Medium-depth Chemical Peel Research Articles

Facial psoriasis in the etiology of prolonged erythema following medium-depth chemical peels for severe photodamage.

Chemical peeling is the controlled wounding of the epidermis and dermis for skin rejuvenation, involving the application of ablative agents to induce keratolysis and regeneration of damaged cell layers. Prolonged erythema is one complication of this procedure. We report the prevalence and probable etiology of prolonged facial erythema in a cohort of patients treated with medium-depth chemical peels. A retrospective audit was conducted of all medium-depth facial chemical peels performed at two major teaching hospitals. All patients had severe facial photodamage affecting at least 75% surface area of the face. The occurrence of prolonged erythema following this peel was then identified and analyzed. Of our treatment cohort (n= 82, 51 women, 31 men) with 60 years mean (61.3 years for women, 56.7 years for men), 10 patients (12%; eight women, two men) experienced prolonged erythema beyond a month of treatment. Facial psoriasis was not apparent at the time of chemical peel but manifested as prolonged erythema beyond the expected timeframe following the procedure. When patients experience prolonged erythema beyond a month of treatment and fail to respond to standard treatments, clinicians should examine carefully for extra-facial psoriasis prior to this procedure, and also consider facial psoriasis a possible cause of prolonged post-peel erythema.

34317 The unmasking of facial psoriasis by medium-depth chemical peels in the context of severe sun damage

Background: Chemical peeling is the controlled wounding of the epidermis and dermis for medical and aesthetic rejuvenation, involving the application of ablative agents to the skin to induce keratolysis and regeneration of damaged cell layers. Prolonged erythema is a distressing complication of medium-depth chemical peels. We report on the prevalence of prolonged facial erythema in a cohort of patients who underwent this procedure for severe photodamage. In each case there was an aetiology of facial psoriasis.

Medium-depth Trichloroacetic Acid and Deep Phenol-Croton Oil Chemical Peeling for Facial Rejuvenation: An Update.

Face-lift is an established rejuvenation modality; however, when performed alone, it lacks the ability to improve the appearance of fine wrinkles and dyschromias that are an important component of facial rejuvenation. Although it is only natural to be attracted by the latest technologically advanced innovative skin resurfacing techniques, chemical peeling has been proven to be a simple and effective method with a relatively good safety profile. Unfortunately, the practice of chemical peeling has relied for a long time on dogmas perpetuated by early reports without any real scientific basis. Moreover, application of peels has been hindered by difficult estimation of penetrance and control of depth. Three decades ago, a shift has occurred from early dogmatic empirical application to better understanding of the peeling formulations and mechanism of action together with appreciation of the interaction between the various components of the peeling formulations in addition to better estimation of clinical end points and peel depth. Given the increasing demand for none or minimally invasive cosmetic procedures, the current review is aimed at highlighting the recent applications of available medium-depth and deep chemical peels for optimal facial rejuvenation and for the treatment of photo-related aging skin changes.

SKIN MICRONEEDLING PLUS SPOT TRICHLOROACETIC ACID PEEL IN THE TREATMENT OF ATROPHIC POST ACNE SCARS: COMPARATIVE SPLIT FACE STUDY

Background: Post Acne scarring is an unfortunate and frequent complication of acne vulgaris that results in many psychological and emotional problems for patients and the families. Acne scarring may be either atrophic or hypertrophic. Atrophic acne scars are further subdivided morphologically into boxcar, icepick, or rolling scars. Objective: To compare between the effect of microneedling using dermapen and microneedling plus medium depth chemical peeling using T.C.A 30% in post acne atrophic scars. Patients and methods: This study was carried out on 30 patients with different clinical variants of atrophic post acne scars diagnosed clinically on the basis of typical appearance of skin lesions. Patients were recruited from Dermatology Department outpatient clinic in Al-Azhar University hospitals from April 2019 to December 2019. Their ages ranged from 18: 30 years. Assessment of scars in both sides of face was done for their type, number, depth (severity) before and after each session and when the follow up period became completed (2 weeks after the last session). Digital Facial photographs for right and left sides of the face were obtained before treatment, during each session, and when the follow up period became completed (2 weeks after the last session). Results: Most of the patients (60%) achieved marked improvement, 30% achieved good improvement and 10% achieved excellent improvement on the left side of the face, while on the right side of the face most of patients (73.3%) achieved good response and 26.7 % achieved poor response. The mean percentage of improvement of the left side was 55.5 %, while the percentage of improvement of the right side was 33%. Conclusion: Automated microneedling (Dermapen) and T.C.A 30% chemical peel were minimally invasive simple, cheap and effective techniques in the treatment of post acne atrophic scars and improved skin homogeneity and texture. Microneedling plus spot T.C.A 30% have the advantage of rapid healing, short down time, eliminating most of risks and negative side-effects of laser resurfacing or cross technique. The treatment can be performed in an office setting and did not need any extensive special training or expensive instruments and can be used for rejuvenation of the skin, remodeling of the scar. Combination of automated microneedling with other modalities as spot T.C.A 30% for the treatment of post acne atrophic scars gave better results than the use of single modality of treatment as microneedling alone.

