Chemical and Physical Procedures: Maria Claudia Almeida Issa Bhertha Tamura Editors
Chemical and Physical Procedures: Maria Claudia Almeida Issa Bhertha Tamura Editors
Chemical and Physical Procedures: Maria Claudia Almeida Issa Bhertha Tamura Editors
Chemical and
Physical
Procedures
Clinical Approaches and Procedures in
Cosmetic Dermatology
Series Editors
Maria Claudia Almeida Issa
Department of Clinical Medicine – Dermatology
Fluminense Federal University
Niterói, RJ, Brazil
Bhertha Tamura
Clínicas Hospital of São Paulo of the University of São Paulo
São Paulo, SP, Brazil
Barradas and Bourroul’s Ambulatório de Especialidades in São Paulo
São Paulo, SP, Brazil
Sorocaba’s Ambulatório de Especialidade in Sorocaba
São Paulo, SP, Brazil
The series “Clinical Approach and Procedures in Cosmetic Dermatology”
intends to be a practical guide in Cosmetic Dermatology. Procedures in
cosmetic dermatology are very popular and useful in medicine, indicated to
complement topical and oral treatments not only for photodamaged skin but
also for other dermatosis such as acne, rosacea, scars, etc. Also, full-face
treatments using peelings, lasers, fillers and toxins are increasingly being
used, successfully substituting or postponing the need for plastic surgeries.
Altogether, these techniques not only provide immediate results but also help
patients to sustain long-term benefits, both preventing/treating dermatological
diseases and maintaining a healthy and youthful skin. Throughout this series,
different treatments in Cosmetic Dermatology will be discussed in detail
covering the use of many pharmacological groups of cosmeceuticals, the
new advances in nutraceuticals and emerging technologies and procedures.
When I received the invitation from Maria Claudia Issa, M.D., Ph.D., and
Bhertha Tamura, M.D., Ph.D., to write one of the chapters of this marvelous
book, I was very happy. Later, upon receiving the mission to write the prologue
of this book, whose editors, with numerous publications in the international
scientific field of cosmetic dermatology, dignify the Brazilian dermatology, left
me extremely honored. In this book, some of the leading medical doctors and
research scientists from Brazil and from all over the world present their
professional experience in the cosmetic dermatology area.
Cosmetic dermatology is constantly evolving. Procedures for rejuvenating
the skin are actively sought by people, nowadays. As dermatology grows as a
specialty, an increasing proportion of dermatologists will become proficient in
the delivery of different procedures. Even those who do not perform cosmetic
procedures must be well versed in the details to be able to guide their patients.
Numerous major advances in the field of the cosmetic dermatology area,
including botulinum exotoxin, soft tissue augmentation, chemical peels, cuta-
neous lasers, light source–based procedures, and the state of the art of derma-
tologic and cosmetic prescriptions, have been developed and enhanced by
dermatologists and plastic surgeons.
Cryotherapy and electrosurgery are routinely used to remove unaesthetic
lesions, contributing with skin rejuvenation. Peelings are still a very important
tool in the armamentarium of the dermatology. Very interesting results in the
treatment of photoaging can be obtained with relatively low cost. However,
accuracy in its management as well as the knowledge of possible complica-
tions and their management are of extreme importance. In this volume, the
different types of peelings are thoroughly scattered as well as innovations in
this well-established area.
The series Clinical Approach and Procedures in Cosmetic Dermatology
offers a wonderful and embracing text. It was a pleasure to contribute in this
unique book with so many well-renowned authors.
This work project is a text certainly of inestimable value for those who wish
to deepen their knowledge in the field of cosmetic dermatology.
Hoping that you will enjoy learning a lot from this book!
v
Preface
Nowadays, life expectation had increased and for a better quality of life, people
are looking for beauty, aesthetics, and health. Dermatologists and plastic
surgeons who work with cosmetic dermatology can help patients to maintain
a healthy and youthful skin. Topical and oral treatments associated with full-
face procedures using peelings, lasers, fillers, and toxins are increasingly being
used, successfully substituting or postponing the need for plastic surgeries.
This series of book is very special among other ones already published as it
encompasses all subjects related to this area of dermatology. All authors are
experts in the field of cosmetic dermatology. Literature review and its corre-
lation with authors’ experience is a differential feature of this work.
This work had been divided into four volumes due to the breadth of the
subjects, which cover skin anatomy and histopathology, physiology, patient’s
approaches, common cosmetic dermatosis, topical and oral treatments, and
cosmetic procedures.
In Chemical and Physical Procedures, Prof. Maria Issa, Prof. Bhertha
Tamura, and collaborators provide the applicability and benefits of physical
and chemical procedures in cosmetic dermatology. Here, the use of superficial,
medium, and deep peelings; cryotherapy; and electrosurgery are discussed in
detail. These procedures are commonly used to treat unaesthetic lesions, which
cannot be treated with topical or oral approaches, offering a rejuvenated
appearance. Indications, contraindications, complications, and its manage-
ment are also reported.
The Clinical Approach and Procedures in Cosmetic Dermatology was
prepared to be a guide in cosmetic dermatology. It can be considered a
complete encyclopedia in the field of cosmetic dermatology and, for this
reason, it is extremely useful for those who already work with cosmetic
dermatology as well as for beginners in this field. This is a new reference
work project, and we are delighted to have you on board.
vii
Acknowledgments
ix
Contents
Jessner’s Peel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Jane Marcy Neffá Pinto, Lilian Mathias Delorenze, Wellington
Vasques, and Maria Claudia Almeida Issa
xi
xii Contents
xiii
xiv About the Editors
Bhertha Tamura has M.Sc. and Ph.D. degrees in Dermatology from the
Hospital das Clínicas de São Paulo – Universidade de São Paulo. Specialist in
general surgery and dermatology. Counselor for the Brazilian Society of
Dermatologic Surgery and for the Brazilian Society of Dermatology. Member
of the Scientific Commission of the Brazilian Society of Dermatology. Chief of
the Department of Dermatology at the Complexo Hospital Heliopolis (São
Paulo, Brazil). Member of several international dermatological societies.
Contributors
xv
xvi Contributors
Heloisa Hofmeister
Abstract Contents
Chemical Peels may be defined as “controlled Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
wounds” of the skin made by the dermatologist History of Retinoic Acid Peels . . . . . . . . . . . . . . . . . . . . . . . . 4
to multiple purposes. They are classified as
Mechanism of Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
superficial, medium, and deep according to the
depth of penetration of the chemical solution. Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
The deepest the peelings, the best results and the Contra-Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
greatest range of complications. Superficial che-
Classification of the Superficial Peels . . . . . . . . . . . . . . . . 4
mical peels are useful procedures to enhance the
appearance of the skin with fast results and little Preparation of the Patient, Use, and Dose . . . . . . . . . . . 5
or no downtime. They are appropriate to all skin Postpeeling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
phototypes. Retinoic acid is a well-established Side Effects and Their Managements . . . . . . . . . . . . . . . . 6
agent in the treatment of acne from the 1960s
Take Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
and photoaged skin, and it has been used for this
purpose since the 1980s. Photoaged skin is References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
characterized by wrinkles, hyperpigmentation,
enlarged pores, laxity, and loss of brightness,
among other alterations. For the last decades, Introduction
retinoic acid has been used in higher concentra-
tions for superficial peelings as an effective and The development for the treatment of
safe tool for the dermatologist. This chapter will photodamaged skin has been enormous in the
drive you through the stages and techniques of last decades. New concepts and better under-
this peeling step by step based on my 30 years of standing of the aging process caused huge
personal experience and medical literature. changes in the way dermatologists can treat
their patients. Better equipments of lasers and
Keywords lights, radiofrequency, ultrasound, 3D rejuvena-
Superficial peeling • Tretinoin • Retinoic acid • tion and volumization, botulinum toxin and
Collagen enhancing • Rejuvenation their new targets, lifting sutures, and collagen
enhancers among others are new tools
always being renewed and reinvented. But one
H. Hofmeister (*)
Pontificia Universidade Católica do Rio de Janeiro, Rio de
Janeiro, RJ, Brazil
e-mail: [email protected]
exfoliation of the granular layer until the basal treatment with hydroquinone prepares the skin to
layer (depth = 0.45 mm) (Yokomizo et al. the peeling, making it safer. However, be sure you
2013). The depth of the superficial peel, as of trust the pharmacist who will manipulate your
any peelings, will depend on the type of skin, formula. A wrong manipulated hydroquinone for-
pretreatment preparation of the skin, concentra- mula as monobenzylether may cause disasters
tion of the retinoic acid, vehicle, and the tech- such as permanent hypopigmentation, even far
nique of the application of the retinoic acid on from the treated area. Be sure to refer your patient
the skin. The depth of the peeling will determine to the pharmacist you trust!
the post-peel healing with no downtime, little The patient must understand what is going to
erythema, and mild desquamation, or, if exfoli- happen during and after the procedure and the
ating until the basal layer, a little downtime with importance of daily sun protection.
darkening of the treated area and more desqua- Even in superficial peels, herpes infection must
mation. The post-peel reaction and recovery be prevented. Perform a careful anamnesis and, if
time must be discussed previously with the the patient has a herpes history, the prophylactic
patient and an informed consent must be signed. antiviral therapy with valacyclovir 500 mg
12/12 h for 5 days is given right before the
peeling.
Preparation of the Patient, Use, By the time of the procedure, the room must be
and Dose silent and calm, relaxing music is welcome and
the environment must be friendly. The room tem-
The ideal patient has had a previous home routine perature should be as nice as possible. The patient
treatment given by the dermatologist. The purpose must use a disposable cap and gown and must be
of the pretreatment phase is to prepare the skin for wearing comfortable clothes. The dermatologist
the peeling process and for the following regen- must wear gloves. It should be a pleasant time for
eration phase. To achieve this, tretinoin is usually the patient.
applied for 1 month before hand because its action The concentrations of retinoic acid as a peel-
on the skin facilitates a more homogeneous pene- ing agent vary from 3% to 12%. The most com-
tration of the peel, leading to a more consistent mon and probably safer concentration is 5%.
result. Moreover, preparation with tretinoin also Published in 2011, a study found no difference
facilitates to accelerate the post-procedure healing in treatment results for melasma between 5%
process. To prevent postinflammatory hyperpig- and 10% concentrations (Magalhães et al.
mentation, the epidermal melanogenesis needs to 2011). The solution can be prepared in tinted
be inhibited by the daily use of sunscreens gel, lotion, or cream of propilenoglycol. The
(Fischer et al. 2010). most common vehicle is propylenoglycol, and
Darker skin individuals, Fitzpatrick’s the color of the solution is yellowish. The
phototype 3 to more, are prone to develop a retinoic acid peeling solution may be formu-
post-peeling hyperpigmentation. They must be lated by the pharmacist with a skin-colored
treated with hydroquinone or other approved sub- tone to make up the strong yellow natural color
stance at least for 3 weeks before the procedure. It of the retinoic acid. It may be applied with a silk
may be used at daylight, even at the beach or at the disposable brush, gently and evenly in the entire
pool with proper skin sun protection. It rarely area to be treated. The application of the solu-
causes contact allergy, but it will frequently tion is completely painless, although in some
cause primary irritant dermatitis if the patient sensible skin patients it may prickle a little.
uses it in a thick layer. So, it must be used in a The patient must keep the solution on the skin
minimal amount, “almost nothing” as I tell my for at least 6 h and then wash it out. At the next
patients. In melasma, it may be used as much as day there might be a mild to a strong erythema,
three times a day. The results are outstanding, and depending upon the depth of action of the
we think it is a golden standard for melasma! The superficial peel.
6 H. Hofmeister
The depth of the peeling depends on the thick- Side Effects and Their Managements
ness of the epidermis, the density of the follicles,
the degree of photodamage, the gender (male skin Retinoic acid peel can cause strong erythema spe-
is oilier, hampering penetration), skin phototype, cially in very thin and degreased skin. In this case,
the integrity of the epidermal barrier, and the the prescription of a mild topical corticosteroid
skin’s previous preparation (Yokomizo et al. like desonide cream for a couple of days will
2013). minimize the problem. Prolonged erythema
Degreasing the skin is the key to control the is rare and if happens, a halogenated corticoste-
depthness and uniformity of any peeling, and it roid must be used under strict dermatological
is not different for retinoic acid peel. The skin supervision as inflammation may lead to
can be degreased by vigorous rubbing using postinflammatory hyperchromia.
gauze embedded with Hoffman solution and it If postinflammatory hyperchromia occurs, it
will cause erythema immediately after the peel. will be easily controlled with formulas containing
If the skin is thicker, it can be a good method to hydroquinone and sunscreens.
apply the peel. It will cause much more scaling
after the procedure, and just before peeling
begins, the skin will be darker. The patient Take Home Messages
must be aware of these posttreatment details as
though as that this procedure can worsen telan- 1. Retinoic acid peels are precious for the derma-
giectasia and rosacea. The skin can also be tologist routine.
degreased with gauze and alcohol with no rub- 2. If you do not have experience with this proce-
bing, and then the retinoic acid is applied in the dure, start with caution.
same way described above. 3. Always take before and after pictures and ask
If treating striae distensae, rubbing is very your patient to return to daily visits to check them
important to provoke a deeper action of the until you feel comfortable with the procedure.
retinoic acid. For this indication and even for 4. It is a relatively easy and safe treatment and the
photodamaged skin, the peel may be preceded patient, if well oriented by the doctor with a
by microdermabrasion or even fractional lasers good medical-patient relationship, will be
to enhance the results. For striae, the area pleased and grateful.
treated with the solution can be also occluded
with a PVC film to improve the effect of the
peeling.
References
2014 Plastic Surgery Statistics. http://www.plasticsurgery.
Postpeeling org/Documents/news-resources/statistics/2014-statistics/
plastic-surgery-statsitics-full-report.pdf. Accessed 05 Apr
At home, at least 6 h with the retinoic acid, the 2016.
Baldwin HE, Nighland M, Kendall C, Mays DA,
patient is instructed to wash out the retinoic acid Grossman R, Newburger J. 40 years of topical tretinoin
solution peel with water and a soft soap. During use in review. Br J Dermatol. 2010;163(6):1157–65.
the week after the procedure, sunscreen and/or Brody HJ, et al. A history of chemical peeling. Dermatol
sunscreen and/or sun blocks are mandatory. Surg. 2000;26:405–9.
Cordero Jr A. La vitamina a acida em la piel senil.
After a superficial peeling, hydration may be Actualizaciones Terapéuticas Dermatológicas.
very important for a better outcome. 1983;6:49–54.
Retinoic Acid Peel 7
Decherol JW, Mills O, Leyden JJ. Naevus comedonicus – Kligman AM, Grove GL, Hirose R, Leyden JJ. Topical
treatment with retinoic acid. Br J Dermatol. 1972; tretinoin for photoaged skin. J Am Acad Dermatol.
86(5):528–9. 1986;4:836–59.
Fischer TC, Perosino E, Poli F, Viera MS, Dreno B, Magalhães GM, Borges MF, Querioz ARC, Capp AA,
Cosmetic Dermatology European Expert Group. Pedrosa SV, Diniz MS. Double-blind randomized study
Chemical peels in aesthetic dermatology: an update of 5% and 10% retinoic acid peels in the treatment of
2009. J Eur Acad Dermatol Venereol. 2010;24(3): melasma: clinical evaluation and impact on the quality of
281–92. life. Surg Cosmet Dermatol. 2011;3(1):17–22.
Kligman AM. Photoaging:manifestations, prevention and Mills OH, Kligman AM. Acne aestivalis. Arch Dermatol.
treatment. Dermatol Clin. 1986;4(3):517–28. 1975;111(7):891–2.
Kligman AM, Plewig G, Mills Jr OH. Topically applied Yokomizo VMF, Benemond TMH, Chisaki C, Benemond
tretinoin for senile (solar) comedones. Arch Dermatol. PH. Chemical peels: review and practical applications.
1971;104(4):420–1. Surg Cosmet Dermatol. 2013;5(1):58–68.
Glycolic Acid Peel
Advantages and Disadvantages of Glycolic Acid The alpha hydroxy acids were developed by
Peel: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Van Scott and Yu as more superficial peels for
Take Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 hyperkeratosis in the early 1980s. Subsequently,
Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
peeling with glycolic acid was developed (Fischer
et al.2010). AHAs represent a group of organic
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
acids, which share the same hydroxyl in the alpha
position. They are naturally found in foods such as
fruits, sugarcane, and yoghurt. Among the alpha
Introduction hydroxy acids are glycolic acid (derived from
sugarcane), lactic acid (derived from sour milk),
Chemical peeling (chemexfoliation) is the appli- citric acid (derived from lemon and orange), malic
cation of a chemical agent to the skin, which acid (derived from apples), and tartaric acid
causes controlled destruction of a part of or the (derived from grapes).
entire epidermis, with or without the dermis, lead- The natural source of glycolic acid is sugar-
ing to exfoliation and removal of superficial cane, but the glycolic acid used in practice is
lesions, followed by regeneration of new epider- created in laboratories from chemical reagents.
mal and dermal tissues (Khunger 2008). Chemical The simplest and most used among the AHAs is
peels are classified as very superficial, superficial, glycolic acid (GA), with a two-carbon structure
medium, and deep according to the depth of pen- with a highly hydrophilic feature, allowing for
etration of the peeling solution. better cutaneous penetration.
In a very superficial light peel, there is necrosis GA peels are usually performed in a 30%–70%
up to the level of stratum corneum. A superficial concentration, inducing epidermolysis and desqua-
light peel will reach the entire epidermis up to the mation. AHAs are weak acids that cause rejuvena-
basal layer. A medium peel is characterized by tion by their metabolic and caustic effect and need to
necrosis up to the upper reticular dermis. be neutralized with basic solutions like sodium
According to Rubin, who developed a classifica- bicarbonate, sodium hydroxide, or water in order
tion of photodamaged skin based on the histologic to end its action (Murad et al. 1995).
depth of the damage, the peel must be as deep as In this section we will consider the strengths
the deepest skin problem to achieve the best and doses for GA peel, followed by the appropri-
results, which means that the proper selection of ate mechanisms of action. This leads into a dis-
the patient and sort of lesion to be treat is a key cussion of what GA is used for, proper patient
determinant for achieving the desired result (Ditre selection, and mechanism of action. We will then
2006; Fabbrocini et al. 2009). Chemical peels can discuss prepeel assessment, how to safely perform
be used to treat acne, acne scars, dyschromias, and the procedure, and how to deal with post-peel
photoaging which includes wrinkles, actinic ker- care. Potential complications for the procedure
atoses, and senile lentigines. and combination therapies are also discussed.
Chemical peels have stood the test of time, and
today, a great number of peel preparations are avail-
able. Various chemicals have been used as peeling Glycolic Acid Peel
agents, of which the most used are the alpha hy-
droxy acids, such as glycolic acid, or beta hydroxy Peel Strengths and Doses
acids, such as salicylic acid (Fabbrocini et al. 2009).
In this chapter we will specifically approach the use GA is a versatile peeling agent and can be admin-
of the glycolic acid as peeling agent, which has a istered in various peel strengths, with resulting
keratolytic, germinative layer, and a fibroblast stim- implications for dosage and the extent of skin
ulating action (Fabbrocini et al. 2012). Before deal- exposure. Glycolic acid concentration ranges
ing with GA specifically, a brief introduction to from 20% to 70%, and the pH varies between
alpha hydroxy acids (AHAs) is warranted. 1 and 3. They are commercially available as free
Glycolic Acid Peel 11
acids, partially neutralized (higher pH), buffered, pigmentation, for example. It is also recommended
or sterified solutions. When buffered preparations to start with low concentration of the acid
are used, the necessary exposure time should be (20–30%) and to increase its concentration and
longer. The absorption of glycolic acid in human contact time in the next sessions (Landau 2007).
skin is pH-, strength-, and time dependent Neutralization is a crucial part of the procedure and
(Fabbrocini et al. 2012). The formulation varies should be done promptly with sodium bicarbonate
from solution and gel, which is preferred since it or plain water as soon as the end point is achieved.
has a slower penetration and is easier to control. If the GA peel is left on the skin unneutralized for
Free acid solutions have lower pH values than the too long, it can cause dermal wounds (Monheit and
partially neutralized, allowing a more deep Chastain 2012).
chemoexfoliation. Also, the risk of uneven pene-
tration is higher with very low pH solutions, lead-
ing to deeper peeling areas. Indications
Dermis penetration risk and pH values are
inversely correlated; the lower the pH value, the GA can be used to treat postinflammatory pigmen-
higher the penetration risk and the more intense tation, solar lentigines, epidermal melasma (Fig. 1),
the peeling will be, which can cause scarring. seborrhea, and fine wrinkling (Fig. 2) (Monheit and
Otherwise, the higher the pH value, the more Kayal 2003). Acne (Fig. 3) of varying severity has
neutralization takes place, and there is less free also been one of the well-evaluated indications for
acid available (less bioavailability) and lower pen- GA peels. In these patients glycolic acid is more
etration. Formulations with lower pH value cause widely used than Jessner’s solution, considering the
more burning, stinging, and erythema and are less equal treatment effect but a reduced exfoliation in
tolerable than solutions with a higher pH (Kede glycolic acid (Fabbrocini et al. 2012; Kim et al.
and Guedes. 2012). 1999). The number and frequency of the applica-
It is important to have in mind that the depth of tions depended on the degree of the clinical
the peel should be adjusted to the depth of the response, and it is usually well tolerated by the
pathological process to be treated; thereby superfi- patients. Considering the use of GA peels to treat
cial peels can improve acne, fine wrinkles, and melasma, it can result in a more uniform distribution
epidermal melasma, but will not improve deep of melanin and the elimination of melanin accumu-
wrinkles, dermal melasma, or postinflammatory lations, being useful in the treatment of epidermal
melasma. However, the studies comparing the effi- All skin type patients are eligible for a superficial
cacy of chemical peels have mixed results when it GA peel; however, a medium-depth GA peel should
comes to melasma, and the use of non-inflammatory be avoided in Fitzpatrick skin types IV and V
peeling agents such as salicylic acid is preferred for patients because they have a greater risk of devel-
such a disorder as there is less propensity to cause oping hyperpigmentation or hypopigmentation.
postinflammatory hyperpigmentation (Monheit and
Chastain 2012).
Glycolic acid can also be used in combination Contraindications
with 5-fluorouracil for the treatment of pre-skin
cancer conditions, such as actinic keratosis and Glycolic acid peels are contraindicated in certain
actinic cheilitis, as a so-called fluorouracil- conditions such as pregnancy, nursing patients,
hydroxy pulse peel (Jackson 2014). active herpes simplex, contact dermatitis, and
Glycolic Acid Peel 13
patients with glycolate hypersensitivity. Further- recent isotretinoin treatment in the last 6 months
more, they may enhance skin sensitivity to ultra- (for medium-depth GA peel), and tendency for
violet light (Fabbrocini et al. 2012; Fischer et al. postinflammatory hyperpigmentation. Patients
2010). with darker skin type have a tendency to develop
postinflammatory hyperpigmentation. Also, a
complete medical history and current medications
Mechanism of Action
should be informed by the patient.
Informed consent and also photographic
Glycolic acid aims the corneosome, increasing
record and standard good-quality photographs
damage and decreasing cohesiveness, leading to
are highly recommended for all types of peelings.
desquamation (Fartasch et al. 1997). AHA super-
Written information about the type of the peel-
ficial peels also increase epidermal activity of
ing they will be subjected to, what they should
enzymes, causing epidermolysis and exfoliation
expect, and post-care peel is a necessity.
(Fischer et al. 2010). The epidermis becomes
The physician should also explain to the patient
thinner, and the multiplication of the epidermal
the need for multiple procedures to achieve the
cells results in regeneration and remodeling, with
expected outcome and evaluate the patient’s expec-
improvement of texture and surface abnormality.
tations and motivation. The patient should be
Stimulation of the epidermis also leads to the
advised about the recovery time, importance of
production of cytokines, which activates the fibro-
maintenance regimens after the peel, and possible
blasts to produce collagen type I and type IV and
side effects and complications (Khunger 2008).
elastin fibers, improving the appearance of photo-
aged skin. Deeper peels result in a greater deposi-
tion of collagen and glycosaminoglycans (Murad
Required Materials
et al. 1995).
Concerning acne, it is effective in treating
– Gloves
non-inflammatory lesions and inflammatory erup-
– Disposable hair cap
tions because of its antibactericidal effects on
– Alcohol to clean the skin
Propionibacterium acnes and antioxidant action.
– Acetone to degrease the skin
It may also improve penetration of topical acne
– Cotton-tipped applicators or gauze pads
therapies, and thus it may be used as an adjuvant
– A timer
treatment for acne. However, it has very few
– Neutralizing solution
effects on atrophic or hypertrophic scars (Atzori
et al. 1999). By causing epidermolysis, dispersing
basal layer melanin and epidermal dermal
Performing the Peel
hyaluronic acid, they can also correct altered kera-
tinization seen in these cases, in addition to
Performing the peel requires consideration of the
improving collagen gene expression through an
following steps: skin preparation, cleansing,
elevated secretion of IL-6 (Bernstein et al. 2001).
application, and neutralization.
The provider and the patient should keep in
mind that multiple peels are usually necessary to
obtain optimal results, in average once every
Skin Preparation
15 days for 4–6 months, until the expected out-
come is observed.
It is imperative that the patient maintain a rigorous
skin care regimen during the immediate preoper-
Prepeel Assessment ative and postoperative periods in order to obtain
the most favorable results. The physician should
The patient should be interrogated about the be prepared to provide guidance, sources, and
degree of sun exposure, history of herpes simplex, examples that help formulate this regimen.
14 D. Steiner and M.G. Pascini
The patients should have their skin treated with It is better to start applying the glycolic acid on
products like retinoic acids, AHAs, and some- the forehead and then to the rest of the face since
times bleachers for 2–4 weeks prior to the peel the forehead is less sensitive and can tolerate a
and discontinue 3–5 days before the procedure. little more exposure to the acid than other parts of
Thus, patients may be primed at home by using the face can. Very sensitive areas, like the corners
mild topical peeling agents such as tretinoin of the nose and lips, should be protected with
0.025%, adapalene 0.1%, glycolic acid 6–12%, Vaseline. Training is necessary for the application
kojic acid, or azelaic acid (Khunger 2008). of this peel, since the whole skin should be
The use of tretinoin prior to chemical peeling exposed to the acid in the same amount of time,
amplifies the procedure’s effects. By decreasing and the risk of excessive penetration is high when
the stratum corneum’s thickness, it increases the the provider is not familiar with the procedure
peel’s depth. Tretinoin is also known to reduce (Ditre et al. 2006). The depth of penetration of
healing time after resurfacing. the peeling agent can be observed and controlled
Hydroquinone (2–4%) is useful in patients by the changes in the skin color:
with skin type III or higher, as it blocks the tyro-
sine enzyme and decreases epidermal melanin – Diffuse homogeneous erythema indicates epi-
production during preoperative and healing dermal penetration.
periods, even without history of pigmentary – White frost means coagulative necrosis of the
abnormalities (Monheit and Chastain 2012). papillary dermis.
The choice of the primer agent will depend on – Gray-white frost indicates coagulative necrosis
the need of each patient and risk of complications. of the reticular dermis (Fabbrocini et al. 2009).
The same primer agent may be used for mainte- – There is no determinable end point for this
nance afterward. peeling, which should be decided based on
the depth of the skin problem. Usually a
uniform erythema is seen by 3–5 min, when
Cleansing Procedures it should be neutralized. If frosting is
observed in any area before the set time or
Cleansing the skin before a chemical peel is end point, it should be neutralized at the same
extremely important to obtain a homogeneous time. This is specially important at some
penetration of the peel and thus a uniform result. areas with a thinner stratum corneum, like
First, the patient is asked to wash the face with the alar groove or nasolabial fold, which
soap and water. Then, the skin surface must be absorb the acid faster than others, and may
mildly cleansed to remove any remaining traces of need to be neutralized before the rest of the
makeups or oils. Isopropylic alcohol is used to face (Sharad 2013).
clean the skin and acetone for degreasing.
Neutralization
Application
GA peels need to be neutralized to have their
The patient should be seated in a comfortable action stopped. Neutralizing agents for AHA
position, wearing a hair cap, and must keep their peels are basic solutions, such as ammonium
eyes closed during the entire procedure. The salts, sodium bicarbonate, sodium hydroxide,
acid can be applied with gauze pads, fan brush, or water. The most used is a 10–15% sodium
gloved fingers, or a cotton-tipped applicator, bicarbonate solution, and as it produces carbon
depending on the formulation of the peel. In dioxide in the process of neutralizing the acid,
general, gel formulations have a slower penetra- bubbling is seen on the surface of the skin,
tion time and are easier to control (Fabbrocini which is important as it assures the physician
et al. 2009). that they have neutralized the acid (Rubin
Glycolic Acid Peel 15
1992). After that, the patient should wash his or normal maintenance regimen (AHAs, retinoic acid,
her face with a large amount of cool water. bleaching creams, moisturizers) should be started as
Failing to neutralize the peel at the proper soon the skin looks and feels normal again.
moment can lead to dermal wound and scarring. The patient should be aware of the need to
Therefore, the neutralization agent should be avoid sun exposure for at least 6 weeks after the
close by at the moment of the procedure. peel and use broad-spectrum sunscreen since the
The strength of the GA peel will be determined new skin is fragile and more susceptible to injury.
by the concentration of the solution and time of
contact; therefore, neutralization is determinative.
For example, 30%–50% GA, applied for 1–2 min, Complications
is a very superficial peel; a 50%–70% GA peel,
applied for 2–5 min, is considered a superficial GA is an established, widely accepted peeling
peel. A medium-depth peel would be 70% GA, agent, and it was found to be quite safe, but side
applied for 3–15 min (Fabbrocini et al. 2009). effects and complications may occur. These com-
It is essential to recall that more important than plications of chemical peel can be prevented by
painstaking monitoring of the peel clock is to proper patient selection, patient counseling, and
watch the patient closely, observing the reaction adequate priming and with good intra-peel and
of the skin and looking for any area of frosting that post-peel care. Compliance to the post-peel care
should be neutralized before any others. With this is essential to ensure success of a series of GA
peeling in particular, uneven penetration is com- peels and to avoid complications.
mon, and the provider should pay close attention Immediate complications are undesirable reac-
to this fact when performing it. Also, the increas- tions like erythema, desquamation, and sensation
ing discomfort reported by the patient is associ- of pulling of facial skin that take place within
ated with an area of deeper penetration. The minutes or hours after the peeling. These reactions
majority of the patients will refer symptoms like are expected and depend on the depth on the peel.
stinging, itching, or tingling, and it should stop Delayed complications, which develop within
rapidly after the neutralization. a few days to weeks, include scarring, infection,
postinflammatory hyperpigmentation, persistent
erythema, and herpetic infection.
Post-Peel Care Herpes labialis: Antiviral therapy is
recommended in all patients subjected to a
Preventing or reducing the risk of complications medium GA peel, regardless of whether there
and assuring prompt recuperation of the skin are is a history of herpes simplex infection. It
the purposes of the post-peel care. The patient should be started 2 days before the procedure
should be asked to interrupt the use of his or her and continued for 7–10 days, until full
daily products for a few days, until the skin is reepithelialization. The recommended regimen
completely recovered, and apply only the pre- consists of acyclovir 400 mg, three times a day;
scribed agents. valacyclovir 500 mg, twice daily; or famciclovir
Bland topical steroid cream can be used for 2 or 250 mg twice daily. Patients who undergo a
3 days in the case that significant inflammation superficial GA peel do not need prophylaxis
occurs, in order to accelerate resolution. Although against herpes infection, because this injury is
infection is a rare complication, antibactericidal not enough to reactivate the virus. However, the
ointment should be used in case of crusting, to prophylaxis should be considered in patients
assure no infections develop. For those with nor- with a history of repeating herpetic infection
mal skin, but experience high skin sensitivity, the (Monheit and Chastain 2012).
use of emollients is enough. Persistent erythema: In a few cases, some
The daily routine of skin care should be degree of erythema remains many weeks after
suspended during the postoperative period, and the the peel and should not concern the provider.
16 D. Steiner and M.G. Pascini
This kind of erythema worsens with increasing helps in enhancing the depth of penetration of
blood flow to the area, which can occur in sim- both agents while decreasing the toxicity and
ple daily activities such as exercise. morbidity associated with deeper peels.
Low-potency corticosteroid creams may be
helpful, besides the use of sunscreens (Tung
and Rubin 2010). GA and TCA Peel
Postinflammatory hyperpigmentation: This is
usually not a problem with very superficial and Dr. Coleman proposed the use of GA and tri-
superficial GA peeling but may become a significant chloroacetic acid (TCA). Since the glycolic acid
problem to patients with Fitzpatrick skin type III or causes a debridement at the stratum corneum, it
higher and to all patients subjected to a medium- favors a uniform penetration of TCA, producing
depth peel. The use of hydroquinone (2–4%) may a medium-depth peel (Coleman and Futrell
reduce the risk in patients prone to postinflammatory 1994). Beyond that, the combination of 70%
pigmentation since the hydroquinone blocks the glycolic acid gel, rather than solution, and 35%
enzyme tyrosinase, and patients may benefit from TCA has been used to treat nonfacial skin, for
using it during the pre- and postoperative period example, lentigines, actinic keratoses on the
(Monheit and Chastain 2012). neck, and balding scalp, arms, and hands
Infection: This is a rare complication that can (Tung and Rubin 2010).
be seen mainly with medium-depth GA peels and Performing the peel: After degreasing the
combined peels, caused by loss of cutaneous bar- skin, apply a uniform layer of 70% GA and
rier and tissue injury followed by inappropriate neutralize it in 2 min. Then apply the 35%
wound care. Delayed healing and persistent red- TCA following the usual procedure. This will
ness are early warning signs. For viral, bacterial, result in a more even and deeper peel than the
or fungal infection, culture of the area and empiric use of TCA alone. GA and TCA peels are
antimicrobial therapy should be readily initiated performed as a single procedure to remove
to minimize scarring. mild rhytides, actinic keratosis, or pigmented
Scarring: Scarring is extremely uncommon, dyschromias. They can be repeated in every 6
but GA peels can cause dermal wounds in case months or yearly depending on the actinic dam-
of poor technique during application or use of age (Fabbrocini et al. 2012; Kadunc 2012).
excessively concentrated solution. To avoid
this complication, the provider should watch
constantly the face during the procedure and Jessner’s Solution and GA Peel
neutralize the acid rapidly in case of frosting,
which indicate dermal injury (although the The combination of Jessner’s solution and GA
correlation with the depth of injury is not (Monheit peel) results in a more uniform peel,
always complete). because the Jessner’s solution has a keratolytic
effect, allowing an even permeation of the GA
(Monheit 1989). However, the use of Jessner’s
Combined Therapies solution followed by a GA peel may increase the
risk of overpeel and scarring, since the end point
The foundation of combined peels is to use two of the GA peel may be difficult to observe, espe-
superficial peels to reach the same depth of the cially in dark-skinned patients. Actinic keratosis,
skin you could reach with only one agent, increas- rhytides, and photoaged skin may be treated with
ing safety and reducing the risk of scarring. This this combined peel.
Glycolic Acid Peel 17
References
Advantages and Disadvantages
of Glycolic Acid Peel: Atzori L, Brundu MA, Orru A, Biggio P. Glycolic acid
peeling in the treatment of acne. J Eur Acad Dermatol
Venereol. 1999;12:119–22.
Advantages Disadvantages Bernstein EF, Lee J, Brown DB, Yu R, Van Scott
Very mild erythema Burning sensation and erythema E. Glycolic acid treatment increases type I collagen
during application mRNA and hyaluronic acid content of human skin.
Dermatol Surg. 2001;27(5):429–33.
Mild desquamation No uniformity of application
Coleman III WP, Futrell JM. The glycolic acid tri-
Short Neutralization is mandatory chloroacetic acid peel. J Dermatol Surg Oncol.
postoperative period 1994;20(1):76–80.
Useful in Necrotic ulcerations if time of Ditre CM. Alpha hydroxy acid peels. In: Rubin MG, Tung
photodamage application is too long and/or R, editors. Procedures in cosmetic dermatology series;
skin pH is reduced chemical peels. St Louis: Elsevier; 2006. p. 27–35.
Fabbrocini et al. (2009) Fabbrocini G, De Padova MP, Tosti A. Chemical peels:
what’s new and what isn’t new but still works well.
Facial Plast Surg. 2009;25(5):329–36. doi:10.1055/s-
0029-1243082. Epub 2009 Dec 18.
Take Home Messages Fabbrocini G, Padova MP, Tosti A. Glycolic acid. In: Tosti A,
Grimes PE, Padova MP, editors. Color atlas of chemical
peels. London: Springer; 2012. p. 9–16.
• The success of any peel is crucially dependent Fartasch M, Teal J, Menon GK. Mode of action of glycolic
on the physician’s understanding of the chem- acid on human stratum corneum: ultrastructural and
ical and biological processes, safety profile and functional evaluation of the epidermal barrier. Arch
efficacy, as well as of indications and side Dermatol Res. 1997;289:404–9.
Fischer TC, Perosino E, Poli F, Viera MS, Dreno
effects of the peeling agent. B. Cosmetic Dermatology European Expert Group
• The GA peels always need to be neutrali- Chemical Peels in aesthetic dermatology: an update.
zed, and the neutralizing agent should be J Eur Acad Dermatol Venereol. 2010;24:281–92.
close by. Jackson A. Chemical peels. Facial Plas Surg. 2014;
30(1):26–31.
• GA peels can create dermal wounds and post- Kadunc BV. Peelings químicos: médios e combinados. In:
inflammatory hyperpigmentation. Kadunc B, Palermo E, Addor F, editors. Tratado de
• GA peels need to be repeated several times for cirurgia dermatológica, cosmiatria e laser: da sociedade
their best effect. brasileira de dermatologia. Rio de Janeiro: Elsevier; 2012.
p. 311–8.
• There is great variability between patients in Kede MPV, Guedes LS. Peelings químicos: superficiais.
terms of results. In: Kadunc B, Palermo E, Addor F, editors. Tratado de
• The perfect choice of patient for a GA cirurgia dermatológica, cosmiatria e laser: da sociedade
peel is one with moderate skin damage brasileira de dermatologia. Rio de Janeiro: Elsevier;
2012. p. 311–8.
and dyschromia, who is disposed for a Khunger N. Standard guidelines of care for chemical peels.
series of treatment, and cannot bear out a Indian J Dermatol Venereol Leprol. 2008;74(Suppl
downtime. S1):5–12.
18 D. Steiner and M.G. Pascini
Kim SW, Moon SE, Kim JA, Eun HC. Glycolic acid versus Sharad J. Glycolic acid peel – a current review. Clin
Jessner’s solution: which is better for facial acne patients? Cosmet Investig Dermatol. 2013;6:281–8.
