillage.
in the media-hyped patient who may have vi Neutralizing solutions: Specific neutralizers are unrealistic expectations.
mentioned under “description of individual peels.” Indian J Dermatol Venereol Leprol | Supplement 2008 Khunger N: Standard guidelines of care for chemical peels Safety Precautions before peeling: The label on the bottle
must be checked before applying the peel; the head should be
Glass cup or beaker in which the required agent is elevated to 45º. To avoid accidental spillage, the open bottle or the soaked applicator should not be passed over the face. A syringe filled with water or saline should be kept ready for irrigation of the eyes in case of accidental spillage.
iv. Cotton-tipped applicators or swab sticksv. The patient is asked to wash the face with soap and ii. The hair is pulled back with a hair band or cap.
iii. The patient lies down with head elevated to 45º with 1. Alpha-hydroxy acids, AHA Monocarboxylic acids: iv. Using 2” x 2” gauze pieces, the skin is cleaned with Glycolic acid (Level A)[8-14], Lactic acid[15] (Level B), alcohol and then degreased with acetone. Bicarboxylic acid: Malic acid (Level C), Tricarboxylic 2. Beta-hydroxy acids, BHA (salicylic acid)[16-19] (Level A)3. Trichloroacetic acid (TCA)[20-22] (Level A) 1. The required strength of the peeling agent is poured into a glass beaker and the neutralizing agent is also 2. Sensitive areas like the inner canthus of the eyes and solution[24, 25] (Salicylic acid 14 g, Lactic acid nasolabial folds are protected with Vaseline.
14 g, Resorcinol 14 g with Ethanol to make 100 mL) 3. The peeling agent is then applied either with a brush or cotton-tipped applicator or gauze.
4. The chemical is applied quickly as cosmetic units 8. Phenol[27-30] Type I-II skin (Level A) Type III-IV skin on the entire face, beginning from the forehead, then the right cheek, nose, left cheek and chin in that order. If required, the perioral, upper and Classification of peels according to the histological depth lower eyelids are treated last. Feathering strokes are applied at the edges to blend with surrounding skin A. Very Superficial light peels: Necrosis up to the level
of stratum corneum. Agents used: TCA 10%, GA 30- 5. For glycolic acid peels, the peel is neutralized after 50%, Salicylic acid 20-30%, Jessner’s solution 1-3 the predetermined duration of time (usually three minutes). However, if erythema or epidermolysis B. Superficial light peels: Necrosis through the entire
occurs, seen as grayish white appearance of epidermis up to basal layer. Agents used: TCA 10- the epidermis or small blisters, the peel must 30%, GA 50-70%, Jessner’s solution 4-7 coats be neutralized immediately irrespective of the C. Medium depth peels: Necrosis up to upper reticular
duration. Neutralization is done with 10-15% sodium dermis. Agents used: TCA 35-50%, GA 70% plus TCA bicarbonate solution or neutralizing lotion and then, 35%, 88% phenol un-occluded, Jessner’s solution plus 6. For TCA peels, the end-point is frosting and D. Deep peels: Necrosis up to mid-reticular dermis.
neutralization is either with a neutralizing agent or cold water, starting from the eyelids and then the entire face. 7. When the salicylic acid peel is applied, it crystallizes forming a pseudo-frost; generally, 1-3 coats are Anesthesia: Anesthesia is not required in superficial and applied to get an even frost. It is then washed with medium depth peels. Mild tranquilizers or anxiolytics may water after 3-5 minutes, after the burning subsides. 8. Jessner’s solution is applied in 1-3 coats to get even Indian J Dermatol Venereol Leprol | Supplement 2008 Khunger N: Standard guidelines of care for chemical peels frosting; the endpoint is erythema or even frosting. skin and supportive medical therapy in addition to good 9. A cooling fan helps to reduce burning of the skin. intra- and postoperative care, are essential for satisfactory 10. The skin is gently dried with gauze and the patient cosmetic results. The best way to avoid complications is to is asked to wash with cold water until the burning identify patients at risk and use lighter peels. The deeper subsides. The face is patted dry; rubbing should be the peel, the greater is the risk of complications. The patients at risk are those with a history of postinflammatory 11. Tretinoin peels are yellow peels that are left on for hyperpigmentation, keloid formation, heavy occupational exposure to sun such as field workers, uncooperative 12. Very superficial peels may be repeated every 1-2 patients and patients with a history of sensitive skin who weeks and superficial peels every 2-4 weeks. are unable to tolerate sunscreens, hydroquinone etc. Pigmentary changes: Postinflammatory hyperpigmentation and hypopigmentation. These can be very persistent Medium depth peels should be done with great caution and often difficult to treat. They may be treated with in dark skinned patients because of the high risk of broad-spectrum sunscreens, topical corticosteroids, prolonged hyperpigmentation.[1, 31] Deep phenol peels are tretinoin, hydroquinone or alpha-hydroxy acids.