Efficacy of a repair cream based on Rhealba Oat plantlets extract and active healing compounds in peelings: benefit to patient's downtime and pain.

The frequency of dermatological procedures is steadily increasing, accompanying a growing demand from patients. Chemical peels are a method of resurfacing in the treatment of various skin conditions. However, during the early healing process, patients may impose downtime on themselves. The erythema, pain and poor aesthetic appearance of the skin can lead to unwillingness to participate in social or professional activities. The objective of this study was to evaluate the tolerance and efficacy of a repair cream based on Rhealba Oat plantlets extract and active healing compounds after a peeling procedure. Men and women, aged 18-65years, with Fitzpatrick phototype I-IV, who had previously received a medium-depth chemical peel on the face (TCA 30%) entered with their consent a clinical study evaluating the new test product based on Rhealba Oat and active healing compounds. At the beginning of the study, the selected patients received a TCA 30% medium-depth peel. Afterwards, they were treated during 29days with the repair cream and evaluated for the benefits to downtime and pain. Significant reductions of pain (P<0.0114) and erythema (P<0.0001) were observed in the study. The downtime reduction with the tested cream was 92% - from 9days after the previous peeling procedure to 0.74days with application of the tested cream - a difference of 8.39days. In consequence, the tested repair cream based on Rhealba Oat plantlets extract and active healing compounds brings clinical benefit to patients who undergo peeling procedures. By reducing pain and downtime, it allows patients to get back to their daily life activities a week earlier than with previous peels.

Treatment of lateral canthal rhytides with a medium depth chemical peel with or without pretreatment with onabotulinum toxin type A: a randomized control trial.

BackgroundCombination therapies used to treat the photoaged skin have become more popular as studies demonstrate greater efficacy and improved clinical outcomes compared to single treatment modalities.ObjectivesTo evaluate the safety and effectiveness of treating the lateral canthal rhytide complex with a Jessner’s and 35% TCA peel with and without pretreatment with BTX-A.MethodsTwenty-six subjects with Fitzpatrick skin types I -III were randomized to receive treatment of their lateral canthal rhytide complex with a Jessner’s and 35% TCA peel with or without pretreatment with BTX-A. A single blinded dermatologist assigned a lateral canthal wrinkle score of subjects’ at baseline and week 8-10.ResultsComparison between the two treatment groups demonstrated that the group receiving combination treatment had significantly greater improvement in wrinkle reduction as compared to the group only receiving the chemical peel (P =0.002). In addition, there was no significant association between skin type and treatment groups (P = 0.11).ConclusionsThese findings suggest that treating the lateral canthal rhytide complex with a combination of BTX-A followed by Jessner’s and 35% TCA peel is more effective than chemical peel alone. These results are independent of skin type and demonstrate an additional treatment strategy for lateral canthal rhytides.