A randomized prospective clinical trial of split-face model Tung R, Rubin MG. Procedures in cosmetic dermatology
therapy. Dermatol Surg. 1999;25(4):270–3. series: chemical peels. 2nd ed. Philadelphia: Saunders;
Landau M. Chemical peels. Clin Dermatol. 2010.
2007;26:200–8. l therapy. Dermatol Surg 25(4): 270.
Monheit GD. The Jessner’s? TCA peel: a medium-depth
chemical peel. J Dermatol Surg Oncol.
Denise Steiner Residency in Dermatology at Hos-
1989;15:945–50.
Monheit GD, Chastain MA. Chemical and mechanical skin pital das clínicas- University of São Paulo,
resurfacing. In: Bolognia JL, Jorizzo JL, Schaffer JV, Doctorated in Dermatology at UNICAMP, presi-
editors. Dermatology, 3rd ed. Philadelphia: Elsevier dent of the Brazilian Society of Dermatology
Mosby; 2012. p. 2496–8.
Monheit GD, Kayal JD. Chemical peeling. In: Nouri K,
2013–2014
Leal-Khouri S, editors. Techniques in dermatologic
surgery. St Louis: Elsevier; 2003. p. 233–44. Mirella Pascini Residency in Internal Medicine
Murad H, Shamban AT, Premo PS. The use of glycolic acid and Dermatology at Irmandade Santa Casa de
as a peeling agent. Dermatol Clin. 1995;13:285–307. Misericórdia de São Paulo, member of the Brazil-
Rubin MG. Manual of chemical peels. Philadelphia: JB
Lippincott; 1992. p. 14. ian Society of Dermatology
Salicylic Acid Peel
Abstract Contents
Chemical peels, also known as chemical exfo- Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
liation, consist of the application of one or Salicylic Acid (SA) Peel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
more exfoliating skin agents, leading to the Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
destruction of some layers of the epidermis or Indications and Contraindications . . . . . . . . . . . . . . . . . . . . 20
dermis, followed by regeneration of the skin. SA Peel Formulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Pre-Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Each patient should be evaluated to decide Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
which exfoliating agent will produce the best Post-Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
outcome with the least morbidity, according to Complications and Management . . . . . . . . . . . . . . . . . . . . . . 21
the indication of the chemical peeling, the Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
patient’s lifestyle, the depth of the lesions to
Take Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
be treated, and their skin type. Salicylic acid
(SA) is a β-hydroxy acid that is keratolytic in References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
concentrations of 3–5% and facilitates the top-
ical penetration of other agents. In concentra-
tions under 3%, SA has a keratoplastic effect. It Introduction
is more frequently used in a 20% or 30% con-
centration alcohol solution and has a low inci- Chemical peels, also known as chemical exfoliation,
dence of complications. The mild exfoliation consist of the application of one or more exfoliating
starts 3–5 days after the peel and lasts for up to skin agents, leading to the destruction of some layers
10 days. SA is efficient for the treatment of of the epidermis or dermis, followed by regeneration
initial photoaging, melasma, acne with or with- of the skin (Fischer et al. 2010).
out inflammation, superficial acne scars, and Use of an appropriate chemical peel application
disorders in darker skin phototypes. technique causes programmed and controlled dam-
age, resulting in rejuvenation of the skin (Butler
Keywords et al. 2001). The first reported use of chemical
Salicylic acid • Chemical peel • Exfoliation • peels was 1941, when Eller and Wolf used the
Acne • Melasma • Photoaging technique for the treatment of acne scars. American
interest in this particular field increased with the first
reports from the European in 1930 and 1940. Ayres
M.P.V. Kede (*) • L.S. Guedes (1960) and Baker and Gordon (1961) introduced
Brazilian Society of Dermatology, Rio de Janeiro, RJ, what is known as the ‘modern age of the chemical
Brazil
e-mail: [email protected]; [email protected] peels’. In 1986, Brody and Hailey used the
Fig. 1 Application of a
salicylic acid peel using
gauze
22 M.P.V. Kede and L.S. Guedes
Fig. 2 White color of the skin caused by salicylic acid (SA) precipitation a few minutes after application: (a) after one
layer of SA peel; (b) after three layers of SA peel
Fig. 4 Before and after one session. Clinical improvement after 10 days
Fig. 5 Closer view of the same patient before and after one1 session. Clinical improvement after 10 days
post-inflammatory pigmentation and texture of Butler PE, Gonzalez S, Randolph MA, Kim J, Kollias N,
acne. Yaremchuk MJ. Quantitative and qualitative effects of
chemical peeling on photoaged skin: an experimental
• SA can be used to treat the face and extra-facial study. Plast Reconstr Surg. 2001;107(1):222–8.
region. Eller JJ, Wolf S. Skin peeling and scarification. JAMA.
• SA can be given in association with other 1941;116:934–8.
superficial peeling to increase the second- Fischer TC, Perosino E, Poli F, Viera MS, Dreno B. Chem-
ical peels in aesthetic dermatology: an update 2009.
agent penetration, improving clinical results. J Eur Acad Dermatol Venereol. 2010;24(3):281–92.
• SA is commonly very well-tolerated, with thin Guedes LS. Hidroxiácidos. In: Costa A, editor. Tratado
desquamation. internacional de cosmecêuticos. Rio de Janeiro:
• The patient should know the limits of this Guanabara Koogan; 2012. p. 365–73.
Kede MP. Peelings químicos superficiais e médios. In:
procedure and have real expectations. MPV K, Sabatovich O, editors. Dermatologia Estética.
3a ed. São Paulo: Ed. Atheneu; 2015. p. 601–34.
Monheit G. The Jessner’s þ TCA peel: a medium depth
References chemical peel. J Dematol Surg Oncol. 1989;15:945.
Tung RC, Bergfeld WF, Vidimos AT, Remzi BK. Alpha-
hydroxy acid-based cosmetic procedures. Guidelines
Ayres S. Dermal changes following application of for patient management. Am J Clin Dermatol. 2000;1
chemical cauterants to aging skin. Arch Dematol. (2):81–8.
1960;82:578. Van Scott EJ, Yu RJ. Hyperkeratinization, corneocyte
Baker TJ, Gordon HL. The ablation of rhytides by chem- cohesion, and alpha hydroxy acids. J Am Acad
ical means: a preliminary report. J Fla Med Assoc. Dermatol. 1984;11:867–79.
1961;48:541 Van Scott EJ, Ditre CM, Yu RJ. Alpha-hydroxyacids in the
Brody HJ. Peeling químico e resurfacing. 2a ed. Rio de treatment of signs of photoaging. Clin Dermatol.
Janeiro: Reichmann & ffonso; 2000. 1996;14(2):217–26.
Brody HJ, Hailey CW. Medium depth chemical peeling of Yokomizo VMF, Benemond TMH, Chisaki C, Benemond
the skin: a variation of superficial chemosurgery. PH. Peelings químicos: revisão e aplicação prática.
J Dematol Surg Oncol. 1986;12:1268. Surg Cosmet Dermatol. 2013;5(1):58–68.
Pyruvic Acid Peel
mild dermal edema and hydration along with mild acne scars, and dermal pigmentation. The addition
keratolytic, antimicrobial, anti-inflammatory, and of croton oil for better collagen stimulus is exper-
sebostatic properties, added to the ability to stimu- imental, with need of better formulas and treat-
late new production of collagen and elastin. By ment protocols. For thicker epidermal conditions,
possessing undisputed biochemical properties that it is frequently ineffective. Thus, combined treat-
act directly on energy metabolism in mitochondria ment with TCA provides better results for treat-
of all aerobic organisms, pyruvate is converted to ment of actinic keratoses.
acetyl coenzyme A before being oxidized
completely to CO2. When oxygen levels are not
Patient Selection and Skin Preparation
enough, pyruvate is metabolized to lactate. Thus,
its fundamental biochemical energy transferring
The selection of patients is mandatory when choos-
potential may affect intracellular metabolism, and
ing pyruvic acid peels. Warning: this peel may pen-
its effects may not depend only on chemical coagu-
etrate fast and furiously on a skin with disrupted
lation or damage.
barrier such as ongoing dermatitis, such as retinoid
Pyruvic acid is very unstable, so formulas
irritation, seborrheic dermatitis, atopic dermatitis,
should be kept air-tight in the refrigerator
and perioral dermatitis. If frosting occurs during
(2–8 C). It is volatile, with a strong bitter smell
pyruvic acid peels, the affected area is certainly to
of burned wine with seasonings. Its vapors may
develop severe postinflammatory hyper-
irritate airways and eyes, so it is mandatory to
pigmentation (PIH). Over degreasing the skin prior
have a fan during the procedure and the patient
to treatment is not recommended.
should refrain from opening the eyes during the
Phototype I-III healthy patients are the ideal can-
procedure. If there is no refrigerator available in
didates for such procedure. The penetration is usu-
the office, formulas and even the dry salt cannot
ally uniform even on unprepared skin. In some cases
be safely kept stable. Office delivery of the for-
with extreme oiliness and comedos, it is advisable to
mulas by pharmacies may represent a concerning
start agents with mild keratolytic properties, which
issue, so the author would recommend having the
the patient may continue as a maintenance treatment
formulas you desire to use being carefully super-
after the series of peels sessions, such as glycolic
vised by a compounding pharmacist experienced
acid 10%, pyruvic acid 8%, azelaic acid 15%, or
on pyruvic acid solutions.
adapalene 0.1% for at least 1 month prior to the first
peeling session, to allow time for the patient to adapt
to his home regimen, which usually irritates the skin
Indications and Limitations
in the first week. It is advisable to stop topical
medications 48–72 h before the peeling day to
Major indications for pyruvic acid peels are: acne
avoid excessive irritation in areas prone to hot
(grades I-IV) (Cotellessa et al. 2004; Marczyk
spots such as perioral or periocular areas. PIH is a
et al. 2014), oily skin (Marczyk et al. 2014),
dangerous side effect if the patient presents hot
folliculitis, mild photodamage with superficial
spots. Patients should be aware of this risk and that
wrinkles (Glogau I-II) (Ghersetich et al. 2004),
they may experience temporary pigmentary side-
and superficial scarring and mottled pigmentation
effects for up to 6 months.
(Berardesca et al. 2006). As an alternative agent, it
may provide benefit for melasma on phototype
I-III patients, especially those with associated Application Method
acne scars or hydroquinone-induced pigmentary
changes, such as spotted leucoderma or mild post- Degreasing is done to ensure even penetration by
inflammatory hyperpigmentation. removing excess sebum of the skin. Since pyruvic
This agent has the limitation of superficial der- acid has good penetration in oily skin, degreasing
mal penetration, so it presents no effect on deeper is done in a soft manner, with 70% ethanol, in a
dermal disorders, such as deep wrinkles, deep soft cotton pad (Fig. 1).
Pyruvic Acid Peel 27
Combining Treatments
Retinoic Acid
For better effects on oiliness, some patients may be
candidates to combining 5% retinoic acid in a sim-
ilar way that these combining procedure may be
done following salicylic acid peels or Jessner’s
peels. Retinoic acid solution or cream is applied to
the treatment areas and is allowed to act on the skin
for 2–6 h before being washed with a baby soap
at home.
The addition of retinoic acid improves results
reducing the size of sebaceous glands. However,
retinoic acid peels usually cause significant irrita-
Fig. 4 Face wash in a sink to remove excess pyruvic acid. tion and dry skin in the first 3 days. Figures 9, 10,
Note that this method does not neutralize the solution but 11, and 12 show results of pyruvic and retinoic
causes dilution of the solution acid combo peels.
Fig. 6 Series of weekly pyruvic acid peels. First session was performed with 40%. Second session was performed with
50% pyruvic acid
Fig. 7 Series of weekly pyruvic acid peels. First session was performed with 40%. Second session was performed with
50% pyruvic acid
Fig. 9 Results of first session of pyruvic 40% peel, combined with 5% retinoic acid peel
30 C.G. Wambier
Fig. 10 Results of three sessions of Q-switched 1064 nm LASER toning combined with 40% pyruvic acid and 5%
retinoic acid peels
TCA
For treatment of multiple actinic keratoses with
peeling, Pyruvic acid can be used at 50%,
followed, after 5 min, by application of 35–40%
TCA, which usually causes a deeper peel in the
keratosis than using TCA alone. Pyruvic acid may
be neutralized (Figs. 15 and 16) or not neutralized Fig. 11 Before three sessions of Q-switched 1064 nm
for increased chemical damage (Fig. 17). LASER toning combined with 40% pyruvic acid and 5%
retinoic acid peels
Croton Oil
For treatment of dermal problems. The main issue
is the solubility of croton oil in hydroalcoholic to pyruvic acid 50% with friction alone. How-
solution of pyruvic acid 50%. The author has ever, the author has noticed that croton oil is not
tried this combination of 50% pyruvic acid in mixable with this specific solution. It is possible
hydroalcoholic solution in some patients in that 100% ethanol solution or adding a surfac-
restricted areas of treatment such as scars or tant to the solution may increase solubility; how-
deep wrinkles, without improvement after ever, this is still to be reported on clinical
3 months of follow-up and no additional benefits experiments.
Pyruvic Acid Peel 31
Fig. 13 Results of a single session of Q-switched 1064 nm LASER toning and pyruvic acid 40% peel combo. Reduction
of pigmentation
Fig. 15 Results of two sessions of 50% pyruvic acid + spot 40% TCA peels for hand melanoses
Fig. 16 Results of a single session of 50% pyruvic acid peel full-face followed by 35% TCA on pigmented patches
Fig. 17 Treatment of
severe actinic keratosis on
scalp with a series of three
sessions of 50% pyruvic
acid peel followed by 35%
TCA combo peel
Pyruvic Acid Peel 33
Fig. 18 Hot spots with pyruvic acid peels. Frosting during bleaching creams (left). After 4 monthly treatments with
pyruvic acid peels in a hot spot caused severe persistent Q-switched 1064 nm laser peels and Kligman formula, the
erythema followed by development of postinflammatory skin was only with mild PIH (right)
hyperpigmentation on a area with mild irritation due to
Take Home Messages treatment with a new 50% pyruvic acid peel. Dermatol
Surg. 2006;32(4):526–31.
Coleman WP, Brody HJ. Advances in chemical peeling.
• Pyruvic acid peels are versatile Dermatol Clin. 1997;15(1):19–26.
• Anti-inflammatory and antibiotic effects are its Cotellessa C, Manunta T, Ghersetich I, Brazzini B, Peris
greater difference K. The use of pyruvic acid in the treatment of acne.
• High risk of PIH can be minimized by proper J Eur Acad Dermatol Venereol. 2004;18(3):275–8.
Ghersetich I, Brazzini B, Peris K, Cotellessa C,
preparation and patient selection Manunta T, Lotti T. Pyruvic acid peels for the treat-
• Combination treatments can achieve better ment of photoaging. Dermatol Surg. 2004;
effects 30(1):32–6. discussion 36
Kadunc BV. Pyruvic acid: standardization technique for
the use in chemical peelings by means of experimental
study. University of Sao Paulo; 1998.
References Marczyk B, Mucha P, Budzisz E, Rotsztejn H. Comparative
study of the effect of 50% pyruvic and 30% salicylic peels
Berardesca E, Cameli N, Primavera G, Carrera M. Clinical on the skin lipid film in patients with acne vulgaris.
and instrumental evaluation of skin improvement after J Cosmet Dermatol. 2014;13(1):15–21.
Jessner’s Peel
Bourelly and Lotsikas-Baggili 2005; Fischer et al. Although superficial peelings can be used in all
2010). Salicylic acid is photosensitive, and lactic Fitzpatrick phototypes (I to IV) (Zakopoulou and
acid absorbs water present in the air; hence, the Kontochristopoulos 2006), caution is recommended
solution is sensitive to light and air (Jacobs and when applying Jessner’s solution for the treatment
Roenigk 2010; Yokomizo et al. 2013). of patients with cutaneous phototypes more
Its mechanism of action is based on the pigmented (IV to VI), due to higher risk of compli-
salicylic acid and resorcinol’s keratolytic property cations, including post-inflammatory hyper-
and the lactic acid’s epidermolysis action (Jacobs pigmentation (PIH) and hypopigmentation
and Roenigk 2010; Yokomizo et al. 2013). The (Jackson 2014; Salam et al. 2013).
keratolytic agents in Jessner’s solution cause A careful patient history should focus on some
corneocyte loss of cohesion within the stratum skin disorders such as various forms of dermatitis,
corneum and subsequently producing intercellular rosacea, psoriasis (risk of a Koebner phenomenon
and intracellular edema within the upper epider- after a peel), or herpes simplex virus (HSV) infec-
mis following continued application. The clinical tion (Jackson 2014; Salam et al. 2013; Yokomizo
end point is erythema and streaky frosting, it is et al. 2013; Landau 2008; Langsdon and Shires
self-neutralizing, and multiple applications can be 2012). In patients with a history of HSV infection,
performed to obtain a deeper injury (Jackson prophylactic treatment should be considered
2014; Bourelly and Lotsikas-Baggili 2005). starting 2 days before peel treatment until 7–14
The penetration depends on the number of days after the procedure. Immunocompromised
layers, and medium-depth peelings can be used. patients, such as patients infected with HIV,
It can cause a burning sensation which may should not routinely receive treatment due to post-
(or may not) be helped with water. It can be treatment infection risks (Salam et al. 2013).
applied in the face and body (neck, dorsum); History of radiation exposure, immunosup-
nevertheless, the procedure must be carried out pression, autoimmune disease, and collagen vas-
in only one area per session in order to avoid risk cular disease could potentially compromise the
of salicylism (Jacobs and Roenigk 2010; Bae et al. healing process (Salam et al. 2013; Langsdon
2013; Yokomizo et al. 2013). and Shires 2012).
Salicylism or salicylic acid intoxication is a Drug history may be consulted. We recommend
rare complication of salicylic acid peels that that patients wait 6–12 months from the end of
occur after peeling of extensive areas. The clinical isotretinoin therapy before undergoing peeling
manifestations include dizziness, tinnitus, and because isotretinoin can reduce skin-healing capac-
central nervous system toxicity (Landau 2008). ity (Salam et al. 2013; Langsdon and Shires 2012).
Topical retinoids may be discontinued 1 week
before application. It’s also important to identify
Patient Selection any photosensitizers (e.g., minocycline,
amiodarone, thiazides, tricyclic antidepressants)
Jessner’s solution is used as superficial chemical and systemic therapies that may cause hyper-
peeling agent and can be applied in many cases pigmentation such as oral contraceptives and hor-
such as acne, post-inflammatory hyperpigmentation, monal treatments and inquire about smoking,
mild melasma, improvement of skin texture, and previous keloid/hypertrophic scarring, and previ-
photoaging (Salam et al. 2013; Jacobs and Roenigk ous cosmetic procedures (Salam et al. 2013).
2010; Bourelly and Lotsikas-Baggili 2005; Some patients report that they have sensitive
Zakopoulou and Kontochristopoulos 2006). How- skin. These patients must be patch-tested with
ever, some authors do not recommend Jessner’s the peel in a small inconspicuous location before
solution to be used alone for the treatment of pig- the decision is made to undergo on a full-face
mentary changes, acne, or scarring (Salam et al. chemical peel (Langsdon and Shires 2012; Cortez
2013). et al. 2014).
Jessner’s Peel 37
Glossary
Cosmetic dermatology. Berlin: Springer; 2005. Langsdon PR, Shires CB. Chemical face peeling. Facial
p. 53–83. Plast Surg. 2012;28:116–25.
Cortez EA, Fedok FG, Mangat DS. Chemical peels: panel Monheit GD, Chastain MA. Chemical peels. Facial Plast
discussion. Facial Plast Surg Clin North Am. 2014; Surg Clin North Am. 2001;9:239–55.
22(1):1–23. Salam A, Dadzie OE, Galadari H. Chemical peeling in
Fischer TC, Perosino E, Poli F, Viera MS, Dreno B, Cos- ethnic skin: an update. Br J Dermatol. 2013;169
metic Dermatology European Expert Group. Chemical Suppl 3:82–90.
peels in aesthetic dermatology: an update 2009. J Eur Sharquie KE, Al-Tikreety MM, Al-Mashhadani SA. Lactic
Acad Dermatol Venereol. 2010;24(3):281–92. acid chemical peel as a new therapeutic modality in
Jackson A. Chemical peels. Facial Plast Surg. melasma in comparison to Jessner’s solution chemical
2014;30:26–34. peel. Dermatol Surg. 2006;32:1429–36.
Jacobs A, Roenigk R. Superficial chemical peels. In: Draelos Yokomizo VMF, Benemond TMH, Chisaki C, Benemond
ZD, editor. Cosmetic dermatology – products & proce- PH. Chemical peels: review and a practical applica-
dures. Oxford: Wiley-Blackwell; 2010. p. 377–83. tions. Surg Cosmet Dermatol. 2013;5(1):58–68.
Landau M. Chemical peels. Clin Dermatol. 2008; Zakopoulou N, Kontochristopoulos G. Superficial chemi-
26(2):200–8. cal peels. J Cosmet Dermatol. 2006;5:246–53.
Combining Superficial Chemical Peels
Abstract Keywords
Some dermatological interventions may be Acne • Acne scars • Melasma • Post-inflamma-
combined with superficial peelings to achieve tory pigmentation • Photodamage • Photoag-
better results by speeding results with ing • Chemical peels • Salicylic acid • Glycolic
increased epidermal turnover. To achieve uni- acid • Pyruvic acid • Mandelic acid • Jessner’s
formity of skin tone, combination treatments solution • Modified Jessner’s solution • Alpha-
with Q-switched frequency-doubled Nd-YAG hydroxy acids mix • Tretinoin peels
(532 nm) and Q-switched Nd-YAG (1064 nm)
lasers are possible effective options. In cases Contents
of rosacea, some superficial peels may be asso- Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
ciated with intense pulsed light. Superficial
Indications and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . 42
peels may also be associated with cryotherapy
and 5-fluorouracil cream to improve actinic Combining with Other Peels or Chemicals . . . . . . . . 42
keratosis. Any superficial- or medium-depth Combining with Q-Switched Nd-YAG Laser . . . . . . 43
peel may be used before ablative fractionated
Combining with IPL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
lasers, to achieve better uniformity of results Solar Melanoses, Ephelides, Post-inflammatory
and to boost the final effects. This chapter Pigmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
describes how to better combine different treat- Acne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
ments and focuses on up-to-date alternatives Combining with Ablative Fractionated Lasers . . . . 48
for the classical peeling formulas and combi- Take Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
nation treatments.
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Introduction
J.C.L. Simão (*) Superficial peels are intended to maximize the epi-
Division of Dermatology, Department of Internal
Medicine, Ribeirão Preto Medical School, University of dermal turnover in order to hasten what could be
São Paulo, São Paulo, SP, Brazil achieved by waiting a long period of time. The best
e-mail: [email protected] example, and probably the best indication for super-
C.G. Wambier ficial peels, is post-inflammatory hyperpigmentation
Department of Medicine, State University of Ponta Grossa, (PIH) or superficial erythematous scars caused by
Ponta Grossa, PR, Brazil acne. If the skin is allowed to heal at its own pace, in
e-mail: [email protected]
about 6–12 months, without new active acne effects (Cook and Cook 2000; Monheit 2001). The
lesions, these would probably spontaneously same can be done with another superficial peel, for
resolve. With superficial chemical peels, these example, using 30% salicylic acid peel before using
results can be obtained in about 1–2 months. On 5% retinoic acid peels. In this scenario, multiple
the other hand, when a patient is prescribed topical treatments are necessary, but the control of acne
retinoids or azelaic acid, the results are expected to and the resolution of acne scars happen sooner
be achieved in a time frame in between the natural than with a single superficial chemical peel
gradual resolution and the fastest resolution by a (Fig. 1). Retinoic acid 5% is easily combined as a
chemical peel. “leave-in” mask, because it does not have any spe-
Other excellent indications for superficial peels cific immediate action, since its pH is almost phys-
are acne, oiliness, melasma, irregular tanning, and iological and its mechanism of action is through
melanoses. Combining superficial peels with other nuclear retinoic acid receptors and protein synthesis
treatments intended to improve the same condition modulation (Cucé et al. 2001; Ivanov et al. 2006),
could potentially increase the effects in a synergic which starts in the following day, and the phenom-
way. The objective of this chapter is to provide the ena are better clinically appreciated after 48 h and
reader with good applications of combining super- usually last 48–72 h. Thus, this go-home yellow
ficial peels to maximize results in a safe manner. mask may be applied soon after removing residual
chemicals or neutralization of a variety of peels,
including 10% TCA, 30% salicylic acid in
Indications and Limitations hydroalcoholic (SA-HA) or polyethylene glycol
(SA-PEG) vehicles, Jessner’s solution, modified
The main indications for combining a procedure Jessner’s solution (MJS), and glycolic acid. The
with a superficial chemical peel are increasing 5% tretinoin mask may be improved with the addi-
strength/penetration and accelerating recovery pe- tion of skin color pigments (neutracolor) and sun-
riod through epidermal turnover. The latter is prob- screen, which protect extremely photosensitive
ably the best indication for adding a superficial peel tretinoin against visible light and ultraviolet rays.
to another treatment. Some superficial treatments For improvement of comedones, acne, and
might not cause increased epidermal turnover, so dilated pores, our preferred combo is SA-PEG
normal turnover time is required to peel off treated (Dainichi et al. 2008a, b), left in the skin for
spots. Intense pulsed light (IPL) and frequency- 5–10 min, removed with a soft wet rayon tissue,
doubled quality-switched neodymium-doped yttri- followed by 5% tretinoin mask (solution or cream).
um aluminum garnet light amplification by stimu- This combination is particularly effective because
lated emission of radiation (Q-Switched Nd-YAG SA-PEG does not evaporate and penetrates deeply
laser, 532 nm) treatments commonly cause super- in the follicles. After applying tretinoin, all-trans
ficial temporary darkening by formation of brown retinoic acid (ATRA), the residual intrafollicular
scales in the sites of ephelides or melanoses. peel blends with the mask, producing an occlusive
The main limitations of combining a treatment intrafollicular effect of both agents.
with superficial peeling are that some patients do When facing a patient with extensive facial
not tolerate irritation or temporary burning pain. palpable actinic keratosis (AKs), with the intent
Very few patients may be allergic to chemicals. of treating the whole field of cancerization, many
methods may be used, including photodynamic
therapy (PDT), medium- or deep-depth chemical
Combining with Other Peels or peeling, or dermabrasion. But those methods are
Chemicals usually performed after scheduling, and also, the
patient has to plan for downtime. Less painful and
The use of superficial peels before application of no-downtime procedures include daylight PDT
medium-depth 35–40% trichloroacetic acid im- and superficial peels, followed by either localized
proves its penetration, causing more uniformity in cryotherapy on the thicker AKs or by a mask of
Combining Superficial Chemical Peels 43
Fig. 1 Combined superficial peels for treatment of super- 30% hydroalcoholic solution, followed by removal of
ficial acne scars with post-inflammatory hyper- pseudofrosting and application of retinoic acid 5% cream
pigmentation and erythema. Sessions performed every mask for 4 h. Right: After second treatment
2 weeks. Left: After first treatment with salicylic acid
Efudex ®, 5% 5-fluorouracil (5-FU) cream. The solution (Fig. 2), an ethanol solution containing
superficial peels of choice for these procedures 17% lactic acid, 17% salicylic acid, and 8% citric
are 30% SA-HA, Jessner’s solution, 70% glycolic acid (Rohrich and Herbig 2009), or retinoic acid
acid, or 40–50% pyruvic acid. These procedures 5% peel (Figs. 3 and 4) may be used (Cucé et al.
may be repeated every 7–14 days, until no resid- 2001; Cucé and Bertino 2002).
ual AKs are palpable, usually after five sessions. Although melanoses and melasma can be
The whole combo may be performed in the fol- treated with prescription bleaching creams and
lowing way: 40% pyruvic acid peel for 5 min, sunscreen only, the association of oral tranexamic
neutralization with 10% sodium bicarbonate solu- acid and/or low-fluency treatment sessions with
tion in a wet rayon soft tissue, removal of residual 1064 nm Q-switched Nd-YAG laser (Shin et al.
bicarbonate with a wet rayon soft tissue, and fric- 2013) may improve results. Some patients, even
tion with gauze sponge on areas of AKs or soft with adhesion to home treatments, sunscreen, and
curettage, application of Metvix ®, daylight proce- laser, may exhibit very mild improvement. In such
dure for 2 h, or exposure to 37 J/cm2 red LED cases, the association of superficial peels may be
(about 7 min), cryotherapy on the thicker AKs, beneficial (Figs. 2, 3, 4, and 5).
and 5% 5-FU mask for 4–6 h. This latter proce- Focal or full-face 532 nm Q-switched Nd-YAG
dure is much more valuable, and may remove laser treatments cause dark-brown spots in the
most palpable AKs in a single session. sites where melanoses are treated. The natural
peeling off of thick brown scales usually takes
over 10 days. Facial treatments usually take
Combining with Q-Switched Nd-YAG 7–11 days for full epidermal recovery, with faster
Laser resolution of inflammation and relatively less pos-
sibility of post-inflammatory hyperpigmentation
To maximize skin lightening of low-fluency (PIH). Other sites such as the hands and feet
Q-switched 1064 nm laser (laser toning), a super- might take over 6 weeks until these spots are
ficial chemical peel, such as modified Jessner’s resolved, sometimes with mild residual PIH.
44 J.C.L. Simão and C.G. Wambier
Fig. 2 Combined Q-switched Nd-YAG 1064 nm LASER inflammatory hyperpigmentation caused by acne. Sessions
followed by two layers of modified Jessner’s solution for performed every 2 weeks. Left: before. Right: after six
the treatment of recalcitrant melasma with post- sessions
Fig. 3 Treatment of nevi, oiliness, and diffuse melanosis followed by retinoic acid 5% peel. Left: before. Right:
of the face and neck. Right side of the face. Monthly after four sessions
treatments of Q-switched Nd-YAG 1064 nm LASER,
Thus, superficial peels may be performed right Q-switched Nd-YAG laser facial treatments with
after the laser application to accelerate healing 5% retinoic acid peels decreases the downtime
period. They may also be used long after healing due these dark-brown spots, without compromis-
to improve PIH. The combination of 532 nm ing the final results (Figs. 6 and 7).
Combining Superficial Chemical Peels 45
Fig. 4 Treatment of nevi, facial oiliness, and diffuse LASER, followed by retinoic acid 5% peel. Left: before.
melanosis of the face and neck. Left side of the face. Right: after four sessions
Monthly treatments of Q-switched Nd-YAG 1064 nm
Fig. 5 Monthly treatment of melasma and ephelides with Q-switched Nd-YAG 1064 nm and focal 532 nm, followed by
retinoic acid 5% peel mask for 3 h. Left: before. Right: after two sessions
Fig. 6 Monthly treatment of facial melanosis with Q-switched Nd-YAG 1064 nm and focal 532 nm, followed by retinoic
acid 5% peel mask for 3 h. Left: before. Right: after three sessions
Fig. 7 Monthly treatment of facial melanosis with Q-switched Nd-YAG 1064 nm and focal 532 nm, followed by retinoic
acid 5% peel mask for 3 h. Left: detail of the nose, before. Right: detail of the nose, after three sessions
DiBernardo and Pozner 2016; Degitz 2010; Choi Solar Melanoses, Ephelides, Post-
et al. 2010). inflammatory Pigmentation
IPL is used in combination with superficial
peels on the face for treatment of some pigmen- IPL is applied at wavelengths that are quite ab-
tary and acne changes. sorbed by melanin (between 520 and 540 nm,
Combining Superficial Chemical Peels 47
with short pulses of 10–15 ms). In the case of which leads to the generation of reactive oxygen
post-inflammatory hyperpigmentation, we used species with subsequent bactericidal effects
longer pulses and lower energies, with a greater (Degitz 2010; Choi et al. 2010).
number of sessions. The IPL at wavelength 400 nm is effective for
It takes between 5 and 10 min to observe the the treatment of acne, especially inflammatory
immediate response in the treated area. We should lesions, with a histological decrease in the density
observe darkening of the lesions with greater con- of the inflammatory infiltrate and the size of the
centration of the chromophore melanin with sebaceous glands (Barakat et al. 2017).
surrounding edema and erythema, with areas in- The sessions for treatment of acne with IPL
terspersed by the skin with virtually no reaction should be weekly. When peels are combined at
(where there is not enough target). the same time, the sessions can be weekly or
The cream is then applied with 5% tretinoin biweekly, depending on the peeling response of
(all-trans retinoic acid (ATRA)). Do not use the skin. Treatment may be indicated for mild
manipulations containing alcohol or other pri- to moderate acne. The association of the superfi-
mary irritants that may cause burning. The cial peeling of conventional 30% SA-HA imme-
patient is asked to remove it gently at home diately after the application of IPL promotes a
after 4–6 h. Micellar waters are excellent faster improvement of comedones and inflamma-
removers. In patients with very severe erythema tory lesions.
and/or burning sensation soon after IPL, con- Salicylic acid is a beta hydroxy acid and
comitant application of a low- to medium- lipophilic, which removes the intercellular
potency corticosteroid cream is recommended. lipids that are in covalent attachment to the
The application of topical corticosteroids is also cornified envelope around the epithelial cells
recommended shortly after IPL in cases of PIH in the superficial layers of the stratum corneum.
and home use for 1 week. The treatments for There is therefore a decrease in corneocyte
PIH should not be aggressive, thus avoiding cohesion and desquamation. Likewise, there is
worsening of hyperpigmentation. comedolytic and dry action, with progressive dim-
Melanocytic lesions treated by IPL become inution of comedones and inflammatory lesions
darker and have scaling and crusting. Tretinoin (Lee and Kim 2003).
increases epidermal turnover and facilitates the After the application of 30% SA peeling, a
dispersion and removal of melanin. pseudofrost is obtained and gently removed.
The use of 5% ATRA will promote homoge- The result can be even better if, after the
neous desquamation of the entire face, optimizing removal of salicylic acid, we apply 5% retinoic
the LIP result. Other products with or without acid and ask the patient to take it out 4–6 h at
tretinoin may be used, provided they are compat- home. The sessions are fortnightly or more dis-
ible with the combination formulation (vitamin C, tant. The association of peelings promotes addi-
ferulic acid, etc.), or even other retinoids available tional improvement of the acne lesions, especially
from commercial peelings. the comedones, promotes homogeneous skin
IPL treatment in IV to VI phototypes is not peeling, also acting in post-inflammatory hyper-
recommended because of the high risk of pro- pigmentation (Ahn and Kim 2006).
longed or permanent pigmentary changes. The use of salicylic acid in a polyethylene
glycol vehicle demonstrates no sensation of
burning, erythema, desquamation, and crusting
Acne (Dainichi et al. 2008b). There is also no histo-
logical inflammatory response, which reduces
The lesions of acne, comedones, papules, and the risk of post-inflammatory hyper-
pustules are treated with IPL at the wavelength pigmentation. There is no pseudofrost, and the
of 400 nm. This wavelength is absorbed by the product should be removed after 5 min of con-
porphyrins produced by Propionibacterium acnes tact with the skin.
48 J.C.L. Simão and C.G. Wambier
Fig. 10 Jessner’s solution + 35% trichloroacetic acid + CO2 LASER – 4th to 15th postoperative day
Fig. 11 Jessner’s solution + 35% trichloroacetic acid + CO2 LASER – 15th postoperative day
The most suitable surface peeling agent for penetration ability in the skin. With the forma-
application after ablative laser is 5% tretinoin. tion of MTZs, retinoic acid reaches deeper
Retinoic acid stimulates neocolagenesis, in layers faster, increasing the power of its action.
addition to causing homogeneous desquamation The combination of a Jessner and 35% tri-
in the areas between the MTZ. The vehicle chloroacetic acid peel followed by a fractional
should be in cream, without alcohol. We verified ablating laser, such as CO2, allows a homogenous
a more homogeneous skin in terms of coloration removal of the entire epidermis, combined with
and texture after performing the combined treat- the thermal effect of the MTZs. This association
ment. We have the habit of performing allows effective removal of melanoses and actinic
IPL + CO2/erbium + ATRA with optimization and seborrheic keratoses, renewal of the epider-
of the results, in the same session. Retinoic acid, mis, and neocolagenesis. Marked rejuvenation
even with intact skin barrier, has a high occurs (Figs. 8, 9, 10, and 11). Only profissional
50 J.C.L. Simão and C.G. Wambier
with great experience are able to associate ablative Dainichi T, Ueda S, Furue M, Hashimoto T. By the grace of
lasers and chemical peels. peeling: the brace function of the stratum corneum in
the protection from photo-induced keratinocyte carci-
nogenesis. Arch Dermatol Res. 2008a;300(Suppl):
S31–8.
Take Home Messages Dainichi T, Ueda S, Imayama S, Furue M. Excellent clin-
ical results with a new preparation for chemical peeling
in acne: 30% salicylic acid in polyethylene glycol vehi-
• Superficial peels are extremely versatile for cle. Dermatol Surg. 2008b;34(7):891–9.
combination treatments, including other peels Degitz K. Phototherapy, photodynamic therapy and lasers
and technology. in the treatment of acne. J Dtsch Dermatol Ges.
• Combination with superficial peels provides 2010;7:1048–54.
DiBernardo BE, Pozner JN. Intensed pulsed light therapy
faster detachment of treated melanosis by for skin rejuvenation. Clin Plast Surg. 2016;43(3):
Q-switched 532 nm laser or IPL. 535–40.
• After the skin has been wounded by lasers or Ivanov II, McKenzie BS, Zhou L, Tadokoro CE,
IPL, the best superficial peel to be applied is Lepelley A, Lafaille JJ, et al. The orphan nuclear recep-
tor RORgammat directs the differentiation program of
tretinoin, because it is a peel that has no imme- proinflammatory IL-17+ T helper cells. Cell. 2006;
diate action. 126(6):1121–33.