not recommended for dark skins of types IV-VI because of ii. Infection: Bacterial (Staphylococcus, Streptococcus, high risk of prolonged or permanent pigmentary changes,[1] Pseudomonas), viral (Herpes simplex) and fungal although modified phenol peels are being used in types III- (Candida). They should be treated aggressively and iii. Scarring is rare in superficial peels. Proper priming, proper choice of peeling agent and postoperative care can help in prevention of this complication.
The aim of good postoperative care is to prevent or minimize complications and ensure early recovery. This is most important in dark skinned patients in whom pigmentary alterations are common. A careful maintenance program is essential to maintain the results of chemical peeling in most patients.
viii. Textural changesix. Persistent erythema: Erythema persisting for more i. In the postpeel period, edema, erythema and than three weeks after a peel, is indicative of early desquamation occur. In superficial peels, this lasts scarring and should be treated with potent topical for 1-3 days, whereas in deeper peels, it lasts for x. Toxicity: Although rare, it may occur with resorcinol, ii. Mild soap or a non-soap cleanser may be used. If there is crusting, a topical antibacterial ointment should be used to prevent bacterial infection. iii. Clear instructions must be given to the patient for A. combination of peeling agents enhances the depth iv. Cold compresses or calamine lotion may be used to of the peel without using a higher concentration of the peeling agent. However, these medium depth v. They should be told to use broad-spectrum peels should be used cautiously in darker skinned sunscreens and only bland moisturizers until peeling patients because of the risk of uneven depth of peeling and increased risk of side effects, such as vi. They should avoid peeling or scratching the skin. postinflammatory hyperpigmentation and scarring. vii. Analgesics are not usually needed but may be advised (Coleman’s Peel)[36] (level C). In darker skins, lower concentrations of TCA (10-25%) may be used CO combined with 35% TCA (Brody’s peel) Proper patient selection, adequate counseling, priming the Indian J Dermatol Venereol Leprol | Supplement 2008 Khunger N: Standard guidelines of care for chemical peels iii. Jessner’s solution with 35% TCA (Monheit’s Peel) laser resurfacing for skin rejuvenation. First, a chemical peel is performed and then, the deeper B. Two procedures can also be combined to blend wrinkles in the periorbital and perioral areas are cosmetic units and avoid demarcation lines:[38-40] i. Chemical peeling combined with dermabrasion: iii. Chemical Peel with dermasanding using combining application of 50% TCA followed by iv. Chemical peeling with Botulinum Toxin (level C).
dermabrasion for post-acne scarring. However, v. Chemical peeling with fillers (level C).
50% TCA causes scarring and its use is not advocated anymore. ii. Chemical peeling can also be combined with Chemical peeling is a simple office procedure used for the treatment of dyschromias, photoaging, and superficial Table 1A: A useful classifi cation of peels, peeling agents and
indications in Indian skin
scarring that can lead to excellent cosmetic improvement, Peel depth
Level of peel
Peeling agent
Indications
when repeatedly performed in carefully selected patients. Although various depths of peels have been described, superficial and medium depth peels are safer for Indian patients. Deep chemical peels should be avoided because depth and concentration of the peel should be selected according to the pathology of the condition (Table 1). be repeated with maintenance peels to achieve maximum improvement and prevent recurrence. With the advent of lasers and newer techniques, the use of chemical peels has Table 1B: Comparison between commonly used peeling agents
Agent Advantages
Disadvantages
Even very superfi cial peels achieve signifi cant results Results not always predictable. Great variability Safe and effective at low concentrations Endpoint diffi cult to judge, greater chances of Dermal wounds and scarring can occur.