Treatment of lateral canthal rhytides with a medium depth chemical peel with or without pretreatment with onabotulinum toxin type A: A randomized control trial

Treatment of lateral canthal rhytides with a medium depth chemical peel with or without pretreatment with onabotulinum toxin type A: A randomized control trial

Short and long term clinical and histological evaluation of medium-depth chemical facial peel with 35°/o trichloroacetic acid on photo damaged skin

Chemical peeling involves the topical application of a wounding agent with the goal of effecting an organized regeneration of the skin. The histological features of photo aged skin include structural abnormalities that disrupt normal epidermal and dermal architecture. In the present prospective study we compared short and long term clinical and histological changes that occur after three sessions of enhanced medium depth chemical facial peel with 35% trichloroacetic acid on ten patients with photo aged skin changes. Biopsy specimens were taken pre-peel (control), and 3, 12, 48, months post-peel, for histological, and immunohistochemical analysis to assess total collagen type I content throughout the study that reach up to four years. Histological evaluations during the course of treatment have revealed an array of time­ dependent morphologic changes that were classified into early, intermediate, and late. Clinical resolution of actinic damage corresponded with restoration of epidermal and dermal polarity. Characteristic histological and immunohistochemical analysis post-peel include decreased elastic fibers, increased activated fibroblasts and organized parallel arrays of collagen fibrils. As treatment is continued beyond 12 months, the neocollagen synthesis and organization continues to increase and elastosis continues to decrease. Besides, increases in epidermal and dermal mucin and decreases in epidermal melanin. We concluded that although there was no direct correlation between histological changes and clinical improvement, the major structural changes appear to be directed at restoring the skin to the pre-sun-damaged state.

Chemical Peels

Chemical peels are a method of resurfacing with a long-standing history of safety in the treatment of various skin conditions. This article reviews the classification of different chemical agents based on their depth of injury. The level of injury facilitates cell turnover, epidermal thickening, skin lightening, and new collagen formation. Preprocedural, periprocedural, and postprocedural skin care are briefly discussed. To select the appropriate chemical peel, the provider should evaluate the patient's expectations, medical history, skin type, and possible complications to determine the best chemical peel to achieve the desired results. Patients with Fitzpatrick skin types IV to VI have increased risk of dyspigmentation, hypertrophic, and keloid scarring. These individuals respond well to superficial and medium-depth chemical peels. Advances in the use of combination peels allow greater options for skin rejuvenation with less risk of complications.

A comparative study of skin resurfacing using a fractional Er: YAG laser versus medium-depth peeling in the management of post-acne sequelae Fractional Er:YAG versus medium-depth peeling in post-acne sequel

Background: Post-acne scarring is a common permanent disfigurement to the face and various treatment modalities are available. Chemical peeling and ablative lasers have been used with varying degrees of success and complications. Objective:In this study we compared the effects of medium-depth chemical peel by sequential use of glycolic acid (GA) and trichloroacetic acid (TCA), with a combination treatment of fractional and conventional Er:YAG lasers. Methods: one hundred and twenty patients with post-acne scarring were randomly divided over two equally-sized groups. Group I underwent medium-depth chemical peeling and group II was treated with fractional Er:YAG laser. Patients were evaluated both subjectively and objectively during each follow-up visit. Results: Laser therapy was more effective than medium-depth peel. Subjective evaluation showed a higher satisfaction rate of 87.5% in group IL satisfaction fell to 52.5% in group I. Objective evaluation showed very goodto excellent outcome in 82.5% of cases treated in group II. In group I outcome was good in 47.5% and poor in 32.5% of cases. Conclusion: Combined Er:YAG laser therapy had a shorter downtime, was more effective, showed a longer lasting effect and proved safer than the combined use of GAITCA chemical peels.

Comment:A comparative study on 100% tca versus 88% phenol for the treatment of vitiligo

The study performed by Puri and Puri appearing in this issue suggested that TCA and phenol, the two medium depth chemical peeling agents, may be used to induce repigmentation of stable vitiligo lesions. Although different modalities have been introduced for vitiligo treatment, surgical intervention is still considered as an important treatment option for stable vitiligo lesions that do not respond to conventional therapies. Different surgical techniques, some requiring cellular cultures, have been established for treating stable vitiligo. More recently, dermabrasion has also been suggested to be an alternative intervention, especially if followed by phototherapy [1]. While it is of academic importance to clarify if the mechanisms involved in repigmentation differ between these different surgical approaches, it is perhaps even more crucial to identify “stable” vitiligo lesions that will most likely respond to surgical interventions. REFERENCES