• Before ablative lasers, any superficial- or Kositratna G, Evers M, Sajjadi A, Manstein D. Rapid
medium-depth peel can be used, with fibrin plug formation within cutaneous ablative
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Trichloroacetic Acid Peel
Table 1 Classification of peels based on depth of action Table 2 Possible indications of medium-depth chemical
peels
Classification Depth Examples
Very Necrosis up to the TCA 10%, Epidermal lesions
superficial- level of stratum Glycolic Acid Seborrheic keratoses
light peels corneum (GA) 30–50%, Actinic keratoses
Salicylic acid Warts
20–30%, Milia
Jessner’s solution Sebaceous hyperplasia
(1–3 coats), Dermatoses papulosa nigra
Tretinoin 1–5% Pigmentary disorders
Superficial- Necrosis through TCA 10–30%, Melasma
light peels the entire GA 50–70%, Postinflammatory hyperpigmentation
epidermis up to Jessner’s solution Freckles
basal layer (4–7 coats) Lentigines
Medium- Necrosis up to TCA 35–50%, Facial melanoses
depth peels upper reticular GA 70% plus Acne related
dermis TCA 35%, 88% Superficial to mild acne scars
phenol Postacne pigmentation
un-occluded, Comedonal acne
Jessner’s solution Acne excoriee
plus TCA 35%, Acne vulgaris-mild to moderately severe acne
solid CO2 plus
Aesthetic
TCA 35%
Photoaging
Deep peels Necrosis up to Baker-Gordon
Fine superficial wrinkling
mid-reticular phenol peel
Dilated pores
dermis
Superficial scars
prolonged medical treatment with a medium-depth The indication also depends on the patient’s tol-
chemical peel (with or without dermasanding), a erances and expectations for correcting his skin
deep chemical peel, dermabrasion, laser resurfacing condition. Some individuals do not wish to enhance
or associations between them. In type IV patients, skin surface regardless of serious issues, and others
the therapies described to type III would certainly be desire marked improvement in relatively minor
indicated; however, invasive surgical operation such problem areas. The condition severity and the
as blepharoplasty, rhytidectomy, scar revision, and patient wishes will lead the treatment (Gadelha and
others are frequently needed in addition to achieve Costa 2009). These wishes ought to be tempered
the expected results (Bolognia et al. 2012; Tung and with data on what is conceivable and what is allur-
Rubin 2011; Khunger 2008; Monheit 2004). ing for the patient regarding treatment. Approach
During the discussion on correct indication, every patient honestly, discussing about plausible
some data are of extreme relevance. Head and outcomes, risks, advantages, and alternatives
neck are the most important areas due to their aes- (Gadelha and Costa 2009; Bolognia et al. 2012).
thetic value, and one must take caution when
treating the neck due to its propensity for complica-
tions. It is known that areas with more pilosebaceous Contraindications
units have better re-epithelialization (Bolognia et al.
2012). Also beware when indicating procedure to History of AIDS, hepatitis, immunosuppressive
hands and arms because they have less predictable systemic diseases, or usage of immunosuppres-
and less impressive results (Gadelha and Costa sive medication must be identified, as they seem
2009). Lesions originated in the epidermis (actinic to grant higher frequency of secondary infection
keratosis, lentigines) have betters responses to after the procedure. In a similar way, a history of
chemical peels than lesions originated in the dermis abnormal scars or keloids deserves more attention
(Tosti et al. 2006). as these patients may end up with an unpleasant
54 P.S. Damasceno et al.
Table 3 Glogau photoaging classification or oral isotretinoin use in the last 6 months as
Type I – No wrinkles these can also increase complications (Dingman
Early photoaging: mild pigmentary disorders, minimal et al. 1994; Rubenstein et al. 1986). History of
wrinkles, no keratosis radiation therapy is important as it can destroy the
Patients typical age (years): 20s or 30s pilosebaceous units, which are essential to
Makeup: Minimal or none
re-epithelialization (Wolfe 1982).
Type II – Wrinkles in motion
Early to moderate photoaging: Early senil lentigines
Special care should be taken in patients with
visible, parallel smile lines beginning to appear, keratosis some dermatologic diseases. Vitiligo and psoria-
palpable but not visible sis can be exacerbated due to the isomorphic
Patients typical age (years): 30s or 40s response. The vasomotor instability in rosacea
Makeup: Usually wear some foundation
can lead to an exaggerated inflammatory response
Type III – Wrinkles at rest
postprocedure (Gadelha and Costa 2009). Con-
Advanced photoaging: Obvious dyschromia,
telangiectasias, visible keratosis, wrinkles even when not nective autoimmune diseases, such as cutaneous
moving facial muscles lupus and scleroderma, can be activated by the
Patients typical age (years): 50s or older chemical peeling trauma. The contraindications in
Makeup: Wears heavy foundation mild-depth peels can be divided into absolute and
Type IV – Only wrinkles
relative (Table 5).
Severe photoaging: yellow-gray color of skin, prior
skin malignancies, wrinkled throughout with no normal
Besides the contraindications, it is also impor-
skin tant to consider the presence of inflammation
Patients typical age (years): 60–70s (seborrhea, retinoid dermatitis, etc.) and skin
Makeup: Cannot wear (“cakes and cracks”) translucency as the more inflammation present
and the more translucent the skin is, the more
likely the peeling will increase its depth, leading
Table 4 Fitzpatrick’s classification of sun-reactive skin to possible complications. Have in mind that tel-
types
angiectasia treatment is not a good chemical peel-
Skin Reaction to first summer ing indication because it has an unsatisfactory
type Color exposure
response. Besides, the peeling can also exacerbate
I White Always burn, never tan
them by removing the pigmentary irregularities
II White Usually burn, tan with
difficulty (Bolognia et al. 2012; Tung and Rubin 2011).
III White Sometimes mild burn, tan Patients must completely understand the peel-
average ing limitations, pre and post care, risks and poten-
IV Moderate Rarely burn, tan with ease tial benefits, and must sign an informed consent
brown prior to the procedure. If you feel vulnerability in
V Dark browna Very rarely burn, tan very physician-patient relationship, do not perform the
easily
procedure.
VI Black No burn, tan very easily
a
Asian Indian, Hispanic, Oriental, or light African descent,
for example
Trichloroacetic Acid Peel
outcome. Fitzpatrick sun-reactive skin type clas- Trichloroacetic acid (Fig. 1) is very versatile as it
sification is another concern, as skin types IV, V, can be used to create very superficial, superficial
and VI tend to develop postinflammatory hyper- and medium-depth peels depending on the con-
pigmentation (Table 4) (Rullan and Karam 2010; centration of TCA used (Table 1), adequacy of
Monheit 1995). Patients in use of contraceptives, skin priming, coats of acid applied, and technique
supplemental hormones, or minocycline should of application. TCA is most commonly used for
be alerted due to the high risk of postinflammatory medium-depth peels, especially to treat pigmenta-
hyperpigmentation. Always question about his- tion disorders and early facial rhytides (Lee et al.
tory of facial surgery, prior resurfacing procedure, 2002).
Trichloroacetic Acid Peel 55
Table 6 Efficacy TCA treatment grants a keratolytic action altering the epidermal
Excellent to good response barrier prior to TCA application, inducing a better
Actinic keratoses uniform and rapid uptake (Figs. 4, 5, and 6) (Tung
Superficial melasma and Rubin 2011).
Superficial hyperpigmentation
Ephelides In preparation for this association, the patient
Lentigines should be positioned with the head elevated at 30
Depressed scars (CROSS technique) and vigorous scrub of the area with acetone or
Variable response alcohol is applied for 2 min. Pay attention to
Seborrheic keratoses sebaceous regions such as glabella, hairline, tem-
Hypertrophic keratoses
Mixed melasma ples, nose, and upper lip. This action leads to
Mixed hyperpigmentation greater penetration of agents and better uniformity
Poor response of procedure. Patient must be instructed to keep
Thick seborrheic keratoses their eyes closed during the procedure (if the peel-
Deep melasma
ing will be applied on face). In case of hypertro-
Deep hyperpigmentation
phic actinic keratosis, curettage may be performed
before procedure to induce better peel absorption.
400 mg three times daily, famciclovir 250 mg The Jessner’s solution can be applied with
twice daily or valacyclovir 500 mg twice daily gauze pads folded in four or large cotton swabs.
beginning in the procedure day during at least One or two coats of this solution are applied
10–14 days (Gadelha and Costa 2009; Bolognia producing erythema and speckled white frost,
et al. 2012). however, lighter than the TCA (applied later). It
Using topic tretinoin on a nightly regime prior is preferable to begin the procedure with the fore-
to the procedure could lead to faster head, followed by the malar regions, nose, and
re-epithelialization as retinoids increase epider- chin. After applying Jessner solution, it is
mal proliferation. Tretinoin increases the depth recommended to wait 2 min prior to TCA appli-
of a chemical peel by decreasing the thickness of cation. Some authors apply a topical anesthetic
the stratum corneum. A retinoid, typically tretin- (i.e., EMLA-lidocaine 2.5% and prilocaine
oin 0.02–0.1% cream, is prescribed as soon as 2.5%) to the area prior to TCA, making the pro-
possible. Its effect is observed after just 14 days cedure more tolerable. Next step is to apply TCA
of daily use. Beware of retinoid dermatitis, which 35% in the same manner described, taking care
should delay the procedure to prevent prolonged not to use gauze soaked with the product. The
postoperative erythema. After the procedure, you eyelids are left for last, respecting 3–4 mm away
must wait the complete re-epithelialization to from the eyelid edges. To the eyelids, use cotton
restart using retinoids. Exfoliants such as glycolic swabs. Possible tears must be dried during the
acid or lactic acid result in decreased corneocyte procedure to prevent eye damage by capillary
adhesion and stimulate epidermal growth by attraction. Furthermore, tears run through face
disrupting the corneum stratum (Lupi and Cunha diluting agent causing a strip of skin with more
2011; Gadelha and Costa 2009; Khunger 2008). superficial exfoliation than planned. Tears with
the product can get to the neck, bringing acid for
an unprogrammed area. At this stage, patient will
Jessner’s Solution and 35% TCA feel low- to moderate-intensity pain.
(Monheit Combination) After application, contiguous white frosting
begins to appear within 30 s and matures over
The most popular combination for medium-depth 2–3 min. At this time, the frosting level (Table 7)
peels is the Jessner’s solution plus TCA 35% peel. should be evaluated having in mind that the desired
It uses Jessner’s solution (14 g resorcinol, 14 g frosting level for medium-depth peelings is the level
salicylic acid, 14 g 85% lactic acid, with ethanol II to III. Have in mind that areas with higher ten-
added to create a total volume of 100 ml) which dency to form scars, such as the zygomatic arch and
58 P.S. Damasceno et al.
bony prominences of the jaw line and chin, should careful with the reapplication, reserving them for the
not receive frosting level higher than II. Few incomplete areas. When necessary, you must wait
minutes later, the frost is clear, as well as discomfort 3–4 min to identify the frosting peak areas avoiding
due to the important burning sensation, which can extra-coats in these areas to prevent greater depth
be alleviated with the use of fans. You should be and consequently unexpected responses.
Trichloroacetic Acid Peel 59
Infections
Medium-Depth Peels Complications
(See chapter ▶ “Managing Chemical Bacterial, viral, or fungal infections may arise and
Peels Complications”) should be readily handled based on etiology. Bac-
terial infection is rare in TCA and phenol peels
Complications from chemical peels include pro- since these peels are bactericidal. An important
longed erythema and pruritus, pigmentation risk factor for bacterial infection is prolonged
changes such as postinflammatory hyper- application of biosynthetic membranes or thick
pigmentation, delayed wound healing, infection, occlusive ointments and poor wound care. It is
textural changes to the skin, induction of acne or important to get a swab for culture and sensitivity
milia, bruises, and scarring (Levy and Emer whenever is possible. Pay attention to immuno-
2012). compromised patients and diabetics as they are
candidates for candidal infection. Superficial pus-
tules can be seen in candidal infections. Also
Pigmentary Disorders consider recent intake of antibiotics and pro-
longed topical steroid use as a pre-disposing fac-
Hyperpigmentation is more common in skin types tor. Herpes simplex infection is characterized by
IV–VI (Table 4). May arise during the first 5 days or reactivation of herpes simplex on face and perioral
until 2 months after the procedure. These complica- area presenting as sudden appearance of grouped
tions are best handled with sunscreens, hydroqui- erosions associated with pain (Brody 2001).
none, kojic acid, and azelaic acid. In resistant cases,
another exfoliation can be performed (TCA 10%,
Jessner’s solution or glycolic acid 50% are the best Scars
choices). Hyperpigmentation is common but, in
general, are transitory and respond well to Scars may occur in patients with a history of
established treatments. Hypopigmentation usually keloid, who underwent peeling when using oral
happens when the procedure gets deeper than isotretinoin in the first 6 months of use. They can
planned and is difficult to treat. also occur in case of secondary infections, trauma,
Trichloroacetic Acid Peel 61
or if the scales are taken off by the patient in the Brody HJ. Complications of chemical resurfacing.
postpeeling period. The risk of hypertrophic scar- Dermatol Clin. 2001;3:427–37.
Brody HJ, Monheit GD, Resnik SS, Alt TH. A history of
ring from medium-depth peels is rare. If it occurs, chemical peeling. Dermatol Surg. 2000;26:405–9.
it is most commonly seen along the mandibular Dingman DL, Hartog J, Siemionow M. Simultaneous
region and in the perioral regions. TCA is more deep-plane face lift and trichloroacetic acid peel. Plast
caustic than phenol and may be more likely to Reconstr Surg. 1994;93:86–93. ; discussion 4–5.
Fischer TC, Perosino E, Poli F, Viera MS, Dreno B, Cos-
produce scarring (Nikalji et al. 2012). The treat- metic Dermatology European Expert Group. Chemical
ment should be initiated as soon as possible with peels in aesthetic dermatology: an update 2009. J Eur
use of a potent topical corticosteroids or Acad Dermatol Venereol. 2010;24(3):281–92.
intralesional corticosteroid. Gadelha AR, Costa IMC. Cirurgia dermatológica em
consultório. 2nd ed. São Paulo: Atheneu; 2009; 71–75.
Glogau RG. Aesthetic and anatomic analysis of the aging
skin. Semin Cutan Med Surg. 1996;15(3):134–8.
Other Complications Handog EB, Datuin MS, Singzon IA. Chemical peels for
acne and acne scars in asians: evidence based review. J
Cutan Aesthet Surg. 2012;5(4):239–46.
Pruritus, delayed wound healing, bruises, acneiform Hession MT, Graber EM. Atrophic acne scarring. A review
rash, and allergic reactions to products used are of treatment options. J Clin Aesthet Dermatol. 2015;
some other complications. Agents as trichloroacetic 8(1):50–8.
Khunger N. Standard guidelines of care for chemical peels.
acid (TCA) or glycolic acid have no report of gen- Indian J Dermatol Venereol Leprol. 2008;74 Suppl
uine allergic reactions; however, the TCA can lead S1:5–12.
to cholinergic urticaria (Tung and Rubin 2011). Landau M. Chemical peels. Clin Dermatol.
2008;26:200–8.
Lawrence N, Cox SE, Cockerell CJ, et al. A comparison of
the efficacy and safety of Jessner’s solution and 35%
Take Home Messages trichloroacetic acid versus 5% fluoracil in the treatment
of widespread facial actinic keratosis. Arch Dermatol.
• It is noteworthy that one medium-depth peel 1995;131:176–81.
Lee JB, Chung WG, Kwahck H, Lee KH. Focal treatment
session can result in a significant improvement of acne scars with trichloroacetic acid: chemical recon-
in moderate photoaging hardly achieved in a struction of skin scars method. Dermatol Surg.
single session of newer technologies. 2002;28:1017–21.
• Never forget to photograph patient’s skin areas Levy LL, Emer JJ. Complications of minimally invasive
cosmetic procedures: prevention and management. J
to be submitted to the procedure before the Cutan Aesthet Surg. 2012;5(2):121–32.
chemical peel for future comparison. Lupi O, Cunha PR. Rotinas de diagóstico e tratamento da
• The most popular combination for medium-depth Sociedade Brasileira de Dermatologia. 2a edição. Rio
peels is the Jessner’s solution plus TCA 35% peel. de Janeiro: Editora GEN; 2011.
Monheit GD. Chemical peeling for pigmentary
• Applying compresses with cold saline 0.9% dyschromias. Cosmet Dermatol. 1995;8:10–5.
makes the procedure more comfortable and Monheit GF. Chemical peels. Skin Ther Lett. 2004;
provide great relief after the procedure. The 9(2):6–11.
scaling and re-epithelialization will be com- Monheit GD, Kayal JD. Chemical peeling. In: Nouri K,
Leal-Khouri, editors. Techniques of dermatologic sur-
plete within 7–10 days. Edema may last several gery. Elsevier; 2003. p. 233–44.
days with a peak in 48 h. Nikalji N, Godse K, Sakhiya J, Patil S, Nadkarni
• Collagen remodeling occurs for as long as N. Complications of medium depth and deep chemical
3–4 months after the procedure. peels. J Cutan Aesthet Surg. 2012;5(4):254–60.
Patel L, McGrouther D, Chakrabarty K. Evaluating evi-
dence for atrophic scarring treatment modalities. J Roy
Soc Med Open. 2014;5(9):1–13.
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Wang B. Evidence and considerations in the applica-
Bolognia JL, Jorizzo JL, Schaffer JV. Dermatology tion of chemical peels in skin disorders and aesthetic
3rd ed. Philadelphia: Elsevier Saunders; 2012. resurfacing. J Clin Aesthet Dermatol. 2010;3(7):32–43.
Chapter 154 Rubenstein R, Roenigk HH, Stegman SJ, Hanke
CW. Atypical keloids after dermabrasion of patients
62 P.S. Damasceno et al.
taking isotretinoin. J Am Acad Dermatol. Tosti A, Grimes PE, de Padova MP. Color Atlas of chem-
1986;15:280–5. ical peeling. Springer; 2006.
Rullan P, Karam AM. Chemical peels for darker skin types. Tung RC, Rubin MG. Procedures in cosmetic dermatology
Facial Plast Surg Clin North Am. 2010;18(1):111–31. series: chemical peels. 2nd.ed. 2011.
Salam A, Dadzie OE, Galadari H. Chemical peeling in ethnic Velasco MVR, Ribeiro ME, Bendin V, Okubo FR, Steiner
skin: an update. Br J Dermatol. 2013;169 Suppl 3:82–90. D. Facial skin rejuvenation by chemical peeling: focus
Savant SS. Superficial and medium depth chemical peel- on phenol peeling. An Bras Dermatol, Rio de Janeiro.
ing. In: Savant SS, editor. Text book of dermatosurgery 2004;79(1):91–9.
and cosmetology. 2nd ed. Mumbai: ASCAD-Mumbai, Wolfe SA. Chemical face peeling following therapeutic
India; 2005. p. 177–95. irradiation. Plast Reconstr Surg. 1982;69:859–62.
Small R. Aesthetic procedures in office practice. Am Fam
Physician. 2009;80(11):1231–7. 1238.
Combining Trichloroacetic Acid Peel
Abstract Contents
Chemical peelings are among the most wide- Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
spread aesthetic procedures used in derma- Trichloroacetic Acid (TCA) Peel . . . . . . . . . . . . . . . . . . . . 64
tology, since the past centuries. Their best TCA: Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
indications include active acne, rosacea, dy- TCA: Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
schromias, facial and extrafacial photoaging, Chemical Peels: Previous Preparation . . . . . . . . . . . . . . . . 65
Chemical Peels: Application Technique . . . . . . . . . . . . . . 66
and some other skin disorders. Successful out-
comes can be achieved with careful patient Photoaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
selection as well as appropriate use of specific TCA Superficial and Very Superficial Peels . . . . . . . 67
peeling agents. Trichloroacetic acid is consid-
TCA Medium Peels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
ered the most useful substance in chemical
peels for its versatility, accuracy of action on Combining TCA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
the skin, and absence of systemic toxicity. It CPs and Actinic Keratosis (AK) . . . . . . . . . . . . . . . . . . . . 69
can be used, as a caustic agent, for several Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
types of chemical peels and other procedures.
Take Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
In the present review, we summarize the his-
tory records about this procedure and the cur- References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
rent knowledge on trichloroacetic acid peels,
including indications, contraindications, the
skin conditioning, details of application, results, Introduction
and complications. The combination of trichlo-
roacetic acid peelings with other substances Chemical peels (CPs) have been prominently used
and procedures is also covered. in dermatological procedures since ancient times.
Improvements in skin quality and appearance
Keywords through exfoliation dating back to 1560 are de-
Chemical peels • Trichloroacetic acid • Photo- scribed in the Egyptian Ebers Papyrus. In the
aging • Dyschromias • Acne • Rosacea • Actin- 1882 book Therapéutique générale de la peau,
ic keratosis • 5FU • Dermabrasion written by Unna, dermatology is mentioned as a
lead specialty using chemical peels for therapeutic
purposes (Collins 1987).
B.V. Kadunc (*) Emerging from empirical experiences long
Pontifícia Universidade Católica de Campinas, São Paulo, explored by the laymen, these dermatological
SP, Brazil
e-mail: [email protected]
procedures have since become academic tech- reduce the risks associated with each substance
niques with ethical standards after their properties used alone.
have been confirmed by experimental, toxicolog-
ical, and histological studies.
CPs are commonly indicated for the treatment
of acne vulgaris, dyschromia, rosacea, and photo- Trichloroacetic Acid (TCA) Peel
aging at different severity levels of presentation.
The indication of this kind of treatment must TCA: Literature Review
always be based on etiopathogenic criteria and
anatomopathological correlations. The first major study on the application of TCA
According to the depth of penetration into the (see chapter ▶ “Trichloroacetic Acid Peel,” Vol. 2)
skin, CPs are classified as very superficial, super- in human skin was published by Monash in
ficial, medium, and deep. Very superficial peels (1945). He locally applied TCA for the treatment
penetrate the stratum corneum and the granular of xanthelasma palpebrarum, flat warts, and
layer; superficial peels, also known as epidermal molluscum contagiosum. He also treated pityri-
peels, can affect the dermoepidermal interface and asis versicolor, chronic eczema, and skin lesions
penetrate the papillary dermis up to 0.45 mm; caused by lupus erythematous using this sub-
medium peels reach the superior reticular dermis stance. TCA CPs were applied all over the face
up to 0.6 mm; and deep peels penetrate the in cases of melasma and acne scars. He used
medium reticular dermis and can reach 0.8 mm, TCA water solutions diluted between 15% and
which is the upper limit of penetration to prevent 50% because he previously observed that higher
scarring (Rubin 1995). concentrations led to the development of keloid
Resorcinol, salicylic acid, trichloroacetic acid lesions.
(TCA), and phenol are among the most common Between 1960 and 1962, Ayres (1960, 1962), a
substances found in CPs along with the more dermatologist from Los Angeles, published two arti-
recently introduced alpha hydroxyacids, pyruvic cles on TCA. He reported that TCA is extremely
acid (alphaketo acid), and retinoic acid. Each of potent at its maximal concentrations and has a caus-
these substances is associated with a different mech- tic action much stronger than that of phenol but
anism of action: keratolysis, keratocoagulation, and established that it could be used safely at 25% or
epidermolysis. 50% dilutions. He also tested the substance in the
TCA stands out for its safety and versatility. urine of his patients and concluded that there was no
At different concentrations (between 15% and systemic absorption. In his histopathological stud-
45%), volumes, and degrees of friction during ies, he was the first to notice the importance of the
application, very superficial, superficial, and evaluation of necrosis and tissue repair induced by a
medium peels can be obtained (Collins 1989). chemical substance on the skin. The thickness of
It has been used alone or in combination with other necrosis during acute phase and the new collagen
substances, as well as associated with other layer formed in the dermis were measured 3 weeks
procedures. after the exfoliation, and he noticed that those values
It has been reported that 50% TCA, if were similar.
occluded with tape, can yield deep CPs. How- In 1976, a study by Resnik et al. (1976) eval-
ever, in concentrations higher than 45%, it can uated CPs: superficial, using 20% TCA; medium,
cause necrosis through deeper layers of the skin, using 35% TCA; and deep, using 50% or 70%
leading to the development of dyschromic and TCA. The latter was considered a safer alterna-
hypertrophic scars (Resnik 1984; Ayres 1960; tive to phenol, which could be contraindicated
Resnik et al. 1976; Stagnone et al. 1987). For because of its systemic toxicity. However, reports
this reason, 35% TCA is used for combined of hypertrophic and atrophic scarring caused by
medium CPs as it is well established that the com- TCA at a concentration higher than 45% became
bination of different substances or procedures can frequent (Lober 1987).
Combining Trichloroacetic Acid Peel 65
A histological study on pig skin concluded that vehicle for its use. Several different methods can
the depth of aggression to the skin caused by TCA be employed for the preparation of solutions from
is proportional to the concentration used, as crystals. To produce 30% TCA, for example, two
35–50% TCA penetrate 0.3/0.4 mm and 80% different methods for dilution are used: the
TCA penetrate 0.8/0.9 mm. They concluded that European method, weight/weight (30 g TCA crys-
the use of TCA at 50% or higher could cause tals +70 g water), and the standard pharmaceutical
scarring due to deep necrosis (Roenigk and (American) method, weight/volume (30 gTCA
Broadland 1993). crystals + water to bring the final volume of the
Thus, since 1980, the aim of specialists has solution to 100 mL).
been to deepen exfoliations with TCA in smaller Studies have shown that a weight/volume
concentrations, to obtain results comparable with method should be adopted, and the physician
phenols with lower risks. should inform the intended method to the phar-
To address this issue, studies emerged in liter- macist so that the responses can be compared and
ature on combined CPs that consist of the appli- reproduced (Brindestine and Dolezal 1994).
cation of other exfoliation procedures or substances For stability, the initial concentration is main-
prior to treatment with 35% TCA. In 1986, Brody tained after 23 weeks of storage in amber glass
and Hailey (1986) described this combination for bottles at ambient temperatures.
the first time, recommending superficial exfolia- According to several studies, there is no sys-
tions with solid carbon dioxide followed by the temic toxicity associated with the use of this sub-
immediate application of 35% TCA. According to stance on the skin (Ayres 1960; Resnik et al. 1976;
the authors, with this association, there was suffi- Stagnone et al. 1987).
cient epidermal renewal and a good dermal stim- TCA absorption correlates directly with the
ulus with a reduced risk of scarring. presence and intensity of erythema and frosting.
For the same purpose, Monheit (1989) de- These signs are very important and have almost
scribed a variation of this technique in 1989: he precise histological correspondence (Johnson
combined the Jessner’s solution, containing 14% et al. 1996). This advantage makes TCA applica-
resorcinol, salicylic acid, and lactic acid in ethanol tion easy and safe.
(also known as Combes formula), with 35% TCA, The visual features of TCA action on the skin
and reported the occurrence of keratolysis and comprise the following: level 0, absence of ery-
protein coagulation caused by each substance, thema and frosting; level 1, irregular light frosting
respectively. In 1994, Coleman also published a and mild erythema; level 2, mottled frosting with
similar technique for medium CPs that combined visible erythema; and level 3, continuous and in-
70% glycolic acid and 35% TCA (Coleman and tense solid frosting without erythema. The faster,
Futrell 1994). more solid, and uniform the bleaching, the greater
the depth achieved (Rubin 1995).
TCA: Features
Chemical Peels: Previous Preparation
Trichloroacetic acid (C2HCl3O2) is the prototype
of chemical substance for CPs. Its mechanism of One disadvantage in using TCA is its irregular
action is cutaneous necrosis through the coagula- absorption by the skin. It can be observed that
tion of intracellular proteins. It consists of deli- frosting is not always uniform and results in
quescent white crystals highly hygroscopic and is variable degrees of exfoliation. Therefore, con-
soluble in water, alcohol, and ether. TCA has very ditioning the skin with tretinoin to make the cu-
intense caustic power and is more potent than taneous surface more even is very important
phenol at maximum concentrations. because this procedure helps to make the absorp-
Alcoholic solutions of TCA do not cause good tion faster and more uniform and as consequence
skin penetration, and therefore water is the ideal more predictable.
66 B.V. Kadunc
Using tretinoin before the CP procedure also considered at the time of the application, so that
shortens the healing period as this substance can the exfoliation results in the desired therapeutic
stimulate epidermal proliferation and blood flow proposal without risk of scarring or unnecessary
to the tissue (Hevia et al. 1991). The standardized aggressions.
photoprotection measures should be adopted The use of topical or infiltrative anesthesia for
when using tretinoin as well as for patients under- superficial and middle CP is not common. It may
going CP procedures. be possible to use the trigeminal nerve blocks in
In preparing patients for CP, necessary mea- the mid-pupillary line for medium exfoliations,
sures are taken to prevent an outbreak of her- especially in more sensitive patients. Anxiolytics,
pes simplex, an acute complication frequently sedatives, and systemic analgesics may be admin-
reported. The use of antiviral drugs – acyclovir istered prior to the procedure to make the painful
(800 mg 8/8 h), valacyclovir, or famciclovir – effects bearable.
with a prophylactic effect is recommended, Cleansing the skin with neutral soap and water
starting 2 days before the procedure and pro- and degreasing it with ethyl alcohol, ether, or
longing it from 3 days to 2 weeks after, acetone is necessary for uniformity of the skin
depending on the depth of exfoliation. The surface, control of the intended absorption of the
deeper the exfoliation, especially in the perioral agent, and removal of sebum, cell debris, or a
region, the more intense the care should be, even certain portion of the stratum corneum. It should
in patients who did not mention previous out- be graded according to the tolerance and sensi-
breaks (Perkins and Sklarew 1996). tivity of the skin, the substance in use, and the
planned depth of the CP.
The chosen caustic substances are then ap-
Chemical Peels: Application Technique plied. The mode of application – gauze or
cotton-tipped applicators – can be elected by the
The basic materials required to perform a CP are specialist. The application is initiated on the fron-
simple and inexpensive and comprise deffating tal region, where the skin is less sensitive, more
material, peeling chemical agents, applicators, uniform, and shows a more predictable response
gauze, neutralizing substances, and a syringe compared to the rest of the face, followed by the
containing saline to be used in case of unintended zygomatic-malar region, upper lip, chin, nose,
eye contact with any of the substances. The and, finally, the eyelids. A new applicator must
modern air-cooled systems, which have become be used in each region, and undesirable absorption
popular with laser procedures, now replace the by excessive volume of caustic substance must
ventilators used for pain control during the appli- be avoided.
cation of CP. In the medium-depth CPs where Jessner’s so-
Before starting the procedure, a detailed exam- lution (see chapter ▶ “Jessner’s Peel,” Vol. 2) is
ination of the target skin is carried out, associating used, the application of 35% TCA starts imme-
it to the pathology in focus and to the degree of diately after only one pass of the first drug. It
previous preparation. is necessary to observe the dynamically interac-
The depth of absorption of the substance is a tive variables mentioned above, until solid
consequence of multiple factors, dubbed dynam- and uniform bleaching is obtained. There is no
ically interactive variables by Duffy (1998). need to wash or neutralize the skin after the
These include thickness and degree of oiliness of procedure.
the target skin, integrity of the skin barrier, pres- The painful sensation after the application of
ence and density of skin appendages, degree of TCA decreases as frosting occurs and may take
previous degreasing, drug concentration, rubbing, several minutes. Therefore, the speed of applica-
occlusion, and the number of coats (volume) of tion – with time interval or not between aesthetic
agents used. The latter is the most important fac- units – may vary according to the patient’s degree
tor. All these details must be simultaneously of discomfort.
Combining Trichloroacetic Acid Peel 67
In the cutaneous region of the upper lip, the indication is of high importance in the treatment
application must penetrate 2 or 3 mm in the vermil- of pregnant patients (see chapter “Cosmetic
ion to treat the local characteristics rhytids. The Approach during Pregnancy”) due to the absence
mandibular area must be exceeded by 1 cm and of percutaneous absorption of the drug avoiding
always deserves special attention because it is toxicity. Superficial peels can also be used in the
adjacent to the area with lower concentration of adjuvant treatment of melasma and frictional
skin appendages and great muscle mobility and melanosis since it causes a very superficial exfo-
prone to hypertrophic and keloid scars. Front and liation, optimizes the percutaneous absorption
back sides of earlobe should also be included. of topical bleaching agents, and reduces the risk
The eyelid area, because of its ultrafine epithe- of postinflammatory hyperpigmentation. (See
lium, is usually the last target, and its skin must chapter “Cosmetic Approach for Melasma,” Vol.
be stretched for further application, up to 2 mm 1; chapter “Q-Switched Lasers for Melasma, Dark
away from the ciliary border. At this moment, Circles Eyes, and Photorejuvenation,” Vol.
care should be taken to wipe out tears to avoid the 3; Rivas and Pandya 2013; Sacchidanand et al.
caustic from reaching the orbital cavity by capil- 2015.)
lary action. Superficial CPs with 15% or 20% TCA also
The cervical region should also be treated to results in excellent therapy for mild facial aging
avoid demarcation lines but always with super- corresponding to Rubin level 1.
ficial CPs. During the days following superficial CP, the
skin presents a dry appearance, but without signs
of inflammation, and should be maintained with
Photoaging gentle cleansing lotions, physical sunscreens, and
mild moisturizers.
CPs have a very precise indication in the treatment Very superficial or superficial CPs for the face
of this pathology, which is clinically characterized are indicated in a series of three to five procedures
by roughness and irregularity of the skin surface, with some weeks of interval, enough to recover
dyschromia, growth of benign and malignant neo- the skin barrier on the face.
plasias, telangiectasias that arise by the enlarge- A 15% or 20% TCA can be a good choice for
ment of small vessels and fine wrinkles due to extrafacial CPs, since there is no absorption and
the weakening of the tissues’ support and loss of consequent toxicity, even for wide-area applica-
elasticity. According to Rubin, levels 1, 2 and tions. It may be applied until erythema or grade
3 are based on the location of changes in the 2 mottled frosting occurs, always taking into
different skin layers (Rubin 1995). Thus, irregu- account that the action of the TCA is slow and
larities and roughness of the skin surface and the erythema and frosting should always be
epidermal dyschromias can be treated with su- expected within 5 min before the application of
perficial CPs. Actinic melanoses and keratoses a new layer. For extra-facial areas, the ideal range
require medium CPs for their resolution, while of sequential peels is monthly.
elastosis from photoaging and deeper pigmenta- Contraindications are very rare for superficial
tion require procedures that deepen in the dermis CPs with TCA, including active herpes simplex or
for its reversal. atopic dermatitis lesions or other skin diseases in
the area to be treated.
Very superficial CPs with 10% or 15% TCA have Photoaging of levels 2 and 3 with solar lentigines,
a preferential effect on the epidermis, being useful actinic wrinkles, and a considerable degree of
for the control of active acne and rosacea. This elastosis are the most precise indications for
68 B.V. Kadunc
medium-depth CPs, performed with 35% TCA then the use of physical sunscreens is started.
preceded by the application of solid carbon diox- Restoration of routine care occurs 2 weeks after
ide, Jessner’s solution, or glycolic acid. Jessner’s the procedure.
solution, as described by Monheit, is the most Direct sun exposure should be avoided for up
commonly used for combined medium CPs to 60 days. A casual solar exposition does not,
(Monheit 1989). They can also be indicated for however, compromise the good recovery.
the treatment of molluscum contagiosum in im- Complications including postinflammatory hy-
munodepressed patients and for prophylaxis of perpigmentation may occur in skins with II–IV
malignant lesions of xeroderma pigmentosum phototypes and can be treated with standard com-
(Nelson et al. 1995; Garrett et al. 1992). binations of tretinoin, hydroquinone, and medium-
Medium CP contraindications include active potency corticosteroids.
or recent herpes simplex, chronic radiodermatitis, Definitive hypochromic scars may arise in areas
and extensive scars due to the decrease or absence where there has been excessive deepening, with
of appendages for the perfect re-epithelialization formation of thick crusts and re-epithelialization
process. Emotional instability also contraindicates exceeding a period of 10 days. Hypochromias are
this type of procedure that can result in struggle preceded by localized persistent erythema and
to deal with the discomfort during the postopera- hypertrophic scars that can be treated with oc-
tive period. cluded high-potency corticosteroids or intrale-
Due to the depth that the medium CPs can sional infiltrations.
reach (papillary to superior reticular dermis), Medium exfoliations may be repeated, if nec-
their use should be restricted to the face, where essary, after a minimum period of 60 days. The
there are enough skin annexes to ensure proper durability of these clinical results extends on aver-
re-epithelialization. age by 18–24 months.
The recovery of medium CP requires 7–10 days.
There may be erythema, edema, and thick brown-
ish crusts. The patient does not require rest, but Combining TCA
activities requiring a direct contact with the public
should be avoided. With regard to CP, the term combination can
Nonhormonal anti-inflammatory drugs may be have several meanings: (Collins 1987) applica-
used systemically for 5 days. tion of two chemical caustics, one on top of the
Despite the prophylaxis, monitoring of the pos- other, in the same area, quoting Jessner’s peel-
sible presence of herpes simplex, which may ing as an example, (Rubin 1995) chemabrasion
appear late, sometimes after a week, and eventual that defines the use of a caustic followed by
bacterial infections, is important. dermabrasion in the same area, and (Collins
The face should be washed with nonirritating 1989) the use of different techniques in different
cleansing lotions and moistened with warm run- aesthetic units of the face.
ning water for 5 min, four to six times a day. After According to Gonzales-Ulhoa, the face can
washing, cutaneous lubrication with liquid petro- be divided into 11 aesthetic units – forehead,
latum or other nonirritating agents is recom- eyelids, ears, zygomatic-malar regions, nose,
mended. This care should start 4–6 h after the lip, chin, and neck – each possessing a charac-
procedure. The crusts, until they come off spon- teristic type of skin as color, texture, and thick-
taneously, should be kept clean and lubricated. ness, which consequently determines different
The patient should be instructed not to remove responses against chemical aggressions. In
them before their spontaneous release, thereby CPs, this concept is important because different
preventing delayed recovery and possible scars. levels of absorption, and therefore depth in each
After total detachment of the crusts, the patient aesthetic unit, are expected (Gonzalez-Ulhoa
is allowed to return to their daily activities, and et al. 1954).
Combining Trichloroacetic Acid Peel 69
On the eighth day, AKs curettage is done, and Fig. 4 Appearance 10 months later
small volumes of 88% phenol are applied in the
curetted areas. Infiltrative anesthesia can be used
if necessary. Phenol has an immediate and uni- Take Home Messages
form caustic effect, reinforcing the destruction
of the lesions. About 35% or 45% TCA is then 1. The indication CPs must always be based on
applied in the whole face (Figs. 1, 2, 3, and 4). etiopathogenic criteria and anatomopatholog-
This type of treatment can also be done on the ical correlations.
male scalp presenting multiple AKs (see chapter 2. The depth of absorption of a substance through
“Photodynamic Therapy,” Vol. 1; chapter “Photo- the skin is a consequence of the “dynamically
dynamic Therapy for Photodamaged Skin” in interactive variables” which include skin thick-
Vol. 3). ness, density of appendages, and degree of
oiliness, integrity of the skin barrier, drug con-
centration, and volume of agents, rubbing and
Conclusion occlusion. All these details must be simulta-
neously considered at the time of the application.
Despite recent advances in laser and other technol- 3. TCA stands out for its safety and versatility.
ogies used in dermatological procedures, CPs are It can be used alone for very superficial and
still widely used by dermatologists with low costs superficial peels, combined with other sub-
and great results (Fischer et al. 2010; Jackson stances for medium depth peels, and with other
2014). CPs can be combined with other proce- procedures at the same moment, without sys-
dures for higher effectiveness and at reduced risks. temic toxicity, even in large extra-facial areas.
Combining Trichloroacetic Acid Peel 71
4. TCA can be used on the skin only up to 45%. variable-depth peel: a study of clinical signs correlating
It has a very intense caustic power and is more with histological findings. Ann Plast Surg. 1996;36:
225–37.
potent than phenol at maximum concentration. Lawrence N, Cox SE, Cockerell CJ, Freeman RG. A com-
Its action is slow and the erythema and frosting parison of the efficacy and safety of Jessner’s solution
should always be expected within some min- and 35% trichloroacetic acid vs 5% fluorouracil in the
utes before the application of a new layer. treatment of widespread facial actinic keratoses. Arch
Dermatol. 1995;131:176–81.
