APEELE is an advanced next generation hybrid peel designed to provide controlled exfoliation of damaged skin with significant visible results just after a single treatment. This powerful yet non-invasive approach to chemical peeling uses a synergistic combination of alpha-hydroxy acids (mandelic acid, lactic acid), beta hydroxy acid (salicylic acid), other exfoliating agents (tricholoroacetic acid, phenol, retinoic acid) in combination with hydroquinone and built-in topical anesthetics to achieve a superficial to medium depth peel. APEELE's clinical objective is to remove a predictable and uniform thickness of damaged skin and minimize potential complications such as scarring and pigmentary changes. APEELE provides consistent and predictable results in improving the quality and appearance of facial skin for all skin types.
What are the advantages of APEELE vs. currently available products?
Adequate evaluation and photographic documentation of the patient prior to applying APEELE is absolutely essential. This includes consideration of the severity of actinic damage, depth and number of wrinkles, and need for additional or alternative procedures. A cornerstone of the evaluation of the patient for chemical peeling is Fitzpatrick's scale of sun-reactive skin types. Patients with lighter skin types can expect to undergo peeling with minimal concern for abnormal pigment changes, whereas individuals with darker skin are at higher risk for unwanted hyperpigmentation or hypopigmentation. A thorough medical history and review of systems should be completed in concert with the physical examination. Preexisting cardiac, hepatic, and renal disease may influence the treatment decision and choice of peeling agents. The use of exogenous estrogens, oral contraceptives, and other photosensitizing medications are known to predispose to unpredictable pigment changes. Therefore, such agents should be avoided several weeks before and after APEELE.
If the patient has a history of herpes simplex infection, the physician should provide antiviral prophylaxis several days before and after the peel. This will help minimize chances of unwanted viral reactivation as the re-epithelialization process occurs. Patients must also be aware that cooperation and compliance with the post peel regimen is required to ensure normal wound healing and to avoid complications. Patients likely to be noncompliant or unable to avoid sun exposure
because of occupation are unsuitable candidates. In general, men are considered less optimal candidates because of thicker, oilier skin that risks uneven penetration of the peeling agent. Men are also less likely to be willing to use camouflage makeup in the event of pigmentary disturbances. Patients with prior radiation treatment or current isotretinoin (Accutane) use are also poor candidates because healing will proceed more slowly and scarring is more likely. Consider recent use of Accutane, pregnancy or nursing an absolute contraindication.
Preconditioning the skin is a useful adjunct to improving overall results. Retnoic Acid or Retinol (RETISOME) based exfoliating agent, is believed to facilitate uniform penetration of APEELE and promote more rapid re-epithelialization. This may be applied nightly or every other night for several weeks prior to peeling, depending on the degree of skin irritation caused and patient tolerance. This promotes a thinning of the stratum corneum with shedding of keratinocytes while fibroblasts are stimulated. Prior to the peel, the patient should thoroughly cleanse the face with non-residue soap on the evening before and morning of the procedure.
The application of APEELE is a 3 step process that takes about 20 minutes. Cleanse face with soap or gentle cleanser to remove any remaining traces of makeup or oils. Wipe area that is being treated with acetone-alcohol pads that is provided to prevent uneven penetration of APEELE. Apply 2-3 layers of STEP 1 using a 2x2 gauze sponge. Typically, the cheeks are treated first, applying APEELE from medial to lateral areas, followed by application to the chin and forehead. Allow STEP 1 to air dry with the aid of a cooling fan for 10 minutes. Apply STEP 2 and allow to air dry for 5 minutes. Apply STEP 3 and allow to air dry for 5 minutes. Vigorous rubbing of the agent, as compared with blotting, yields a deeper penetration.
Postoperative care is aimed at providing an ideal environment for moist wound healing. Initially, a generous amount of Zinc Oxide 20% is applied to the entire treated area. Patients are instructed to reapply the ointment throughout the day, any time the face feels tight or dry. As the outer layers begin to shed, the patient is allowed to shower and gently wash the face with non-residue soap using fingertips only. After showering, the face should be patted dry and a new coating of ointment applied. Instruct patients to not pick at the face during the recovery period. Understanding the process of re-epithelialization and the importance of compliance with the prescribed post-treatment regimen is essential information for every patient. This includes awareness of likely facial edema that may contribute to symptoms such as diplopia. If antiviral therapy is instituted, continue therapy until re-epithelialization is complete. In the early stages of wound healing, re-examine the patient within 48 hours and again every several days. Instruct patients to read the patient information guide and follow the instructions until the face is healed to the satisfaction of the treating physician.
APEELE may result in a profound improvement in the quality of facial skin, but this treatment also has potential complications. Results and complications are generally related to the depth of wounding, with deeper peels providing more marked results and a higher incidence of complications. Complications are also more likely with darker skin types and certain peeling agents. Erythema generally subsides within 90 days but may become prolonged and even manifest as hyperpigmentation. Patients at increased risk are those taking oral contraceptive pills, exogenous estrogens, or other photosensitizing medications. The application of topical hydrocortisone lotion and/or a short course of systemic steroids may lead to earlier resolution. Other treatment options for hyperpigmentation include trans-retinoic acid, glycolic acid, or hydroquinone. Accompanying pruritus may be treated with oral antihistamines. Following chemical peeling, the skin is typically sensitive to the sun, which also may be a source of hyperpigmentation. Instruct patients to use sunscreen daily for 6-12 months following a chemical peel. Patients should also be educated in the appropriate application of camouflaging makeup. Hypopigmentation is the result of melanocyte destruction or inhibition.Hypopigmentation is more noticeable on darkly pigmented patients. Hypopigmentation may be difficult to assess until erythema has subsided, at which point the condition unfortunately becomes permanent. The line of demarcation between treated and untreated skin is usually the most noticeable. Prior to the peel, with the patient in the sitting position, note the position of the skin draping over the mandibular border. The peel may be feathered at this line of natural shadowing to create a transition zone. This may be performed by using a less concentrated formulation or by applying less of the agent in these regions. Camouflage makeup may help conceal this and other pigmentary disturbances.