Early Chemabrasion for Acne Scars After Treatment with Oral Isotretinoin

Acne is an inflammatory disease of the pilosebaceous follicles. Oral isotretinoin is the treatment of choice for severe acne. Exaggerated cicatrization related to oral isotretinoin was reported in the 1980s and 1990s. Currently, dermabrasion for acne scar revision is only recommended 6 to 12 months after the completion of oral isotretinoin treatment. To evaluate the evolution of healing from manual chemabrasion of depressed scars resulting from acne conducted within 1 to 3 months after oral isotretinoin treatment. This was an interventional, prospective study involving 10 patients with depressed facial scars. A medium-depth chemical peel was applied to the entire face. Manual sandpaper dermabrasion was performed to areas of scarring until the appearance of bloody dew. A 6-month reepithelization follow-up was conducted. All of the patients presented with normal cicatrization, and neither hypertrophic scars nor keloids were observed. Depressed acne scar revision was satisfactory. Our observations may contribute to the discussion of the negative influence of oral isotretinoin on wound healing. Other studies are necessary to reevaluate the current recommendation of a 6- to 12-month waiting period after oral isotretinoin treatment before performing dermabrasion or fractional ablative laser for acne scar revision.

Evaluation of Two Medium-Depth Peels: Glycolic Acid 70% Versus Trichloroacetic Acid 35%: A Histological and Immunohistochemichal Study on Rat Skin

Background: Chemical peels represent useful tool for improving skin texture and the effects of ageing. With the advent of newer chemical peels, there is now a wide range of peeling agents that can be applied on specific patients. Aim of the work: The present work was designed to evaluate and compare histologically between two of the most commonly used peeling agents in medium depth chemical peel: TCA (35%) and GA (70 %). Materials and Methods: This study was carried out on forty adult male albino rats. They were divided into five groups, eight rats each. Group І: Control rats that received no peeling session. Groups П and ПI: Received a peel session of TCA 35% and skin specimens were taken after one week and three weeks respectively. Groups IV and Group V: Received a peel session of glycolic acid 70% and skin specimens were taken after one week and three weeks respectively. Sections were prepared to be stained by H&E, Masson's trichrome, Orcein and immunohistochemichal staining for CD34, which is a marker for stem cells in hair follicle bulge region. Morphometric measurements of epidermal thickness, dermal thickness, area percent of collagen and elastic fibers, area percent and optical density of immunopositive cells for CD34 were done by image analyzer. Data obtained were statistically analyzed. Results: The present study revealed that after one week of medium depth chemical peel (by TCA (35%) or GA (70 %), the skin showed increase in epidermal and dermal thickness, increase in elastic and collagen fibers which became more organized and regularly arranged. It also showed pronounced increase in CD34 immunopositive cells (hair bulge stem cells, spindle cells of the reticular dermis, endothelial cells of dermal vessels and sebaceous glands). Three weeks after the chemical peel, the skin showed further significant increase in epidermal thickness, dermal thickness, collagen and elastic fibers. However, there was marked decrease in area percent and optical density of CD34 immunopositive cells. Conclusion: The present study revealed that both TCA (35%) and GA (70%) are effective in stimulation bulge stem cells and in improving the skin morphology with no significant difference between the two reagents.

Superficial and medium-depth chemical peels

The use of chemicals for facial rejuvenation has been explored since ancient times. A sound knowledge of skin anatomy and wound healing is important for understanding the principles of chemical peeling. Chemical peels are classified according to the depth of skin resurfacing produced. The main clinical indications in the cosmetic field are photoaging, dyschromias, and acne scars, which are classified according to the histologic depth of the clinical changes. Proper patient selection, skin priming, and postpeel care are of utmost importance in ensuring a satisfactory outcome. Chemical peels are combined with other rejuvenating treatments for best results in photoaging.

Improvement in Favre-Racouchot Disease Treated with a Combination Medium-Depth Chemical Peel Containing Jessner's Solution/35% Trichloroacetic Acid

