A peeler's thoughts on skin improvement with chemical peels and laser resurfacing.

The new pulsed CO2 lasers are an exciting modality. They have the ability to do what no other procedure can do with the same safety profile. The drawbacks of cost, pain and prolonged healing, however, serve to limit the lasers use to a niche, rather than replacing all other means of skin resurfacing. Skin problems of the epidermis and superficial papillary dermis are more easily and less expensively treated with chemical peeling. This includes most types of hyperpigmentation as well as actinic keratoses and poorly textured skin. This is especially true of postinflammatory hyperpigmentation, in which any procedure that creates prolonged erythema dramatically increases the risk of increased pigmentation. In these patients, the use of CO2 laser resurfacing is risky, if not even contraindicated. Skin problems of the deeper papillary dermis and reticular dermis, such as rhytides and scars, however, respond as well to laser resurfacing as they do to deep chemical peels, but with a better safety profile and a more natural clinical appearance of the healed skin. In many cases, the patient would be better served with a medium depth chemical peel of the entire face and laser resurfacing of the rhytides in the perioral or periorbital areas. This would give the patient the best clinical result with the fastest recovery. The major drawback to this type of therapy has been that the postoperative care of the two treatment regions is different. This may cause some logistical difficulties for the patient, as well as some confusion. Certainly, another option is to treat the patient on two separate occasions; that is, first peel the entire face and then later go back and laser resurface the areas of the remaining rhytides. Although this approach creates more healing time for the patient, it minimizes the areas of prolonged erythema, thereby allowing the patient a faster return to normal. As laser technology continues to advance, we can expect faster healing times and less expensive machinery. Presumably, with our current understanding of the wound healing process, we should expect better post laser treatment regimens, with associated faster healing. Therefore, it is distinctly possible that the current niche for pulsed CO2 lasers will be expanded greatly in the next year or two.