History facial chemical-peels

Facial Chemical PeelsFacial Chemical Peels

HistoryHistory

Egypt - first evidence of Egypt - first evidence of exfoliants use exfoliants use – Sun-damaged skin was a Sun-damaged skin was a

sign of lower rank in sign of lower rank in societysociety

– Sour milk- contain lactic Sour milk- contain lactic acid, an alpha-hydroxy acid acid, an alpha-hydroxy acid commonly used today commonly used today

Turks - use fire to Turks - use fire to produce a thermal produce a thermal exfoliationexfoliation

HistoryHistory

1882 P.G Unna, German dermatologist 1882 P.G Unna, German dermatologist described resorcinol, salicylic acid, phenol, described resorcinol, salicylic acid, phenol, trichloroacetic acidtrichloroacetic acid

1903 Mackee began using phenol for acne 1903 Mackee began using phenol for acne scarring (Chairman of dermatology at NYU)scarring (Chairman of dermatology at NYU)

1961 Baker and Gordon presented a peel 1961 Baker and Gordon presented a peel formula with one patient with a 3 month follow formula with one patient with a 3 month follow up, became the standard formulaup, became the standard formula

1966 Baker published results in 250 patients1966 Baker published results in 250 patients

AgingAging

Define as the process of Define as the process of system's deterioration system's deterioration ((Hanbook of Hanbook of the Biology of Agingthe Biology of Aging 2006) 2006)

Facial skin changes is one of Facial skin changes is one of the most apparent examples of the most apparent examples of agingaging

HistologyHistology

Actinic changes - photochemical effects of solar Actinic changes - photochemical effects of solar radiation exposure radiation exposure – Disorderly arrangement of epidermisDisorderly arrangement of epidermis– Degeneration of the elastic networkDegeneration of the elastic network– Mottled pigmentation Mottled pigmentation – Lymphocytic infiltrationLymphocytic infiltration– Decrease in collagen Decrease in collagen – Flattening of the dermal-epidermal junctionFlattening of the dermal-epidermal junction– Epidermal cell atypia Epidermal cell atypia – Increased melanocytes, but they were unevenly Increased melanocytes, but they were unevenly

distributed and contained variable amounts of melanin distributed and contained variable amounts of melanin

Peel Skin HistologyPeel Skin Histology

Chemical burn of the epidermis and the outer Chemical burn of the epidermis and the outer dermisdermis


First 2 to 5 days - Regenerates from follicular First 2 to 5 days - Regenerates from follicular and eccrine duct epithelium and eccrine duct epithelium

Peel Skin HistologyPeel Skin Histology Fresh, orderly, organized epidermisFresh, orderly, organized epidermis


At 2 weeks - new At 2 weeks - new collagen formation collagen formation begins and may begins and may continue up to 1 yearcontinue up to 1 year– New bands of dermis New bands of dermis

2- to 3-mm-thick 2- to 3-mm-thick – Thin, compact, parallel Thin, compact, parallel

collagen bundles collagen bundles arranged horizontally arranged horizontally along the epidermal-along the epidermal-dermal matrixdermal matrix


Other changesOther changes– Melanocytes contain fine, evenly distributed Melanocytes contain fine, evenly distributed

melanin granulesmelanin granules– Impaired melanin synthesis with a generalized Impaired melanin synthesis with a generalized

bleaching effect bleaching effect – Decrease lymphocytic infiltrationDecrease lymphocytic infiltration

Treat cutaneous lesions Treat cutaneous lesions

Replace atypical Replace atypical keratinocytes with normal keratinocytes with normal epidermal cellsepidermal cellsKligman concluded that Kligman concluded that chemical peel reduced the chemical peel reduced the development of new development of new neoplasmsneoplasmsLitton decreased the rate of Litton decreased the rate of appearance of precancerous appearance of precancerous and early cancerous lesions and early cancerous lesions after a phenol chemical peel after a phenol chemical peel

Patient Selection Patient Selection

"The ideal patient is a thin-skinned female "The ideal patient is a thin-skinned female with fair complexion and fine rhytids." with fair complexion and fine rhytids."