5. The use of 5% 5-FU, twice daily during the Lober CW. Chemexfoliation – indications and cautions.
7 days preceding medium 35%–45% TCA J Am Acad Dermatol. 1987;17:109–12.
CPs, may be a therapeutic alternative for the Maldonado RR. Satured phenol as a local anesthetic
treatment of multiple actinic keratosis, includ- for manual dermabrasion. Dermatol Surg. 1997;23:
187–90.
ing the cancerization field. Meski APG. Chemabrasion for the treatment of perioral
wrinkles: clinical analysis and epidermal Langerhans
cells qualifi cátion. Surg Cosmet Dermatol. 2009;1:
74–9.
References Monash S. The uses of dilluted trichloroacetic acid in
dermatology. Urol Cutan Rev. 1945;49:934.
Monheit GD. The Jessner’s + TCA peel: a médium depth
Ayres S. Dermal changes following application of chem-
chemical peel. J Dermatol Surg Oncol. 1989;15:
ical cauterants to aging skin. Arch Dermatol. 1960;
953–63.
82:146.
Nelson BR, Fader DJ, Gillard M, Baker SR, Johnson
Ayres S. Superficial chemosurgery in treating aging skin.
TM. The role of dermabrasion and chemical peels in
Arch Dermatol. 1962;85:125–33.
the treatment of patients with xeroderma pigmentosum.
Brindestine JB, Dolezal JF. Standardizing chemical peel
J Am Acad Dermatol. 1995;32:472–8.
solution formulations to avoid mishaps. Great flutu-
Perkins SW, Sklarew EC. Prevention of facial herpetic
ations in actual concentrations of trichloroacetic acid.
infections after chemical peel and dermabrasion: new
J Dermatol Surg Oncol. 1994;20:813–6.
treatment strategies in the prophylaxis of patients
Brody HJ, Hailey CW. Medium-depth chemical peeling
undergoing procedures in the perioral área. Plast
of the skin: a variation of superficial chemosurgery.
Reconstr Surg. 1996;98:427–33.
J Dermatol Surg Oncol. 1986;12:268–75.
Resnik SS. Chemical peeling with trichloroacetic acid.
Coleman WP, Futrell J. The glycolic acid trichloroacetic
J Dermatol Surg Oncol. 1984;10:549–50.
acid peel. J Dermatol Surg Oncol. 1994;20:76–80.
Resnik SS, Lewis LA, Cohen B. Trichloroacetic acid peel-
Collins PS. The chemical peel. Clin Dermatol. 1987;5:
ing. Cutis. 1976;17:127–9.
57–74.
Rivas S, Pandya AG. Treatment of melasma with topical
Collins PS. Trichloroacetic acid peels revisted. J Dermatol
agents, peels and lasers: na evidence-based review. Am
Surg Oncol. 1989;15:933–40.
J Clin Dermatol. 2013;14:359–76.
Duffy DM. Alpha-hydroxi acids/trichloroacetic acids – risk
Roenigk RK, Broadland DG. Facial chemical peel with
benefit strategies. Dermatol Surg. 1998;24:181–9.
trichloroacetic acid, Chapter 47. In: Roenigk RK,
Fischer TC, Perosino E, Poli F, Viera MS, Dreno B. Chem-
Roenigk HHJ, editors. Surgical dermatology. Philadel-
ical peels in aesthetic dermatology: na update 2009.
phia: Mosby; 1993.
J Eur Acad Dermatol Venereol. 2010;24:281–92.
Rubin MG. Manual of chemical peels – superficial and
Garrett SJ, Robinson JK, Roenigk HH Jr. Trichloroacetic
médium-depth. Philadelphia: Lippincot; 1995.
acid peel of molluscum contagiosum in immunocom-
Sacchidanand S, Shetty AB, Leelavathy B. Efficacy of
promised patients. J Dermatol Surg Oncol. 1992;
15% trichloroacetic acid and 50% glycolic acid peel
18:855–8.
in the treatment of frictional melanosis: a comparative
Goldenberg G. Treatment considerations in actinic kerato-
study. J Cutan Aesthet Surg. 2015;8:37–41.
sis. J Eur Acad Dermatol Venereol. 2017;31:2–16.
Stagnone GJ, Orgel MG, Stagnone JJ. Cardiovascular effects
Gonzalez-Ulhoa M, Castillo A, Stevens E, et al. Prelimi-
of topical 50% trichloroacetic acid and Baker’s phenol
nary study of the total restoration of the facial skin.
solution. J Dermatol Surg Oncol. 1987;13: 999–1002.
Plast Reconstr Surg. 1954;13:151–61.
Ultrich M. Actinic Keratoses: non-invasive diagnosis for
Hevia O, Nemeth AJ, Taylor JR. Tretinoin accelerates
field cancerisation. Br J Dermatol. 2007;156:13–7.
healing after tricloroacetic peels. Arch Dermatol.
Vasconcelos BN, Figueira GM, Fonseca JCM,
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Mendonça LM, Fonseca CR. A splitface comparative
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modified trichloroacetic acid (TCA) controlled-
Phenol Solutions for Deep Peels
Introduction
C. Chisaki (*) • G. Horn • L.F. Noriega
Department of Dermatology, Hospital do Servidor Público Chemical peels consist of the application of exfo-
Municipal de São Paulo, São Paulo, SP, Brazil
liating agents on the skin in order to produce
e-mail: [email protected];
[email protected]; controlled damage of skin’s layers with therapeu-
[email protected]; [email protected] tic and cosmetic purposes. First, a new epidermis
# Springer International Publishing AG 2018 73
M.C.A. Issa, B. Tamura (eds.), Chemical and Physical Procedures, Clinical Approaches and Procedures in
Cosmetic Dermatology 2, https://doi.org/10.1007/978-3-319-16805-0_10
74 C. Chisaki et al.
is formed from the deeper portion of the cutaneous their careers, and they proclaimed the technique as
adnexa. Caution should be taken to leave these “the fountain of youth” (Hetter 2000a). A medical
adnexa unharmed during chemical peels; there- article dated 1917, by Montgomery, described an
fore, the maximum safe limit of exfoliation is up aesthetician that used occlusive phenol in
to the middle reticular dermis. Finally, during the New York (Hetter 2000a).
wound healing process, regeneration and new col- Over time, physicians would pay or permute
lagen production occur. information on these formulas, and in 1927, a
Phenol-based formulas are traditionally used surgeon from Los Angeles – H. O. Bames –
for deep peels, reaching the middle reticular der- described in details the occluded phenol peeling
mis. In recent literature, phenol-based deep peels technique. He wrote about the importance of
are found under the name of “phenol-croton oil applying it by areas and with time interval
peel” or “croton oil peel,” because of the croton between areas during procedure, which was not
oil’s role in increasing the depth of the peel. performed by most aestheticians. He also reported
Phenol peel remains the gold standard of that they did not do it on the neck (Bames 1927).
chemical peeling, as no other agent rejuvenates In 1959, Adolph Brown, from Los Angeles, pat-
as much as phenol. It is also a standard of com- ented a formula with phenol and croton oil (Hetter
parison for other rejuvenation methods such as 2000b). In 1960, he published in the British Jour-
laser and dermabrasion. nal of Plastic Surgery the first detailed study of
In addition to wrinkle treatment, it also pro- phenol formulas, histology, and toxicity after
duces a “lifting effect” due to a major skin retrac- Bames’ study (Brown et al. 1960). In that paper,
tion, leading to a more natural expression. It he outlined some of the incorrect dogmas that
should be highlighted, however, that it is inappro- persisted for many years, such as (1) phenol is
priate to compare phenol peeling and its indica- the active ingredient, (2) phenol penetrates more
tions with the effects of a surgical lifting. at lower concentrations, and (3) the addition of an
Phenol peeling corrects pigmentary and actinic agent that reduces the superficial tension increases
changes with the additional advantage that it penetration (Hetter 2000b, c). An example of an
diminishes the appearance of photoaged precan- agent that reduces the superficial tension is
cerous and cancerous skin lesions (Figs. 1 and 2). Septisol ® (liquid soap). Still in 1959, the plastic
Due to its toxicity, phenol should be carefully surgeon Clyde Litton obtained a formula from an
applied, following the recommended technique aesthetician and presented, in 1961, in the Plastic
and the contraindications. Patients should be Surgery Annual Meeting in New Orleans, the
monitored for emergency assistance in case of 2-year follow-up of 50 patients (Hetter 2000a, b).
any systemic effect. But the modern era of phenol peeling began when
For this outstanding method of rejuvenation, Thomas Baker obtained data from formulas held
there are numerous formulas; in this chapter, we by three aestheticians and developed a modified
will focus on deep chemical peeling with Baker’s solution of phenol with croton oil, Septisol®, and
formula (Table 1). water (Table 1) and published it in 1962 in Plastic
and Reconstructive Surgery (Baker 1962).
Although this formula is extremely strong, it
History has been the most commonly used and studied
during all these years, probably because it is sim-
Phenol peeling and its secret formulas were held ple and it was the first formula fully published in a
by aestheticians up to the early 1960s. Lay peelers journal of great circulation among plastic
are reported to be using formulas with phenol and surgeons.
croton oil in Hollywood since the early 1920s. After that, among numerous papers, those by
They were famous for helping celebrities to keep Stegman in 1980 and 1982 (Stegman 1980, 1982)
Phenol Solutions for Deep Peels 75
brought a more controlled and scientific under- The series of articles by Hetter in 2000 (2000a,
standing of peelings. He concluded that some fac- b, c, d) reported a relevant role of croton oil in
tors may enhance the skin injury of Baker’s phenol peeling. Varying its concentration a pro-
formula: 1) increase in phenol concentration; portional modulation of the peeling’s penetration
2) greater number of layers of Baker’s emulsion; is obtained. Phenol concentrations were also stud-
3) and occlusion, offering greater penetration. ied. A more intense tissue reaction was observed
Also, by removing croton oil, less injury was with higher concentrations of phenol, therefore
obtained from Baker’s formula. In 1996, histolog- challenging Brown’s dogmas. The surfactant’s
ical studies by Moy et al. (1996) reinforced (soap or detergent) role is to decrease the superfi-
Stegman’s findings, stating that the more intense cial tension, emulsifying more easily the oil and
and deeper reaction of Baker’s peeling is due to the phenol/water mixture, allowing a more even
combination of the ingredients. application.
76 C. Chisaki et al.
face (Truppman 1979), once phenol is directly toxic introduced in Europe in 1630 for that purpose, and
to the myocardium (Stagnone et al. 1987). Another it may even lead to death. On the skin, it may
rationale for cardiotoxicity is the release of adrena- cause vesiculation, necrosis, and severe burning
line due to the pain, transmitted from the trigeminal (Hetter 2000c).
nerve to the cardiac vagus nerve or from the cerebral
cortex directly to the sinoatrial node (Stagnone and
Stagnone 1982). The application at each cosmetic Deep Peeling Modalities
unit followed by a pause seems to reduce the risk of
cardiac toxicity. Occlusion
Diuresis promotes the excretion of phenol and
reduces arrhythmias. The alkalinization of urine Deep peeling may be occluded or not (Figs. 3, 4,
may also contribute by increasing the renal tubu- and 5). Occlusion acts as a mechanic barrier
lar excretion (Matarasso 1994). against phenol evaporation and increases skin
If a mild supraventricular arrhythmia occurs, maceration, promoting higher absorption and
application should be discontinued until the sinus deeper penetration. Occlusion may be performed
rhythm returns to normal. It is advisable to wait using strips of impermeable adhesive tape, mea-
15 min after the normalization of the rhythm suring 1–1.5 cm wide, overlapped in two to three
before resuming the procedure. If a severe supra- layers, and placed directly on the skin for 48 hours
ventricular or a ventricular arrhythmia occurs, (Figs. 6 and 7). However, patients feel a little
phenol should be replaced with another exfoliat- discomfortable, and many will prefer occlusion
ing agent (Brody 1997a). with petrolatum (Stuzin 1989) or silicone gel,
It is useful to understand that the efficacy of a immediately applied on the phenol-treated skin.
chemical agent can be modified by associations with But be aware that phenol may be carried together
other agents that modulate its potency and toxicity. with the petrolatum or silicone gel into the eyes
It is tried to “tame” phenol, as well as tri- due to the capillarity through the wrinkles. So in
chloroacetic acid, by associating them with addi- our practice, we do not recommend the applica-
tives, emulsifiers, saponins, and surfactants that tion of petrolatum or silicone nearby the eyelids
increase the efficacy and safety of these exfoliat- during or just after the procedure.
ing agents. Thus, for example, knowing that the Among the various post-peeling occlusion
low molecular weight of phenol (94,11) and its techniques, thymol iodide powder or bismuth sub-
polarity allow it to rapidly pass through the cell gallate powder may be used after the removal of
and endothelial membranes and that it is more the adhesive plaster. They form a second mask
rapidly absorbed in an aqueous solution than in that stays in place for 6–9 days (Figs. 8, 9, and 10).
an oily solution; it is found in many modified This mask is reported to avoid mobilization and to
formulations, glycerin, sesame, and/or olive oils, improve wound healing which results in a more
which solubilize phenol and reduce its systemic even peeling. With this second mask, wound care
absorption and aggressiveness (Deprez 1998). is not needed, with the benefit that the skin will be
fully reepithelized after mask removal. Patient
support is advisable, since they may feel a little
Croton Oil depressed with the use of this mask for several
days.
Croton oil is extracted from the seed of Croton
tiglium, a native shrub from India and Ceylon. It is
composed of 7% glycerin, 37% oleic acid, 19% Baker’s Formula
linoleic acid, 7.5% myristic acid, 1.5% arachidic
acid, and less than 1% stearic, palmitic, lauric, The old Baker’s formula, published in 1962, is
valeric, tiglic, butyric, acetic, and formic acids. still up-to-date and is the most commonly used
Croton oil was used as a purgative in India and (Table 1).
78 C. Chisaki et al.
Fig. 4 The same patient of Fig. 3. (a) 24 hours post- fibrin, skin scaling and detachment. (c) 48 h post-peeling.
peeling. Severe edema and darker coloration of the face. Cleaner face after removal of secretion, fibrins and
(b) 48 h post-peeling, before washing the face. Edema, detached skin
Baker-Gordon’s formula is prepared by drawing Hetter (2000c) shows that peelings with increasing
up 3 ml of phenol into a syringe and depositing it into concentrations of phenol at 18%, 35%, and 50%
a recipient. Next, 2 ml of water, eight drops of liquid with Septisol® soap and without croton oil, respec-
soap, and finally, three drops of croton oil are added. tively, cause an increased reaction of edema and
This dilutes the concentration of phenol to about erythema without significant dermal injury, while
50%. It is an immiscible emulsion and should be 88% phenol without Septisol® causes injury to the
well stirred at each application (Figs. 11, 12, and 13). dermis. The addition of croton oil to 50% phenol,
Phenol Solutions for Deep Peels 79
Fig. 5 The same patient of Figs. 3 and 4. (a) 4 days post- fibrin areas. (b) 12 days post-peeling, skin reepithelized,
peeling, using petrolatum ointment, already without but still with erythema. (c) 2 months post-peeling showing
necrotic epithelium, but with diffuse erythema and some improvement of flaccidity and wrinkles
Fig. 6 67-year-old patient. (a) Pre-phenol peeling with of a compression dressing (not routinely used). (c) 24 h
occluded Baker’s formula. (b) Immediately after the adhe- post-peeling with more eyelid edema
sive tape mask. Note the eyelid edema initiating and the use
however, causes remarkable increase of peeling Hetter associated with a 16–50% phenol solution
depth in the dermis. associated with croton oil between 0.25% to 2.78%
The same author (Hetter) reports in a personal used healing time to judge peeling depth and con-
communication that 33% phenol may produce a cluded that peel depth increases with the concentra-
mild medium-depth, deep medium-depth, or deep tion of both agents (Hetter 2000d). Croton oil
peeling when the croton oil concentration varies of concentration in Baker’s formula is 2.08% and
0.35%, 0.7%, or 1.1%, respectively (Stone 1998). seems to play an important role on the peeling depth.
80 C. Chisaki et al.
Fig. 7 The same patient of Fig. 6. (a) 48 hours post- humid skin with secretion, fibrin, and necrotic epithelium.
peeling, before adhesive tape removal. Improvement of (c) 3 days post-peeling, face with erythema and edema,
eyelid edema. (b) 48 hours post-peeling. Adhesive plaster scale, and fibrin
removal. Note the epithelium adhered to the adhesive tape,
Fig. 8 The same patient of Figs. 6 and 7. (a) 6 days post- with erythema, edema, and dry skin. (c) 15 days post-
peeling, face more reepithelized with erythema, dry skin, peeling. Note the irregularity of application on the left
and scaling. (b) 10 days post-peeling, face reepithelized side of the eyelid and lip border
Other studies seem to confirm histologically in the application, friction, the number of coats on
Hetter’s statements about the role of phenol and the same area, exposure time to the substance,
croton oil concentration (Moy et al. 1996; Stone volume applied, vehicle used, and patient skin
1998). Nevertheless other factors may influence type. When using Baker’s formula, which is
depth such as occlusion method, pressure exerted quite concentrated, it is important to take these
Phenol Solutions for Deep Peels 81
Fig. 13 Homogenized
emulsion after well stirring
Fig. 14 Pre-phenol
peeling, thin wrinkles in a
mosaic pattern. (a) Frontal
view. (b) Right frontal-
lateral view
However, topically, phenol in high concentra- uniform all over the face, may sometimes draw more
tions causes an extremely quick denaturation and attention than in types III and IV. In the latter
coagulation of keratin (frosting), which is patients, hyperpigmentation is the rule but often
irreversible. reversible. It is not advisable to perform a deep
phenol peel in skin types V and VI, due to the high
risk of post-inflammatory hyperpigmentation, irreg-
ular hypopigmentation with vitiligo-like appear-
Indications
ance, and keloid.
Phenol peeling is indicated for rejuvenation of
skins with more severe, thin, and mosaic wrin-
kles in order to correct pigmentary changes, Contraindications
actinic damage, and irradiated skin damage if
the adnexa are present for reepithelization Contraindications to phenol peeling include car-
(Figs. 14, 15, and 16). diac, renal, or hepatic diseases and skin photo-
Traditionally, it is indicated for patients with types V and VI.
Fitzpatrick skin types I to III, once phenol – as Relative contraindications include herpes
well as other deep exfoliation procedures – may simplex infection, hormone therapy with estro-
cause hypopigmentation. Light skins also have gen or progesterone, continuous or prolonged
lower possibility of visible contrast between the exposure to ultraviolet light that may lead to
treated and untreated skin. However, localized peel- post-peeling hyperpigmentation, recent use of
ings in types I and II patients may produce contrast isotretinoin that may lead to healing changes,
between the thicker, elastotic, yellowish photo- psychological problems or unrealistic expecta-
damaged skin and the treated thinner rejuvenated tions, previous ionizing radiation therapy, skin
area without spots. When this occurs, the only phototypes III and IV, predisposition to
option is to treat the entire face (Stuzin 1998). keloids, anatomic location with few adnexa,
Some authors also state that, in types I and II with and recent facial surgery with undermining or
naturally less pigment, the hypochromia, even when flaps.
84 C. Chisaki et al.
previous use of topical agents, such as retinoid fasting, with an intravenous access, cardiac
and other acids, check if there is no skin irritation monitoring, and pulse oximeter installed
that could lead to an undue peel deepening. (Fig. 17).
Prophylaxis for herpes simplex infection is
mandatory, with or without previous history. Acy-
clovir 400 mg three times daily, valacyclovir Local Care and Edge Delimitation
500 mg twice daily, or famciclovir 250 mg twice of the Peeling
daily is recommended, initiated 1 or 2 days prior
to the procedure and maintaining it for Instruct the patient to perform facial hygiene, usu-
10–14 days. Note that cases of herpes infection ally in the morning of the procedure, and to avoid
may occur even after full reepithelization (Perkins the use of makeups (Brody 1997a).
and Sklarew 1996). Draw a demarcation line just below the man-
Bacterial and mycotic infections are rare and, dible (peel border), preferably with the patient in
in general, do not require prophylaxis on phenol sitting position. Below this line, phenol must not
peeling. be applied, and this is critical to minimize the risk
of permanent color change, visible as a contrast
between the face and the cervical region (Brody
Technique (Full-Face Phenol Peel) 1997a).
Just before the beginning of the peeling, the
General Care and Safety skin should be evenly degreased with acetone or
alcohol, following the cosmetic units. This step is
Phenol peelings should be performed with sup- crucial for uniformity of application.
portive equipment and staff, cardiac monitoring, Knowing the risk of systemic absorption and
and potent analgesia, preferably in a hospital for phenol’s hepatic and renal metabolism, patient
greater patient and medical staff safety. Use a hydration is important and may reduce the risk
ventilated room (to dissipate phenol) and always of toxicity (especially cardiac arrhythmias)
have cardiopulmonary resuscitation (CPR) (Brody 1997b).
equipment and emergency medications available Overall, we use lactated Ringer’s solution,
and easily accessible. The patient should be because it also alkalinizes the urine and contribute
86 C. Chisaki et al.
Table 3 Summary of the main characteristics and dosages of fentanyl and midazolam (Abeles et al. 2000; Otley and
Nguyen 2000; American Society of Anesthesiologists 2002; Di Santis et al. 2014)
Onset
Preparation Dilution/[final of Duration
Medications (ampoules) concentration] Dosage Effects action of effect
Fentanyl 50 μg/mL 2 mL in 8 mL of 1–2 μg/Kga (in cases of Analgesia 2–3 min 30 min to
citrate distilled water or intense pain, a dose of up and 6 hc
0.9% NaCl/ to 100 μg/Kg may be sedation
[10 μg/mL] reached)
Midazolam 5 mg/mL 3 mL in 12 mL of 0.05–0.075 μg/Kg Sedation, Up to 1–2 h
distilled water or intravenouslyb amnesia, 2 min
0.9% NaCl/ and
[15 mg/mL] anxiolysis
a
It can begin with an infusion of 2 mL of the solution, evaluating the need for complementary doses during procedure
b
In general, it can begin with 2 mL of the solution. Wait for about 2 min to evaluate the effect from the administered dose.
During procedure, new doses can be administered according to the need, always avoiding excessive sedation. Patients in
use of other anxiolytics require low doses and chronic alcoholics need higher doses
c
The duration of effect varies according to the dose, with the dose of 100 μg generally lasting 30 min
to reduce the risk of toxicity (Beeson 1987; This anesthetic modality causes a depressed
Matarasso 1994), but 0.9% NaCl solution may state of consciousness, keeping the protective
be an alternative (Table 2). reflexes, independent and pervious airway, and
A 250–500 mL infusion of 5% dextrose during response to physical and verbal stimuli (Otley
the procedure may be associated, in order to avoid and Nguyen 2000; Di Santis et al. 2014). In addi-
hypoglycemia and prevent nausea (Asken 1989). tion, it shows analgesic and anxiolytic action and
retrograde amnesia. The most common associa-
tion with this goal is fentanyl with midazolam.
Sedation and Analgesia Table 3 summarizes the main characteristics and
dosages of these medications.
Pain with phenol peeling is typically intense, thus Another advantage of these two medications is
drug combinations are needed for significant anal- the possibility of reversion of their effects by using
gesia and patient’s comfort. Adequate analgesia antagonists. Therefore, naloxone may be used in
allows higher safety, replicability of the proce- cases of respiratory depression related to excessive
dure, and avoids prolonged and repeated interrup- doses of fentanyl, while in the case of excessive
tions (due to patient’s discomfort and/or dose of midazolam, flumazenil may be used
agitation). Consequently, it generates more assur- (American Society of Anesthesiologists 2002).
ance to the medical staff (Otley and Nguyen 2000; Other combinations of sedation with analgesia
Di Santis et al. 2014). may be used according to the physician’s experi-
Conscious sedation is an excellent option; ence or, preferably, with assistance of an anesthe-
however, it requires expertise and practice in the siologist. Among these, we could mention
use of the medications involved, as well as inpa- propofol (sedative and anxiolytic effect, although
tient procedure. It has been more commonly used without analgesia), ketamine (sedative and anal-
in dermatological procedures, in virtue of its gesic), lorazepam (anxiolytic and sedative),
safety and efficacy. and meperidine (analgesic and sedative) (Abeles
Phenol Solutions for Deep Peels 87
et al. 2000; Di Santis et al. 2014; Otley and Divide the face in aesthetical units; the fore-
Nguyen 2000). head can be subdivided in two areas, if desirable.
We often use an intramuscular dose of cortico- The agent should be applied using cotton
steroid, in the end of the procedure (in case there swabs respecting the aesthetical unit. It is impor-
are no contraindications), for example, 1–2 mL of tant to wait about 15–20 min between units, in
injectable 5 mg betamethasone dipropionate solu- order to reduce phenol toxicity.
tion + 2 mg betamethasone disodium phosphate. The application should advance into the scalp
In addition to the analgesic effect, it acts on the border, 1–2 mm inward the vermilion border of
reduction of the edema. The use of corticosteroids the lips, to correct perioral wrinkles, where the
after deep peelings is controversial, and some complaint that “the lipstick runs out” is frequent.
authors mention that this medication may delay Do not forget the anterior and posterior areas of
local healing (Wicke et al. 2000). the earlobes, which improves its flaccid aspect
In case an anesthesia team is not available, after a skin retration (Fig. 19).
there is the possibility of using analgesic, anti- On the eyelids, excessive emulsion in the cot-
inflammatory, and anxiolytic medications with ton applicator should be cleaned using gauze
lower risk of complications (particularly, respira- before application. It is important to previously
tory depression). However, these have lower verify if there is subclinical ectropion or previous
potency for controlling patients’ anxiety and dis- blepharoplasties that could result in ectropion due
comfort (pain). Diazepam (Dienpax ®) 5–10 mg or to retraction of the eyelids.
oral bromazepam (Lexotan ®) 3–6 mg may be The application on the upper eyelid should be
used as anxiolytics. For initial analgesia, 1 g acet- only performed above the superior border of the
aminophen diluted in 50 mL of isotonic solution tarsal plate away from the ciliary margin; and on
for i.v. infusion may be used (this dose may be the lower eyelid, about 4–5 mm from the ciliary
complemented until it reaches 15 mg/kg) (Kocum margin. The skin turns whitish (frosting) immedi-
et al. 2013). For better pain control, association of ately after the application and in a few minutes it
a nonsteroidal anti-inflammatory may be useful changes to dark red color.
(e.g., 100–300 mg ketoprofen diluted in 100 mL Finally apply adhesive tape by areas, in two or
of isotonic solution, infused during the procedure) three layers, directly on the treated skin (occluded
(Bassanezi and Oliveira 2006). In case the patient phenol), during the time interval to apply the
does not tolerate the procedure with this analgesia, agent on the next aesthetical unit (Figs. 20, 21,
tramadol may be associated at a dose of 100 mg, and 22). The patient should be observed and mon-
intravenously. It is important to infuse a new dose itored for at least 1 h after the end of the
of acetaminophen after procedure, not exceeding procedure.
the dosage recommendation. Phenol peeling may be performed in only one
Remember that drug associations facilitate the aesthetical unit, complementing the rest of the
emergence of complications such as cardiac face with a TCA peel, for example. In these
arrhythmias, cardiorespiratory and central ner- cases, cardiac monitoring and intravenous hydra-
vous system depression. Therefore, always eval- tion are not needed (Figs. 23, 24, 25, and 26).
uate the possibility of interactions with the However, a contrast between the different treated
patient’s continuous-use medications. areas may occurs, as mentioned in the topic
Indications.
Agent’s Application
Evolution
Prepare the emulsion just a few minutes before the
application (Fig. 18). The emulsion should be well Pain is intense and may persist for 8–14 h. At this
stirred before each application, and to prevent acci- point, the patient must keep the use of acetamin-
dents, do not stir it near the patient’s eyes. ophen at 500–1,000 mg/dose (respecting the
88 C. Chisaki et al.
Fig. 26 The same patient of Figs. 23, 24, and 25, 9 years
Fig. 25 1 year after upper perioral peeling with post-peeling
non-occluded Baker’s formula and 10 days after Jessner
and TCA peeling on the rest of the face
Post-peeling erythema disappears within
dried exudate in non-occluded areas or where 45–90 days, generally 90 days when using
there was early detachment of the adhesive tape Baker’s formula, and exceptionally may persist
mask. It is also common to see edema on the neck for as long as 6 months. The use of makeup for
and chest. camouflage should be encouraged.
Gentle wound cleaning should be performed Photoprotection is mandatory, and sunscreens
by removing fibrin, crusts, and necrotic epithe- are reintroduced as soon as they are tolerated after
lium, avoiding aggressive removal of the epithe- reepithelization. It can be initiated with inorganic
lium that is still adhered. sunscreens, which are less irritant.
Once the dermal-epidermal barrier is broken, Pruritus and xerosis begin just after
desiccation and discomfort caused by the direct reepithelization and may be intense. In these
exposure to environment should be minimized cases, topical hydrocortisone and emollients are
with the application of an ointment, such as useful.
5–10% dimethicone in petrolatum (Odo and Retinoid or other acids for skin aging preven-
Chichierchio 1998) or petrolatum alone. tion may often be reintroduced after about 60 days
Bacterial infection is a rare event with phenol or more.
peeling, but careful cleaning should be done by Peeling may be repeated in 12 months and
the patient that may clean the wound with saline localized retouch session may be done after
solution or water several times a day before apply- 6 months. In our practice these periods may be
ing the ointment. This wound cleaning routine shortened in selected cases, such as on sites that
continues until full reepithelization, which nor- clearly there was no penetration of the agent,
mally occurs within 7–10 days. leaving non-exfoliated irregular areas (Fig. 28).
Phenol Solutions for Deep Peels 91
rest of the face may be treated with a medium or the use of systemic retinoid or topical tretinoin,
deep peeling. A demarcation line on the neck genetic susceptibility, or the presence of active
should not be treated with Baker’s formula, infection (Brody 1989; Maloney et al. 1998). If
because the neck has fewer adnexa for there is erythema associated with induration, we
reepithelization and higher risk of scars and con- indicate the use of local massage, application of
tractures. For this purpose more superficial silicone sheets, potent topical, systemic, or
chemical peels as trichloroacetic acid or modi- intralesional corticosteroids, and pulsed dye laser
fied phenol formulas may be used. to prevent scar formation.
The darkening of preexisting nevi and the Flushing may last for months; there are reports
appearance of new nevi sometimes occur after of persistence for 2 or more years. Hot weather
phenol peeling. Large nevi may be removed and emotional agitation may worsen it.
before the peeling.
Scars
Persistent Erythema and Flushing
Scars are second ranked among the complications
Persistent erythema may mean potential scar or from chemical peelings. It is a feared local com-
contact dermatitis. This may be a consequence of plication, because they may be disfiguring.
Phenol Solutions for Deep Peels 93
Infections
Fig. 34 Post-herpes simplex keloid
Although rare, bacterial infections may result
Hypertrophic and contracture-related scars from patient’s fear of taking care of their wounds,
may affect facial function and movement, and accumulating necrotic debris and secondary
most cases require surgical interventions associ- impetiginization. A bacterial infection should be
ated with a number of measures to minimize the treated with oral antibiotics and local care. All
problem. Scars are usually formed within chemical peelings have the potential to induce
2–3 months after the peeling (Fig. 35). reactivation of herpes simplex.
Scars are more common on the mandibular, peri- Perkins (Perkins and Sklarew 1996) reports
oral, and zygomatic lines, chin, inner corner of the that 50% of patients with history of herpes have
Phenol Solutions for Deep Peels 95
To minimize the risk of cardiac arrhythmias, epidermis and the underlying elastotic tissue.
minimal quantities of phenol should be used, This new band is formed by thin, compact, orga-
applying it by cosmetic unit respecting a minimal nized, parallel collagen bundles, horizontally
time interval, intravenous hydration, and promot- arranged in relation to the surface. The elastic fibers
ing diuresis. are regenerated and numerous, forming a network
arranged by chance, and sometimes parallel to the
new collagen formation.
Other Complications The follow-up of patients conducted by
Kligman, Baker, and Gordon shows that these
Milia resulting from the reepithelization process changes in the epidermis and dermis persist for
are formed within 1–3 months after the peeling. at least 20 years after the peeling (Kligman et al.
The small, superficial cysts of epidermal inclusion 1985).
are usually self-limited, but they may be removed. Although technically simple and low cost, phe-
Pruritus is common after reepithelization and nol peeling largely depends on the applicator’s
usually starts within the first 2 weeks after treat- technique and experience, and may have excep-
ment and continues for about 1 month. Antihista- tional results.
mines, aspirin, nonsteroidal anti-inflammatories, It has been known for a long time, but it is still
and topical corticosteroids may also be used. rarely used by dermatologists. The probable rea-
Telangiectasias are not directly affected by the son would be phenol toxicity that may be mini-
peeling, but it may become more apparent since a mized with planning and proper care.
lighter skin is expected after treatment. Prevention Phenol peeling has a dramatic clinical and
of purpura is achieved by avoiding physical exer- histological effect, and although the aging pro-
cises and exposure to sunlight. cess continues, histological studies prove that
Laryngeal edema may be more commonly seen post-phenol dermal reconstruction is long-lasting
in smokers. and probably permanent. Phenol peel is mentioned
Other post-peeling complications are psycho- by some authors as one of the most long-lasting
logical destabilization and depression in some therapeutics in medicine (Fig. 41).
patients; therefore, a careful selection of patients
is crucial for the procedure.
Take Home Messages
Fig. 38 (a, b) Pre-auricular Histological evaluations (H&E) before Baker’s peel – dermis with intense elastosis and
moderate perivascular lymphocytic inflammatory infiltrate
Fig. 39 (a, b) Histological evacuativos (H&E) 1 month deposition of collagen, parallel to the epidermis. Note
after treatment. Dermis with elastosis, but on the superficial that there are some well-formed fibroblasts
dermis, just above the elastosis, there is a modest
Fig. 41 62-year-old
patient with sun-induced
melanosis. (a) Before
phenol peeling with Baker’s
formula. (b) 12 years after
phenol peeling. Showing a
long-lasting result
Monheit GD, Chastain MA. Chemical and mechanical skin Stegman SJ. A study of dermabrasion and chemical peels
resurfacing. In: Bolognia JL, Jorizzo JL, Rapini RP, in an animal model. J Dermatol Surg Oncol. 1980;
editors. Dermatology. Spain: Elsevier; 2008. p. 2321–7. 6(6):490–7.
Moy LS, Peace S, Moy RL. Comparison of the effect of Stegman SJ. A comparative histologic study of the effects
various chemical peeling agents in a mini-pig model. of there peeling agents and dermabrasion on normal
Dermatol Surg. 1996;22:429–32. and sun damaged skin. Aesthet Plast Surg. 1982;6:123.
Odo MEY, Chichierchio AL. Peelings quimicos. In: dos Stone PA. The use of modified phenol for chemical. Clin
Santos H, editor. Práticas em Cosmiatria e Medicina Plast Surg. 1998;25:21–44.
Estética. 1st ed. São Paulo: Tecnopress Editora e Stuzin JM. Chemical peel. A change in the routine. Ann
Publicidade Ltda; 1998. p. 63–87. Plast Surg. 1989;23:166–9.
Otley CC, Nguyen TH. Safe and effective conscious seda- Stuzin JM. Phenol peeling and the history of phenol. Clin
tion administered by dermatologic surgeons. Arch Plast Surg. 1998;25(1):1–19.
Dermatol. 2000;136(11):1333–5. Truppman ES. Major electrocardiographic changes during
Perkins SW, Sklarew EC. Prevention of facial herpetic chemical face peeling. Plast Reconstr Surg. 1979;
infections after chemical peel and dermabrasion, new 63(1):44–8.
treatment strategies in the prophylaxis of patients Wexler MR, Halon DA, Teitelbaum A, et al. The preven-
undergoing procedures of the perioral area. Plast tion of cardiac arrhythmias produced in an animal
Reconstr Surg. 1996;98:427–33. model by the topical application of a phenol prepara-
Price NM. EKG changes in relationship to the chemical tion in common use for face peeling. Plast Reconstr
peel. J Dermatol Surg Oncol. 1990;16:37–42. Surg. 1984;73:595–8.
Stagnone JJ, Stagnone GJ. A second look at chemabrasion. Wicke C, Halliday B, Allen D, Roche NS, Scheuenstuhl H,
J Dermatol Surg Oncol. 1982;8:701–5. Spencer MM, Roberts AB, Hunt TK. Effects of steroids
Stagnone GJ, Orgeel MB, Stagnone JJ. Cardiovascular and retinoids on wound healing. Arch Surg. 2000;135
effects of topical 50 % trichloroacetic acid and Baker’s (11):1265–70.
phenol solution. J Dermatol Surg Oncol. 1987;
13:999–1002.
