Chemical Peeling
CHEMICAL
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History
Vanity has always been the core of existence
of women and men (whether they admit it or not) across the
centuries. In an attempt to fight wrinkles and other harbingers
of aging as well as attain a clear, smooth complexion, man
has experimented since time immemorial and it is this comprehensive
experimentation that has laid the foundation for modern day
chemical rejuvenation.
Tracing a medical procedure is often an uphill and deterring
task, there are many reason for this. No written records exist
from the prehistoric era, interpretation of medical terminology
is often confusing. With the passage of time operative and
medical procedures are lost and only to be discovered and
rediscovered many times over.
1600-1700 BC
during the Elizabeth times, cosmesis became very fashionable. Elizabeth 1 of England herself, painted lines
on her face following outlines of superficial veins preserve
the appearance of youth. Ladies of the haute monde like the Romans before them, employed cloth patches
followed by minute wax prostheses on their wrinkles and scars.
Of course should the Elizabethan lady become over heated for
some reason, her wax prostheses would melt!!
1750 BC
There were many attempts in this period cover cosmetic influenced
by disease and age with substances such as lead carbonate
face powders. It become apparent in due course that leaded
face masks could lead to death but nevertheless their popularity
continued with periodic withdrawals and reintroductions.
1834-1867
Phenol face peels began with the famous German chemist Friedrich
Ferdinand Runge who discovered carbolic acid(phenol)
by mixing cresols obtained from coal tar.
1841
Charles F Gerhardt coined the term phenol.
1842
French chemist Auguste Laurence prepared
phenol in a pure form from coal tar which he named phenolic
acid.
1816-1888
The era of master dermatologist Ferdinand Hebra,
from Veinna, considered the father of modern
dermatology by many. There is no documented evidence that
Hebra treated wrinkles but he used various original combinations
of exfoliating agents to treat freckles and even melasma.
1866
Arnold J Cooley, an English pharmacist published
a book curiously labeled ‘The Toilet in Ancient and
Modern Times’. In this book he had extensive literature
on removal of old scars. He used a gentle massage with warm
iodized oils, a glycerinated solution of bichloride of mercury
and warm sea water baths. He did not however mention the use
of phenol. He interestingly and uniquely presented plans to
prevent permanent skin disfigurement by small pox. He insisted
that the way to do this was to exclude light and air. On the
third day he applied a facial mask in which holes were cut
for the nostrils, eyes and mouth after it had been thickly
covered with mercurial ointment. The procedure was repeated
daily or every third day, always by candlelight and continued
till the pustules disappeared. He was however pessimistic
about treating wrinkles and loose skin.
1871-1881
Two landmark dermatological works were published. Tilbury
Fox’s formulary comprised 190 prescriptions:cantharides,
almond oil, glycerine, borax.Piffard’s book ‘A Treatise on the Materia Medica and therapeutics of
the skin’- the first dermatological book published in
America that was limited to therapy.
1927
H.O. Bames in the Medical Journal and Record
published the first article on cosmetic phenol peeling. He
described a light peel using resorcin in alcohol and a dry
peel using 50% to 80% phenol. He spoke at length on phenol
toxicity as well as it’s virtues as a plastic surgery
peel.
1960
Maxillofacial surgeon Adolph M Brown and
his dermatologist wife Martha Brown published
an in depth account of phenol induced histological skin changes.
1960
Thomas J. Baker and Howard L Gordon established
the modern day procedure of cosmetic phenol peeling. Over
the years Baker and Gordon’s formula and technique have
maintained their popularity and it is largely their work which
removed the technique of phenol peeling from semi obscurity
to a respectable position in aesthetic surgery. Samuel
Ayres, Litton and others debated as well as contributed
to this literature along the way.
1970s
This era witnessed a rebirth in interest in TCA peeling primarily
by dermatologists. Resnik, Lewis, Cowan and Howarth reviewed their work with TCA peels.
Simultaneously Vanscott and yu worked on alpha hydroxyl acids which culminated in it’s
wide spread usage in the 1980s and 1990s.
1980s
Stegman published his work on the histologic
study of the effect of various peeling agents, thereby providing
a scientific approach to chemical peeling. His work amongst
others influenced Brody and Hailey.
1986
Brody and Hailey combined two superficial
agents, solid carbon dioxide and TCA to produce a medium depth
peel.
1989
Monheit employed another medium depth technique
utilizing resorcinol, salicylic acid lactic acid (jessner’s
solution) followed by TCA.