Skin type and the amount of photodamage Skin type and the amount of photodamage presentpresent

Fitzpatrick classified the skin types Fitzpatrick classified the skin types – Color and acute solar radiation responseColor and acute solar radiation response

The Glogau classification based on the The Glogau classification based on the degree of photoagingdegree of photoaging

Fitzpatrick ClassificationFitzpatrick Classification

Fitzpatrick skin type I and type II are good candidatesFitzpatrick skin type I and type II are good candidatesType III and greater - increased risk pigment complicationsType III and greater - increased risk pigment complications

TypeType ColorColor Tanning responseTanning response

II WhiteWhite Always burns, never tansAlways burns, never tans

IIII WhiteWhite Usually burns, tans less than averageUsually burns, tans less than average

IIIIII WhiteWhite Sometimes burns mildly, tans about averageSometimes burns mildly, tans about average

IVIV BrownBrown Rarely burns, tans more than average and with easeRarely burns, tans more than average and with ease

VV Dark brownDark brown Very rarely burns, tans very easilyVery rarely burns, tans very easily

VIVI BlackBlack Never burns, tans very easilyNever burns, tans very easily

Glogau classificationGlogau classification

GroupGroup ClassificationClassification Skin characteristicsSkin characteristics PeelPeel

II MildMild Little wrinkling or scarring and no Little wrinkling or scarring and no keratoseskeratoses

SuperficialSuperficial

IIII ModerateModerate Early wrinkling, mild scarring, and Early wrinkling, mild scarring, and sallow color with early actinic sallow color with early actinic

keratoseskeratoses

MediumMedium

IIIIII AdvancedAdvanced Persistent wrinkling, discoloration Persistent wrinkling, discoloration with telangectasias and actinic with telangectasias and actinic

keratoseskeratoses

MediumMedium

IVIV SevereSevere Wrinkling—superficial to deep Wrinkling—superficial to deep actinic keratoses ± skin canceractinic keratoses ± skin cancer

Medium to DeepMedium to Deep

Aesthetic IndicationsAesthetic Indications

RhytidsRhytids

Spotty Spotty hyperpigmentation hyperpigmentation

Superficial acne Superficial acne scarringscarring

Therapeutic IndicationsTherapeutic Indications

Actinic keratosesActinic keratoses

Superficial basal cell Superficial basal cell carcinomascarcinomas

Lentigo maligna Lentigo maligna lentigineslentigines

Melasma Melasma (discoloration of skin (discoloration of skin caused by pregnancy)caused by pregnancy)

ContraindicationsContraindications

Relative Relative ContraindicationsContraindications– Darker skin type Darker skin type

(Fitzpatrick IV-VI)(Fitzpatrick IV-VI)– History KeloidHistory Keloid– History of herpes infectionsHistory of herpes infections– Cardiac abnormalitiesCardiac abnormalities– A history of diabetes A history of diabetes

mellitus or previous facial mellitus or previous facial irradiationirradiation

– Unrealistic patient Unrealistic patient expectationsexpectations

– TelangiectasiasTelangiectasias– Anticipation of inadequate Anticipation of inadequate

photo protectionphoto protection

Absolute Absolute ContraindicationsContraindications– Significant hepatorenal Significant hepatorenal

diseasedisease– HIV-positive patientHIV-positive patient– Significant Significant

immunosuppressionimmunosuppression– Emotional instability or Emotional instability or

mental illnessmental illness– Ehlers-Danlos syndromeEhlers-Danlos syndrome– Scleroderma or collagen Scleroderma or collagen

vascular diseasesvascular diseases– Accutane treatment (within Accutane treatment (within

6–12 months before)6–12 months before)

Patient PreparationPatient Preparation

History of herpes infectionsHistory of herpes infections– Prophylaxis with Valtrex or Acyclovir for 2 wksProphylaxis with Valtrex or Acyclovir for 2 wks