Diffi cult to prepare and obtain standardized Peel depth correlates with intensity of skin frost. Scarring can occur with high concentration.
Superfi cial peeling agent with a predictable response. Can be absorbed systemically, when applied over large areas in high concentrations, causing Lipophilic, hence very effective for acne, oily skin. Causes a white pseudofrost, hence, easy to visualize Contraindicated in patients allergic to aspirin and Minimal effi cacy in severe photodamaged skin.
Safer, low incidence of signifi cant complications.
Indian J Dermatol Venereol Leprol | Supplement 2008 Khunger N: Standard guidelines of care for chemical peels declined; however, its simplicity as an office procedure, minimal morbidity, easy availability and cost-effectiveness 17. Lee HS, Kim IH. Salicylic acid peels for the treatment of acne ensure that it still holds an important place as a tool vulgaris in Asian patients. Dermatol Surg 2003;5:1196-9.
to treat dyschromias and photoaging. Careful patient 18. Grimes PE. Salicylic acid peels. Chemical Peels. Procedures in cosmetic dermatology. In: Rubin MG, editor. Elsevier Inc.; selection, priming of the skin, standardization of peels, postpeel care and maintenance programs are essential to 19. Bari AU, Iqbal Z, Rahman SB. Tolerance and safety of superficial chemical peeling with salicylic acid in various facial dermatoses. Indian J Dermatol Venereol Leprol 20. Leonhardt JM, Lawrence N. Trichloroacetic acid (TCA) peels. 1. Savant SS. Superficial and medium depth chemical peeling. Chemical Peels. Procedures in cosmetic dermatology. In: In: Text book of dermatosurgery and cosmetology. In: Savant Rubin MG, editor. Elsevier Inc.; 2006. p. 73-86.
SS, editor. 2nd ed. ASCAD; 2005. p. 177-95 21. Chun EY, Lee JB, Lee KH. Focal trichloracetic acid peel 2. Brody H. History of chemical peels. In: Baxter S, editor. method for benign pigmented lesions in dark-skinned Chemical peeling and resurfacing. 2nd ed. St. Louis: Mosby patients. Dermatol Surg 2004;30:512-6.
22. Rubin MG. Trichloroacetic acid peels. Manual of chemical 3. Stegman SJ. A comparative histologic study of the effects of peels-superfical and medium depth. In: Rubin MG, editor, the three peeling agents and dermabrasion on normal and 1st ed. Philadelphia: JB Lippincot Co.; 1995. p. 110-29.
sun damaged skin. Aesth Plast Surg 1982;6:123-35.
23. Ghersetich I, Brazzini B, Peris K, Cotellessa C, Manunta T, 4. Monheit GD, Kayal JD. Chemical peeling. In Techniques of Lotti T. Pyruvic acid peels for the treatment of photoaging. Dermatologic Surgery. Nouri K, Leal-Khouri, editors. Elsevier; 24. Rubin MG. Jessner’s peels. Manual of chemical peels- 5. Chemical Peels. In: Rubin MG, editor. Procedures in cosmetic superfical and medium depth. In: Rubin MG, editor, 1st ed. dermatology. Elsevier Inc.; 2006 p. 1-12. Philadelphia: JB Lippincot Co.; 1995. p. 79-88.
6. Roenigk RK, Retinoids, dermabrasion, chemical peel and 25. Fulton JE Jr. Jessner’s Peel. Chemical Peels. Procedures in keloids. In: Roenigk RK, Roenigk HH Jr, editors. Surgical cosmetic dermatology. In: Rubin MG, editor, Elsevier Inc. Dermatology: advances in current practice. St Louis: Mosby; 26. Khunger N, Sarkar R, Jain RK. Tretinoin peels versus glycolic 7. Hevia O, Nemeth AJ, Taylor JR. Tretinoin accelerates healing acid peels in the treatment of Melasma in dark-skinned after TCA chemical peels. Arch Dermatol 1991;127:678-82.
patients. Dermatol Surg 2004;30:756-60.