1994
Coleman and Futrell worked on the concept
of combination peel using both glycolic acid and TCA.
2007
Sachin Maurya, Behl’s skin institute, New Delhi, also worked on combination peel using 70% glycolic acid, 30%
salicylic acid and Jessner’s solution for acne scars
and has very well appreciated.
Chemical peels thrive today with continuing experimentation
with superficial, medium depth, combination peels and so forth.
Alpha hydroxyl acids are present in OTC preparations. Beta
hydroxyl acid is the new kid on the block, now available in
many OTC preparations and the future probably holds many more
exciting discoveries.
Cornelius celsus in as early as 25 BC amidst
this flutter of excitement stated his disinterest and disdain
in cosmetology, a feeling palpable even today in certain sections
but it is becoming increasingly hard to ignore as long as
vanity remains an integral part of the human psyche chemical
peeling will flourish, in different forms and various adaptations,
but it will.
THEORY
Chemical peeling is basically an accelerated form of exfoliation induced by the use of a chemical cauterant or escharotic agent. Very light peeling agents induce a faster sloughing of the cells in the stratum corneum, whereas deeper peeling agents create necrosis and inflammation in the epidermis, papillary dermis, and/or, reticular dermis.
Although a wide variety of agents have been shown to be effective for peeling, alpha-hydroxy acids (AHAs), beta-hydroxy acid(BHA), Jessner’s solution, modified Jessner’s solution, resorcinol, and trichloroacetic acid (TCA).
Chemical peeling can be categorized into the following according to the agents used.
DEPTH AGENT ADVANTAGES/DISADVANTAGES
Very superficial Lactic acid, salicylic acid, simple, time efficient,<lunch time peel>
i.e. only shedding TCA 10% single coat, GA35%
of the keratin layer 1 to 3 minutes
only stratum corneum
which encourage further
epidermal regeneration.
Superficial TCA 15% to 20% 2 coats, simple, time efficient,<lunch time peel>
These agents destroy up GA 35 – 50% 1 to 5 min
to whole thickness of Jessner’s peel
the epidermis.
Medium depth TCA 35% to 50% till deep Time efficient, simple little
These agents will cause uniform frosting is seen anesthesia
Destruction up to papillary GA + 35% TCA(coleman) 1 week healing
Dermis with or without inf- iced Co2 + 35% TCA(brody)
lammation. Jessners + 35% TCA(monheit)
70%GA + 40%SA + Jessners(maurya)
Deep
Upto reticular dermis Baker-Gordon peel Not advised for Asian skin as there are
Phenol 88% very high chances of scarring and other
TCA 50% complications. But these are good as
Focal or regional peels. This peeling is
long lasting.
About peeling agents
ALPHA-HYDROXY ACIDS
AHAs are naturally occurring compounds that contain the hydroxyl group in the alpha position. Although AHAs are a wonderful addition to an anti-aging armamentarium, it is necessary that pts have realistic expectations. These versatile groups of acids include
- 1. Glycolic Acid-
Most commonly used peel, derived from sugar cane, popularly known as “ the lunchtime peel” because it can be completed during the patient’s lunch hour and the pt. can return to work without any telltale signs.
Mechanism of action-
Stimulation of epidermal growth through removal of the stratum corneum.
Destruction of specific layers of damaged skin.
Induction of an inflammatory reaction deeper in the tissue than the necrosis induced by the peeling agent. It is able to induce production of new collagen and ground substance in the dermis. Epidermal wounds are capable of inducing deposition of collagen and glycosaminoglycans in the dermis.
- 2. Lactic Acid-
It is a popular AHA, derived from sour milk that is found in many at-home products and prescription moisturizers.
It is usually not used as an in-office peel.
Mechanism of Action-
Same as Glycolic acid.
- Other AHAs are Citric acid derived from citrus fruits, Phytic acid derived from rice, Tartaric acid from Grapes and Malic acid derived from Apples having same mechanism of action approximately
BETA HYDROXY ACID
BHA, also known as salicylic acid, is another type of in-office peel, commonly used by many dermatologist, also available in over the counter home products. Salicylic acid is the only member of the BHA family, so named because the aromatic carboxylic acid has a carboxylic acid has a hydroxyl group in the beta position. This is actually a misnomer because the carbons of aromatic compounds are traditionally given Arabic numerals (1,2, etc.) rather than the Greek letter designations typical for the nonaromatic structures. It is likely that SA was labeled a BHA at the time BHA peels were introduced in order to benefit from the popularity of AHAs.