Skin preparationSkin preparation– Vitamin A derivative therapy 4 weeks before the Vitamin A derivative therapy 4 weeks before the

procedureprocedureSpeeds epidermal healing Speeds epidermal healing

Thins stratum corneum Thins stratum corneum

Increases the depth of a chemical peelIncreases the depth of a chemical peel

– Stop sun exposure - 2 months before the Stop sun exposure - 2 months before the procedureprocedure

Chemical Peel DepthsChemical Peel Depths

SuperficialSuperficial– Epidermal lossEpidermal loss

MediumMedium– Injury to superficial Injury to superficial

dermisdermis

Deep Deep – Mid-dermal injuryMid-dermal injury

Chemical PeelChemical Peel

Frosting - keratin protein Frosting - keratin protein denaturation denaturation – Level I - erythema with Level I - erythema with

streaky surface whiteningstreaky surface whitening– Level II - white-coated Level II - white-coated

frosting with erythema frosting with erythema showing throughshowing through

– level III - solid white level III - solid white enamel frosting with little or enamel frosting with little or no background of erythema no background of erythema (penetration through the (penetration through the papillary dermis)papillary dermis)

Superficial Peels Superficial Peels

Necrosis of the epidermisNecrosis of the epidermis

Healing time from 1 to 4 daysHealing time from 1 to 4 days

Improve pigmentary irregularities Improve pigmentary irregularities

Improve minor surface changes Improve minor surface changes

Fresher appearance to facial skinFresher appearance to facial skin

Superficial PeelsSuperficial Peels

Different SolutionsDifferent Solutions– 10% to 20% Trichloracetic 10% to 20% Trichloracetic

acid (TCA)acid (TCA)– Jessner's solution Jessner's solution (resorcinol, 14 g; salicylic acid, 14 g; (resorcinol, 14 g; salicylic acid, 14 g;

lactic acid, 14 mL; ethanol, 100 mL)lactic acid, 14 mL; ethanol, 100 mL)

– Glycolic acid (50% to 70%)Glycolic acid (50% to 70%)

Level I frostingLevel I frostingPostoperative Postoperative – Mild cleanser, moisturizers Mild cleanser, moisturizers

and sunscreensand sunscreens

Glycolic acid can be used Glycolic acid can be used to peel skin of all skin to peel skin of all skin types with minimal risktypes with minimal risk

Medium Peel Medium Peel

Necrosis of the epidermis & inflammation within Necrosis of the epidermis & inflammation within the papillary dermisthe papillary dermis

Improvement of skin texture in moderate Improvement of skin texture in moderate photodamaged skin (grade II Glogau)photodamaged skin (grade II Glogau)

Removes of epidermal or superficial lesionsRemoves of epidermal or superficial lesions– Actinic keratosesActinic keratoses– Repair mild rhytidesRepair mild rhytides– Improve pigmentary dyschromiasImprove pigmentary dyschromias– Improve depressed scarsImprove depressed scars

Trichloracetic acid (TCA)Trichloracetic acid (TCA)

TCA approaching 50% or higher were used to TCA approaching 50% or higher were used to achieve injury to the superficial dermisachieve injury to the superficial dermisAt this concentration TCA is unreliable and At this concentration TCA is unreliable and associated with a higher incidence of associated with a higher incidence of complications (complications (pigmentary dyschromia, textural change, and pigmentary dyschromia, textural change, and even scarringeven scarring))Combination of products improves the Combination of products improves the absorption of the lower concentration of TCA absorption of the lower concentration of TCA without the associated complicationswithout the associated complications– Solid CO2 freezing with trichloracetic acid 35% Solid CO2 freezing with trichloracetic acid 35% – Jessner's solution + 35% TCA Jessner's solution + 35% TCA – Glycolic acid 70% plus 35% TCAGlycolic acid 70% plus 35% TCA

Medium PeelMedium Peel

Brody Brody – First developed solid CO2 applied with acetone to the skinFirst developed solid CO2 applied with acetone to the skin– Freezing technique break the epidermal barrier for a more even Freezing technique break the epidermal barrier for a more even

and complete penetrationand complete penetration

Monheit Monheit – Jessner's solution destroyed the epidermal barrier by breaking Jessner's solution destroyed the epidermal barrier by breaking

up individual epidermal cellsup individual epidermal cells

Coleman Coleman – 70% glycolic acid before the application of 35% TCA. 70% glycolic acid before the application of 35% TCA. – Results similar to that of Jessner's solutionResults similar to that of Jessner's solution