8. Rubin MG. Glycolic acid peels. Manual of chemical peels- 27. Stone PA. Phenol peeling. Chemical Peels. Procedures in superfical and medium depth. In: Rubin MG, editor, 1st ed. cosmetic dermatology. In: Rubin MG, editor, Elsevier Inc.; Philadelphia: JB Lippincot Co; 1995. p. 89-102.
9. Ditre CM. Alpha-hydroxy acid peels. Chemical Peels. 28. Piamphongsant T. Phenol-castor oil: Modified peel for Procedures in cosmetic dermatology. In: Rubin MG, editor. dermal melasma. Dermatol Surg 2006;32:611-7. 29. Park JH, Choi YD, Kim SW, Kim YC, Park SW. Effectiveness 10. Grover C, Reddy BS. The therapeutic value of glycolic acid of modified phenol peel (Exoderm) on facial wrinkles, acne peels in dermatology. Indian J Dermatol Venereol Leprol scars and other skin problems of Asian patients. 11. Javaheri SM, Handa S, Kaur I, Kumar B. Safety and efficacy of glycolic acid facial peel in Indian women with melasma. 30. Landau M. Cardiac complications in deep chemical peels. 12. Wang CM, Huang CL, Hu CT, Chan HL. The effect of glycolic 31. Al-Waiz MM, Al-Sharqi AI. Medium-depth chemical peels acid on treatment of acne in Asian skin. Dermatol Surg in the treatment of acne scars in dark-skinned individuals. 13. Lim JTE, Tham SN. Glycolic acid peels in the treatment 32. Resnick SS, Resnick BI. Complications of chemical peeling. of melasma among Asian women. Dermatol Surg 33. Duffy DM. Avoiding complications. Chemical Peels. 14. Burns RL, Prevost-Blank PL, Lawry MA, Lawry TB, Faria Procedures in cosmetic dermatology. In: Rubin MG, editor, DT, Fivenson DP. Glycolic acid for post inflammatory hyperpigmentation in black patients. Dermatol Surg 34. Baumann L. Chemical Peeling. Cosmetic dermatology. 1997;23:171-5.
Principles and Practice. In: Baumannn L, editor. 1st ed, New 15. Sharquie KE, Al-Tikreety MM, Al-Mashhadani SA. Lactic acid York: The McGraw- Hill Companies; 2002. p. 173-86.
as a new therapeutic peeling agent in melasma. Dermatol 35. Moy LS. Superficial chemical peels with alpha-hydroxy acids. Atlas of cutaneous surgery. In: Robinson JK, Arndt KA, Le 16. Vedamurthy M. Salicylic acid peels. Indian J Dermatol Boit PE, Wintroub BU, editors. Philadelphia: WB Saunders Indian J Dermatol Venereol Leprol | Supplement 2008 Khunger N: Standard guidelines of care for chemical peels dermatology. Elsevier Inc.; 2006. p. 115-36.
36. Coleman WP 3rd, Futrell JM. The glycolic, trichloroacetic 39. Fulton JE, Rahimi D, Helton P, Dahlberg K. Neck rejuvenation acid peel. J Dermatol Surg Oncol 1994;20:76-80.
by combining Jessner/TCA peel, dermasanding and CO2 37. Monheit GD. The Jessner’s + TCA peel: A medium-depth laser resurfacing. Dermatol Surg 1999;25:745-50.
chemical peel. J Dermatol Surg Oncol 1989;15:953-63.
40. Landau M. Combination of chemical peelings with botulinum 38. Monheit GD. Combinations of therapy. Chemical peels. In: toxin injections and dermal fillers. J Cosmet Dermatol Rubin MG, editor, Chemical Peels. Procedures in cosmetic Appendix
Table 1: Fitzpatrick skin phototypes
Table 2: Glogau photoaging classifi cation
Skin type
Reaction to skin
Description
Shallow color with early actinic keratoses Persistent wrinkling at rest, moderate acne scarring Discoloration with telangiectasia and actinic keratoses Dynamic and gravitational wrinkling, severe acne scarring Author Help: Online Submission of the Manuscripts
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