The original Blue Peel is a highly controlled, trichloroacetic acid (TCA)-based device procedure, which was created to augment the results achieved with the Obagi Nu-Derm® skin health transformation system. The peel process, including the preparation of skin, application, as well as the comprehensive post peel treatment plan has ensured that the variables which contribute to the complications surrounding medium depth peels may be all but eliminated.
Advantages:
- Gradual skin tightening.
- Mild skin leveling.
- Suitable for all skin types: facial and non-facial skin (standardised process: acid concentration, volume, recognised endpoints to control peel penetration and depth, maximum of 2 x 5% body surfaces per procedure and a coat system) thus eliminating variables.
- The procedure can be modified according to individual indications.
- Short and painless recovery phase.
- TCA is self-neutralising.
- Procedure can be repeated.
Potential complications:
- Post-inflammatory hyperpigmentation (PIH)
- Prolonged erythema
- Infection
- Scars
- Keloids.
The indications for performing the Obagi Blue Peel are:
- Pigmentation management
- Sebaceous gland hyperplasia
- Stretchable scars and wrinkles
- Solar lentigines
- Solar elastosis
- Actinic keratosis
- Skin tightening.
The ideal patients are those who have been adequately prepared with the Obagi Nu-derm® system.
Skin conditioning pre and post TCA peel ensures optimal healing and minimises post procedural complications.
Before treatment, Obagi Blue Peel 20%. Original reference: C DOF 517 30/03/2004
Obagi® Medical Products, a division of Valeant Pharmaceuticals.
Post treatment, Obagi Blue Peel 20%. Original reference: C DOF 4054 30/03/2004
Obagi® Medical Products, a division of Valeant Pharmaceuticals.
Technique
- The Blue Peel is a surgically clean procedure. The procedure requires pain management. Apprehensive patients and those undergoing designer Blue Peels or medium depth peels will benefit from intravenous and / or oral sedation. I work with an anaesthetist who provides intravenous sedation and find this to be the most suitable outcome for the patient. A hand-held ZIMMER Cryo 5 cooling device is also helpful for relieving discomfort for patients who are not sedated. Topical anaesthesia is inappropriate in this instance because its lipid base prevents the peel from penetrating evenly. Facial nerve blocks are helpful in patients requiring periorbital / oral peels who are not sedated.
- The patient is positioned supine with their head as flat as possible.
- The treatment area is thoroughly cleansed.
- The skin is de-greased with 70% isopropyl alcohol and acetone using soft gauze.
- 30% TCA is added to each 2ml Blue Peel base. Mix one 15 or 20% coat solution at a time.
- Apply the solution evenly to a 5% body surface area according to visible endpoints, waiting for at least a minute prior to re-application in the same area.
- Apply the solution in a clockwise, systematic fashion, until the endpoints have been achieved to a maximum depth of the immediate reticular dermis.
- Facial peel applications must include feathering to the neck, ears and post auricularly.
- Treat the periorbital area to the lash margin.
- Always use a wooden cotton tip applicator which is never too wet.
- Treat upper lids with the eyes shut and lower eyelids with the eyes open.
- Always stretch the skin and ensure that the peel has dried before applying extra solution.
- Tears neutralise acid; therefore re-apply solution to avoid an uneven result.
- Obagi foaming cleanser used without water will remove most of the colour.
Post-procedural treatment day one to re-epithelialisation (seven to ten days):
- Cleanse skin meticulously and keep it well hydrated. Sun avoidance replaces sunscreen.
- Treat folliculitis.
- Herpes simplex prophylaxis: Famvir (famciclovir), 500mg BD / Zovirax (acyclovir), 400mg TDS / Valtrex (valacyclovir), 400mg BD.
- I use Hypochlorous Acid (HOCI spray 100-130ppm) QID to aid recovery. The healing time is reduced because of the anti-inflammatory, disinfectant and bactericidal properties of HOCI preventing possible infection in treated areas.
I have enjoyed a long career, using TCA peels in clinical practice. The Obagi process, including the preparation of skin pre-peel, the safe application of the Blue Peel and the post-peel protocols have ensured a predictable outcome for patients and offer a robust example of best practice.
Further reading
• Obagi ZE. Obagi Skin Health Restoration and Rejuvenation. Springer-Verlag; New York; 2000.
• McKenna SM, Davies KJ. The inhibition of bacterial growth by hypochlorous acid. Possible role in the bactericidal activity of phagocytes. Biochem J 1988;254:685-92.
Declaration of competing interests: The author has been paid by the Healthxchange Pharmacy and Valeant Pharmaceuticals for compiling educational material and for running educational programmes.
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