Deeper penetration of the 35% TCA and a more even Deeper penetration of the 35% TCA and a more even application of the peeling solutionapplication of the peeling solutionPhenol 88% by itself will give a medium-depth peel Phenol 88% by itself will give a medium-depth peel

Patient PreparationPatient Preparation

Vigorous cleaning and degreasing are Vigorous cleaning and degreasing are necessary for even penetration necessary for even penetration – Septisol and acetoneSeptisol and acetone– Debrided of stratum corneum and excessive Debrided of stratum corneum and excessive

scalescale

A splotchy peel is usually the result of A splotchy peel is usually the result of uneven penetration of peel solution uneven penetration of peel solution because of residual oil or stratum corneum because of residual oil or stratum corneum


TCA is painted evenlyTCA is painted evenly– Forehead to temple to Forehead to temple to

cheeks and finally to the cheeks and finally to the lips and eyelids lips and eyelids

– Eyelids within 1 to 2 mm of Eyelids within 1 to 2 mm of the lower eyelid marginthe lower eyelid margin

Amount of TCA delivered Amount of TCA delivered is dependent on:is dependent on:– Number of applicationsNumber of applications– Degree of saturationDegree of saturation– Pressure applied to the Pressure applied to the

skinskin– Contact timeContact time


White frost appears complete White frost appears complete on the treated area within 30 on the treated area within 30 seconds to 2 minutes seconds to 2 minutes

Before re-treating an area one Before re-treating an area one should wait at least 3 to 4 should wait at least 3 to 4 minutes before determining for minutes before determining for asymmetry asymmetry

Eyelid skin and bony Eyelid skin and bony prominences have a high prominences have a high propensity for scarring (limited propensity for scarring (limited to a level II frosting)to a level II frosting)

An assistant standby with An assistant standby with sterile eye wash in case agent sterile eye wash in case agent spills into the eyespills into the eye

Jessner's TCA peel for moderate photoaging skin, Glogau level II.

A, Preoperative view demonstrating rhytides, lentigenes, keratoses, and sallow skin.B, Jessner's solution applied to face. C, Full application 35% TCA with a level III

frosting. D. Four days after chemical peel. E, Six months after chemical peel


Dark crusts peels off on day 5 to 7 then Dark crusts peels off on day 5 to 7 then erythema appears and soon fadeerythema appears and soon fade

Repeat medium-depth chemical peel Repeat medium-depth chemical peel should not be performed for at least 1 yearshould not be performed for at least 1 year

There is improvement of collagen There is improvement of collagen thickness progressing over a 6- to 13-thickness progressing over a 6- to 13-month period month period

Deep Chemical PeelDeep Chemical Peel

Glogau III and IV photoaging skinGlogau III and IV photoaging skin– Deeper grooves and wrinklesDeeper grooves and wrinkles

Deep peels are usually performed using the Deep peels are usually performed using the Baker-Gordon solution Baker-Gordon solution – Phenol 88% 3 mL, Septisol 8 drops, Croton oil 3 Phenol 88% 3 mL, Septisol 8 drops, Croton oil 3

drops, Distilled water 2 mLdrops, Distilled water 2 mL

Septisol acts as a surfactant which results in Septisol acts as a surfactant which results in more even penetrationmore even penetrationCroton oil is epidermolytic enhancing the Croton oil is epidermolytic enhancing the absorption of phenolabsorption of phenol


Phenol >80%Phenol >80%– Keratin protein binds to the phenol creating Keratin protein binds to the phenol creating

large molecules preventing further penetration large molecules preventing further penetration of the peel solutionof the peel solution