Combining Phenol-Croton Oil Peel
Phenol-croton oil peels are certainly not for every- Phenol-croton oil peels induce extreme edema,
one. Selection of patients with the proper psycho- which is completely formed in the first 24 h and
logical profile to follow adequate post-peel care is usually last 3–4 days (Fig. 1 and 2). During the
mandatory for satisfactory results. Deep peeling is first day, while the edema builds up, pain is usu-
absolutely contraindicated in patients with com- ally severe. Sometimes, periocular edema may be
pulsive skin picking and excoriations. Patients so severe as to completely block vision. There-
should quit smoking for at least 1 year and must fore, patients need to have a helping hand during
not be frequently exposed to the sun or other the first 24 h. Pain usually fades away within the
known carcinogens. Phototype I-III, Glogau IV, first 48 h, when mild to moderate serous to puru-
healthy patients are the ideal candidates for such lent exudate is commonly seen. After 72 h, edema
procedure. To ensure uniform and easy penetra- faded almost completely, and patients present
tion of the peeling compounds, patients may be with crusts of both the peeled skin and dry exu-
prescribed to apply, for at least 1 month, a topical date, therefore it is useful to remind the patient
retinoid such as 0.1% tretinoin (Retin-A™) or about proper ointment use (Fig. 3). Facial skin is
0.3% adapalene (Differin™), in association with usually clear of crusting and exudate by the sev-
4% hydroquinone for patients with history or enth to tenth day after the peel, when epidermis is
increased risk for intense post-inflammatory completely healed. Finally, after the first critical
hyperpigmentation (PIH). It is advisable to stop week, mild to severe persistent erythema occurs in
the topical prescription medications 48–72 h the sites where deep peeling was achieved
before the peeling day to avoid excessive irritation (Fig. 4), which is directly related to both the
in areas prone to hot spots such as perioral or depth and the strength of the solution. Neo-
periocular areas. PIH is one expected side effect. collagenesis is at its full throttle during this period,
104 C.G. Wambier and F. Pires de Freitas
check for infections and general wound care are irrelevant. For pain management, immediate after-
recommended. After 48 h, wound crusts and peel application of 4% lidocaine cream before
fibrin must be gently debrided washing with ster- applying petroleum jelly, and previous prescrip-
ile saline jets, after at least 15 min of soaked tion of codeine 30 mg every 4 h, starting 2 h
sterile saline compresses. Wet cotton-tip applica- before peeling. If severe pain is experienced dur-
tors may be used for gentle lift and debride crusts ing the first postoperative day, patients are
and fibrin. Delicate sterile surgical instruments instructed to double the dose of codeine. Stronger
such as scissors and atraumatic tissue forceps opioids, such as oxycodone 10mg can be pre-
may be used do debride necrotic skin, crusts, scribed for better pain control, taken 3h before
and fibrin. the peel and repeated 2 hours after the end of the
During such visits, it is not uncommon to start peel, then, every 8 hours, as needed. Tramadol
oral and topical antibiotics due to purulent exu- 100mg every 8h is also an effective alternative.
dates, increased odor, and erythema. Routine use Both oxycodone and tramadol may cause nausea,
of prophylactic antibiotics should be avoided. which is usually controlled with sublingual
Valaciclovir for herpes prophylaxis must be pre- ondansetron 4mg.
scribed to all patients, 500 mg 2 times a day Topical and systemic retinoids and steroids are
during the first 7 days, previous herpes history is avoided for at least 6 months. Erythema and
106 C.G. Wambier and F. Pires de Freitas
hyperpigmentation are best managed with hypo- formulas, the final volume will always be
allergenic cosmeceuticals, such as topical vitamin 10 ml. First, add 1, 2, 3, or 4 ml of the stock
C, E, nicotinamide, and topical hyaluronic acid. solution to 3, 2, 1, or “0” ml of 88% phenol, to
prepare 0.4% croton oil (mild), 0.8% (medium),
1.2% (potent), and 1.6% (very potent) formulas,
Strengths and Preparation of Phenol- respectively. Observe that the sum of ml of the
croton oil Formulas stock solution plus phenol should always be 4 ml
in order to obtain 35% phenol solution. Then,
There is a variety of possible phenol-croton oil add 5.5 ml of water mixed with 0.5 ml of
formulas. The strongest formula is the stock solu- Septisol (remaining 6 ml). To prepare 50% phe-
tion by itself, which contains one drop of croton nol formulas, the volume of phenol may be
oil per ml of liquid 88% phenol (Hetter 2000b). increased to 5.5 ml, with decrease of water vol-
This formula contains completely solubilized 4% ume to 4 ml. In order to prepare a solution very
croton oil in 85% phenol; presents a uniform, similar to Baker Gordon formula with this volu-
monophasic, yellowish hue; provokes very deep metric technique, mix 5.5 ml of the stock solu-
peeling; and is currently used by the author to tion to 0.5 ml of Septisol dissolved in 4 ml of
repair incomplete earlobe cleft and treat actinic water (2.2% croton oil in 50% phenol), or mix
cheilitis (Fig. 5), xanthelasma, icepick, and box- 5 ml of the stock solution, plus 0.5 ml of 88%
car acne scars by chemical reconstruction of scars phenol into 0.5 ml of Septisol dissolved in 4 ml
(CROSS). The author has baptized this full of water (2% croton oil in 50% phenol).
strength solution “capeta” (devil), as a reminder The mildest formula is 0.105% croton oil in
for the novice on chemical peels to be extremely 27.5% phenol (Orra et al. 2015), which is a very
cautious when using this dangerous and extremely safe and tolerable formula with mild edema dur-
strong formula. To prepare this stock solution, add ing healing time, with faint desquamation. To
1 ml of croton oil to 24 ml of pure 88% liquefied prepare this formula, which was named by Hetter
phenol (Hetter 2000b). For smaller volume, mix as a “very light peel” of his 1996 Heretic Formu-
0.5 ml of croton oil into 12 ml of 88% phenol. las, mix 4 ml of phenol 88% with 1 drop of croton
The most traditional formula is the Baker Gor- oil, 16 drops of Septisol, and 6 ml of water. Take
don solution, which contains about 2.1% croton 3 ml of this mixture and add 2 ml of phenol 88%
oil in 50% phenol (Baker et al. 1966). This for- and 5 ml of water (Hetter 2000b). Alternatively, a
mula causes diffused melanocyte toxicity and very similar formula may be prepared by mixing
requires at least 60 min to peel the whole face 0.3 ml of stock solution with 3 ml of 88% phenol,
with adequate room air exhaustion, due to higher and add 6.5 ml of water and 0.6 ml of Septisol.
cardiotoxic risk. Extreme acne scars That will produce a 0.12% croton oil with 27.5%
(in association with CROSS technique using phenol formula, which can be safely used to atten-
“capeta”) or extreme facial elastosis on phototype uate fine wrinkles in lax eyelids.
I-II are best managed with this formula. The The decision to which strength to be used is
author does not recommend this peeling for crucial for adequate treatment of each condition.
lower eyelids due to increased risk of ectropion. The author considers formulas stronger than 0.4%
To prepare this super potent formula, mix 3 ml of croton oil in 35% phenol deep chemical peels and
88% phenol with three drops of croton oil. Then, more diluted formulas mid to superficial peelings.
add eight drops of Septisol and 2 ml of water and
mix well before use, because this and all the next
formulas are biphasic. Combining with Other Chemical Peel
Hetter’s formulas are the most versatile; cro-
ton oil concentration varies from 0.4% to 1.6% The traditional combination treatment for phenol-
in 35% phenol, although 50% phenol can also be croton oil peels is to apply a milder peel in the
prepared (Hetter 2000b). To prepare the remaining facial skin, such as depicted in Fig. 6, in
Combining Phenol-Croton Oil Peel 107
Fig. 6 Combination
treatment of periocular
phenol 35% and croton oil
0.4% with Monheit’s
medium-depth peeling in
the remaining facial skin.
(Jessner’s solution followed
by 35% trichloroacetic
acid). Left: pretreatment.
Right: after 30 days
Fig. 8 Full-face phenol-croton oil peeling for treatment of Periocular area was further treated after 2 months with
acne scars. Lower periocular area was skipped bilaterally plain 88% phenol with no complications. Left: before.
because of asymmetric lower eyelid retraction caused by Right: after 14 days of initial phenol-croton oil peel
lower eyelid blepharoplasty performed 5 years earlier.
snap-back test, there is a very high risk for • When combining with milder phenol-croton
ectropion with a deep chemical peel. Although oil peel: same day.
phenol-croton oil actually ameliorates superficial • When combining with other chemicals
skin laxity after full healing, it does not act on (Jessner/TCA): 14–30 days (full epidermal
deeper structures, such as ligaments. Thus, super- recovery). Do not apply in the area peeled
ficial skin tightening can induce retraction and with phenol-croton oil.
ectropion.
Furthermore, the periorbital edema in the Combining with Botulinum Toxin A
healing process can produce temporary corneal
exposure. Skipping lower eyelid during phenol- The most common phenol-croton oil peeling com-
croton oil peeling is advisable in patients with bination treatment is the use of BTxA. Pretreatment
compromised snap-back test, ectropion and with BTxA, 2–3 weeks before the peeling appoint-
lower eyelid retraction (Figs. 7 and 8). In these ment, is indicated to reduce facial movement during
patients it is advisable to combine the procedure the immediate post-peeling period and facilitate
with a medium depth peel, which does not cause healing. Pretreatment could also reduce pain in the
skin retraction, or a very light phenol-croton oil intraoperative and postoperative period. However,
peel (Table 1). croton oil may stimulate neural regeneration as
Best timing recommendations: observed during historic reports of treatment of
Combining Phenol-Croton Oil Peel 109
Fig. 9 Combining botulinum toxin A pretreatment with properties of croton oil chemicals. In this case, movement
phenol-croton oil peeling. Patient experiences less pain was fully reestablished after 3–4 months, when it was
and movement is inhibited in the post-peeling period, decided to anticipate the usual five to six monthly injec-
producing excellent results; however, there is a risk of tions. Left: before. Right: after 4 months, day of reinjection
reduced duration of neuromuscular blockage by healing of botulinum toxin A
Fig. 10 Multiple combination treatments. After 14 days Fig. 11 Excellent results of multiple combination treat-
of initial intervention with phenol 35% and croton oil 1.6% ments. Four months after initial intervention with phenol
forehead peel (erythema is seen) associated with malar and 35% and croton oil 1.6% forehead peel (mild hypo-
perioral poly-L-lactic acid injection, botulinum toxin A was pigmentation seen) associated with malar and perioral
injected in the upper third of the face (red injection spots) poly-L-lactic acid injection, followed by botulinum toxin
and Monheit’s medium-depth chemical peel was applied in A injection to the upper third of the face and Monheit’s
the lower two thirds of facial skin (white frosting) medium-depth chemical peel
hoarseness and facial paralysis with topical applica- of diffusion of the toxin by the extreme edema
tion of croton oil (Hutchinson 1833). noticed in the first 24 h of peeling (Figs. 1 and 2).
Combining BTxA in the same day of deep Reduced BTxA duration may be observed
peeling is not recommended, because of high risk after phenol-croton oil peeling (Fig. 9), and
110 C.G. Wambier and F. Pires de Freitas
Fig. 12 Combination treatment with botulinum toxin patient is ready for post-peeling injections to boost and
A. After 21 days after initial full-face 35% phenol and maintain peeling effects on wrinkles
1.2% croton oil peel, facial expression has recovered and
Fig. 13 Combining fillers with phenol-croton oil peel. malar filler injection for malar filler injection. In this case,
After 3 months of full-face phenol 35% and 1.2% croton deep 30% polymethyl methacrylate was injected with 21G
oil with stronger formula, 1.6% croton oil, in the periocular microcannula with excellent results. Left: before chemical
area (erythema and post-inflammatory hyperpigmentation peel. Right: before filler injection
still observed in this picture), patient was submitted to
Fig. 14 Combining multiple treatments with phenol- with 21G microcannula with excellent persistent results.
croton oil peel. Before (left) and after (right) 1 year of Two months after the initial chemical peel, the patient also
full-face phenol 35% and 1.2% croton oil, and periocular required combined Q-switched 532 nm treatment of resid-
35% phenol and 1.6% croton peel, followed by malar ual spots of macular seborrheic keratosis seen jaw line
injection of deep 30% polymethyl methacrylate injected
Fig. 15 Chemical repair of incomplete earlobe cleft with every 14 days, combined with hyaluronic acid filling to the
five applications of croton oil one drop per ml of liquefied remaining depressed scar. Persistent erythema still present
88% phenol (full strength stock solution, 4% croton oil), after 4 months of the last application of the peeling solution
or intradermal injections, hyaluronic acid or poly-L- • When combining on different areas: same day
lactic acid is preferred (Fig. 15). • When combining in the same area: inject
Best timing recommendations: 4–6 months after peeling (full healing)
112 C.G. Wambier and F. Pires de Freitas
Fig. 16 Chemical reconstruction of acne scars with three oil), combined with full-face Q-switched Nd-YAG
monthly CROSS with croton oil one drop per ml of lique- (1064 nm) LASER before each treatment to improve irreg-
fied 88% phenol (full strength stock solution, 4% croton ular skin pigmentation and melasma
Abstract Keywords
Facial peels are widely spread across der- Chemical agent • Body peels • Non-facial areas •
matology practice for either cosmetic or dis- Supplement to other treatments • Guidelines
ease purposes. Body peel techniques borrow
the knowledge from facial treatments and Contents
apply it to body area respecting some Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
differences. Peculiarities of Non-facial Areas . . . . . . . . . . . . . . . . . . . . 116
The right agent and the correct technique Preliminary Care Before Chemical Body Peels . . . . . 116
are the pillars to promote an effective and safe Main Chemical Agents and Their Indications . . . 117
body chemical exfoliation. In order to obtain Salicylic Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
the best therapeutic results, very superficial Jessner Solution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Resorcin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
stratum corneum and superficial epidermis are Tretinoin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
the most suitable for body treatments. Body 5-Fluorouracil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
peels should be performed in serial sessions Glycolic Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
and in a gradual manner according to the Trichloroacetic Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Thioglycolic Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
indications.
These rules avoid persistent erythema, post- Special Care After the Procedure . . . . . . . . . . . . . . . . . 124
inflammatory hyperpigmentation, acromia, Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
delayed wound healing, and even necrosis
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
which would generate an unaesthetic dermal
scarring. Take Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Introduction
M.C. Molinaro (*) Despite of the growing demand for new technolo-
Policlínica Geral do Rio de Janeiro – (PGRJ), Rio de gies, the use of exfoliative chemical agent to pro-
Janeiro, RJ, Brazil mote body and facial peels plays an important role
e-mail: [email protected]
in dermatology, regarding its efficiency, safety pro-
P.S. Torreão file, practicality, or low cost. It is observed, however,
Hospital Federal dos Servidores do Estado do Rio de
Janeiro, Rio de Janeiro, RJ, Brazil
that the scientific literature gives greater emphasis to
e-mail: [email protected] chemical peels for facial areas. Nevertheless,
chemical peels for non-facial areas are used not only skin gets thinner with age. Caution is
for specific disease recommendations but also as a always required for choosing the correct
supplement to other treatments. This chapter aims to peel agent to be used.
systematize available information on techniques, • Blood supply: reduced blood supply in
care, and guidelines for this type of treatment. areas as the lower limbs complicates the
healing process. When treating these areas,
very superficial peels or superficial peels
Peculiarities of Non-facial Areas are indicated in order to minimize possible
complications.
Non-facial areas carry some particularities, which The right agent and the correct technique are
should be considered: pillars to promote an effective and safe body
chemical exfoliation. In order to obtain the best
(a) Extension of the skin surface: it constitutes a therapeutic results, very superficial stratum
major factor for skin absorption of chemicals corneum and superficial epidermis are the
that have systemic toxicity. It is recommended most suitable for body treatments. Body peels
to perform the treatment on a segmented basis should be performed in serial sessions and in a
for areas of the body previously defined gradual manner according to the indications
according to its length, respecting the safety (Landau 2008).
profile of each chemical agent. Some These rules avoid persistent erythema, post-
chemicals are time dependent and require neu- inflammatory hyperpigmentation, acromia, delayed
tralization. In large areas it is therefore neces- wound healing, and even necrosis which would
sary to plan the surface to be treated not to generate an unaesthetic dermal scarring. Some
compromise the neutralization. important considerations are discussed below.
(b) Degree of desquamation and of small crust
formation: in the days that follow body peels,
we observe the occurrence of desquamation Preliminary Care Before Chemical Body
in different degrees according to the depth Peels
of treatment. This phenomenon occurs through
a longer period compared to facial peels. • Rigorous medical history, especially regarding
This particularity is especially valid for superfi- past adverse reactions such as allergies, previous
cial body peels when the entire epidermis is keloids, chronic dermatological diseases (sebor-
treated. rheic dermatitis and atopic dermatitis), the use of
(c) Healing period: it is longer on the body treat- medications, and mainly oral isotretinoin. It is
ment due to the following features: also important to be cautious with patients with a
• Number of pilosebaceous units: the healing positive history of post-inflammatory hyper-
processes after a chemical peel occur through pigmentation, especially those with Fitzpatrick’s
the adjacent epidermal proliferation and skin types IV, V, and VI.
migration of stem cells present in the • The procedure has a relative contraindication
pilosebaceous units. As non-facial areas for individuals who have undergone radiation
have fewer skin appendages comparing it therapy on the body area, due to possible
with the face (even 30 times less in regions destruction of skin appendages, compromising
of the neck and chest and up to 40 times less the reepithelialization. In such cases, the obser-
on the back of the hands and arms), special vation of the vellus hair assures the integrity of
attention with peel’s depth is necessary to adnexal structures. Longer healing period or
avoid deep necrosis (Kede 2009). scars also can occur in people who used oral
• Epidermis’ thickness: In thinner skin, isotretinoin for less than 6 months.
chemical peels penetrate faster. This is • Excessive sun exposure should be avoided in
especially true for older people, as the the days before the procedure to minimize the
Nonfacial Chemical Peels 117
risk of melanocyte activation and subsequent acting as an adjuvant in the treatment of acne,
hyperchromia after the procedure. pillar keratoses, and post-inflammatory hyper-
• Previous skin preparation is not completely nec- pigmentation. Its therapeutic effect extends to
essary in very superficial procedures, but it can the treatment of mild photoaging, irregularities
be done with the aim of preventing dyschromia. in skin texture, and fine rhytides (Peterson and
The skin preparation should begin with at least Goldman 2011). The treatment protocol ranges
14 days in advance. It is suggested the use of from three to six sessions at intervals of 15–30
depigmenting agents such as hydroquinone and days, depending on the clinical indication and
kojic acid associated with retinoids or alpha the morbidity of the lesions. There is often a
hydroxy acids. Those accelerate the healing pro- white precipitation of salicylic acid in 1–3 min,
cess, preventing possible hypercromic areas, par- which serves as a parameter for a homogeneous
ticularly in Fitzpatrick’s phototypes IV, V, and application (Fig. 1a, b).
VI. These drugs should be suspended 3–5 days There is, then, moderate burning which gives
before the procedure not to interfere with the in a few minutes, leaving a feeling of light anes-
chemical peel agent, avoiding deeper penetration thesia in treated area. Small frostings (level 1)
of the peel into the skin. can be seen in the areas of inflammatory acne
• In the treatment of epidermal lesions with higher lesions, not requiring neutralization. The excess
degrees of hyperkeratosis, such as seborrheic and of white precipitate is removed, after 5–10 min
actinic keratoses, the use of electrocoagulation with water or cleansing lotion. In 3–5 days, very
and cryosurgery as previous supporting treat- fine whitish scaling occurs.
ment can optimize clinical results. Symptoms of salicylism, while rare, may
• Finally, shaving and removal of body hair occur, ranging from light (rapid breathing, tinni-
should not be performed in the area to be tus, hearing loss, dizziness, nausea, vomiting,
treated during the 5 days before treatment, and abdominal pain) to severe (central nervous
avoiding epidermal injury, allergic contact der- system changes simulating alcohol intoxication).
matitis, or primary irritant dermatitis that may For this possibility, the use of this substance is
compromise the integrity of the skin. only recommended on smaller surfaces such as
• At the day of the procedure: important precau- neck and presternal region (Brubacher and Hoff-
tions at the day of the procedure include the mann 1996). Recently, a new preparation
proper choice of substance to be used for containing 30% salicylic acid in a polyethylene
cleansing: mild cleansing lotion, alcohol- glycol (PEG)-based vehicle has been used with
ether, or pure acetone. This choice determines good clinical results in volunteers with aged skin,
greater or lesser penetration of the chemical showing improvement in skin texture, and in
agent, in particular those with a higher ability acne patients with disappearance inflammatory
to penetrate the epidermis, such as tri- acne and comedones. For being little volatile,
chloroacetic acid (TCA). PEG has a higher affinity for salicylic acid and
thereby releases it only in small amounts in the
superficial layers of the epidermis. This affinity
Main Chemical Agents and Their justifies lower absorption of the substance, with
Indications lower systemic toxicity as well as a reduction of
burning sensation during application (Dainichi
Salicylic Acid et al. 2008). On the other hand, salicylic acid
formulated in ethanol, being highly lipophilic,
Salicylic acid consists of a beta hydroxy acid has high affinity for the pilosebaceous units, pro-
used in concentrations of 20% and 30% in etha- viding certain dryness desirable in patients suf-
nol as a superficial peel. It has comedolytic, fering from body acne (Peterson and Goldman
keratolytic, and anti-inflammatory properties by 2011).
118 M.C. Molinaro and P.S. Torreão
Fig. 1 (a, b) Salicylic acid peel at 30 % in ethanol for inflammatory acne. The image (b) shows the whitish precipitation
of the acid
Fig. 2 (a–c) Jessner peel (three layers) for moderate photoaging. (a) Before the procedure, (b) after the first session (14th
day), and (c) after two sessions (40th day)
Fig. 3 (a–c) Tretinoin peel at 5% in propylene glycol for traumatic post-inflammatory hyperpigmentation. (a) Before the
procedure, (b) immediately after the procedure, and (c) after the first session (14th day)
and compaction of the stratum corneum, reverse such as seborrheic and actinic keratosis, milia,
atypia in epidermal cells, stimulate neo- sebaceous hyperplasia, and papulosis nigricans.
collagenesis in the dermis, increase the deposition Studies show that this association seems to pro-
of glycosaminoglycans, stimulate the reorganiza- vide a better healing (Hung et al. 1989), promot-
tion of collagen fibers damaged by sun exposure, ing uniformity of skin tone and improvement in
and remove and disperse the melanin granules skin quality.
formed in keratinocytes (Kede 2009). Its use is The tretinoin peel is painless and easy to per-
widespread in photoaging treatments and actinic form. The chemical agent is applied with the help
skin changes (e.g., poikiloderma of Civatte) (Lan- of a gloved finger. In the mean interval of 3–4
dau 2008), in pigmentation disorders such as post- days, there is a white desquamation, dry, fine, and
shaving folliculitis, acne, insect bites, and proportional to the concentration and length of
melasma in non-facial areas, and in traumatic exposure to the substance. The application, in a
injuries, especially in trunk regions and upper biweekly or monthly interval, is completely pain-
and lower members. In the treatment of acne, it less, because tretinoin has no acidic pH capable of
corroborates with home-based use of tretinoin promoting protein coagulation. Being a photosen-
promoting the elimination as well as the preven- sitive drug, it should be applied late in the day and
tion of follicular hyperkeratosis. remain on the surface for at least 6 h (Landau
The tretinoin peel is often used after micro- 2008). For best results it is possible to perform a
dermabrasion with aluminum oxide crystals in gradual increase of the length exposure in each
which the stratum corneum is removed mechani- application from 4 to 12 h limit. This peel is not
cally. This combined procedure optimizes the recommended for pregnant women and should
therapeutic results with an epidermal deepening not be carried out throughout the breastfeeding
(Hexsel et al. 2005). The indication extends to the period (Fig. 3a–c).
treatment of the old stretch marks, of pearly color,
as well as those of recent emergence, in pinkish
color. For this purpose the concentration should 5-Fluorouracil
be of 10%, for a contact period of 4–6 h until the
removal with water (Kede 2009). This peel is 5-Fluorouracil (5-FU) is a fluorinated pyrimidine
recommended after procedures like electro- from the group of antimetabolites which acts as a
coagulation or cryosurgery of epidermal growths cytostatic agent in the treatment of preneoplastic
Nonfacial Chemical Peels 121
and neoplastic cutaneous diseases. It is also called in pigmentary disorders such as melasma and
fluorouracil-pulsed peel and consists of a combing post-inflammatory hyperpigmentation (Clark and
two superficial peel agent. Usually it is combined Scerri 2008; Takenaka et al. 2012; Callender et al.
with Jessner or glycolic peel. The first step begins 2011). Good clinical results can also be achieved
with the Jessner solution or with glycolic acid in the treatment of folliculitis and pseudo-
70% in fluid gel. When starting with the Jessner folliculitis of groin and buttocks. The GA’s action
solution, it is recommended to apply one or two results from compaction effect of the stratum
layers to reach an initial (level 0) erythema or corneum, epidermal thickening, and dermal depo-
salicylic precipitation, not requiring neutraliza- sition of collagen and mucin.
tion. In the case of the glycolic acid, neutralization The GA peels are sold as free acids, partially
with water or sodium bicarbonate is required. neutralized. There are different manufacturers
Then, 5% 5-FU is applied in propylene glycol or with different pHs ranging from 1.0 to 3.0. Some
cream on a body surface which should not exceed formulations have even lower pH around 0.6. The
500 cm2 (about 2323 cm) leaving it to act for lower the pH, the greater the amount of acid in the
6–12 h. free form, allowing to deeper penetration into the
This procedure is performed in weekly or skin with formation of faster and more extensive
biweekly interval, until eight pulses, for the treat- frostings. These frostings show areas of cell
ment of multiple actinic keratoses. In a study epidermolysis, color ranging from white to gray-
conducted by Katz (1995), the combined peel ish white, according to the dermal penetration of
with the Jessner solution has enabled a reduction GA (Clark and Scerri 2008). In areas with
of 86% of studied injuries; in another study, increased thickness of the stratum corneum, for-
Marrero (1998) obtained the best results, with mulations with lower pH (0.6–1.0) can be chosen,
92% injury reduction with the combination with in order to facilitate penetration of the acid with-
glycolic acid at 70%. out compromising the security of the application.
All peels with alpha hydroxy acids require neu-
tralization when the desired depth is reached. This
Glycolic Acid is done using an alkaline solution or water. It’s
preferable to use sodium bicarbonate at 10% in
Glycolic acid (GA) has its natural source in sug- fluid gel as neutralizing agent because, by having
arcane, being produced in the laboratory for use as a clearly alkaline pH, it promotes certain efferves-
a chemical peel. It has one of the smallest mole- cence in the place to be neutralized when in con-
cule sizes among the alpha hydroxy acids. There- tact with the acid pH of the peel. This
fore, the penetration of GA in the skin occurs, effervescence provides better control over the
compared to other alpha hydroxy acids, more peel, reaching the exact depth we desire.
easily. GA can be used as very superficial or In GA peel after complete cleanup, a thin layer
superficial peeling agent, depending on the con- of the product is applied. The neutralization is
centration used, the pH of the formulation, and the done in steps, with sodium bicarbonate, as soon
exposure time on the surface (Clark and Scerri as some frosting area begins. This is done with the
2008; Fischer et al. 2010). The concentration of aid of a cotton tip, in order to avoid a deeper
70% in pHs lower than 1.0 can become a medium- dermal penetration of the product. Then, with the
depth peel, depending on the exposure time on the emergence of a uniform and evident erythema
skin. The higher the concentration of GA, at a (levels 0–1), total neutralization of the area is
lower pH and at longer exposure, the deeper is performed. The erythema shows that all stratum
the peel. This is due to the greater bioavailability corneum was achieved and the stratum
of the chemical in these conditions (Kede 2009). granulosum penetration is beginning (Clark and
This peel is indicated as an adjunct in the Scerri 2008; Fischer et al. 2010). It is advisable to
treatment of non-facial areas for photoaging, start with 50% GA and increase to 70% GA for
inflammatory acne, and atrophic acne scars and subsequent applications. Patients very well
122 M.C. Molinaro and P.S. Torreão
Fig. 4 (a–e) Glycolic peel acid at 70% (pH=0.6) in gel for gel; (c) effervescence of the gel after neutralization with
post-inflammatory hyperpigmentation. (a) Prior to appli- sodium bicarbonate, 10%; (d) immediately after applica-
cation; (b) immediately after application of the translucent tion; and (e) after the second session (60th day)
tolerate this peel with high concentration of GA, is a widely used nontoxic peel, therefore confer-
with an initial feeling of warmth and then a certain ring systemic safety. However, it is recommended
“sting” and subsequent slight burning (Fig. 4a–d). to use the same product suppliers to avoid signif-
Despite being time dependent, it is not prudent icant variations of vehicles and pHs.
to rely on the application time, but in getting the
erythema as uniform as possible in this peel. Spe-
cial attention must be paid in treatments of the Trichloroacetic Acid
neck due to the thinner corneal layer, which facil-
itates a rapidly penetration of the product. In such Trichloroacetic acid (TCA) is a stable substance,
areas the emergence of frostings or isolated inexpensive, that does not require neutralization
epidermolysis in greater numbers is common, and has no systemic toxicity. It is easily handled
often necessitating agility when handling the neu- because the depth of application is determined by
tralizer. Special care must also be taken in areas of clinical parameters related to the degree of ery-
skin folds where larger volume acid should not be thema, areas of frostings, and modification of skin
retained and occasionally the emergence of small turgor, already mentioned in the previous topics.
necrosis. The treatment algorithm proposes Its frosting or whitening is generated by the attack
around six or more applications with a biweekly capacity of TCA, leading to protein denaturation
or monthly interval (Clark and Scerri 2008). This and necrosis of skin cells. It is a versatile peel,
Nonfacial Chemical Peels 123
with very good action in body rejuvenation and concentration of TCA can be used, which can
epidermal pigmentation. TCA can be found in vary from 35% to 50% according to anatomical
different presentations as described below: location of the body. It should only be done as a
punctual and localized peeling on a specific lesion
• In vehicle with distilled water in order to treat the injury isolated.
Cook and Cook (2000) described a combined
TCA in distilled water is used in the concen- chemical medium-depth peel not suitable for
tration of 10–15% for the achievement of very facial area, in which peel glycolic acid is used in
superficial body peels; 20–25% for superficial 70% gel, in an abundant manner, followed by the
peels; and above 30% for medium depth, up to application of TCA 40% in distilled water. The gel
45% or 50% for reaching superior reticular der- vehicle for glycolic acid is essential, because it
mis, with higher degree of unpredictability and acts as a partial barrier for the penetration of TCA.
high risk of complications both in facial region After obtaining the desired frosting, neutralization
and mainly in extra-facial areas (Landau 2008). is done with sodium bicarbonate solution at 10%,
Born from the concern about unnecessary terminating the peel.
deepening of the chemical, combined peels were
developed, linking two or more chemical sub- • In vehicle paste
stances in the same session. The effect of each
substance is thus combined. In this modality, TCA can also be used in paste at concentra-
keratolytic agents are used initially with the help tions of 10–20%. Its application is carried out with
of Jessner solution or glycolic acid 70%, the aid of a spatula. Once applied, it is necessary
succeeded by the immediate use of TCA 35% in to make a “window,” removing part of the paste to
distilled water. This type of combined peel, of visualize the deepening parameters, hidden by the
medium depth, has become very common, espe- opaque color of the vehicle. This “window” con-
cially in face treatments, for its ease of applica- trol could not represent what is occurring in all
tion, greater control on the agent’s penetration, anatomical area treated, but is the correct way to
and uniformity and certainty in getting the desired evaluate the endpoint to neutralize the peel. The
frosting level compared to TCA applied alone at neutralization is done using alcohol solution to
higher concentrations (Monheit 1995; Coleman remove the TCA paste. This is a safe and good
and Futrell 1994). Some professionals reproduce option for treating the hand and forearms.
this peel in body treatments with good results,
especially for moderate photoaging. However, in • In gel vehicle
order to avoid possible iatrogenic events, this peel
is not recommended for inexperienced hands This presentation, made at the desired concen-
(Costa and Gomes 2012). tration by prescription, is the most suitable for
In superficial combined peels, the use of lower body peels when the choice of agent lies on the
concentrations of TCA in distilled water is pre- TCA. This peel appears as a translucent gel, with
ferred, between 15% and 25%, preceded by one or high plasticity, easy to use, less prone to accidents,
two layers of Jessner solution. Great results can be and allowing full view of the areas of whitening
achieved in mild photodamage, dyschromia, and and skin turgor, elements needed to implement
the pigment component of poikiloderma of depth control. The TCA is dispersed homoge-
Civatte (Tung and Rubin 2011). The application neously throughout the gel vehicle.
of the TCA is made with progressive deepening The skin preparation is done by following the
into the epidermis layers to reach the level 1 frost- same guidelines of TCA peel, with suspension of
ing (erythema with lacy white color). In deeper keratolytic agents prior to the procedure. This peel
dyschromias and lingering lentiginoses, after this is used at lower concentrations, ranging from 10%
superficial and combined peel, a higher to 20%, depending on the epidermal thickness of
124 M.C. Molinaro and P.S. Torreão
the body segment and the depth to be obtained. mercaptoacetic acid; it has sulfur in its composi-
This peel is indicated for the treatment of mild to tion and a high water, alcohol, and ether solubility,
moderate cutaneous photoaging, most commonly with easy oxidation. It has a strong and specific
in the presternal region, neck, forearms, and back odor. The affinity of this acid with iron is similar
of the hands. to that of apoferritin: the thiol group in its struc-
It is done, with gloved fingers, by applying a tural composition gives it the ability to chelate
single thin layer of gel (0.1–0.2 mm thick) in the iron from hemosiderin (Costa et al. 2010). This
area being treated (Zanini 2007). The penetration peel is used in patient’s skin type I to IV in the
of this peel, for the occlusive effect of the gel, treatment of hyperchromias with hemosiderotic
occurs more quickly and uniformly and without and melanin origin, as in constitutional
the need to apply several layers, compared to infraorbital pigmentation (Costa et al. 2010) and
vehicle distilled water (Zanini 2007). in ochre dermatitis (Yokomizo et al. 2013).
The depth to be obtained with TCA gel ranges The acid concentration ranges from 5% to 12%
from level 0 (uniform erythema), for very super- in gel vehicle. In body peels to treat ochre derma-
ficial epidermal peels, in which the removal of the titis of the lower limbs, we recommend its use in
whole corneal layer is desired, to level 1 (stringy serial, biweekly, or monthly sessions in concen-
or blotchy frosting with background erythema) for trations between 10% and 12%. After cleansing
peels where we want to destroy the epidermis the body area, a single thin layer of gel
partially or more extensively. When it comes to (0.1–0.2 mm thick) is applied with gloved fingers.
body surface areas, the stringy frosting should be Its effect on the skin is directly proportional to the
the maximum depth parameter that results in pre- application time and should be removed with
dictability. Differently from TCA peels in distilled water, once an initial erythema or level 0 of frost-
water, we proceed to immediate removal as soon ing is present. The peel can cause mild discomfort,
as we get the whitening pattern desired for the associated with discrete erythema at the time of
peel. The removal is done with gauze moistened application. Around 3 days later, mild erythema to
in alcohol or, more easily, with simple local wash- the appearance of small areas of fine scales in
ing with water, preventing thus the deepening of brownish color is expected, depending on the
the peel (Fig. 5a–d). time of exposure to the agent. Special attention
This treatment is done in two to three sessions must be paid to a possible unnecessary penetration
at intervals of 45–60 days. Serial sessions in lower of this peel in the lower limbs presented as diffi-
concentrations enable greater security with good, cult healing in the area.
constant, predictable results and in lower rate of
dyschromia and unsightly scars. The recovery
time after the procedure is very similar to TCA Special Care After the Procedure
peels in distilled water or paste, with thin and
brown scaling. It is worth remembering that the We have subdivided special care after the proce-
occurrence of vasodilatation caused by the TCA dure in two modalities: care at the end of the
on large body surfaces can cause, atypically, procedure and care in days following the
hypotension, tachycardia, and syncope. procedure.
Care at the end of the procedure: very superfi-
cial body peels are painless, but the patient may
Thioglycolic Acid experience some itching sensation or slight burn-
ing, which disappears within minutes. Superficial
Thioglycolic acid is one of the representatives of peels, with necrosis of the entire epidermis, espe-
the thioglycolate class whose substances are used cially with the use of TCA, initially cause a feel-
for years in cosmetic industry for the manufacture ing of heat, followed by moderate burning
of body hair removal, hair straighteners, and hair sensation, which gives in with cold compresses
dyes (Costa et al. 2010). It is known as or air coolers.
Nonfacial Chemical Peels 125
Fig. 5 (a–d)
Trichloroacetic acid peel at
20% in gel for cutaneous
photoaging. (a) Before the
procedure, (b) during the
procedure (frosting level 1),
(c) scales and brownish
crusts (sixth day), and (d)
after the first session (40th
day)
Care in days following the procedure: such After 2 days of treatment, the use of sunscreens
care is very similar to the facial area. The treated with broad-spectrum anti-UVA and anti-UVB
area should be kept clean with soaps or cleansing should be initiated, preferably those with physical
lotions for sensitive skin and should always be filter in its composition. Applying filters immedi-
well moisturized for 5–7 days with emollients, ately after the procedure may cause some burning
such as solid or liquid Vaseline, or other recovery sensation; therefore chemical-free sunscreen is
moisturizing cream or gel, in order to mimic skin indicated to avoid irritation. Sun exposure should
barrier injured by chemical agents. Such wetting be avoided in the days following the procedure
procedures reduce any burning or pain after the even if using a suitable sunscreen. In peels in
procedure. In oilier body areas, we recommend forearms and hands, we recommend the suspen-
using skin products with lower oil content in its sion of the chemicals linked to domestic activities,
composition. Such care prevents the emergence of such as abrasive soap and detergents, until com-
acneiform eruptions following the procedure. plete reepithelialization.
126 M.C. Molinaro and P.S. Torreão
• Some peeling agents are indicated for body Cook K, Cook JR. Chemical peel of nonfacial skin using
peels, such as salicylic acid, Jessner solution, glycolic acid gel augmented with TCA and neutralized
based on visual staging. Dermatol Surg. 2000;26:11.
retinoic acid, glycolic acid, TCA, and Costa IMC, Gomes CM. Peelings médios/Peles clara e
thioglycolic acid. negra/Áreas extrafaciais. In: Mateus A, Palermo E, edi-
• Healing period is longer on the body treatment tors. Cosmiatria e laser: prática no consultório médico.
compared to facial peeling. 1ath ed. São Paulo: AC Farmacêutica; 2012. p. 167–74.
Costa A, Basile AVD, Medeiros VLS, Moisés TA, Ota FS,
• While medium-depth peels in the facial region
Palandi JAC. Peeling de gel de ácido tioglicólico 10%:
can be considered a simple procedure, this is opção segura e eficiente na pigmentação infraorbicular
not a good choice for body peels, due to the constitucional. Surg Cosmet Dermatol. 2010;
high incidence of adverse effects such as diffi- 2(1):29–33.
Dainichi T, Ueda S, Imayama S, Furue M. Excellent clin-
cult healing and even unsightly scars.
ical results with a new preparation for chemical peeling
• Superficial peeling is advised for non-facial in acne: 30% salicylic acid in polyethylene glycol vehi-
area, and a good clinical result can be seen cle. Dermatol Surg. 2008;34:891–9.
after some sessions of treatment. Fischer TC, Perosino E, Poli F, Viera MS, et al. Chemical
peels in aesthetic dermatology: an update 2009. J Eur
• The body chemical peels should be accompa-
Acad Dermatol Venereol. 2010;24:281–92.
nied by a home care practice that can optimize Hexsel D, Mazzuco R, Dal’forno T, Zechmeister
and perpetuate the benefits produced. D. Microdermabrasion followed by a 5% retinoid acid
• It is possible to combine body chemical treat- chemical peel vs. a 5% retinoid acid chemical peel for
the treatment of photoaging – a pilot study. J Cosmet
ment with other technologies such as electro-
Dermatol. 2005;4(2):111–6.
coagulation or cryosurgery when treating thick Hung VC, Lee JY, Zitelli JA, Hebda PA. Topical tretinoin
lesions. and epithelial wound healing. Arch Dermatol.
• Body chemical peels offer an effective treatment, 1989;1255:65–9.
Katz BE. The fluor-hydroxy pulse peel: a pilot evaluation
with low cost and excellent clinical results.
of a new superficial chemical peel. Cosmet Dermatol.
• Excessive sun exposure should be avoided in 1995;8:24–30.
the days before and after the procedure to min- Kede MPV. Dermatologia estética. São Paulo: Ed Atheneu;
imize the risk of melanocyte activation and 2009.