Introduction: Favre-Racouchot disease is a condition typified by grouped comedones occurring on sun-damaged skin. This disorder affects mainly white men who have had extensive exposure to sun and harsh weather and has been estimated to occur in 6% of persons older than 50 years. Although topical retinoids have been the mainstay of therapy for this condition, many patients have an incomplete response to this therapeutic modality, and other treatments such as manual extraction, oral isotretinoin, staged excision, dermabrasion, and combination approaches have been attempted. Materials and Methods: A combination medium-depth chemical peel containing Jessner's solution/35% trichloroacetic acid was used to treat a 53 year-old white woman with Favre-Racouchot disease. The patient showed no response to topical retinoids applied twice daily for greater than 16 weeks and a more superficial combination peel consisting of Jessner's solution/20% trichloroacetic acid. Complicating factors included preexisting rosacea and early rhinophyma. Results: After treatment with a medium-depth chemical peel containing Jessner's solution/35% trichloroacetic acid, marked improvement was noted with concomitant resolution of &gt;90% of comedones. No postoperative complications, such as prolonged erythema, scarring, viral reactivation, or bacterial infection, were observed. The patient was pleased with the overall result. Discussion: These results demonstrate the utility of combination medium-depth chemical peels containing Jessner's solution/35% trichloroacetic acid in the management of Favre-Racouchot disease that is resistant to more conservative therapies. We recommend the judicious use of this procedure in patients who do not respond to more conservative measures.

Facial resurfacing: An overview

Facial resurfacing is a broad topic referring to procedures that change the texture and appearance of skin. Resurfacing procedures are broadly classified as ablative or nonablative. Ablative procedures are considered the first line treatment for the most common indications for facial resurfacing, which are photoaging and acne scarring. The goal of this review is to provide an overview of the factors that optimize the clinical efficacy of an ablative procedure, including careful patient selection, preoperative skin preparation, correct operative technique, and vigilant postoperative care, as well as review both the traditional and some of the latest technologies that effectively resurface facial skin.

Linear and whorled nevoid hypermelanosis

Linear and whorled nevoid hypermelanosis (LWNH) is a rare skin condition characterized by swirls and whorls of hyperpigmented macules in a reticulate pattern along Blaschko's lines; approximately 40 cases have been reported in the English language literature. We report a case of LWNH occurring in a 20-year-old man with widespread involvement over the trunk, face, upper limbs, and genitalia in association with scoliosis. A small hyperpigmented area on the abdomen was treated with a medium-depth chemical peel regimen using 70 percent glycolic acid and 35 percent trichloroacetic acid with no benefit. This is the first report of LWNH treated with medium-depth chemical peel.

The facial rejuvenation algorithm

The cosmetic dermatology approach to facial rejuvenation incorporates both medical and surgical approaches. Medical considerations include the use of pharmaceuticals, nutraceuticals, and cosmeceuticals in combination with surgery designed to resurface, redistribute, and reshape. While the scientific cause of aging is the shortening of the telomere following numerous cell divisions, the dermatology patient characterizes aging as the appearance of wrinkles. Yet wrinkles are eliminated or minimized through corrections to the eroding bony architecture, decreased cartilaginous support, redistributed subcutaneous fat, thinning dermal collagen, decreased epidermal turnover, and the failure of exfoliation to occur in the stratum corneum. Only by considering each of these age-related changes can facial rejuvenation optimally occur. Discrete rounded features formed by the structure of the underlying facial bone characterize a universally beautiful face. Bone demineralization begins around age 25 in females and increases throughout life with less bony support creating the appearance of wrinkled excess facial skin. Dermatologists should master the art of bone loss prevention through the use of estrogen hormone replacement, biphosphenates, and vitamin D and calcium carbonate supplements. There is no logic to implanting expensive fillers to expand deep folds of the face without preserving the underlying bone from facial osteoporosis. Once the issues of bone loss have been addressed, then the subcutaneous compartment requires attention. There is no explanation for the observation that fat redistribution with age leads to loss of subcutaneous fat, especially on the face, and increased deposition intra-abdominally. Autologous fat transfer with fat placement on the bone, within the muscle, and beneath the skin can lead to a long-lasting improvement in facial contour, restoring the gentle curves associated with youth and eliminating the facial angularity seen with advancing age. Once the bone and subcutaneous fat compartments have been considered, the draping of the skin over this framework is the next focus. Fillers, deep chemical peeling, and ablative laser resurfacing can be used to replace or encourage regeneration of lost dermal collagen. Botulinum toxin can be used to minimize the effect of hyperkinetic facial muscles on the thinning skin. Medium depth chemical peeling and intense pulsed light can be used to improve pigmentation. Generally, a combination of techniques is required to achieve the best result. Lastly, attention should be paid to the epidermis and the stratum corneum. Microdermabrasion and superficial glycolic or salicylic acid chemical peels can be used to enhance exfoliation while 5-fluorouracil or diclofenac can be used to remove damaged epidermal cells forming actinic keratoses. The appearance of the stratum corneum may also benefit from the use of a moisturizer containing emollients to smooth the skin surface and sunscreens to prevent further photodamage. Thus, the dermatologic approach to facial rejuvenation crosses many disciplines. We must be skilled at using pharmaceutical preparations, such as tretinoin, 5-fluorouracil, diclofenac, etc. to rejuvenate ill-behaved aging cells. We must be skilled at recommending the use of nutraceuticals, such as oral antioxidants, vitamin D, calcium, etc., to provide the necessary raw materials for the skin and underlying bone to form properly. Lastly, we must understand the world of topical cosmeceuticals, to include moisturizers and sunscreens, such that the skin surface can be protected from damaging UV radiation and the effects of the external environment. Cosmetic dermatology combines pharmaceutic, nutraceutic, and cosmeceutic modalities to achieve state-of-the-art facial rejuvenation.

