Superficial and Medium-Depth Chemical Peels

Medium-depth chemical peels are an effective and popular treatment for actinic damage, fine wrinkles, and pigmentary dyschromias. However, they are also uncomfortable. A previous attempt to study the effectiveness of a topical anesthetic gel in 35% trichloroacetic acid (TCA) peeling found a reduction in discomfort but an increased depth of penetration and delayed healing. To evaluate both the efficacy of two topical anesthetic agents in medium-depth combination peeling as well as the histologic result from chemical peeling combined with topical anesthesia. Seventy percent glycolic acid (GA) was applied to the entire face of 10 patients and diluted with water after 2 minutes. This was followed by the sequential application of EMLA cream (lidocaine 2.5% and prilocaine 2.5%), ELA-Max cream (lidocaine 4%), and placebo to selected areas on the face for 30 minutes without occlusion. These agents were then removed and 35% TCA was applied to the entire face. The level of discomfort felt by the patients during the TCA peel was recorded, clinical photographs were taken, and bilateral preauricular biopsies were performed at baseline, 48 hours, and 90 days postoperatively. Clinically there was a statistically significant decrease in pain felt during the 70% GA-35% TCA peel with topical anesthesia when compared to the control. There was no statistically significant difference in efficacy between EMLA and ELA-Max. There was also no difference in either the clinical or the histopathologic appearance between the medium-depth peel combined with topical anesthesia and the medium-depth peel with control. Both EMLA and ELA-Max decrease the discomfort felt during medium-depth combination chemical peeling without influencing either the clinical or the histopathologic result.

Treatment of photodamaged skin with trichloroacetic acid and topical tretinoin

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.

Textbook of chemical peels: Superficial, medium and deep peels in cosmetic practice

Acne scars can cause emotional and psychosocial disturbance to the patient. Various modalities have been used for the treatment of acne scars like punch excision, subcision, peels, microdermabrasion, unfractionated and fractioned lasers. The latest in the treatment armamentarium is microneedling. Acne scars commonly coexist with postinflammatory hyperpigmentation. A combination of microneedling and glycolic acid (GA) peels was found to give excellent results in the treatment of such scars. The aim was to study the efficacy of a combination of microneedling with glycolic peel for the treatment of acne scars in pigmented skin. Thirty patients in the age group of 20-40 years with atrophic box type or rolling scars with postinflammatory hyperpigmentation were chosen for the study. Two groups were made. The first group comprised of 30 patients in whom only microneedling was performed once in 6 weeks for five sessions. In the second group of 30 patients, a combination of microneedling and 35% GA peels was carried out. Patients from both groups were evaluated on the basis of Echelle d'Evaluation clinique des Cicatrices d'acné classification. Based on the objective scoring and its statistical analysis, there was significant improvement in superficial and moderately deep scars (grade 1-3). There was also improvement in skin texture, reduction in postacne pigmentation in the second group. Microneedling is a simple, inexpensive office procedure with no downtime. It is safe in Indian skin (skin types III-IV). The combined sequential treatment with GA peel caused a significant improvement in the acne scars without increasing morbidity.

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.

A Peeler’s Thoughts on skin Improvement with Chemical Peels and Laser Resurfacing

Background: Acanthosis nigricans (AN) presents as thickened, hyperpigmented, and velvety skin primarily over flexures.Its impact on appearance can affect psychosocial well-being, making cosmetic improvement a critical therapeutic goal.Objectives: This study aims to assess and compare the efficacy and safety of fractional carbon dioxide (CO2) laser and 70% glycolic acid (GCA) peel in treating AN of the neck.Materials and Methods: Thirty individuals with AN were randomly assigned either to Group A (fractional CO2 laser) or Group B (70% GCA peel).Treatments were administered over 18 months, with 4-sessions in each group-at four-week interval for Laser and two-week interval for peel.Efficacy was evaluated through the ANASI score, Burke's texture scale, physician-assessed improvement, and patient satisfaction (5-point Likert scale).Results: Group A showed a mean reduction in ANASI score of 48%, while Group B showed a reduction of 42%.Although Group A demonstrated greater improvement in skin texture and clinical ratings, the difference was not statistically significant.Physician ratings noted 20% of Group A patients had excellent outcomes, compared to none in Group B. Group A reported significantly higher patient satisfaction.Temporary erythema and oedema were common in Group A, while 40% of Group B experienced transient erythema.Two cases of post-inflammatory hyperpigmentation occurred in Group A, resolving with topical treatment.Conclusion: Both treatment modalities are effective and well-tolerated treatment options for AN.While the laser group exhibited slightly better outcomes, the difference was not statistically significant.Patient satisfaction, however, was notably higher in the laser-treated group.

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.

Patients with XP experience various premalignant and malignant skin tumors and pigmentary changes, including multiple freckles, lentigines, actinic keratosis, melanoma, non-melanoma skin cancers, and sunburns from an early age.In addition, patients are at risk of ultraviolet-related ocular injury, progressive neurological degeneration, and worsening of skin disorders over time. 1 Currently, there is no curative treatment for XP.Early diagnosis of XP is mandatory to establish adequate sun protection and regular examinations to detect and treat premalignant and malignant overgrowths as early as possible.Managing ultraviolet-damaged skin, actinic keratosis, field cancerization, dyspigmentation, and poikilodermatous changes is mandatory to prevent skin cancer.Chemoprevention and treatment with oral retinoids, topical imiquimod, and topical 5-fluorouracil, as well as physical modalities including various skin resurfacing options, (e.g., dermabrasion, chemical peelings, carbon dioxide or erbium-YAG laser), are frequently performed for XP patients. 1However, even if the most appropriate and effective treatment is applied, the need to comply with the treatment and come for regular follow-up visits throughout the lifespan may be challenging for XP patients.