Phenol <50%Phenol <50%– produce deeper penetration and more produce deeper penetration and more

destruction than desireddestruction than desired

Tape OcclusionTape Occlusion

Occlusion of the Occlusion of the peeling solution with peeling solution with tape increases its tape increases its penetration creating penetration creating injury to the mid-injury to the mid-reticular dermisreticular dermis


Face is divided into six aesthetic Face is divided into six aesthetic subunitssubunits – Forehead, perioral region, Forehead, perioral region,

bilateral cheeks, nose, and bilateral cheeks, nose, and periorbital regionperiorbital region

– 15-minute time interval between 15-minute time interval between unitsunits

White frost that is carried 2 to 3 White frost that is carried 2 to 3 mm across the vermilion bordermm across the vermilion borderLower eyelids need to be treated Lower eyelids need to be treated to within 1 to 2 mm of the ciliary to within 1 to 2 mm of the ciliary marginmarginUpper eyelid above supratarsal Upper eyelid above supratarsal foldfold


Erythema may take months to resolveErythema may take months to resolve

Evaluated in 3 to 4 days to observe the amount Evaluated in 3 to 4 days to observe the amount of wound healing and residual crustingof wound healing and residual crusting

Sun avoidance 6 weeks and minimize sun Sun avoidance 6 weeks and minimize sun exposure for up to 6 months (Sunscreen with an exposure for up to 6 months (Sunscreen with an SPF of 3)SPF of 3)

Splotchy hyperpigmentation (2 – 6 weeks) Splotchy hyperpigmentation (2 – 6 weeks) – Retin A, hydroquinone and triamcinolone may provide Retin A, hydroquinone and triamcinolone may provide

an improvement an improvement


Phenol ToxicityPhenol Toxicity

Cardiotoxic & eliminated hepatic and renal Cardiotoxic & eliminated hepatic and renal Monitored setting Monitored setting – Cardiac status, pulse-oximetry, and blood pressureCardiac status, pulse-oximetry, and blood pressure

Volume loading with intravenous fluids before, during, Volume loading with intravenous fluids before, during, and after phenol peeling and after phenol peeling Botta advocates force diuresis (furosemide given 10 min Botta advocates force diuresis (furosemide given 10 min before phenol)before phenol)Waiting as much as 20 to 30 minutes between unitWaiting as much as 20 to 30 minutes between unitRecognizeRecognize– First - CNS stimulation, First - CNS stimulation,

Tremors, hyperreflexia, and hypertension. Tremors, hyperreflexia, and hypertension. – Later - CNS depression, respiratory failure, hypotension, and Later - CNS depression, respiratory failure, hypotension, and

cardiac arrhythmias ensuing rapidly. cardiac arrhythmias ensuing rapidly.

SequelaeSequelae– Pigmentary changes Pigmentary changes – Persistence of rhytidsPersistence of rhytids– Prolonged erythemaProlonged erythema– Hypertrophic subepidermal Hypertrophic subepidermal

healinghealing– MiliaMilia– Skin pore prominenceSkin pore prominence– Increased prominence of Increased prominence of

telangiectasiastelangiectasias– Darkening and growth of Darkening and growth of

preexisting nevipreexisting nevi

ComplicationsComplications– Skin infection Skin infection

Herpes simplex virusHerpes simplex virus

Pseudomonas organisms Pseudomonas organisms

Staphylococcus/Staphylococcus/Streptococcus organismsStreptococcus organisms

Candida organismsCandida organisms

– EctropionEctropion– Cardiac arrhythmiasCardiac arrhythmias– Renal failureRenal failure– Facial scarringFacial scarring

HyperpigmentationHyperpigmentation

HypopigmentationHypopigmentation

Herpes outbreakHerpes outbreak

Candida infectionCandida infection

Pseudomonal infectionPseudomonal infection

ScarringScarring

ConclusionConclusion

Chemical peeling is an technique that removes Chemical peeling is an technique that removes superficial lesions and improves the texture of skinsuperficial lesions and improves the texture of skinCareful patient selection and education are crucial to Careful patient selection and education are crucial to both the patient's final result and his or her satisfactionboth the patient's final result and his or her satisfactionLearning the technique is a small part of the process; Learning the technique is a small part of the process; postoperative care and close patient follow-up are postoperative care and close patient follow-up are equally importantequally importantClinical and histological changes are long-lasting (15 to Clinical and histological changes are long-lasting (15 to 20 years) and may be permanent for some patients20 years) and may be permanent for some patientsA complication can also be permanent!A complication can also be permanent!