Treatment of periorbital wrinkles by repeated medium‐depth chemical peels in dark‐skinned individuals

The periorbital region serves as a barometer of chronological and environmental age and, as such, persons often seek its cosmetic rejuvenation. This study was conducted to determine the efficacy and safety of repeated, medium-depth chemical peels in the treatment of periorbital wrinkles in dark-skinned individuals. A total of 12 subjects (10 women and 2 men) with fine and/or medium-sized wrinkles were included in the study, the ages ranged from 30 to 55 years with a mean of 41.25. Focal, medium-depth peels of periorbital area including crow's foot wrinkles were performed using a combination of Jessner's solution followed by the application of 35% trichloroacetic acid (TCA). The study involved a four-session regimen. To be included in this study, the subject completed at least two peeling sessions, 1 month apart, and returned for follow-up according to the research schedule. Improvement occurred in 11 of 12 subjects. Marked improvement occurred in four subjects (33%), moderate improvement in three (25%), mild improvement in another three (25%), minimal improvement in one subject (8%), and no response in one subject (8%). There were seven patients with fine and five with medium periorbital wrinkles. For statistical analysis, the no and minimum response groups were categorized as nonresponders. The improvement that ranged between marked to mild occurred in 100% of subjects with fine wrinkles and 60% of subjects with medium wrinkles. Mild side effects appeared in four subjects (33%). It can be concluded that fine and/or medium periorbital wrinkling responds favorably to repeated, medium-depth chemical peels even in dark-skinned individuals with few mild side effects.

Optimal management of recalcitrant disorders of hyperpigmentation in dark-skinned patients.

Alterations in skin pigmentation may often have a dramatic expression in individuals with a dark skin complexion and can be a source of significant emotional distress in these individuals. Hyperpigmented disorders such as melanosis (melasma), post-inflammatory hyperpigmentation, drug-induced hyperpigmentation, and erythema dyschromicum perstans tend to have a prolonged course and, in many cases, are refractory to treatment, further contributing to the psychological impairment of the affected patients. Melanosis, is a common form of facial pigmentation attributable to sunlight and hormonal factors. A range of treatment modalities, such as depigmenting agents, topical retinoids, and chemical peels in conjunction with rigorous sun protection, can improve the melanosis but the condition usually recurs. Combination regimens, including frequent applications of superficial- and medium-depth chemical peels, appear to be particularly effective and well tolerated in dark-skinned patients with melanosis. Post-inflammatory hyperpigmentation is the result of excess pigment deposition following an inflammatory skin disorder. Topical tretinoin, hydroquinone, azelaic acid, kojic acid, and glycolic acid peels have been employed with variable degrees of success. Drug-induced pigmentation is a frequent cause of acquired hypermelanosis, its clinical expression depending on the triggering molecule and the underlying pathogenetic mechanism. Identifying and discontinuing the offending agent is the main approach in this condition, although, recent reports have demonstrated the efficacy of Q-switched lasers in accelerating the pigment removal. Erythema dischromicum perstans is a characteristic dermal pigmentation occurring mainly in dark-skinned individuals. Immunomodulating agents, such as clofazimine and dapsone have been shown to lighten this disorder, although, the exact mode of action is not clear.