SALICYLIC ACID
It is a lipid soluble, white crystalline powder, is derived from willow bark, wintergreen leaves, and sweet birch, pH determines its efficacy. It has a pKa of 2.98 and to obtain a significant exfoliation
effect, salicylic acid must be formulated at a proper pH to allow enough free acid to be present.
Thus effective formulations are those in which the pH is closer to the pKa.
Salicylic acid solubilizes the intercellular cement with resultant loosening and detachment of the keratinocytes.
Many home care product formulations contain SA. Typically, they are labeled as “acne washes” and contain 2% SA. These products should be avoided in pts who are pregnant, breast feeding, or allergic to aspirin, as there is a risk of Salicylism (nausea, disorientation, and tinnitus).
TRICHLOROACETIC ACID
It is a gold standard of Chemical peeling. 100% TCA available in crystal form.
It precipitates epidermal proteins, thus causing cell death ie. Controlled chemical burns causing necrosis and sloughing of the epidermal and dermal layers. The acidity is neutralized by serum in the superficial dermal vessels and hence no risk of systemic toxicity.
It cannot be used in higher concentration above 20% in Indian skin can cause pigmentary changes, hyper or hypopigmentation.
RESORCINOL
Resorcinol (m-dihydroxybenzene) is a phenol derivative that has antipruritic, keratolytic, anti-mycotic, and antiseptic properties.
Care must be taken to limit the surface area treated because systemic toxicity similar to that seen with phenol has been reported.
Prolonged use has been associated with myxedema because the drug has an anti-thyroid action and methemoglobinemia in children.
It is a primary irritant and a moderately strong sensitizer that seldom produces allergic contact dermatitis.
JESSNERs SOLUTION
Dr. Max jessner originally formulated this peel which is a combination of resorcinol 14 g, salicylic acid 14 g, and lactic acid 14cc in a sufficient quantity of ethanol (95%) to make 100cc of solution.
It is popularly used with other peels because it does not have to be neutralized.
PHENOL PEEL
Nowadays this peel is not recommended because of its systemic toxicity.
SIDE EFFECTS AND CONTRAINDICATIONS OF CHEMICAL PEEL
As such there is no side effect with chemical peel in a normal individual.
It is unfortunate but undeniable truth of chemical peels that some pt will experience complications, as there is rarely a procedure without complications and the same holds true for chemical peeling. Some of the complications occur due to wrong methodology and can be prevented. Those encountered are enumerated as below.
IMMEDIATE
1.Erythema 2.Flaking 3.Crusting 4.Tears dripping down on the face 5.Chemical burns 6.Epidermolysis 7.Contact urticaria 8.cold sensitivity/cold urticaria 9. An ugly look:, wherein the skin appears darker than normal and patient is unable to work .10 failure to follow post peel instructions within these days can result in poor healing due to sun exposure and others . Not so much of a complication, but a person whose profession may demand so, will be unable to wear make up in this period.
WITHIN A WEEK
Pigmentary dyschromias: hyper and hypo pigmentation
Chemical burns result in poor healing and poor results.
Late peelers: the process of exfoliation continues.
Persistent erythema.
Sec. Infections and aggravation of herpes simplex.
Aggravation of preexisting dermatoses.eg. verruca plana, Atopic dermatitis, seborrheic dermatitis, Allergic contact dermatitis.
AFTER A WEEK
Hyper or hypo pigmentation, scarring, no results even after 2-3 peels, aggravation of pigmentation.
Poor doctor patient relationship could worsen the situation.
A pt may need further treatment and a longer duration of treatment.
Sensitivity to topical drugs used after post peel care.
Till this stage all side effects and complications are reversible with a little care, counseling and patient education.
Late complications
Premature peeling, infection, acneiform eruptions, ecchymosis, prolonged erythema or pruritus, Atrophy, Milia, Texural changes, scarring, line of demarcation etc..
RARE
Cardiac arrhythmias
Laryngeal edema
RELATIVE CONTRAINDICATIONS
Seborrheic dermatitis, Atopic dermatitis, Allergic contact dermatitis, Verruca plana, Molluscum contagiosum, Herpes simplex, Xerotic, scaly skin, Open wounds, Cracks on the skin, bleaching, threading, electrolysis, photosensitivity.
Drugs such as isotretinoin, oral contraceptives, chemotherapy, other forms of hormonal therapy,
Dr. Sachin Kashinath Maurya CONSULTANT DERMATOLOGIST AND COSMETO-AESTHETIC SURGEON M.D. ANTI-AGING SKIN CLINIC