Landau M. Chemical peels. Clin Dermatol.
subsequent hyperchromia post-procedure.
2008;26:200–8.
Marrero GM, Katz BE. The new fluor-hydroxy pulse peel.
A combination of 5-fluoruracil and glycolic acid.
References Dermatol Surg. 1998;24:973–8.
Monheit GD. The Jessner’s – trichloroacetic acid peel. An
enhanced medium – depth chemical peel. Dermatol
Anitha B. Prevention of complication in chemical peeling.
Clin. 1995;13:277–83.
J Cut Aesthet Surg. 2010;3(3):186–7.
Peterson JD, Goldman MP. Rejuvenation of the aging
Brody HJ. Superficial peeeling. In: Brody HJ, editor.
chest. A review and our experience. Dermatol Surg.
Chemical peeling and resurfacing. 2nd ed. St Louis:
2011;37:555–71.
Mosby Year Book; 1997. p. 73–108.
Takenaka Y, Hayashi N, Takeda M, et al. Glycolic acid
Brubacher JR, Hoffmann RS. Salicylism from topical
chemical peeling improves inflammatory acne erup-
salicylates: review of the literature. J Clin Toxicol.
tions through its inhibitory and bactericidal effects on
1996;34(4):431–6.
Propionibacterium acnes. J Dermatol. 2012;39:350–4.
Callender VD, St Surin-Lord S, Davis EC, et al. Post-
Tung CR, Rubin MG. Procedures in cosmetic dermatology
inflammatory hyperpigmentation. Etiologic and thera-
series: body peeling. In: Chemical peels, vol. 12. 2nd
peutic considerations. Am J Clin Dermatol. 2011;
ed. Philadelphia: Elsevier; 2011. p. 117–22.
12(2):87–99.
Yokomizo VMF, Benemond TMH, Chisaki C, Benemond
Clark E, Scerri L. Superficial and médium-depth chemical
PH. Peelings químicos: revisão e aplicação prática.
peels. Clin Dermatol. 2008;26:209–18.
Surg Cosmet Dermatol. 2013;5(1):58–68.
Coleman WP, Futrell JM. The glycolic acid tri-
Zanini M. Trichloroacetic acid – a new method for an old
chloroacetic acid peel. J Dermatol Surg Oncol.
acid. Med Cut Iber Lat Am. 2007;35(1):14–7.
1994;20(1):76–80.
Part II
Special Issues in Chemical Peels
Chemical Peels for Dark Skin
Table 1 Peeling agents used in black skin causes bearable burning sensation. The “end point”
Superficial peeling agents (epidermis to upper papillary for this peeling is the appearance of a homogeneous
dermis) erythema with a white powder precipitation. It is
Glycolic acid solution 30–50 % or glycolic gel 70% not necessary to neutralize this peel. Cold compress
Jessner’s solution (Combes’ formula) can be used only to comfort the patient. Coughing
Salicylic acid 20–30 % in ethanol and sneezing can occur during the procedure
Tretinoin 1–7 % (Salam et al. 2013; Roberts 2004; Grimes 1999).
Trichloroacetic acid 10–35 %
Medium-depth peeling agents (epidermis to upper
reticular dermis) Glycolic Acid
Glycolic acid solution 70%
Jessner’s solution and trichloroacetic acid 35% It is an alpha-hydroxiacid and similar to other com-
Phenol 88% (without occlusion) pounds in this pharmacologic group, as lactic, citric,
Trichloroacetic acid 35–50 % mandelic, malic and tartaric acids, glycolic acid peel
Trichloroacetic acid 25–35 % + glycolic gel 70% causes epidermolysis in minutes after application. It
Deep peels should not be used in Fitzpatrick skin types promotes skin peeling and scattering of epidermal
IV–VI
melanin. The “end point” is reached when a homo-
geneous erythema, better seen in caucasian patients,
formulation for dark skin, based on the fact that or when the first points of frosting (epidermolysis)
this association improves the benefits and reduces are noted. For this reason, it is better to neutralize in
side effects. These authors also support the use of 2-3 minutes. At this moment, the dermatologist shall
phytic acid peels. Independently on the type of neutralize the process. The acid should be neutral-
peel chosen to treat melasma in darker skinned ized with sodium bicarbonate solution 1% or with
patient, the rate of recurrence is high; therefore saline solution, or even with water. The effects of
many sessions of peeling and use of lighter sub- glycolic acid peel are time dependent. The concen-
stances as daily routine are necessary. tration ranges from 10% to 70% (Roberts 2004).
Effective peels, traditionally described in the It is indicated for acne, based on the anti-
literature and used in black skin (Salam et al. inflammatory property and antibacterial effect
2013; Roberts 2004; Been and Mangat 2014; against Propionibacterium acnes. Reduction of
Rullan and Karam 2010) are described in Table 1. acne lesions (comedos, papules, and pustules) is
observed as well as improvement on the skin
pigmentation after glycolic acid peels. Studies
Types of Peelings have shown that glycolic acid peel at the concen-
tration of 70% is able of to press out pustules and
Salicylic Acid comedos within few minutes (Salam et al. 2013).
It is less effective in the treatment of superficial
It is a lipophilic beta-hydroxyacid, which cause and mixed melasma and postinflammatory hyper-
desquamation of the superficial layers of the skin, chromia. It offers a slightly higher risk of irrita-
with keratolytic and comedolytic effects. It can be tion, hypochromia, and hyperpigmentation in a
also used in combination with other peels to pro- small percentage of patients. With the aim to
mote better penetration of the second substance. reduce the irritation caused by this peel, it is better
Usually we use hydroalcoholic solutions of sali- to manipulate the substance in gel vehicle instead
cylic acid at 20–30%. It is very useful for acne, of solution and to request for buffering substance
for both inflammatory and noninflammatory with higher pH. The pH of the unbuffered acid
lesions, as well as for postinflammatory pigmented ranges from 0.08 to 2.75. A pH less than
lesions. Salicylic acid peel is also indicated to other 2 increases necrosis index and keratinocytes
types of postinflammatory hyperpigmentation, such destruction. It increases the rate of complications
as melasma and pigmented keratosis. The peeling without increasing its effectiveness. Therefore,
134 K. Conceição et al.
Trichloroacetic Acid
• Melasma is one of the most important and Patients should be collaborative and need to
common diseases in African descent patients. understand all the steps of the procedure, includ-
It is much more prevalent among patients with ing the pre- and postprocedure care. All the ben-
Fitzpatrick phototype between IV and VI, efits and side effects, as well as its limitations
mainly Hispanics, Africans, African- should be very well explained to avoid false
Americans, and Asians. expectations (Roberts 2004; Rullan and Karam
• Jessner’s solution is indicated to be used iso- 2010).
lated or in combination with other peels. Dermatologists should pay close attention or
• We have good experience with a peel called contraindicate chemical peels for dark-skinned
Cimel, and we prefer to use Cimel modified patients who have personal or family history of
formulation which contains 3% hydroquinone, keloids or hypertrophic scars. Chemical peels
3% kojic acid, 3% retinoic acid, 3% lactic acid, are not a good indication for patients with sub-
9% salicylic acid, 3% ascorbic acid, and 1% in jacent diseases, such as contact eczema, sebor-
gel cream vehicle. rheic eczema, rosacea, sensible skin, vitiligo,
• Another option is buffered glycolic acid peel and psoriasis. The smokers have low rate of
(70%) isolated or in combination with retinoic skin recovery. Radiotherapy, recent surgery,
acid 3–7%. and oral retinoids are contraindications as they
can interfere in the collagen modulation. An
interval of 6–12 months is necessary after stop-
Residual Hyperpigmentation ping the oral retinoid to avoid incorrect healing.
The concomitant use of photosensitizing sub-
• We have good experience with superficial stances (cyclins, amiodarone, thiazides, tricy-
peels, combining salicylic acid with clic antidepressants, NSAIDs) or hormones
retinoic acid. should be investigated as they can promote
• The use of substances containing bleaching hyperpigmentation (Salam et al. 2013; Roberts
agents and topical photoprotection (chemical 2004; Rullan and Karam 2010).
and physical) at home, as a daily routine treat-
ment, is advisable.
Before Peeling
Tables 2 and 3 show the level of evidence and
strength of recommendations for various peeling The patient is advised to use photoprotection
agents in ethnic skin, according to literature (Rob- and lightening substances such as hydroqui-
erts 2004; Sarkar et al. 2012; Rullan and Karam none, retinoic acid, glycolic acid, or triple com-
2010): bination of hydroquinone + retinoic acid +
corticosteroid (Kligman formula) with the aim
to prepare the skin, for at least 2 weeks before
Table 2 Levels of evidence and strength of recommenda- the procedure. These substances can be
tions for various peeling agents in ethnic skin. Peeling suspended 3 days before the procedure. It is
agent level of evidence strength of recommendation
important not to perform any depilatory
Glycolic acid peel II-i A methods or exfoliation 7 days before the proce-
Jessner’s solution II- iii B dure. These recommendations decrease the
Lactic acid peel II-iii B chance of complications, especially post-
Phytic acid peel III C inflammatory dyschromia. If the patient has
Pyruvic acid peel III C
past history of recurrent herpes simplex disease,
Salicylic acid peel II-iii B
prophylaxis should be done with oral antiviral,
Trichloroacetic acid peel II-iii B
such as valacyclovir 500 mg – 12/12 h for
Chemical Peels for Dark Skin 137
Table 3 US preventive services task force levels of evi- trichloracetic acid, remembering that deep peels
dence for grading clinical trials are not recommended for skin types V and VI.
Level of evidence At first, the skin should be cleaned with the aim
I Evidence obtained from at least one properly designed, to remove makeup, sunscreens, cosmetics, and
randomized controlled trial also to degrease the skin, preparing for peeling
II-i Evidence obtained from well-designed controlled
application. The patient should wash their face
trials without randomization
II-ii Evidence obtained from well-designed cohort or
with soap or syndet cleanser and water and then
case control analytical studies, preferably from more the professional should remove the remaining res-
than one center or research group idue with gauze soaked in alcohol, acetone, or
II-iii Evidence obtained from multiple-time series with Hoffman liquor with firm and continuous move-
or without the intervention; dramatic results in ment until reaching a clean and degreased skin.
uncontrolled experiments could also be regarded as this
type of evidence Depending on the number of passes and on the
III Opinions of respected authorities based on clinical strength of hand, it is also possible to remove the
experience, descriptive studies or reports of expert very superficial cells of stratum corneum. This is
committees important to promote a homogeneous peel
IV Evidence inadequate because of problems of penetration.
methodology (e.g., simple size or length of
To prevent inflammation around eyes, nose, or
comprehensiveness of follow-up or conflicts in
evidence) lips, a petrolatum or some other cream can be
Strength of recommendations applied before the procedure, mainly for peels
A There is good evidence to support the use of the containing salicylic acid. The hair should be cov-
procedure ered with a cap.
B There is fair evidence to support the use of the The peel substance can be prepared in different
procedure vehicles and are applied according to the prefer-
C There is poor evidence to support the use of the
ence of the professional, including gloved fingers,
procedure
D There is fair evidence to support the rejection of the
cotton swabs, or wooden objects (such as sticks
use of the procedure and tongue depressors). Thicker vehicle can be
E There is good evidence to support the rejection of the applied with gloves. Most formulations are pre-
use of the procedure pared in aqueous or hydro-alcoholic vehicle, and
for this reason cotton or gauze is preferred for the
application. For application, it is suggested to
5 days, starting 2 days prior to the treatment. divide the face into anatomical areas, starting the
Patient should sign the consent term in which all procedure on the frontal region, then malar and
the procedures including its benefits and risks nasal area, finalizing on the chin region.
are explained. Photographs before and after As we know, the depth of the peeling and its
treatment are useful to evaluate clinical effects inflammatory response depends on different fac-
and also to prove the patient the results, tors: the type and concentration of the chemical
avoiding possible complains regarding the substance; the amount of product (number of
procedure. passes); the pressure against the skin when
cleaning or applying the peel; and the period of
time that the skin is exposed to the chemical
Peeling Procedure substance, mainly when neutralization is neces-
sary to interrupt the effect. More aggressive pro-
The peel should be chosen according to the indi- cedure promotes more inflammation and
cation. However, as many superficial peels can subsequently can be responsible for a bad skin
promote similar clinical effect, usually the derma- recovery which is dangerous for dark skin.
tologists choose the peel in which they have more According to the patient tolerance, future peelings
experience to avoid side effects. We recommend can be stronger and the level of next peel can be
all previously mentioned substances, except tested before on a small hidden area (retro-
138 K. Conceição et al.
• Routine home treatment with bleaching agents Chun EY, Lee JB, Lee KH. Focal trichloroacetic acid peel
and topical photoprotection (chemical and method for benign pigmented lesions in dark-skinned
patients. Dermatol Surg. 2004;30(4 Pt 1):512–6; dis-
physical), as an adjuvant treatment, is funda- cussion 516.
mental to reach good results and to avoid Davis EC, Callender VD. Aesthetic dermatology for aging
complications. ethnic skin. Dermatol Surg. 2011;37(7):901–17.
Grimes PE. The safety and efficacy of salicylic acid chem-
ical peels in darker racial-ethnic groups. Dermatol
Surg. 1999;25(1):18–22.
References Khunger N, Sarkar R, Jain RK. Tretinoin peels versus
glycolic acid peels in the treatment of Melasma in dark-
Al-Waiz MM, Al-Sharqi AI. Medium-depth chemical skinned patients. Dermatol Surg. 2004; 30(5):756–60.
peels in the treatment of acne scars in dark-skinned Roberts WE. Chemical peeling in ethnic/dark skin.
individuals. Dermatol Surg. 2002;28(5):383–7. Dermatol Ther. 2004;17(2):196–205.
Been MJ, Mangat DS. Laser and face peel procedures in Rullan P, Karam AM. Chemical peels for darker skin types.
non-Caucasians. Facial Plast Surg Clin North Facial Plast Surg Clin North Am. 2010;18(1):111–31.
Am. 2014;22(3):447–52. Salam A, Dadzie OE, Galadari H. Chemical peeling in
Burns RL, Prevost-Blank PL, Lawry MA, Lawry TB, Faria ethnic skin: an update. Br J Dermatol. 2013;169
DT, Fivenson DP. Glycolic acid peels for post inflam- Suppl 3:82–90.
matory hyperpigmentation in black patients. A compar- Sarkar R, Bansal S, Garg VK. Chemical peels for melasma
ative study. Dermatol Surg. 1997;23(3):171–4; in dark-skinned patients. J Cutan Aesthet Surg. 2012;
discussion 175. 5(4):247–53.
Innovations in Superficial Chemical
Peels
Heloisa Hofmeister
Abstract Contents
Peelings are one of the oldest and most wide- Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
spread cosmetic procedures worldwide and History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
became very popular among dermatologists.
Basic Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Superficial chemical peels, also called
“refreshening peels” or “light peels,” are Indications and Contraindications . . . . . . . . . . . . . . . . 143
defined by the application of one or more Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
agents to the skin aiming a mild desquamation. Choosing the Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Superficial peelings are safe and suitable for Pre-peeling Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
the face and, some of them, also for any part of
Special Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
the body. In recent years several new superfi-
cial peelings were developed. They usually Agents of Peels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
combine alpha hydroxy acids or retinoic acid Jessner Solution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Tretinoin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
and other depigmenting agents. In this chapter TCA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
we are going to discuss peeling’s classification, AHAs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
its indications, the procedure, side effects, and Glycolic Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Lactic Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
its management.
Phytic Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Alpha-Keto Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Beta-Hydroxy Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Keywords Beta-Lipohydroxy Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Superficial chemical peels • Alpha hydroxy Thioglycolic Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
acids • Glycolic acid • Lipohydroxy acids • Combination of Peels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Beta-hydroxy acid • Fluor-hydroxy peels • Fluor-Hydroxy Peel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Photoaging • Melasma • Acne Salicylic-Mandelic Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Other Possible Combinations . . . . . . . . . . . . . . . . . . . . . . 149
Side Effects and Their Managements . . . . . . . . . . . . . 150
Take Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
H. Hofmeister (*)
Pontificia Universidade Católica do Rio de Janeiro, Rio de
Janeiro, RJ, Brazil
e-mail: [email protected]
and combinations of AHAs with appealing names the clinical-histological correlation which
to market not only the peeling agent but also the gives the right depth of action, and choose a
regimen of sunscreens and bleaches to be used good and safe peeling with good reproducibil-
concurrently (Brody et al. 2000). ity index.
We published the first Brazilian scientific arti- The ideal peeling is the one to produce the
cle on glycolic acid peels in Brazil in 1996 in the minor destruction with the induction of as more
Journal of the Brazilian Society of Dermatology. new collagen formation as possible.
A research with good clinical results with the use Some authors discriminate the peelings
of glycolic acid improved photoaged skin in the between very superficial (removing the stratum
clinical point of view either from the patient or corneum – depth 0.06 mm) and superficial
from the physician, with an increase in the amount (causing epidermal exfoliation of the granular
of type I collagen after a 6 month clinical trial layer until the basal layer – depth 0.45 mm).
using 10% glycolic acid at home with a 70% The depth of the peeling depends on several
glycolic acid peels at least monthly at the hospital factors: the substance used, its concentration,
(Hofmeister et al. 1996). the pH of the solution, the technique of appli-
At the end of the twentieth century, the fluor- cation, the pre-peeling preparation of the skin,
hydroxy peel was introduced. It combines and the time of application (Fischer et al.
5-fluorouracil with either glycolic acid or Jessner 2010).
solution to treat actinic keratosis. Traditionally the superficial peeling can make
The combination of substances has been the alterations in texture and pigment. The superfi-
trend in respect of superficial peels in recent years. cial peels are used to enlighten the skin, to
uniformize the color, and to diminish fine lines
and minimize large pores. It can be performed
Basic Concepts isolated or associated to other procedures, as
after microdermabrasion or non-ablative frac-
A peel is a medical process that uses a chemical tionated lasers.
substance on the surface of the skin in order to The superficial peeling, as any other peelings,
stimulate the turnover in the epidermis and in the stimulates the mechanisms of regeneration of
dermis. deep dermal layers. The destruction of the super-
ficial layers leads to a stimulation of the epidermal
“The peel is an act of stimulation!!” (Vigneron JLH, mitosis but also of the dermal mitosis by ways
24th EADV Congress, Copenhagen, 2015) studied during healing: chemical mediators such
as cytokines and stress proteins (HSP). It also
With chemical peelings you can choose the
facilitates the penetration of molecules during
level from sprucing up to radical renovation.
the peeling.
They are irreplaceable aid for aging skins. With
Superficial peels have very little or no
the skin peeling one can have:
downtime.
A rejuvenated appearance
A bright complexion, slightly pink Indications and Contraindications
A reduction in pigmented spots
A decreasing of wrinkles until smoothing Indications
An increased elasticity until a lifting effect
Photoaging: roughness, yellow stains, fine lines,
To be able to perform a peeling with safety, keratosis, and solar lentigines.
the physician must know the mechanism of Pigmentary disorders: melasma and post-
action of the agent of the peel, understand inflammatory hyperpigmentation.
144 H. Hofmeister
Acne: active inflammatory lesions and superfi- routine, and reapplied once or twice during the
cial/hyperchromic scars day depending on the radiation and sun
exposure.
Contraindications
Pregnancy, nursing patients, active herpes sim-
plex, hypersensitivity, and unrealistic patient Special Care
expectations.
Take pictures. Always!
The patient must be sitting at an angle of 45 , in
Choosing the Patient a comfortable position.
Avoid irritated or erythematous skin. Pay close
As in any other medical procedure, the choice of attention to the skin during the peel. Erythema
the right patient is very important. The derma- and/or frosting are common endpoints. Always
tologist must take into account skin color, skin have a Q-tip and saline solution ready to protect
type, and the degree of photoaging. But most of the eyes if needed.
all, the dermatologist must understand the As a general rule, a very superficial peeling
expectations of the patient. This is the key for ends with erythema; a superficial one ends in an
success! irregular erythematous frosting.
The expectations of the patient must be realis- Many superficial peels require neutralization.
tic. The more aggressive the acid, the deeper the Have the neutralizer always on hand.
peeling with better results but more complication
risks. In other words, the more superficial the
peeling, the safer with minor results. And the
patient must be aware of that. Agents of Peels
Superficial peels may be done in the face and
many of them in the body, in any phototypes. Jessner Solution
(face) or erythema is seen (body). It may be depressed area of the scar that produces multiple,
repeated weekly or every other week. frosted white spots on each acne scar. It is com-
Modified Jessner solution is a combination of monly associated with superficial or medium-depth
citric acid 8%, SA 17%, and lactic acid 17% in peels or with lasers. It is intended to thicken the
anhydrous ethanol qs 60 ml with a pH of 1.7 dermis with an enhancing in collagen production. It
(Safoury et al. 2009). has been proven effective even in dark complex-
ioned patients, including phototypes IV to VI.
Tretinoin
AHAs
All-trans retinoic acid is a synthetic vitamin A
analogue used as topical therapy for many skin
The alpha hydroxy acids are a group of organic
diseases. Khunger et al. compared 1% tretinoin
compounds that has a hydroxyl in the position
peel applied on one side of the face versus con-
alpha. AHAs are generally extracted from fruit
ventional glycolic acid peel applied to the other
and sugarcane; they are metabolites of the carbo-
side at weekly intervals for 12 weeks in the treat-
hydrate cycle and other important metabolic pro-
ment of melasma in phototypes III–V. Both
cesses. AHAs include glycolic, lactic, malic,
groups were comparable in the reduction of mod-
citric, tartaric, and mandelic acids, which differ
ified MASI score (Khunger et al. 2004).
in molecular weight and length of carbon chain.
In Brazil, tretinoin is applied in much higher
Glycolic acid is derived from the sugarcane and
concentrations. Five to 10% is applied as a mask
has two carbon atoms in its molecular structure.
for a period of 4–8 h. This allows for a gentle peel
Lactic acid, from the milk, has three carbon atoms
that lasts for 3–4 days and helps reduce pigmen-
in its molecular structure. Malic acid, from apples,
tary disorders and acne (Salam et al. 2013).
presents four carbon atoms. Tartaric acid, from the
It is also effective to reduce photoaging and striae.
grapes, has four carbon atoms, and citric acid,
As all superficial peelings, it must be done
from citric fruits, presents six carbon atoms in its
several times for better results.
molecular structure. Mandelic acid is derived
from almonds. The pyruvic acid is a keto acid
that physiologically is converted into its hydroxy
TCA version, the lactic acid, and vice versa.
All AHAs have one common characteristic when
Trichloroacetic acid has been used as a peeling in lower concentrations, as 5–15%. They diminish
agent for a long time and is still the most effective the cohesion strength of corneocytes, specially in
and safest agent for medium peeling, specially the lower portions of the stratum corneum.
when combined with Jessner solution. Its depth In higher concentrations (50–70%), AHAs
of penetration depends on the TCA concentration diminish the cohesion strength of the keratinocytes
and on the preparation of the skin, specially the and may even cause total epidermolysis and an
degreasing. Up to 20%, it is considered a superficial impact on papillary and reticular dermis being
peel according to the literature (Fischer et al. 2010). able to induce neocollagenesis.
The depth of the peel depends not only on the
concentration but also and mainly on the technique
of application. If the skin is perfectly degreased, I Glycolic Acid
would say 20% is much deeper than expected.
Cross technique (chemical reconstruction of The first AHA peeling agent was glycolic acid. It
acne scars) uses 90–100% TCA in a focal appli- is a small molecule that goes down easily to the
cation using a needle covered by cotton as a very dermis and stimulates without desquamation. It
thin Q-tip pressed down firmly over the entire has been shown that glycolic acid peels act by
146 H. Hofmeister
thinning the stratum corneum promoting the treatment of melasma. The usual concentra-
epidermolysis, dispersing basal layer melanin, tion is 85%, pH of 3.5% in hydroalcoholic solu-
and increasing collagen gene expression (Bern- tion (Sharquie et al. 2005, 2012).
stein et al. 2001). The first pilot study on lactic acid was done
In this peeling, the pH of the solution is very by Sharquie et al., who found it to be a safe and
important. Often, the use of the pH is very low and effective peeling agent for melasma in dark skin.
the limit between efficiency and burning is thin. In their study of 20 patients, 92% pure lactic
Glycolic acid peels are commercially available as acid was applied for a maximum of six sessions,
free acids, partially neutralized (higher pH), buff- and a significant fall in MASI (56%) was
ered, or esterified solutions. observed in all the 12 patients who completed
Glycolic acid is used in solutions at concentra- the study. Further, lactic acid was compared
tions varying between 25% and 70% and a pH with a well-established peeling agent, Jessner
between 1 and 3; tolerance is generally good. The solution in a split-face design, and similar
higher the concentration and the lower the pH, the improvement was seen on both the sides with
more intense the peeling will be (Fischer et al. no relapse at a follow-up after 6 months. These
2010). studies justify further experimentation with lac-
Its application is performed after degreasing tic acid as a peeling agent for dark skin (Sharkie
the skin, with the help of Q-tips, disposable et al. 2005).
brush, or gauze pads (Landau 2008). In my prac- A recent study showed patients with dark cir-
tice, I do prefer disposable brushes. cles around the eyes that were treated with chem-
The skin is covered by a thin film of the solu- ical peelings using 15% lactic acid (LA) in
tion and must be neutralized when erythema association with 3.75% TCA, both agents in low
begins, 2–4 min after. The physician must be concentrations, and found good results, with
observing closely, for the penetration may be brightening and improvement of the dark circles
deeper than expected, with undesired frosting (Vavouli et al. 2013).
that must be stopped immediately to avoid burn-
ing the skin. It can be neutralized by basic solu-
tions such as 1% sodium bicarbonate or water. Phytic Acid
Several sessions of peelings are required to
achieve better results. They can be used every Phytic acid is an AHA that has efficacy at low pH
other week or several weeks apart. As sessions and does not require neutralization. It has progres-
progress, the concentration of the solution used sive and sequential therapeutic action, in a non-
may be progressively increased depending on tol- aggressive manner. It does not cause a burning
erance and the results obtained after preceding sensation, does not need to be neutralized, and
sessions. after being applied is left until the following day.
Glycolic acid is keratolytic and has anti- Five or six sessions are required. It can be
inflammatory and antioxidant effects. repeated weekly or even twice weekly for a faster
effect. It is very safe and effective agent for the
treatment of melasma in darker skins (Yokomizo
Lactic Acid et al. 2013).
keratolytic, antimicrobial, and sebostatic proper- acne, as it is lipophilic and concentrates in the
ties as well as the ability to stimulate the formation pilosebaceous apparatus.
of new collagen and elastic fibers. Apart from It is applied after degreasing the skin. It
being effective for acne, photodamage, and super- immediately feels burning and stinging, and
ficial scarring, the agent has also shown benefit in white crystals of SA appear where the solution
a number of pigmentary disorders in light-skinned has been applied. The burning ceases within a
patients (Griffin et al. 1989). couple of minutes, as soon as the vehicle evap-
However, the intense burning associated with orates. After that the face is washed with water.
pyruvic acid has limited its frequent use as a Peeling begins 2 days post-peel and may persist
peeling agent for various conditions. Recently, a for 5–7 days.
study was conducted by Berardesca, who used a SA peels may be done at weekly sessions for
new non-erythematogenic formulation of pyruvic 6–8 weeks. It can also treat post-inflammatory
acid and assessed its efficacy and tolerability for hyperpigmentation, photoaging, and superficial
the treatment of photodamage, superficial scar- melasma.
ring, and melasma. It was seen that the new prep- It can be formulated in 95% ethyl alcohol and
aration showed significant benefit in all the three in this case may cause stinging, burning, redness,
conditions with no burning either during the peel and frosting, followed by crusting and pigmenta-
sessions or during the post-peel period tion of the treated area. The SA’s absorption is
(Berardesca et al. 2006). high and if done in large areas may cause salicy-
As all the studies have been conducted in late intoxication.
Fitzpatrick types II to IV, it remains to be It may also be formulated in polyethylene gly-
answered if the peel would do reasonably well col vehicle (SA-PEG) with minimal absorption of
when used on ethnic skin as well (Sarkar et al. SA with the same effectiveness (Dainichi et al.
2012). 2008).
In concentrations from 50% to 80% diluted in Still, it can also be used in higher concentra-
ethanol, the pyruvic acid penetrates the skin in tions in ointment (40–50%) for application in
1 or 2 min, and in spite of not having systemic upper limbs (Yokomizo et al. 2013).
toxicity may easily cause burning and scarring. Its
penetration is highly unpredictable, and the ery-
thema resulting from the treatment can last from Beta-Lipohydroxy Acid
15 days to 2 months. Pyruvic acid can treat pho-
toaging, acne, and superficial scars as all AHAs. It It is a peel that uses a lipophilic derivative of SA,
can decompose over time forming carbon dioxide lipohydroxy acid (LHA). It is used in 5% and 10%
gas and acetaldehyde; these vapors if inhaled may concentrations. The LHA molecule acts on the
be caustic and irritating to the upper respiratory corneosome/corneocyte interface to detach indi-
tract. Prevention is achieved using a fan during the vidual corneosomes cleanly. The corneosome is
application (Yokomizo et al. 2013). detached from adjacent corneocytes without frag-
mentation, suggesting that the LHA probably acts
on transmembrane glycoproteins. This action
Beta-Hydroxy Acid occurs at the compactum/disjunction interface
and does not affect keratin fibers or the corneocyte
Salicylic acid (SA) (ortho-hydroxybenzoic acid) membrane. LHA also stimulates renewal of epi-
is used in concentrations of 20–30% to obtain a dermal cells and the extracellular matrix, with an
superficial wounding of the skin specially in effect that is similar to the effect of the reference
patients with acne. It is a lipophilic agent and compound retinoic acid. In contrast to many other
produces desquamation of the upper lipophilic chemical peelings, LHA has a pH that is similar to
layers of the stratum corneum, with a keratolytic that of normal skin (5.5) and does not require
effect. It is the preferred treatment for comedonal neutralization (Fischer et al. 2010).
148 H. Hofmeister
Fig. 1 (a) Cimel Peeling. (b) Appling Cimel Peeling (Yellow Color) with Gloves. (c) Acid precipitation on top of the
inflamatory lesions
Innovations in Superficial Chemical Peels 149
Fluor-Hydroxy Peel ethnic skin because it prevents PIH. The main indi-
cations are acne, post-acne scars, and dyschromias,
5-Fluorouracil (5-FU) is very effective in the treat- including melasma (Garg et al. 2008).
ment of actinic keratoses (AKs). It inhibits RNA Mandelic acid is suitable for skins that are
and DNA synthesis and destroys hyper- sensitive to the other AHAs. Its molecule is big,
proliferative AKs. However, it leads to severe and so its penetration is very slow, causing no
erythema, local irritation, edema, and discomfort burning or stinging. Skin feels soft. It has a good
during almost all the treatment and post treatment capacity of neocollagenesis, increasing elastin
period, from 4 to 8 weeks. fibers and GAGs on the papillary dermis. Besides,
Glycolic acid with 5-fluorouracil is an espe- it has antibacterial and seborregulatory activities.
cially effective combination to treat actinic ker- The best vehicles are gel or mask.
atosis. It has been used in pulses of 70% glycolic It is a safe peel with comparable results with
acid immediately before the application of 5-FU glycolic acid for the treatment of melasma but
weekly for 8 weeks. It combines the keratolytic better tolerated and more suitable for Indian skin
and therapeutic effect of the glycolic acid with (Sarkar et al. 2016).
the efficacy of the 5-FU, the golden standard
treatment of actinic keratosis, without the usual
morbidity associated with the use of 5-FU alone Other Possible Combinations
in a non-pulse dosage (Marrero and Katz 1998).
Many different combinations are possible. The
final formulas will depend on the pharmacolog-
Salicylic-Mandelic Acid ical knowledge of the performing physician, the
indication of the peeling agent, and the patient.
This is a combination of a 20% SA that is a beta- Some of the possible peeling agents are listed
hydroxy acid with a 10% mandelic acid, an alpha below:
hydroxy acid. SA, which is lipophilic, penetrates
active acne lesions quickly, while the mandelic Peeling agents as:
acid that is one of the largest AHAs penetrates the Glycolic acid 0.2–30%
epidermis more slowly and uniformly, which is Lactic acid 5–25%
ideal for sensitive skins. It is especially useful for Citric acid 5–30%
150 H. Hofmeister
With depigmenting agents as: • Superficial peels are very important in any
Kojic acid 5–7% dermatologic practice. They are safe and cost-
Alpha-arbutin 2% effective and their results are fast. They
Azelaic acid 10–20% enlighten and make the skin more beautiful in
Hydroquinone 2–5% just some days.
• It is very important to know how to manage the
different superficial chemical peels.
• Combination of chemical agents (alpha hydroxy
Side Effects and Their Managements acids, retinoic acid, and depigmentant) is the
growing trend.
When done properly, superficial peelings • Basic dermatologic knowledge is the clue to all
are safe, and side effects and complications are peelings, even the more superficial. The physi-
rare. cian must take into account skin classification
Redness is common and may last for in terms of color, thickness, laxity, oiliness, and
several days. fragility.
Mild peeling is desirable and the patient must • A peel, even a superficial one, should not be
be aware of it. performed on a patient unless its skin is condi-
Hyperpigmentation is rare and may be caused tioned for at least 4–5 weeks with dermatologic
by undesired deepening of the peeling agent. It is treatment.
Innovations in Superficial Chemical Peels 151
in the course of recent years as a viable outpatient complications can be foreseen, prevented, and if
technique for skin restoration and also as a treat- they still happen, treated at the earliest. These
ment for an assortment of skin conditions patients include those with darker skin type with
(Schürer and Wiest 2006). A peeling procedure a propensity to develop postinflammatory hyper-
will consider the profundity of the targeted struc- pigmentation; with delicate skin or history of
ture and the skin state of the patient to choose atopic dermatitis; with dry skin and reddish rue;
among the variables, such as chemical class of with open air occupations; with history of photo-
the peeling agent, concentration, frequency, and sensitivity or postinflammatory hyper-
pressure of the application (Fischer et al. 2010). pigmentation; on photosensitizing drugs; with
Chemical peels are classified as superficial, history of keloids, poor healing (Fig. 1), or herpes
medium, and deep according to the depth of the infection; who have recently used isotretinoin;
peeling solution penetration (Landau 2008). Super- with unrealistic desires; uncooperative and fussy
ficial peels, which penetrate just the epidermis, can patients; and individuals who are mentally dis-
be utilized to improve treatment for an assortment of turbed (Anitha 2010).
conditions, including acne, melasma, dyschromias, Selection of the appropriate technique depends
and photodamage. Medium-depth peels, entering to on critical examination of the skin defect one
the papillary dermis, might be utilized for wishes to treat balanced against the risks of treat-
dyschromia, multiple solar keratoses, superficial ment. The final protocol should be individualized
scars, and pigmentary disorders. Deep peels, pene- for the needs of each patient (Matarasso and
trating to the reticular dermis, may be used for Glogau 1991). Despite the fact that complications
extreme photoaging, profound wrinkles, and scars can happen, the procedure is still important for
(Rendon et al. 2010). specific conditions of the skin that cannot be man-
Results and complications are related to the aged effectively by standard surgical procedures
profundity of the procedure. Despite the fact that (Litton and Trinidad 1981).
more evident results are obtained with deep-depth In order to avoid unpleasant situations in the
peels, the utilization of a medium-depth peel per- future, a detailed consent form should be taken
mit to acquire fabulous results with less risks than from every patient and pre-peel photography
deep peels (Camacho 2005). Prior to begin the under proper lighting is advised in all cases
peeling use as a routine method in your practice, (Anitha 2010). Besides, it is always safe to
comprehend that like all medical procedures, instruct the patient not to schedule an important
chemical peeling has numerous potential side event for at least 5 days after a superficial peel
effects.
Complications of chemical peelings might
happen even though a controlled chemical
wound has been induced. The physician must be
absolutely acquainted with the sorts of peels and
the administration of postoperative injury care
based on the skin type of the patient (Brody
2001). Complications are more frequently seen
in darker skin types, certain peeling agents, and
sun exposure (Nikalji et al. 2012). They can vary
from minor irritations, uneven pigmentation to
long-lasting scarring. In extremely unusual
cases, complications can be life threatening. This
knowledge is crucial to prevent and decrease the
occurrence of complications. Fig. 1 Poor wound healing. Over 6 weeks to
The initial step in avoiding complications is to reepithelialization after TCA 25% procedure in the poste-
recognize the patients at danger, so that rior region of the thigh (area with less follicular structures).
Managing Chemical Peels Complications 155
Table 1 Common complications of all peel type treatment. Intralesional, oral, or intramuscular ste-
Persistent Erythema Telangiectasia roids can be used in cases with no response. Per-
Ocular injuries Infection sistent erythema has a tendency to respond well
Swelling Herpes recurrence with intense pulsed light or pulsed dye laser
Pain and burning Milia devices (Tung and Rubin 2011).
Pruritus Demarcation lines Setting expectations before the procedure is
Folliculitis/acne Skin textural changes mandatory, as patients will appreciate being
Allergic reactions Hypopigmentation informed of what to expect in the postpeel period
Blistering Hyperpigmentation (Levy and Emer 2012).
Ecchymosis Scarring
• Ocular Injuries
(Khunger 2009), 20 days after a medium-depth
Unintentional spillage of any chemical peel
peel, and 30 days after a deep-depth peel.
agent in the eyes can prompt corneal harm, so it
Most important complications are displayed in
is essential for the doctor to be truly cautious when
Table 1.
peeling around the eye. If an inadvertent spillage
happens, the eyes should be rinsed with saline to
prevent corneal harm. If phenol peels have been
Possible Complications in Peels of All
used, flushing should be done with mineral oil
Types
rather than saline (Nikalji et al. 2012).
An approach to avoid this complication is to
• Persistent Erythema
have a cotton tipped applicator for quick removal
of tears close to the lashes and a syringe filled with
Erythema is normal after all types of peels, but
saline in case of an accident with the acid solution
persistent erythema is a consequence of angio-
inside the eyes (Tung and Rubin 2011). An oph-
genic variables stimulating vasodilation, which
thalmologist should be consulted in these cases.
indicates that the fibroplasia is being stimulated
Cases of cicatricial ectropion have been
for prolonged period of time. Thus, it can prompt
reported in phenol-peeled patients, and lower eye-
skin thickening and scarring (Nikalji et al. 2012).
lid ectropion has reportedly occurred in patients
Some known reasons for persistent erythema are
undergoing deep-eyelid peel in conjunction with a
the utilization of topical tretinoin just prior and after
blepharoplasty (Dailey et al. 1998). The pre-
the procedure, oral isotretinoin administration pre-
disposing factors are older patients with senile
ceding the peel, alcoholic beverages ingestion(Spira
lid laxity, patients who have experienced previ-
et al. 1974), contact dermatitis, contact sensitization,
ous transcutaneous blepharoplasty, and patients
and some previous skin conditions (rosacea, atopic
with flimsy skin (Nikalji et al. 2012). Most of the
dermatitis, lupus erythematosus).
time, this complication is self-limited and does
Medium and deeper peels have more promi-
not need specific treatment, just conservative
nent and long-lasting erythema. Erythema nor-
care (massaging of lower lid skin, adequate
mally vanishes in 3–5 days in superficial peel,
taping of the eyelid, especially at night and
15–30 days in medium peel, and 60–90 days in
protection of the globe with artificial tears)
deep peel (Monheit 2004). If it continues after the
(Mendelsohn 2002).
time expected, it should be evaluated since there is
a chance of scar development.