Laser skin resurfacing is a very promising new treatment for solar elastosis and acne scars. The Ultrapulse carbon dioxide (CO2) laser and the SilkTouch flashscanner allow precise depth control and char-free ablation. Earlier studies have been done mainly on Caucasian skin types I and II, but very little data were available on pigmented skin. The purpose of this study is to assess the efficacy and safety of laser skin resurfacing in skin types III and IV. Thirty Asian and Hispanic patients were treated for facial rhytides and acne scars. All patients were instructed to use tretinoin cream 0.05%, hydroquinone 5%, and desonide 0.1% cream nightly for 2-4 weeks prior to the laser treatment. The Ultrapulse 5000C CO2 laser with the Truespot 3-mm collimated handpiece at the setting of 250-450 mJ per pulse, or the Silk-Touch flashscanner at the setting of 5-7 W, 0.2-second pulse duration, and 4-mm (M) spot size, was used. Patients were evaluated clinically, and global response was assessed by both clinicians and patients. The facial rhytides and acne scars improved 25-50% in all patients after one laser treatment. The most common side effects were persistent erythema that resolved on the average of 6 weeks. Hyperpigmentation occurred, but was reduced with regular use of tretinoin, hydroquinone, and desonide cream both pre- and postoperatively along with use of broad spectrum sunscreen after treatments. Laser skin resurfacing can be used to treat facial rhytides and acne scars in skin phototypes III and IV. When proper pre- and postoperative management is implemented, the risk of dyspigmentation can be reduced.

Chemical peeling has become increasingly popular. Technique is more critical in medium depth peeling than with deeper peels because of variable penetration of the trichloroacetic acid. This article describes a novel use of two caustic agents, glycolic acid and trichloroacetic acid, to effect a predictable approach to medium depth peeling. Without other skin preparation, 70% glycolic acid was applied to the entire face and diluted with water after 2 minutes. Then, 35% trichloroacetic acid was applied over the same areas. Biopsies were done on selected patients after 24 hours and 30, 60, and 90 days. Both clinically and histologically the glycolic trichloroacetic acid peel resulted in medium depth injury. Improvement in pigmentary dyschromias and actinic damage was impressive. The GA-TCA peel provides a consistent approach to medium depth peeling to add to the armamentarium of the dermatologic surgeon.

We have observed 5 patients with hypertrophic scarring at the lateral boundaries of the chemically peeled area when circumoral peel was combined with facial rhytidectomy. Some of the potential contributory factors include flap elevation, epinephrine, and lidocaine hydrochloride. To discover whether any one of these three factors or a combination played a role, a rat model study was designed. Initially, 40, 400-gm Sprague-Dawley rats were divided into 4 groups, each comprised by 10 rats. Injections with lidocaine or lidocaine with epinephrine, and chemical peel were done in 2 groups. The same injections were used in the remaining 2 groups together with simultaneous preliminary flap elevations and chemical peeling. After the review of the initial study results, another 40 Sprague-Dawley rats were used to repeat the study and compare on a larger scale the effects of lidocaine with and without epinephrine on the depth of chemical peel. The findings of the rat model studies indicate that preliminary injections with lidocaine containing solution (with or without epinephrine) result in a major delay in healing time. Flap elevation and chemical peeling were associated with major morbidity and mortality in the test rats. The presence of epinephrine in lidocaine solution had no significant role in increasing the delay in the healing process.

Objective To explore the effects of wound healing and histological changes by utilizing ultrapulse CO2 fractional laser for the treatment of superficial scar in dermal-epidermal junction (DEJ) in rabbit ears. Methods We adopted traditional iodophor treatment and moist exposed burn ointment treatment repairing the wound and utilizing ultra pulse CO2 fractional laser for the treatment of rabbit ears superficial scar. The superficial scars in rabbit ear were induced with ultra pulse CO2 fractional laser. In 1, 2, 4, 8 weeks tissue samples would be taken. Using electron microscopy we observed DEJ ultrastructure and light microscopy to observe the histological changes of the dermal papilla and PAS staining for epidermis basement membrane. Results The wound healing time of moist exposed burn ointment group was shorter than that of iodophor group (P<0.05). The number of hemidesmosomes and anchoring fibers in the moist exposed burn ointment group on the 8th week was more than the 1th week, The number of hemidesmosomes and anchoring fibers in the iodophor group on 8th week was more than 1th week (P<0.05). The number of hemidesmosomes and anchoring fibers in the iodophor group was less than the moist exposed burn ointment group (P<0.05). Conclusions Ultrapulse CO2 fractional laser can cause ultra structural changes in scarring dermal-epidermal junction area, wet wound healing environment promotes the reconstruction of DEJ district organization, and rebuilding the function of the scar skin has the positive significance. Key words: Ultrapulse CO2 Fractional laser; Superficial scar; Dermal-epidermal junction; Regeneration and reconstruction

Continuous Diffusion of Oxygen Adjunct Therapy to Improve Scar Reduction After Cervicotomy – A Proof of Concept Randomized Controlled Trial