ReferencesReferencesDeborshi R. AblativeFacial Resurfacing Dermatologic Clinics. 23(3), July 2005Deborshi R. AblativeFacial Resurfacing Dermatologic Clinics. 23(3), July 2005Gary D. M. MEDIUM-DEPTH CHEMICAL PEELS. Dermatologic Clinics. 19(3), July 2001Gary D. M. MEDIUM-DEPTH CHEMICAL PEELS. Dermatologic Clinics. 19(3), July 2001Langsdon, P. Comparison of the Laser and Phenol Chemical Peel in Facial Skin Langsdon, P. Comparison of the Laser and Phenol Chemical Peel in Facial Skin Resurfacing.Resurfacing.Brody HJ. Chemical Peeling. St Louis, Mo: Mosby-Year Book; 1992:1-5Brody HJ. Chemical Peeling. St Louis, Mo: Mosby-Year Book; 1992:1-5Brody HJ: Chemical Peeling and Resurfacing. St. Louis, Mosby, 1997, pp 109–110Brody HJ: Chemical Peeling and Resurfacing. St. Louis, Mosby, 1997, pp 109–110Monheit GD: Advances in chemical peeling. Facial Plast Surg Clin North Am 2:5–9, 1994Monheit GD: Advances in chemical peeling. Facial Plast Surg Clin North Am 2:5–9, 1994Monheit GD: The Jessner's-TCA peel. Facial Plast Surg Clin North Am 2:21–22, 1994Monheit GD: The Jessner's-TCA peel. Facial Plast Surg Clin North Am 2:21–22, 1994Monheit GD, Zeitouni NC: Skin resurfacing for photoaging: Laser resurfacing versus Monheit GD, Zeitouni NC: Skin resurfacing for photoaging: Laser resurfacing versus chemical peeling. Cosmet Dermatol 10:11–22, 1997chemical peeling. Cosmet Dermatol 10:11–22, 1997Rubin M: Manual of Chemical Peels. Philadelphia, Lippincott, 1995, pp 120–121Rubin M: Manual of Chemical Peels. Philadelphia, Lippincott, 1995, pp 120–121Stegman SJ: A comparative histologic study of the effects of three peeling agents and Stegman SJ: A comparative histologic study of the effects of three peeling agents and dermabrasion on normal and sundamaged skin. Aesthetic Plast Surg 6:123–135, 1982dermabrasion on normal and sundamaged skin. Aesthetic Plast Surg 6:123–135, 1982Cummings: MANAGEMENT OF AGING SKINCummings: MANAGEMENT OF AGING SKIN.. Otolaryngology: Head & Neck Surgery, 4th Otolaryngology: Head & Neck Surgery, 4th eded, , 2005. Chapter 292005. Chapter 29 Tse Y, Ostad A, Lee HS, et al. A Clinical and histologic evaluation of two medium-depth Tse Y, Ostad A, Lee HS, et al. A Clinical and histologic evaluation of two medium-depth peels: glycolic acid versus Jessner's trichloroacetic acid. Dermatol Surg. 1996;22:781-786peels: glycolic acid versus Jessner's trichloroacetic acid. Dermatol Surg. 1996;22:781-786Kligman A.M. Long-term histologic follow-up of phenol face peel. Kligman A.M. Long-term histologic follow-up of phenol face peel. Plast Reconstr Surg Plast Reconstr Surg (1985) 75 : pp 652-659(1985) 75 : pp 652-659Halaas YP Medium Depth Peels, Facial Plastic Surgery Clinics of North America, Halaas YP Medium Depth Peels, Facial Plastic Surgery Clinics of North America, 12(3):297-304, 2004 12(3):297-304, 2004

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History facial chemical-peels