Persistent erythema must be dealt with as soon • Swelling
as it is diagnosed with strong topical steroids for
1–2 weeks, hats and sunscreens and continued All agents used in peels are possible to cause
emollients. Sometimes, cosmetic cover can be swelling, although it happens more often in
utilized to diminish the erythema during deeper peels. The edema is expected and appears
156 I.M.C. Costa et al.
after the procedure (Gadelha and Costa 2009). It is demonstrated that peeled skin comes back to its
the most common complication of trichloroacetic baseline status within 2–6 months without main-
acid peeling, and it can be persistent if treated tenance therapy. The patient should utilize wide-
improperly. It is additionally important to deter- range (ultraviolet A and B) sunscreens previously
mine through the wood lamp the level of pigmen- and after the peels indefinitely and have strict sun
tation. In superficial peels, complications usually avoidance. The suspension of conception preven-
are transient hyperpigmentation or dyschromia, tion pills during pre-peel period is critical because
particularly in dark-skinned patients (Gadelha it may invoke pigmentary changes.
and Costa 2009) (Fig. 3). Temporary highlighting
of lentigines and nevi may occur since the existing • Scarring
sun harm nearby these lesions has been cleared.
High-risk groups are types III-VI skin, types I Scars are the most feared complications and
and II skin following intense sun exposure and they normally develop 2–3 months after the peel
tanning, utilization of photosensitizing agents, (Gadelha and Costa 2009). Physicians must alert
early exposure to sunlight without adequate patients of its possibility before the procedure and
broad-spectrum sunscreens, and utilization of should also be aware of patients in higher risk of
estrogen-containing medicines, such as oral con- developing scarring. Persistent erythema can
traceptives and hormone-replacement therapy anticipate early scarring. Although it is an unusual
(Nikalji et al. 2012). In patients with a past of complication in chemical peelings, it is the hardest
hyperpigmentation from other skin lesions, there one to manage. Fortunately, scars with some level
is a greater risk of developing postinflammatory of hypertrophy are more common than keloids,
hyperpigmentation and a test spot area must be contractures, atrophy, and necrosis (Gadelha and
done prior to full-face procedures in these Costa 2009). Hypertrophic scars and contractures
individuals. affect the function and movement of the face,
Patients that become pregnant in 6 months after therefore surgical interventions associated with
the peel also have increased risk of this complica- multiple treatments to minimize the issue are fre-
tion, even when sun avoidance is done. The preg- quently necessary. The risk of hypertrophic scar-
nant ones with darker skin may be treated to avoid ring from medium-depth peels is not common, but
postinflammatory hyperpigmentation for up to if it happens, it is normally found in the mandib-
1 year postoperatively (Tung and Rubin 2011). ular line, perioral, cheekbones, jaw, inner corner
Hydroquinone 4–6% is the most utilized treat- of the eyelids, and areas of excessive movement
ment for hyperpigmentation and it can be associ- of the face (Gadelha and Costa 2009). The highest
ated with tretinoin to enhance the bleaching effect frequency of scars in the lower third of the face are
when the skin is healed (Tung and Rubin 2011). If related to the movement for talking and eating and
the patient is oversensitive to hydroquinone, other also related with the highest frequency of inter-
alternatives of treatment are vitamin C, kojic acid, vention in this area. Keep in mind that the neck,
and azelaic acid. In some cases, a superficial peel suprasternal and submental areas are inclined to
(glycolic acid, 30–40%) is utilized to speed the develop hypertrophic scars (Gadelha and Costa
outcome. If there is a preexisting hyper- 2009). Atrophy is uncommon in phenol peeling,
pigmentation, adequate preparation of the skin and trichloroacetic acid (TCA) is more likely to
for no less than 2–4 weeks preceding peel and produce scarring than phenol because it is more
discontinuing 3–5 days before the procedure is caustic (Figs. 4 and 5).
of vital importance (Tung and Rubin 2011; Levy If the patient has a background marked by poor
and Emer 2012). Priming is done by application of injury healing, keloid or hypertrophic scar forma-
a depigmentation agent like hydroquinone or tion, excessive actinic damage, or is undergoing a
retinoic acid. deep peel, he has a greater chance of developing
For more enduring results, a good skin care scarring. Skin of the neck, dorsal hands, and chest
regime is important, since studies have cannot undergo peeling without the risk of
Managing Chemical Peels Complications 161
Fig. 3 Hyperchromic
stains and spots after
30 days post medium-depth
peel application (Jessner +
TCA35%). Second image
show the final result after
retinoic acid plus
hydroquinone treatment
scarring because it does not have enough follicu- and steroid impregnated tape can be useful in
lar structures. Physicians must be careful to not softening firm scars. Intense pulse light and
re-peel an area that has been peeled little time ago pulsed dye lasers devices are helpful to improve
and that have not had sufficient time to recuperate. red scars. Surgical corrections can be done only
Other predisposing factors are history of after a minimum period of 6 months (Gadelha and
smoking, recent facial surgery, recent ablative Costa 2009).
resurfacing procedures (including dermabrasion
or laser within 6 months of procedure) (Singh-
Behl and Tung 2008), numerous applications of Complications with Specific Peeling
TCA, and medium-depth peels on regions like Agents
mandible, neck, and chest. Since the TCA is
more likely to penetrate deep into the reticular Although rare, toxicity may occur with resorcinol,
dermis, thin-skinned patients are more inclined salicylic acid, and phenol (Khunger 2008).
for scarring. Some authors have theorized that
patients recently treated for hair removal with • Salicylism
lasers might experience difficulty healing after
medium- or deep-depth peels since If a great amount of salicylic acid is absorbed,
re-epithelialization happens from adnexal struc- it can have toxic effects as tinnitus, nausea,
tures (Nikalji et al. 2012). The utilization of iso- vomits, deep and rapid breaths, gastrointestinal
tretinoin is also connected to delayed wound irritation, and even stroke. Since it is utilized in
healing and amplified rate of scarring. A patient Jessner’s and Combe’s formulas, which are of
using this treatment should wait at least 6 months general use, patients should be cautioned of the
to undergo a medium- or deep-chemical peel symptoms and oriented to not take an excessive
(Tung and Rubin 2011). amount of aspirin, since it can have synergistic
The first indications of scarring are persistent effects (Tung and Rubin 2011).
erythema, pruritus, and postponed healing (taking
over 2 weeks to reepithelialize). If it happens, • Resorcinism
patient should have immediate treatment with
high-potency topical steroid, without forgetting Resorcinol has ¼ of the strength of phenol and
that atrophy and telangiectasias are risks of pro- should not be applied in large areas such as the
longed utilization of steroids. If the skin takes over back (Tung and Rubin 2011). The physician should
2 weeks to re-epithelialize, there must be a pushy limit the concentration of this agent in the peel
intervention with biologic dressings and antibi- because, if it is over applied, it can prompt systemic
otics (Tung and Rubin 2011). If scars appear, the toxicity that can be seen as different degrees of
best management is with intralesional injections nausea, vomits, diarrhea, pallor, cold sweat,
of steroids (triamcinolone 10–40 mg/cc). Mas- tremors, dizziness, drowsiness, headache, brady-
sage, silicone gel sheet, compression over time, cardia, paralysis, shortness of breath, diaphoresis,
162 I.M.C. Costa et al.
Fig. 4 Scars after 40 days of medium-depth peel (Jessner Fig. 5 Scars after 6 months of TCA 50% procedure
+ TCA 35%)
and nervousness (Tung and Rubin 2011). Contin- (Spira et al. 1974). It can lead to arrhythmias
uous use of resorcinol can lead to myxedema since despite the fact that there was previous normal
it has an antithyroid activity. Repeated applications heart function. The occurrence of arrhythmias is
should be applied with caution in low body weight disconnected to age, sex, or the utilization of
patients (Nikalji et al. 2012). saponified or nonsaponified formulations. Thirty
minutes time after a phenol peel, the patient can
• Phenol Toxicity complain of tachycardia followed by premature
ventricular contractions, bigeminy, paroxysmal
Phenol has hepatic metabolism and renal atrial tachycardia, and ventricular tachycardia
excretion, being harmful when utilized in high (Nikalji et al. 2012). Some patients progress to
doses. From 20 to 25% of the amount absorbed atrial fibrillation (Velasco et al. 2004; Truppman
by the liver is conjugated to glucuronic acid and and Ellenby 1979). In order to prevent complica-
sulfuric acid and then excreted. Seventy to 80% of tions, phenol peels should not be applied in wide
phenol absorbed is excreted in urine within areas. Regional phenol peel associated with a
15–20 min after application. Therefore, when medium-depth peel in the other regions of the
using phenol peeling, the face is divided into at face is more secure than applying phenol in the
least five regions. Thus, applying the product in entire face.
each region with 15 min time interval, so that the Landau et col. observed that the occurrence of
concentration absorbed is eliminated in urine, cardiac complications in properly performed deep
without causing cardiac problems (Glogau and chemical peeling was lower than previously
Matarasso 1995; Stuzin 1998). To raise phenol appreciated. From a total of 181 patients who
excretion and minimize systemic complications, have been treated during the study period, in
patients are hydrated with intravenous fluids and 12 patients (6.6%) cardiac arrhythmia has been
followed with cardiac monitoring (Gross 1984). recorded during the procedure. Cardiac arrhyth-
Cardiotoxicity is the most seen systemic effect mia was more frequent in patients with diabetes,
caused by phenol peeling and the higher the dose hypertension, and depression according to this
is, the more systemic effects are likely to appear study (Landau 2007).
Managing Chemical Peels Complications 163
Dmytryshyn JR, Gribble MJ, Kassen BO. Chemical face Mendelsohn JE. Update on chemical peels. Otolaryngol
peel complicated by toxic shock syndrome. A case Clin N Am. 2002;35(1):55–71.
report. Arch Otolaryngol. 1983;109:170–1. Monheit GD. Chemical peels. Skin Therapy Lett.
Fischer TC, Perosino E, Poli F, Viera MS, Dreno B, Cos- 2004;9:6–11.
metic Dermatology European Expert Group. Chemical Nikalji N, Godse K, Sakhiya J, Patil S, Nadkarni
peels in aesthetic dermatology: an update 2009. J Eur N. Complications of medium depth and deep chemical
Acad Dermatol Venereol. 2010;24:281–92. peels. J Cutan Aesthet Surg. 2012;5(4):254–60.
Gadelha AR, Costa IMC. Dermatologia cirurgia Rendon MI, Berson DS, Cohen JL, Roberts WE, Starker I,
dermatológica. 2nd ed. São Paulo: Atheneu; 2009. Wang B. Evidence and considerations in the applica-
Glogau RG, Matarasso SL. Chemical Peels. Dermatol tion of chemical peels in skin disorders and aesthetic
Clin. 1995;13(2):263–74. resurfacing. J Clin Aesthet Dermatol. 2010;3
Gross BG. Cardiac arrhythmias during phenol face peel- (7):32–43.
ing. Plast Reconstr Surg. 1984;73:590–4. Schürer NY, Wiest L. Chemical peels. Hautarzt. 2006;57
Khunger N. Standard guidelines of care for chemical peels. (1):61–76. quiz 77.
Indian J Dermatol Venereol Leprol. 2008;74:5–12. Singh-Behl D, Tung R. Chemical peels. In: Alam M,
Khunger N. Complications. In: Step by step chemical Gladstone HB, Tung RC, (eds). Requisites in Derma-
peels. 1st ed. New Delhi: Jaypee Medical Publishers; tology: Cosmetic dermatology. Philadelphia, PA:
2009. p. 280–97. Elsevier Ltd; 2009:83.
Klein DR, Little JH. Laryngeal edema as a complication Spira M, Gerow FJ, Hardy SB. Complications of chemical
of chemical peel. Plast Reconstr Surg. 1983; face peeling. Plast Reconstr Surg. 1974;54:397–403.
71(3):419–20. Stuzin JM. Phenol peeling and the history of phenol peel-
Landau M. Cardiac complications in deep chemical peels. ing. Clin Plast Surg. 1998;25(1):1–8.
Dermatol Surg. 2007;33:190–3. Truppman ES, Ellenby JD. Major electrocardiographic
Landau M. Chemical peels. Clin Dermatol. 2008;26:200–8. changes during chemical face peeling. Plast Reconstr
Levy LL, Emer JJ. Complications of minimally invasive Surg. 1979;63:44.
cosmetic procedures: prevention and management. J Tung RC, Rubin MG. Procedures in cosmetic dermatology
Cutan Aesthet Surg. 2012;5(2):121–32. series: Chemical Peels. St Louis, MO. 2nd Ed.
Litton C, Trinidad G. Complications of chemical face Saunders Elsevier. 2011.
peeling as evaluated by a questionnaire. Plast Reconstr Uday K, Sushil P, Nischal K. Sunscreens. In: Handbook of
Surg. 1981;67:738–44. dermatological drug therapy. 1st ed. New Delhi:
LoVerme WE, Drapkin MS, Courtiss EH, Wilson Elsevier; 2007. p. 299–304.
RM. Toxic shock syndrome after chemical face peel. Velasco MVR, Okubo FR, Ribeiro ME, Steiner D, Bedin
Plast Reconstr Surg. 1987;80:115–8. V. Rejuvenescimento da pele por peeling químico:
Matarasso SL, Glogau RG. Chemical face peels. Dermatol enfoque no peeling de fenol. An Bras Dermatol.
Clin. 1991;9(1):131–50. 2004;79(1):91–9.
My Personal Experience with
Chemical Peels
Abstract Contents
The last decades have been marked by the fast Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
expansion of innovative technology. The asso- Basics of Chemical Peeling . . . . . . . . . . . . . . . . . . . . . . . . . 166
ciated strong industry marketing recently dom- Chemistry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
inated the realms of procedural dermatology. Chemical Agent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Chemical peels have no marketing except the Concentration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
pH and Temperature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
few “patented commercial formulas” that try to Vehicle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
find their place in the dermatologic practice. Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
The concepts and techniques written in this Sebum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
chapter are intended to be read by officially Phototype . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
certified dermatologists. Many workshops are Applicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
done regularly during academy and society Feathering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
meetings, and the hands-on experience is the Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
unique way of proper learning. Every medical Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
intervention has its learning curve, and it is
ethical to start the learning curve with super- Indications for Chemical Peels . . . . . . . . . . . . . . . . . . . . 171
vised training such as medical residency. Learning Chemical Peeling . . . . . . . . . . . . . . . . . . . . . . . . 171
May this chapter build enthusiasm to those
Take Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
initiating the practice of chemical peels and
also bring joy to the experienced peelers. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Keywords
Photodamage • Photoaging • Chemical peels • Introduction
Pyruvic acid • Croton oil • Trichloroacetic
acid • Acne • Acne scars • Salicylic acid • As in any form of art, it is not easy to reproduce
Lactic acid • Retinoic acid • Jessner’s solution • exact strokes and movements done by a different
Modified Jessner’s solution • Glycolic acid artist. The same happens when applying chemicals
to the skin. It is much easier to reproduce results
defined by numbers such as when using LASER,
such as number of passes at a specific pulse dura-
C.G. Wambier (*) tion, spot size, density, and fluency. There is no
Department of Medicine, State University of Ponta Grossa, way to predict the exact volume of liquid in a pass
Ponta Grossa, PR, Brazil
of cotton-tipped applicator or brush and if the exact
e-mail: [email protected]
Chemistry
The main determinant of the final result is the The strength of the solution is determined by the
chemical nature of the peeling agent itself. Some concentration and so are the expected results. How-
peeling agents interact with skin biology and are ever, in some scenarios “less is more”; this means
involved in biochemical and pharmacological that there may be one exact concentration to an
actions beyond the physicochemical action (spe- expected effect. Overconcentration may incur in
cially those derived from natural sources), that is, adverse effects or more pronounced side effects.
My Personal Experience with Chemical Peels 167
All solutions have a saturation point, which is Balance and health should be goals for skin
the maximum concentration at a given tempera- preparation before chemical peels.
ture and vehicle. Some peels are used in an over-
saturated solution or “suspension” intended to
further interact with the skin, as a “leave in” for Sebum
some hours.
Stronger effects occur with higher percentage The skin has its own defense mechanisms against
of the agent. natural chemical agents. One of the most impor-
tant is the lipid layer. It dissolves and attenuates
soluble agents and efficiently repels hydrosoluble
pH and Temperature agents. Therefore, it is important to remove oil
from the skin before applying chemical peels.
Some solutions exhibit different penetration in the There are many efficient ways. The most efficient
skin at different pH and temperature, so it is way is to wash the face with a detergent and rinse
important to control both the pH and temperature well. After that, rub mildly but firmly a soaked
of the final solution. Some solutions crystalize pad with acetone, ethanol, or ether–ethanol solu-
upon refrigeration. tion in the skin, especially in sebaceous areas such
Stronger effects occur with lower pH and as the nose, eyebrows, cheeks, forehead, and chin.
higher temperatures of the solution. The agents mostly affected by the skin oils are
TCA and glycolic acid, which are hydrophilic
aqueous solutions.
Vehicle Areas with increased sebum production heal
faster and are thicker. Those are the areas that
Vehicles may evaporate during the procedure, need extra penetration of the chemical agent for
causing a self-limited exposure to the solution, uniform results.
or may provide penetration of the solution in the Try not to irritate the skin during degreasing to
skin. Some vehicles provide occlusion effect with prevent hot spots, especially on superficial peels.
extra penetration of the agents. Some vehicles Beware of seborrheic dermatitis or any other der-
dissolve oil in the skin. matitis before peeling with superficial agents.
Stronger effects occur with oily and solvent Skin inflammation causes hot spots and may hurt
vehicles. when using the degreasing agent, which may
focally increase skin irritation.
Always degrease in the same way for every
Skin peeling agent. So you can vary penetration during
the application of the agent.
The skin of each patient should be treated as a Stronger effects occur in non-oily skin.
mildly modifiable ambient. Some pretreatment
regimens can affect results and therefore should
be prescribed in advance. Phototype
The ideal skin for chemical peels in general is
healthy, soft, young, non-oily, phototypes I–II, Some chemical peels such as phenol peels are not
without irritations on the procedure day. Some of recommended for high phototypes (>IV) due to
these characteristics can be acquired by directed the high possibility of persistent dichromic mac-
treatments as a pretreatment regimen. Beware that ules and scar formation. Luckily, in real life, these
skin irritation may induce hot spots and adverse patients do not present with complaints that would
effects of peelings. Careful examination is man- require deep chemical peeling. Post-inflammatory
datory before every peel. Postpone the procedure hyperpigmentation (PIH) occurs more frequently
if needed. on intermediate phototypes (III/IV).
168 C.G. Wambier
Application
not symmetrical, it can be used on different angles Fingers with gloves are used for thick peels,
to confer different surfaces for applications, making such as gels, creams, and pastes, as an alternative
it a very versatile, spatula-like applicator. to spatulas.
Wooden toothpicks are excellent for CROSS
and for application in deep wrinkles around the
eyes or mouth. Feathering
Glass capillary tubes (hematocrit tube) are
thinner than the inside tube of a Q-Tip. This can be To avoid demarcation of the treated areas, it is
used for TCA CROSS in deep ice picks, since the always good to use the same solution in a light
liquid is expelled only by the very tip of the tube. manner around it, to cause a smooth look.
400 400 cotton gauzes have an advantage of The best way to feather the application is to use
causing a mild abrasion while peeling. They the same applicator, after the whole procedure has
should be folded in half twice to reduce surface been done, when it is semidry, in fast motions,
area and increase precision. There is no need to
cut them into small pieces. These work great for
TCA application. Table 1 List of conditions with medical indications for
chemical peels
Sponges these can be used in many different
ways intended to cause mild to moderate abrasion First
Condition choice Alternative choices
during peels. The green part of the sponge can be
Acne I–II SA–RA SA, RA, JS, MJS, TCA
used during TCA peeling for severe acne scars, 10–20%, PA
allowing deeper penetration in the scar areas. Acne III PA SA, RA
Acne scars J+TCA MJS+TCA, SA + TCA
(mild) 30%, CO2+TCA
Acne scars PC J+TCA+CROSS, CO2
(severe) +CROSS +TCA
Actinic PA+TCA J+TCA+5-FU,
keratoses +5-FU GA+5-FU
Actinic cheilitis PC TCA
Blepharopeeling PC MJS–TCA, TCA,
J+TCA
Keratosis pilaris PA+RA SA+RA
Lentigines/ J+TCA MJS+TCA, SA-RA
ephelides
Melasma MJS TCA, SA, RA, PA
Melasma MJS+TCA Phenol–castor oil
(refractory)
PIH MJS+TCA MJS, TCA, SA, RA
Rosacea TCA SA
Striae TCA+RA PA–RA
Superficial SK TCA PA–TCA, PC
Verruca plana PA+TCA J+TCA
Wrinkles PC J+TCA, PA, CO2
(superficial) +TCA
Wrinkles (deep) PC CO2+TCA
Xanthelasma PC TCA
5-FU 5-fluoruracil, CROSS chemical reconstruction of
skin scars, GA glycolic acid, MJS modified Jessner’s solu-
tion, JS Jessner’s solution, PA pyruvic acid, CO2 Solid
carbon dioxide, PC phenol–croton, PIH post-inflammatory
Fig. 3 Phenol-croton oil peeling. “El Zorro” mask with hyperpigmentation, RA retinoic acid, SA salicylic acid,
perfect feathering SK seborrheic keratosis, TCA trichloracetic acid
170 C.G. Wambier
Removal
Setting
Safety
The peeling room should have air-conditioning
for setting a standard on humidity and tempera- The peeling room should be equipped with oxy-
ture. On the phenol peels, it is important to also gen, medical equipment, and medications for
My Personal Experience with Chemical Peels 171
Fig. 6 Phenol-croton oil peeling rejuvenates the skin more naturally than lasers, and fillers combined. Two-months post-
operative picture
Learning Chemical Peeling The best way of learning how to apply chem-
ical peels to the daily practice is by learning with
Although chemical peeling was traditionally done an experienced physician in formal supervised
by lay peelers, medicine has evolved, and derma- medical training, such as medical residency
tology and plastic surgery have embraced chemi- (Fig. 7). Textbooks may sparkle the interest and
cal peelings as routine procedures, with emphasis give formal guidelines for practical conduct, but
on scientific method for proper knowledge and in no way, it substitutes eye-to-eye, hands-on
teaching of chemical peeling techniques. teaching, as in any other surgical procedure.
172 C.G. Wambier
Fig. 8 Fourth
postoperative day of
medium depth peeling
Proper training not only creates the right set of Cucé LC, Bertino MCM, Scattone L, Birkenhauer MC.
knowledge to precisely indicate each chemical Tretinoin peeling. Dermatologic Surg. 2001;
27(1):12–4.
peel but also builds the visual memory of what is Dainichi T. Paradoxical effect of trichloroacetic acid
expected for each postoperative day of each (TCA) on ultraviolet B-induced skin tumor formation.
chemical peel. So as the physician can act on J Dermatol Sci. 2003 May;31(3):229–31.
any collateral or adverse effect caused by the Dainichi T, Ueda S, Imayama S, Furue M, Ainichi TED,
Eda ÃSEU, et al. Excellent clinical results with a new
peeling procedure (Fig. 8). preparation for chemical peeling in acne: 30% salicylic
acid in polyethylene glycol vehicle. Dermatol Surg.
2008;34(7):891–9; discussion 899.
Take Home Messages Hengge UR, Ruzicka T, Schwartz RA, Cork MJ. Adverse
effects of topical glucocorticosteroids. J Am Acad
Dermatol. 2006;54(1):1–18.
• Chemical peels are diverse and require proper Imayama S, Ueda S, Isoda M. Histologic changes in the
training. skin of hairless mice following peeling with salicylic
• Adequate technique is mandatory for handling acid. Arch Dermatol. 2000 Nov;136(11):1390–5.
Ivanov II, McKenzie BS, Zhou L, Tadokoro CE,
and application. Lepelley A, Lafaille JJ, et al. The orphan nuclear recep-
• Despite innovative technology, chemical peels tor RORgammat directs the differentiation program of
are still regarded as the most effective proce- proinflammatory IL-17+ T helper cells. Cell. 2006
dures for severe photodamage and acne. Sep;126(6):1121–33.
Khunger N, Sarkar R, Jain RK. Tretinoin peels versus
glycolic acid peels in the treatment of Melasma in dark-
skinned patients. Dermatol Surg. 2004;30(5):756–60;
References discussion 760.
Marczyk B, Mucha P, Budzisz E, Rotsztejn H. Comparative
Caperton C, Valencia O, Romanelli P, Fulton J. Pyruvic study of the effect of 50% pyruvic and 30% salicylic
acid facilitates the removal of actinic keratoses and peels on the skin lipid film in patients with acne vulgaris.
seborrheic keratoses. Dermatologic Surg. 2012; J Cosmet Dermatol. 2014;13(1):15–21.
38(10):1710–5. Nolting J, Daniel C, Reuter S, Stuelten C, Li P, Sucov H,
Cotellessa C, Manunta T, Ghersetich I, Brazzini B, Peris K. et al. Retinoic acid can enhance conversion of naive
The use of pyruvic acid in the treatment of acne. J Eur into regulatory T cells independently of secreted cyto-
Acad Dermatol Venereol. 2004;18(3):275–8. kines. J Exp Med. 2009;206:2131–9.
Part III
Physical Procedures in Cosmetic
Dermatology
Percutaneous Collagen Induction with
Microneedles
Fig. 1 Patient 60 days after TCA 35% associate to abrasion to treat acne scars
Fig. 2 Patient 60 days after TCA 35% associate to abrasion to treat wrinkles and laxity
life. Microneedling relies on the principle of neo- production. Based on the same principle of rup-
collagenesis, with the benefits of not causing the turing and removing damaged subepidermic col-
total de-epithelization observed in ablative lagen and subsequently replacing it with new
techniques. collagen and elastin fibers, other authors con-
firmed this initial study. More recently, a system
of microneedles applied to the skin was proposed,
Fundamentals of PCIM with the objective of generating multiple micro-
punctures, long enough to reach the dermis and
Orentreich and Orentreith (Orentreich and cause bleeding, triggering inflammatory response
Orentreich 1995) coined the term subcision to that induces collagen production (Camirand and
describe the subcutaneous incisionless surgery Doucet 1997; Fernandes 2006).
using hypodermic needles for treating depressed The percutaneous collagen induction (PCI), as
scars and wrinkles, aiming to stimulating collagen the technique has been called, begins with loss of the
Percutaneous Collagen Induction with Microneedles 177
Fig. 3 Patient 30 days and 60 days after procedure presenting dyscromias and persistent erythema
cutaneous barrier integrity (causing keratinocyte needle must reach a depth of 1–3 mm, and the
dissociation), resulting in release of cytokines such epidermis must be preserved (only perforated and
as interleukin-1α (predominantly), interleukin-8, not removed). Hundreds of microlesions are cre-
interleukin-6, TNF-α, and GM-CSF and leading to ated, resulting in columns of blood collected in the
dermal vasodilation and migration of keratinocytes, dermis, accompanied by edema of the treated area
a process that restores the epidermal damage (Bal and virtually immediate hemostasis. The intensity
et al. 2008). For didactic purposes, three stages of of these reactions is proportional to the length of
the healing process following trauma with needles the needle used in the procedure. For instance, a
can be clearly delineated. The first stage (injury 1 mm depth entails an almost microscopic hema-
stage) is characterized by the release of platelets toma, while that resulting from a 3 mm depth can
and neutrophils (which are responsible for releasing be seen with the naked eye and can persist for
growth factors that act on keratinocytes and fibro- hours. Nonetheless, it is necessary to understand
blasts, such as transforming growth factors α and β that the needle does not penetrate completely dur-
(TGF-α and TGF-β), platelet-derived growth factor ing the rolling process. It is estimated that a 3 mm
(PDGF), protein III (activator of connective tissue), long needle penetrates only 1.5–2 mm (or roughly
and connective tissue growth factor). In the second 50–70% of its total length). Therefore, with a
stage (healing stage), neutrophils are replaced by 1 mm long needle, the injury caused to the skin
monocytes, and angiogenesis, epithelialization, and would be limited to the superficial dermis,
fibroblast proliferation take place, followed by the resulting in a more limited inflammatory response
production of type III collagen, elastin, glycosami- than that caused by a longer needle (Aust 2008b;
noglycans, and proteoglycans. Concomitantly, Fabroccini and Fardella 2009; Lima et al. 2013;
fibroblast growth factor, TGF-α, and TGF-β are Vasconcelos et al. 2013; Lv et al. 2006;
secreted by monocytes. Roughly 5 days after the Vandervoort and Ludwig 2008).
injury inflicted, the fibronectin matrix is completely
formed, allowing the deposition of collagen directly
beneath the basal layer of the epidermis. In the third Characteristics of PCIM
stage (maturation stage), type III collagen, which is
prevalent in the early phase of the healing process, is The device used to perform PCIM comprises a
slowly replaced by type I collagen (which lasts polyethylene roll studded with sterile stainless
longer and persists for a period ranging from 5 to steel needles symmetrically aligned in rows, total-
7 years) (Fernandes and Massimo 2008; Aust izing around 190 units (a number that may vary
2008a, b). depending on the manufacturer). The length of the
In order for this inflammatory sequence of needles is fixed throughout the structure of the roll
events to take place, the trauma caused by the and varies from 0.25 to 2.5 mm, according to the
178 E. Lima et al.
Fig. 4 Correlation
between the length of
needles and penetration
into skin
model. The procedure is usually well tolerated not be strong to avoid damaging deeper anatomi-
under local anesthesia, with needles not exceeding cal structures and excessive pain. The device is
1 mm in length (Fig. 4). For greater lengths, recommended to be positioned between the thumb
anesthetic blockade supplemented by infiltrative and index finger—as if holding a hashi—control-
anesthesia is recommended (Fernandes 2006). ling the force with the thumb. The back and forth
Aiming to provide more comfort for the patient movements must imprint a uniform pattern of
in situations of prolonged surgical time and perforations (resembling petechiae) throughout
deeper injury, local anesthesia with sedation is the treated area. In order to achieve this, 10–15
recommended. PCIM is a technique-dependent passes in the same direction must be made, and
procedure, and the final outcome is directly at least four crossing passes in the rolling areas
influenced by familiarization with the device seem to be sufficient. In theory, 15 passes allow a
used and mastery of the recommended technique. controlled damage that corresponds to 250–300
The vertical pressure exerted on the roller must punctures/cm2.
Percutaneous Collagen Induction with Microneedles 179
Fig. 6 Superficial
hemorrhage restricted to the
papillary dermis, with
needles 0.5 mm long (HE,
100x)
The time that the petechiae pattern takes to stage of research. The investigation was
arise varies according to the thickness of the performed in vivo, on the skin of living pigs.
treated skin and the selected needle’s length. The right-side region on the dorsum of the pig’s
Therefore, a thinner and looser skin, which is skin was divided into tracks on which the roller
usually photodamaged, will present a uniform with needles was passed back and forth, for 2 or
petechiae pattern earlier than a thicker and fibrotic 3 minutes. Rollers with needles measuring 0.5,
skin, which is commonly observed in patients 1, 1.5, 2, and 2.5 mm in length were used. The
with acne scars, for example. In this manner, the macroscopic appearance of the pigs’ skin after
choice of the needle’s length depends on the type treatment (Fig. 5) evidently suggested that the
of the skin to be treated and the ultimate goal of damage caused by the microneedling holes was
the procedure. There is not yet a classification proportional to the length of the needle used.
correlating the length of the device’s needles to The microscopic examination in the first stage
the depth of the expected damage in the treatment (immediately after the injury) revealed predom-
(Fernandes 2006; Fernandes and Massimo 2008). inantly vascular ectasia with the extravasation
Emerson Lima et al. (2013) proposed to of erythrocytes. This finding was observed
establish the correlation between the length of superficially, having affected the papillary der-
the needles used and the depth of resulting dam- mis with 0.5 mm needles (Fig. 6), reaching the
age, using the skin of living pigs, (considering it reticular dermis with needles of greater length
the most similar to human skin), in this first (Fig. 7). The amount of bleeding also increased
180 E. Lima et al.
proportionally to the length of the needles. tissue. Based on the results, the authors propose
The epidermis remained apparently intact the classification of the injury caused by micro-
under optical microscopy, except for the pres- needling as mild, moderate, and deep, correlat-
ence of the needle path site (Fig. 8). None of the ing to the needles’ length and their ability to
samples presented lesions in the subcutaneous induce the planned trauma (Charts 1 and 2).
Chart 1 Classification of
the severity of the injury
CHART1: Classification of the severity of the injury
caused by microneedling caused by microneedling
Stimulus characteristics Length of needle
Chart 2 Classification of
the severity of the injury CHART2: Classification of the severity of the injury
caused by microneedling caused by microneedling
Procedure: Protocol and Management The microneedles should be applied with back
and forth movements until an uniform bloody dew
PCIM is a technician-dependent procedure. Famil- emerges. At the end of the procedure, a sterile
iarization with the device used and technical mas- gauze dressing is applied for 24 h, when it is
tery are factors that directly influence the final result. removed, at home, during the bath. A cutaneous
The device used to perform the PCIM comprises barrier regenerator is prescribed three times a day
a polyethylene cylinder studded with stainless steel until complete recovery. After procedure, patients
sterile needles symmetrically aligned in rows, total- should be examined to evaluate possible side
ing around 192 units with 2.5 mm length. effects as erythema, edema, or infections. The
We propose the following treatment protocol: return to professional activities occurs within
to degrease the skin with liquid soap and to do 7 to 10 days. Moderate edema and erythema
antisepsis with chlorhexidine and block anesthe- persisted during a period ranging from 25 to
sia of the infraorbital and mentonian nerves, 35 days, but after 15 days, patients are instructed
followed by infiltrative anesthesia with 2% lido- to use topical depigmenting substance (0.05%
caine and saline (1:3) of the genian region, retinoic acid + 4% hydroquinone + 0.01%
observing the maximum anesthetic dose fluocinolone acetonide), alternated with a cutane-
according to the patient’s weight. ous regenerator and sunscreens (SPF 50+). After
Fig. 10 Patient 30 days after PCIM presenting improvement in wrinkles and laxity
Fig. 11 Patient 30 days after PCIM presenting improvement in acne scars, laxity, and melasma
30 days, the depigmenting cream can be used with the use of the depigmenting substance dur-
every night with good tolerability. ing 30–45 days (Figs. 9, 10, 11).
The number of passes before the emergence
of the petechiae pattern varies according to the
skin’s thickness and to the selected needle. Conclusion
Thinner and looser skin, as photodamaged
skin, presents an uniform petechiae pattern ear- PCIM is an innovative treatment that can be used
lier than thicker skins. Acne scar skin is thick, for a broad spectrum of indications, when the
and a larger number of passes and longer objective is to stimulate collagen production,
needles are necessary to promote the uniform being an additional weapon in the dermatologist’s
petechiae pattern. Side effects, such as erythema therapeutic armamentarium. The goal of the pre-
and edema, are similar or more intense when sent study was to establish the correlation between
using more aggressive parameters. Moderate the length of the needles used in the roller and the
post-inflammatory hyperpigmentation can be extent of damage caused to the skin, thereby facil-
observed in some patients, but it is reversed itating the choice of instrument in different
Percutaneous Collagen Induction with Microneedles 183
indications. It is up to the individual dermatologist Bal SM, Caussian J, Pavel S, Bouwstra JA. In vivo assess-
to perform an accurate assessment of the lesion to ment of safety of microneedle arrays in human skin.
Eur J Pharm Sci. 2008;35(3):193–202.
be treated and to be technically prepared to perform Brody HJ. Trichloracetic acid application in chemical peel-
the procedure within the recommended precepts. ing, operative techniques. Plast Reconstr Surg. 1995;
2(2):127–8.
Camirand A, Doucet J. Needle dermabrasion. Aesthet Plast
Surg. 1997;21(1):48–51.
Take Home Messages Cohen KI, Diegelmann RF, Lindbland WJ. Wound
healing: biochemical and clinical aspects. Philadelphia:
• The procedure allows the stimulation of collagen W.B. Saunders Co; 1992.
production, without removing the epidermis. Fabroccini G, Fardella N. Acne scar treatment using skin
needling. Clin Exp Dermatol. 2009;34(8):874–9.
• The healing time is shorter and the risk of side Fernandes D. Minimally invasive percutaneous collagen
effects is reduced, compared to ablative induction. Oral Maxillofac Surg Clin North
techniques. Am. 2006;17(1):51–63.
• The skin becomes thicker and more resistant, Fernandes D, Massimo S. Combating photoaging with
percutaneuos collagen induction. Clin Dermatol.
unlike in ablation techniques, where the cica- 2008;26(2):192–9.
tricial tissue is more susceptible to Lima E, Lima M, Takano D. Microagulhamento: estudo
photodamage. experimental e classificação da injúria provocada. Surg
• It is indicated for all skin types and colors and Cosmet Dermatol. 2013;5(2):110–4.
Lv YG, Liu J, Gao YH, Xu B. Modeling of transdermal
can also be used in areas of lower concentra- drug delivery with a microneedle array. J Micromech
tion of sebaceous glands. Microengim. 2006;16(11):151–4.
• Lower cost when compared to procedures that Orentreich DS, Orentreich N. Subcutaneous incisionless
require technologies demanding high invest- (subcision) surgery for the correction of depressed scars
and wrinkles. Dermatol Surg. 1995;21(6):6543–9.
ment values. Vandervoort L, Ludwig A. Microneedles for transdermal
• It is a technique-dependent procedure and drug delivery;- minireview. Front Biosci. 2008;
requires training. 13(5):1711–5.
• Requires prolonged recovery time if moderate Vasconcelos NB, Figueira GM, Fonseca JCM. Estudo
comparativo de hemifaces entre peelings de fenol (fór-
to deep injuries are inflicted. mulas de BakerGordon e de Hetter) para a correção de
• Demands careful assessment of the patient and rítides faciais. Surg Cosmet Dermatol. 2013;5(1):40–4.
therapeutic proposal compatible with possibly
achievable outcomes, avoiding unrealistic
expectations.
References
Aust MC. Percutaneuos Collagen Induction therapy (PCI)-
an alternative treatment for scars. Wrinkles Skin Laxity.
Plast Reconstr Surg. 2008a;121(4):1421–9.
Aust MC. Percutaneuos Collagen Induction therapy (PCI)-
minimally invasive skin rejuvation with risk of hyper-
pigmatation- fact or fiction? Plast Reconstr Surg.
2008b;122(5):1553–63.
Cryotherapy for Cosmetic Procedures
or an alternate form of treatment (Kuflik and • Immunologic effect: Release of antigenic com-
Kuflik 2012). ponents – controversial in the current literature
Cryotherapy may be used to treat a wide range of (Pasquali et al. 2010; Lawrence and Tefler 2010).
skin conditions. In the USA, cryosurgery is most • pH changes (Kuflik and Kuflik 2012).
commonly used for treating actinic keratoses, seb- • Impairment of homeostatic functions (Kuflik
orrheic keratoses, and verrucae (Farhangian et al. and Kuflik 2012).
2015; Afsar et al. 2015). In this chapter we will only
discuss benign lesions that may cause aesthetic The ideal treatment is considered repeated
impairment to the patient and premalignant lesions. freeze-thaw cycles, rapid freezing, and slow
thawing (the thaw time is usually two or three
times longer than the freeze time) (Kuflik and
Basic Principles Kuflik 2012; Lawrence and Tefler 2010).
Necrosis usually occurs at the center of the area
The aim of cryosurgery is to promote freezing of of application, where the temperature should
the tissue with subzero temperatures, resulting in range between 30 C and 40 C. There is a
tissue damage and subsequent healing by second rim of partially damaged tissue, and in the periph-
intention (Pasquali et al. 2010) (Fig. 1). This pro- eral areas, some cells remain alive, but with such
cess leads to cellular structural changes resulting injury that triggers later apoptosis. Thermocou-
in cell death that occurs due to: ples inside the lesion or electrodes around can
help to monitor the temperature (Pasquali et al.
• Cell injury with water crystalizing outside the 2010; Kuflik and Kuflik 2012), but their place-
cell. Initially, water moves out of the cell by ment is difficult to standardize (Petres et al. 1996).
osmosis, causing internal dehydration and cell In practice, the temperature does not need to be
damage. Freezing causes internal crystal forma- measured because clinical studies suggest deter-
tion and further cell disruption. The thawing mined duration of freezing times for the most
process leads to larger crystal formation The common skin lesions (Lawrence and Tefler 2010).
more freeze-thaw cycles, the longer the thawing The lateral spread of freeze is also important and
time; the coldest the temperature, the greater the refers to the freezing of the tissue beyond
cell damage (Pasquali et al. 2010; Kuflik and the margins of the lesion. Benign lesions require
Kuflik 2012). usually 2–3 mm, and malignant lesions such as
• Vasoconstriction, blood stasis, and anoxia. Free basal or squamous cell carcinomas should reach at
radical formation after compensatory vasodilata- least 3–5 mm, or more, if possible (Kuflik and
tion contributes to the cell damage (Pasquali Kuflik 2012).
et al. 2010; Kuflik and Kuflik 2012; Vujewich Melanocytes are the most sensitive to freeze,
and Goldberg 2008). with cell destruction at 4 C to 7 C (depig-
mentation may occur, especially in more pigmented
Fig. 1 Basal Cell carcinoma treated by open spray technique. In lager lesions,it is necessary to divide into smaller zones
to promote more effective freezing and thawing cycles
Cryotherapy for Cosmetic Procedures 187
• Chamber: Another variation of the open tech- If there is any suspicion of malignancy, a
nique. The spray is released through an ori- skin biopsy needs to be performed prior to the
fice into a metal chamber, firmly held to the cryotherapy procedure. Dermoscopy, ultrasound,
lesion. The turbulent movement of the nitro- radiography, and other imaging tests may be neces-
gen inside the chamber lowers the tempera- sary. Once the location, type, and thickness of the
ture even further. Lower temperatures are lesion are well defined, the surgeon can decide
achieved faster and require extreme caution. which is the preferable technique to be used.
It is usually limited to malignancies (Pasquali et al. 2010).
(Pasquali et al. 2010). Pearls:
• Close/cryoprobe/contact: A copper cryoprobe
(precooled metal tip) is attached to the cryo- • Most lesions do not require previous treatment.
surgical unit. The metal probe should be pre- In some cases, keratolytic substances, curet-
ssed against the lesion on the skin. It is useful tage, or debulking may be necessary.
for treating small and well-circumscribed le- • Irregular surfaces are better treated with the
sions or in confined locations (Vujewich and open technique (spray).
Goldberg 2008). • Always work in bloodless areas. Blood in-
The contact freezing achieves 40 C of creases the local temperature.
temperature but a depth of only about 4 mm • Vascular lesions are better treated with probes,
(Petres et al. 1996). such as hemangiomas and other vascular
• Cryo Tweezers: A variation of the cryoprobe malformations (see “Laser Treatment of Vas-
technique, successfully used in pedunculated cular Lesions”).
lesions such as skin tags and warts (Usatine • Cartilage and bones are very resistant to
et al. 2015). freezing.
• Intralesional: Ideal for voluminous or deep • Local anesthesia, in most cases, is not required. It
tumors. One or several sterile cannula probes may be considered in very anxious patients and
are inserted into one side of the tumor and run- children (Pasquali et al. 2010) and in cases of
ning it interstitially along the lesion (along the deep freezing (chamber, probe, and intralesional
largest axis, at its deepest point) until it appears techniques). Topical agents may help and should
on the opposite side. Liquid nitrogen is sprayed be applied 30–60 min before the procedure.
into the cannula, and an ice cylinder is formed • It is very important to inform, verbally and
within the center of the lesion. There is minimal with a consent form, all the expected postop-
surface destruction compared to the previously erative course, as possible side effects and
mentioned techniques (Pasquali et al. 2010). probable cosmetic outcome (Pasquali et al.
2010; Pasqualli 2013; Usatine et al. 2015).
• If using probes, be careful not to remove a
Preoperative Preparation/Patient probe stuck to the surface of the skin. (Pasquali
Selection et al. 2010) A small container with warm water
may help in case a probe gets stuck to the skin
A great advantage for cryosurgery is that it does (Pasqualli 2013).
not require a special surgical area (Pasquali et al. • Fractional cryosurgery may be helpful to avoid
2010). Therefore it is suitable for patients in deformities and retractile scars in big lesions. It
wheelchairs or for those who cannot leave is performed in stages, first in the center of the
their home or nursery. It is a safe technique to lesion, reducing its size, and then repeated as
patients with underlying medical conditions necessary until the tumor diameter is smaller
(heart diseases, bleeding disorders, metabolic than 10 mm, at which the standard procedure is
diseases). performed (Gonçalves 2009).
Cryotherapy for Cosmetic Procedures 189
normal skin, followed by a contact cryosur- which is pressed on the lesion for about
gery of the base of the keloid. 10–20s. No lateral spread of ice is necessary
4. Surgical debulking + transfixing cryosur- (Usatine et al. 2015).
gery: Surgical excision, not extending to • Pearly penile papules
the normal skin, followed by transfixing Acral angiofibromas often misdiagnosed as
cryosurgery, using a hollow needle, which warts or sebaceous hyperplasia. Occur after
perforates the base of the keloid, transfixing puberty on the corona and sulcus of the glans
the lesion. The liquid nitrogen passes penis. Cryosurgery is a quick and effective
through the needle. With this technique the method. Two cycles of 10s with a fine spray
exudate and swelling set up quickly, with are very effective with low morbidity (Usatine
less tenderness and less hypopigmentation. et al. 2015).
It allows shorter intervals between treat- • Porokeratosis
ments (Usatine et al. 2015). No treatment is entirely effective but cryo-
Recent lesions have an earlier and better surgery is often acceptable despite the hypo-
response. An Egyptian clinical study showed pigmentation. Short freeze of 5–10s with a
that a better therapeutic response was achieved spray is recommended.
after intralesional cryosurgery comparing to • Pyogenic granulomas
contact cryosurgery, with higher flattening If there is any doubt, biopsy should be per-
rates and fewer side effects (Abdel-Meguid formed. Depending on the size of the lesion,
et al. 2015; Weshahy and Abdel 2012). Intra- the cycles may range from 15 s to 45 s. Recur-
lesional therapy also causes minimal damage rent lesions sometimes require more than one
to the skin surface and less complaints of pain cycle of 20–30s. Higher cure rates are obtained
and pruritus (Choudhary et al. 2010; van with prior shaving of the lesion, followed by
Leeuwen et al. 2015). curettage and electrodesiccation.
• Lymphangiomas • Sebaceous hyperplasia
Although lymphangiomas may shrink with These lesions not necessarily need treatment,
cryosurgery, the chance of complete resolution but several therapies are available for aesthetic
is small. purpose. If there is any suspicion of BCC, bi-
• Molluscum contagiosum opsy is mandatory. Cryospray or a tiny probe is
This is a common viral infection. The num- placed in the central depression for 5–10s.
ber of lesions may vary from one to several • Seborrheic keratosis
hundred and can persist for years (Usatine et al. Treatment by cryosurgery is effective, al-
2015). Both open and closed techniques can be though large and hyperkeratotic lesions are
used (Pasquali et al. 2010). Liquid nitrogen is best treated by curettage or shave alone. For
applied until the lesion becomes white, and the lesions with up to few millimeters thick or
central dimple is highlighted. Point the spray in pedunculated ones, liquid nitrogen can be
the center of the lesion, avoiding pendular used. The goal is to produce an ice halo of
movements. It is not necessary to freeze beyond 2 mm. Treatment times vary widely according
the margin of the lesion. If using a probe, it to size and thickness but usually range from
allows the treatment of multiple lesions in a 10–20s. Curettage after cryospray is also a
shorter time. There may be temporary swelling, good option (Pasquali et al. 2010) (Fig. 3).
and then shrinkage until the papule falls off. Er:YAG laser is also an alternative for the
• Mucocele treatment of SKs (Seborrheic Keratosis) in
Also called labial mucoid cyst or retention one-step procedure, with better cosmetic results
cyst, usually on the lower lip, up to 1 cm. They compared to cryotherapy (Gurel and Aral 2015).
respond well to cryosurgery but larger lesions *Dermatosis papulosa nigra is a variant of
should be drained first. Lubricant gel may be SK, mainly seen in high Fitzpatrick’s photo-
applied before the placement of the probe, types. When treated with cryosurgery, this
192 J. Mesquita Filho and F. Papaiordanou
Fig. 3 Seborrheic
Keratosis: before (a) and
after (b) 1 session
lesion has a high risk of pigmentary side considerable flattening of the cysts after
effects. Light cryosurgery is a better alterna- 6 months. (Usatine et al. 2015)
tive (see “CO2 laser for other indications”; • Syringomas
“Fractional Ablative and Non-ablative Lasers Syringomas are purely a cosmetic issue.
for Ethnic Skin”). There are several destructive treatments such as
• Solar lentigo (see “Intense Pulsed Light for electrodessication, laser, topical TCA, and cryo-
Photorejuvenation”) surgery, all of them with limited success. Cryo-
Most importantly prior to treat any of these surgery may cause swelling around the eyes and
lesions, it is to be sure that there are any sign hypopigmentation; however, a test may be
of malignancy (lentigo maligna or lentigo performed prior to the procedure. Freeze times
maligna melanoma). If there is any suspicion, of 5 s are suggested. Care must be taken to avoid
a biopsy is the first step. liquid nitrogen in the eye.
For benign lesion, cryosurgery is a quick • Venous lakes
and effective option. Both spray and cotton- Cryoprobe or cryospray may be useful. The
tipped technique is acceptable. The risk of advantage of the probe is that it compresses
postinflammatory pigment changes exists. the lake in order to treat the deeper portion
Sun protection after the procedure is manda- of the lesion. Freeze times of 5–15 s with
tory. Therefore, a test site in a cosmetically less 1–1.5 mm are suggested, according to the size
noticeable region may be performed first of the lesion.
before treating multiple lesions. Most of them • Verrucous epidermal naevi
are superficial, and a single freezing cycle car- Hamartomas characterized by epidermal and
ried out with the spray technique is sufficient to adnexal structures hyperplasia. Cryosurgery is
cause a small bulla and sloughing (Vujewich considered an effective therapeutic modality to
and Goldberg 2008). treat this condition, with low cost and good
Cryospray can be directed in a zigzag pat- cosmetic results.
tern for 1–5 s and should extend 1 mm of the Panagiotopoulos et al. described two open
normal skin at the periphery. spray technique cycles of 10-15 s each, in
Cryotherapy is considered more effective in 12 patients. Ten patients had their naevi suc-
achieving substantial skin lightening than TCA cessfully treated with no scarring with two to
but more painful and with longer healing time. five sessions. One patient showed relapse within
Hyperpigmentation is almost equal (Raziee 8 months; one patient developed hypochromic
et al. 2008). scarring (phototype 5), but with repigmentation
• Steatocystoma multiplex after 6 months. (Panagiotopoulos et al. 2009).
Although this is not the gold standard treat- • Xanthelasma
ment, the open spray technique is acceptable as Cholesterol-filled yellow plaques usually
an alternative to surgery. A case report de- on the eyelids. They are always benign, and
scribes a 10-s nitrogen spray cycle with treatment is undertaken for cosmetic reasons.
Cryotherapy for Cosmetic Procedures 193
Cosmetic treatment options include TCA to-perform option, with low cost and reduced
50–10%, cryosurgery, and surgical excision. healing times, in cases of widespread actinic
Although excision is preferred, cryosurgery keratoses. It is highly effective, and the inci-
may be used but inevitably leads to dence of squamous cell carcinoma is also
marked swelling (Simon et al. 2015). When greatly reduced (Chiarello 2000).
cryotherapy is chosen, the closed probe tech- • Actinic cheilitis
nique is recommended with 15-s repeated Actinic cheilitis may be treated by cryosur-
freeze-thaw cycles, depending on the size of gery using a single 5–10-s freeze-thaw cycle,
the lesion. no margin/halo needed. A second procedure is
recommended if the first one was not aggres-
sive enough (3–4-week intervals). If the lesion
Premalignant Lesions does not respond to the treatment, a biopsy is
needed to avoid SCC.
• Actinic keratosis (AK) (see chapter “Photody- • Bowen’s disease
namic Therapy” Vol. 1) Also known as a SCC in situ. There are the
The more affected sites are the back of the common type, the hyperkeratotic type, and the
hands, forearms, and upper face. There are genital type. A biopsy is always recommended
different morphological varieties: common, to exclude the progression to an invasive
pigmented, and cutaneous horn. malignancy.
A biopsy should be undertaken in thick For small and thin lesions, curettage and
lesions with rapid growth, lesions that show electrosurgery are appropriate. For small and
any other features of a squamous cell carci- thicker lesions, excision is the best option.
noma (horn, bleeding, pain), pigmented AKs Topical 5-FU 5% and imiquimod 5% cream
if in melanoma suspicion, and AKs that have and PDT can be also considered.
failed prior to cryotherapy or other local Cryospray technique can be applied (except
treatments. in the genital area) with a single 20–30-s freeze
AKs are most often treated by cryosurgery, cycle with a 2-mm halo including healthy tis-
with 97% cure rates and 2.1% recurrence in sue around. Larger lesions can be divided into
1 year (Usatine et al. 2015). Freeze times vary overlapping circles. Larger lesions may be
from 5s to 10s, with a 1-mm halo, depending treated using the spiral or paint-spray tech-
on the size and thickness of the lesion. Longer nique (20–30s).
freeze times may evolute with hypo- Hyperkeratotic lesions do not respond well
pigmentation. (Vujewich and Goldberg 2008; to cryosurgery alone and should be debulked
Usatine et al. 2015). priorly.
A European prospective and randomized For Bowen’s disease of the genitalia, a
study compared the efficacy, tolerability, and 15–20-s freeze-thaw cycle is recommended
safety of low-dose 5-FU topical solution (to) and usually has a rapid healing time with
cryosurgery in patients with moderate/severe good functional and cosmetic results.
AKs (6 weeks of once daily 5-FU or up to two Lesions on the leg, especially in older
cryosurgery treatments with 3-week interval). patients, may have a delayed healing process
They concluded that 5-FU achieved due to underlying venous stasis, and aggres-
greater hystological clearance and lower recur- sive cryosurgery may lead to ulceration.
rence rates than cryosurgery (Simon et al. Recurrence is common if the freeze is not
2015). aggressive enough, because the cells migrate
Cryopeeling is a modality of treatment that back to the surface (recurrence rates range
uses diffuse cryotherapy not only in AKs but from 5% to 10% if adequate cryosurgery
all over the photodamaged skin. It is an easy- is used).
194 J. Mesquita Filho and F. Papaiordanou
Postoperative Care and Follow-Up the removal can be helpful to speed healing (do not
remove crusts of vascular lesions).
Postoperative care varies according to the type of In cases of lesions on the legs and ears, and in
the lesion and location and depth of freeze (Kuflik cases of clinically confirmed secondary bacterial
and Kuflik 2012). Patients should be informed infection (which is rare), some authors recom-
about the expected healing time, secondary ef- mend oral antibiotic (Kuflik and Kuflik 2012).
fects, and complications that may occur, more An appropriate follow-up after cryosurgery is
commonly, erythema, discomfort, or even pain/ needed either soon or in long term, to wound check,
burning usually (Pasquali et al. 2010). management of possible side effects, and repeated
In superficial freezing, there is no need to cover cycles for same or other lesions if necessary and in
the lesion; for deep freezing, the wound should be cases of recurrent lesions (Usatine et al. 2015).
covered with gauze for 48 h, and an antibiotic
ointment is optional.a In most cases, regular wash
with water and soap is sufficient. (Kuflik and Kuflik Side Effects and Complications
2012; Pasqualli 2013) In case of malignancies, there
is an extensive exudation process that diminishes as The incidence of complications after cryosurgery
the wound heals. The same procedure of regular is low. It is important to distinguish between
washing should be done, but more often (3–4 what is expected and what is occasional/unusual,
times/day) in the exudative stage and less often in temporary, and permanent (Table 1). (Pasquali
the granulation phase. A bulla formation is et al. 2010; Kuflik and Kuflik 2012; Lawrence
not considered a complication (Kuflik and Kuflik and Tefler 2010; Vujewich and Goldberg 2008;
2012), and it can be drained or not (Pasqualli 2013). Petres et al. 1996; Pasqualli 2013; Usatine et al.
Exudation can last a few days to 10–15 days after 2015).
the procedure. If a crust formation occurs (Fig. 4),
Conclusion
nitrogen: light and electron microscopic studies. J Am Usatine RP, Stulberg DL, Colver GB. Cutaneous cryosur-
Acad Dermatol. 1990;4(1):681–3. gery. 4th ed. Boca Raton: CRC Press; 2015.
Raziee M, Balighi K, Shabanzadeh-Dehkordi H, Robati RM. Vujewich JJ, Goldberg LH. Cryosurgery and electrosur-
Efficacy and safety of cryotherapy vs. trichloroacetic acid gery. In: Wolff K, Goldsmith LA, Katz ST, Gilchrest
in the treatment of solar lentigo. J Eur Acad Dermatol BA, Paller AS, Leffel DJ, editors. Fitzpatrick’s der-
Venereol. 2008;22(3):316–9. Epub 2007 Oct 18. matology in general medicine. 7th ed. New York:
Simon JC, Dominicus R, Karl L, Rodríguez R, Willers C, Mc Graw Hill; 2008. p. 2330–5.
Dirschka T. A prospective randomized exploratory Weshahy AH, Abdel HR. Intralesional cryosurgery and
study comparing the efficacy of once-daily topical intralesional steroid injection: a good combination ther-
0.5% 5-fluorouracil in combination with 10.0% apy for treatment of keloids and hypertrophic scars.
salicylic acid (5-FU/SA) vs. cryosurgery for the treat- Dermatol Ther. 2012;25(3):273–6.
ment of hyperkeratotic actinic keratosis. J Eur Acad Zimmerman EE, Crawford P. Cutaneous cryosurgery. Am
Dermatol Venereol. 2015;29(5):881–9. Fam Physician. 2012;86(12):1118–24.
Electrosurgery for Cosmetic
Procedures
application. Claude Paquelin developed the use of many sizes with or without cutting tissue and was
electrocautery in 1875; this new modality was the direct forerunner of modern electrosurgical
similar to the old form of hot cautery (in which a devices. The next major event in the development
hot tip is brought directly into contact with tissue of electrosurgery came in 1923 when Dr. George
to transfer heat and burn the tissue without passing A. Wyeth a noted that a tumor surgeon used elec-
any current through it) except that it generated trosurgery to cut tissues (Matzle et al. 2006;
heat electrically (Fewkes et al. 1992; Sebben Pollack 2000). In 1932, the Birtcher Corporation
1988). However, the real beginnings of modern introduced its spark gap-based HyfrecatorTM,
electrosurgery were the recognition and develop- which has become popular for office-based
ment of a high-frequency alternating current. In mono-terminal and bi-terminal electrofulguration,
1891, Jacques Arsene d’Arsonval developed the electrodesiccation, and electrocoagulation. Cur-
circuitry required for generation of high- rently, there are numerous commercially available
frequency electricity. He found that high- electrosurgical devices (Fewkes et al. 1992).
frequency currents above 10,000 cycles per sec-
ond (10,000 hertz) could pass through the body
without pain, muscle contraction, or other obvious Electrosurgical Modalities
harm to the body (Bezerra and Jardim 2013;
Bezerra et al. 2013;Fewkes et al. 1992; Chiarello Variation in the voltage, amperage, frequency, and
2003; Matzle et al. 2006; Pollack 2000; Sebben method of application gives each of the electro-
2000). surgical modalities its unique qualities. Equally
In 1893, Oudin designed a resonated circuit important, however, is the waveform of each cur-
with a balance between capacitive resistance and rent (Bougthon et al. 1987).
inductive resistance; this allowed a maximum There are four different types of waveform in
amount of current flow by minimizing the amount electrosurgery:
of circuit resistance. Oudin used the resonated gap
generator to destroy various skin lesions. In 1908, • Fully filtered (undamped wave), e.g., cut
Walter de Keating-Hart noted that high-frequency (electrosection): suitable for cutting a wave-
currents could spark from the electrode to the form with minimal coagulation.
tissue in long sparks resembling lightning • Fully rectified (slightly damped wave), e.g., cut
(fulgur). He used these long sparks to destroy and coagulation (electrosection with coagula-
skin cancers and therefore developed the modality tion): suitable for cutting and coagulating
of electrofulguration. In 1911, William Clark used simultaneously.
very high voltage and low amperage for mono- • Partially rectified (moderately damped wave),
polar tissue destruction. A current applied directly e.g., coagulation: suitable for coagulation of
to tissue produced marked desiccation in the area bleeding vessels.
of electrical contact. Clark identified the modality • Spark gap wave (markedly damped wave),
as electrodesiccation (Fewkes et al. 1992; Sebben e.g., fulguration: suitable for fulguration
1988; Matzle et al. 2006; Pollack 2000). In 1908, (Chiarello 2003).
Doyen is believed to have been the first to develop
a method for delivering lower-voltage, higher-
current electrical energy to patients by placing a Clinical Applications of Electrosurgery
large indifferent or dispersive electrode under (Table 1)
them. In 1926, William Bovie, a physicist, collab-
orated with Harvey Cushing, a neurosurgeon, to Specific applications for the various electrosurgi-
develop a high-frequency electrosurgical instru- cal modalities are dependent on the surgeon’s
ment that allowed a variable amount of preference and experience; electrosurgery can be
“damping” as well as variable voltage and current used for incisional techniques that produce full-
output. This instrument could coagulate vessels of thickness excision of nevi, shave techniques that
200 S. Martins et al.
undamped tube current, which provides the least cause clean separation with little or no char-
amount of lateral heat spread and causes vapor- ring—charring produces better hemostasis but
ization of tissue without hemostasis (Chiarello causes a larger zone of thermal damage. The
2003). Electrosection can be used to perform motion should be kept at a rate that incises the
rapid and effortless electrosurgical excisions or tissue adequately without a cooked or charred
incisions without bleeding (Chiarello 2003; appearance; an optimal cutting rate of electrode
Sebben 1988, 1998)—virtually no manual pres- movement is 5–10 mm per second (Fewkes et al.
sure is required by the operator. Maximum power 1992; Sebben 1988, 1998). Because a small
density can be achieved with a minimal amount amount of charred tissue may adhere to the cut-
of current; the power density value increases as ting electrode, thereby interfering with the cut-
the radius of the curvature on the electrode ting or coagulating action, the electrode should
decreases. Electrosection can be performed with be cleaned regularly during the procedure. If char
a variety of electrodes, the most common of buildup seems excessive, the power may be too
which are thin wire loops. Blade-shaped elec- high or the cutting speed too slow (Fewkes et al.
trodes are also available but tend to produce 1992).
excessive thermal injury because of the greater Electrosurgery is extremely useful for achiev-
power required and the larger surface area of the ing relatively bloodless excision on the head and
flat electrode that is in contact with the tissue as it of large bulky lesions, for incisional and shave
cuts. A wire loop electrode also produces greater techniques, to treat rhinophyma, hidradenitis
thermal injury than a straight-line wire electrode suppurativa, and some nevus, for the excision of
because of the increased electrical power benign and malignant cutaneous tumors, and for
required to produce the cutting power density skin biopsy, blepharoplasty, scalp reduction, scalp
(Fewkes et al. 1992; Sebben1998; Sebben and flaps, scalp lifting, and all surgical defects when
Davis 1988). The difference between electro- allowed to heal by secondary intention (Fewkes
section and scalp excision is immediately appar- et al. 1992; Popkin 1987; Chiarello 2003; Sebben
ent to the first-time user of electrosection. At the 1988, 1998; Weber et al. 2000).
appropriate power setting, the electrode passes
smoothly through the tissue like a “hot knife
through butter.” However, the tissue should be Direct-Current Surgical Galvanism
hydrated continuously with wet gauze. If percep-
tible sparking occurs during incision, the power Few dermatologists have the equipment available
setting is too high; if the electrode “drags,” the to produce a direct galvanic current as galvanic
power setting is too low (Chiarello 2003). surgery has very few useful applications in every-
The major advantage of electrosection over day practice. Its most common use is in electrol-
scalpel surgery is that hemostasis is achieved ysis, a process by which low-flow direct-current
immediately as the incision is made. However, electricity is passed through tissue between two
large blood vessels (>1 mm in diameter) require electrodes, resulting in tissue damage via a chem-
additional spot electrocoagulation (Chiarello ical reaction that occurs at the tip of one of the
2003) and there can be greater tissue damage electrodes (Fewkes et al. 1992; Sebben 1988;
and slower healing with cutting current proce- Sampaio and Piazza 2009). Electrolysis is com-
dures. Wounds that have been created with a monly used to destroy hair follicles (epilation or
cutting current can often be closed primarily, permanent hair removal). This method is quite
but the wound takes longer to achieve satisfac- effective and associated with little pain and low
tory tensile strength. Excessive energy levels or a risk of scarring, but it is a time-consuming proce-
very slow cutting speed can produce over- dure and with the laser devices available now the
coagulation, a wider band of tissue damage, and indication for its use is restricted to only when we
poorer wound healing. Cutting should be at a want to ablate an occasional hair follicle (Shaw
steady, brisk speed. The optimum speed will et al. 1988).
Electrosurgery for Cosmetic Procedures 203
Wire electrode
Electrocautery
Scalpel blade electrode
Diamond loop electrode
Electrocautery uses a heat-producing electrode
Ellipse electrode
without the transfer of an electrical current. How-
Triangle electrode
ever, this is an old technique that is no longer in use
Epilating needle
(Sampaio and Piazza 2009). Electrodesiccation can
Bipolar forceps
produce essentially the same results but electrocau-
Matricectomy electrode.
tery can cause greater tissue damage and slower
healing. High-frequency equipment has largely
replaced cautery (Blankenship 1979;Sebben 1988).
Electrodes may be rigid or bendable. An elec-
trode becomes less efficient as charred tissue
deposits on its surface. As this occurs, the delivery
Electrodes (Fig. 1) of the electrosurgical current becomes less
precise and higher power settings are required.
There are different types, shapes, and sizes of Therefore, it is important to keep electrode tips
electrode on the market, and they are available in clean during the course of electrosurgical
a sterile or non-sterile form. The choice of elec- procedures.
trode depends on the wave form and diagnosis of
the lesion. The response by the tissue varies Factors Causing Less Collateral Heat Damage
greatly depending on the type of electrode used. Smaller electrode diameter
The larger the electrode, the more lateral heat Shorter contact time between the electrode and
produced and the higher the power setting neces- lesion
sary to operate it. The smaller the electrode, the Lower intensity of power
less lateral heat produced and the lower the power Higher frequency of current
setting necessary to operate it (Sebben 1988; Cutting waveform.
Taheri et al. 2013).
ever, we do not recommend topical anesthesia Fig. 3 The HF Megapulse Fraxx (Wavetronic 5000 Dig-
ital) is a new technology that controls the thermal effects of
because the patient should be very comfortable
radiofrequency through a sophisticated electronic fraction-
and quiet during the procedure. Before the anes- ate energy system
thesia, the lesion and the surrounding skin should
be cleansed with povidone-iodine or chlorhexidine
solution (never alcohol due to the potential ignition Wavetronic 5000 Digital, which allows the same
effect). Electrosurgery should be performed with refinement and precision obtained by traditional
the patient in a comfortable seated or lying position fractional CO2 lasers. Distributed control ensures
on an operating table, with the lesion exposed and that all micro points are not energized simulta-
illuminated (Weber et al. 2000). The electrode neously, work in a predefined random sequence,
should be kept clean and free of eschar. and shoot sequentially through 8 mm needle
Standard post-operative wound management, columns. The two adjacent columns do not
incorporating semi-occlusive dressings, needs to shoot in sequence, avoiding an additive thermal
be followed. Patients should be warned of the side effect: the device allows the selection of
possibility of delayed bleeding and should be active power time (active) and rest time (delay)
reassured that it can be controlled by 10–30 min between columns. With 60% power, an active
of constant direct pressure over the wound. They time (active) of 60 ms, a rest time (delay) of
should also be told that scarring may occur, but 60 ms, and a cut wave, we achieved very similar
that it is usually minimal. Cosmetic results are ablations to that of fractional CO2 lasers with
usually excellent (Fewkes et al. 1992). minimal thermal side effects and no concentrated
Recently, Loktal Medical Electronics devel- ablative effect in the upper reticular dermis
corresponding to “background” ablation
®
oped the HF Megapulse Fraxx (Fig. 3), a new
technology that controls the thermal effects of (Casabona et al. 2014).
radiofrequency through a sophisticated elec- Application Technique: To prepare high photo-
tronic fractionate energy system, used with the type skin, we should use pigmentation inhibitors
Electrosurgery for Cosmetic Procedures 205
and sun filters. In case of a history facial herpes Casabona et al. 2014 demonstrated the thermal
simplex we use preventive of famciclovir 125 mg, effect of fractional ablative radiofrequency in
every 12 hour during 5 days prior to procedure. The 20 women with lower eyelid sagging. The proce-
most important consideration is related to analgesia dure was performed under infiltrative local anes-
because thermal ablation methods cause pain in thesia, one session three times. Before the skin
some patients and this should be mitigated to the was humidified with sterile saline solution, the
patient’s comfort level. The use of oral analgesics device used was the Wavetronic 5000 coupled to
®
may be useful, e.g. ketorolac trometamol 10 mg the HF Megapulse Fraxx . This is an electronic
sublingual 10 min before application or local mea- circuit provided with fractional power connected
sures such as cold compresses, cold plates, etc., to a pen with 64 microneedles of 0.2 mm thick-
infiltration of lidocaine 2% with epinephrine, or an ness and 0.8 mm divided into eight columns of
infiltrated expander solution of 30 ml saline eight needles each. The device parameters used
solution (SF) + 10 ml 2% lidocaine + 0.4 ml epi- were 60% power and cut option. The pen
nephrine + 1 ml 8.4% sodium bicarbonate contacted the skin perpendicularly with a 2 mm
(optional). overlap. The megapulse system allows measure-
Another key aspect is the maintenance of the ment of the time that the skin is exposed to the
humidity of the area via application of SF, while heat of eight needles each in milliseconds, which
avoiding excessive humidity, the purpose of in this case is named sequence 2; this is carried out
which is to increase conductivity and obtain uni by selecting the P key followed by the E key on
form and deep penetrations. the device. The energy delivered is randomized in
To avoid intact skin spaces between pulses, columns in a predetermined sequence to allow
i.e., to “join” the pulses, the subsequent shot cooling between shots and as a result cause less
should “enter” a few millimeters to the side of thermal damage (Casabona et al. 2014).
the pen edge in the previous pulse.” The depth Lima recently developed 2 and 8 tungstem
of thermal effect depends mainly on the active needle electrodes with a diameter of 200 thou-
time of the current. The density of the shots (num- sandths of a millimeter, weight and identical
ber of passes) substantially determines the influ- length arranged parallel in order to reach
ence on the thermal effect. the same depth plane with a length of 1.5 mm.
Attention: micro-ulcerations may appear in These needles act beyond the epidermis and
some areas of thinner skin (eyelids) if the device dermis, stimulating contraction and collagen
head passes more than three times. renewal. This technique has been used for the
Post-operatively, if a rash and not very pro- treatment of various dermatological conditions,
nounced swelling that lasts on average 3 days is including wrinkles, enlarged pores, and
noticed, saline solution cold compresses, thermal also atrophic and hypertrophic scars, skin tight-
water, or skin barrier-repairing unguents can be ening, skin rejuvenation, stretch marks,
used, among other things. chloasma, or other pigmentation (Lima and
The relatively common habit of self-excoriation Martins 2010).
or post-operative manipulation can prolong recov-
ery and surface sequelae (guidance should be given
to the patient). In terms of complications, post- Clinical Applications
inflammatory hyperchromia are relatively frequent
in high prototypes and are mainly temporary. HF These settings may vary depending on tissue
®
Megapulse Fraxx has been used to treat stretch resistance, electrode size, tissue moisture, and
marks and for acne scar revision, skin resurfacing, the electronic unit used. It should be remembered
and non-ablative tightening of the skin to that an insufficient current will produce tissue
improve laxity and reduce wrinkles (Casabona adherence and will decrease the efficiency of the
et al. 2014). procedure.
206 S. Martins et al.
Fig. 4 Xantelasma (parameters: current selector—blend; power setting—35; electrode—cut tip needle; technique—
multiple punctures until the yellow tissue is destroyed + curettage)
Fig. 5 Milium (parameters: current selector—blend; power setting—30; electrode—cut tip needle; technique—one
puncture)
Electrosurgery for Cosmetic Procedures 207
Fig. 6 Hidrocystoma (parameters: current selector—blend; power setting—30; electrode—cut tip needle; technique—
multiple punctures)
Fig. 7 Seborrheic keratosis (parameters: current selector—coagulation; power setting—50; electrode—ball tip needle;
technique—light touch and gaze curettage)
Fig. 8 Piogneic granuloma (parameters: current selector—coagulation; power setting—60; electrode—ball tip needle;
technique—vigorous touch)
Fig. 9 Skin tags or acrochordons (parameters: current selector—blend; power setting—35; electrode—cut tip needle;
technique—cut the pedicle)
Fig. 10 Rhinophima (parameters: current selector—blend; power setting—35; electrode—wire loop tip; technique—
shaving)
Fig. 11 Wrinkles (parameters: current selector—cut; HF Megapulse Fraxx sequence—2; active 60 ms, delay 60 ms;
power setting—60; electrode—HF Megapulse Fraxx tip; technique—two re-passes)
Electrode: HF Megapulse Fraxx tip potential risks to the surgeon and operating room
Technique: two re-passes personnel.
Burns
Risks
Burns may result from inadvertent contact
There are few risks to the patient from properly between the electrode and the skin of the patient
applied electrosurgery. However, potential hazards or surgeon, but the most common burn injury in
should be understood so they can be minimized as electrosurgery occurs when there is inadequate
more emphasis is currently being placed on the contact between the patient and the dispersive
210 S. Martins et al.
electrode plate. Occasionally, the patient or sur- be dispersed by these devices. Transfer of bacteria
geon may inadvertently touch a grounding ele- during electrodesiccation has also been demon-
ment such as the metal on the treatment table, strated in a laboratory setting. The presence of
resulting in a burn or shock (Fewkes et al. 1992; human papillomavirus (HPV) particles from car-
Sebben 1988; Hainer 2002; Pollack 2011). bon dioxide lasers and electrosurgery has also
been investigated and found in the plumes of
both procedures. A graver implication of these
Channeling HPV studies is that other viruses such as human
immunodeficiency virus (HIV) and the hepatitis
So-called channeling is rarely a problem at the lower viruses may also remain intact in the plume and be
power setting used in most office-based cutaneous inhaled by the surgeon or operating room person-
surgical practices. Channeling is always avoided by nel. No laboratory or clinical evidence for this
using bipolar forceps or electrosurgery devices exists as yet, and additional studies are needed;
(Fewkes et al. 1992; Pollack 2011). however, the use of a smoke evacuator from the
operative site and a special face mask being worn
by the surgeon are indicated (Fewkes et al. 1992;
Fire Hazard Chiarello 2003; Sebben 1988; Sampaio and
Piazza 2009; Pollack 2011).
It is important to be aware of the presence of
flammable or explosive liquids or gases. There is
a risk of fire or explosion if electrosurgical pro- Cardiac Pacemaker
cedures are conducted in the presence of alcohol,
oxygen, or bowel gases (methane). Special atten- Most modern pacemakers operate in a demand
tion is necessary in the scalp, where residual alco- mode, requiring sensing and output circuits. Any
hol may remain unnoticed, and care should be of these circuits may be interfered with by a high-
taken in the perianal region. For this reason, frequency electrical current, which may have
non-flammable antiseptic solutions such as adverse effects on pacemaker function. Despite
povidone-iodine or chlorhexidine should be used. the fact that most modern pacemakers are nor-
mally well-shielded and filtered to avoid interfer-
ence from outside electrical currents, high-
Plume frequency electrosurgery should be avoided in
patients with pacemakers (Fewkes et al. 1992;
The smoke from electrosurgery has been shown to Sebben 1988, 1998; Pollack 2011). However,
have mutagenic potential, much like the smoke although sporadic reports have identified device
from cigarettes. However, of potentially greater malfunction following electrosurgery, the inci-
concern is the possible presence of infectious par- dence appears to be extremely low, especially
ticles on the electrode or in the plume or splatter with newer-generation pacemakers and implant-
caused during electrosurgery. Infective hepatitis B able cardiac defibrillators.
virus has been demonstrated to be present on Thus, electrosurgery should not be used by
electrode tips after electrodesiccation. This anyone who uses a pacemaker without consulting
strongly argues against the use of the same the physician to ensure that the pacemaker is
unsterilized electrode on consecutive patients. protected and not affected by high-frequency
Electrodesiccation has been shown to produce a interference. The surgeon should use appropriate
fine aerosol and splatter of blood droplets for at precautions, which include proper grounding and
least several centimeters around the electro- avoidance of high-amperage outputs, particularly
desiccated site. If inhaled, this aerosol may be with current-cutting procedures. Bipolar forceps
infectious. Herpes virus particles have shown to with short bursts and low voltage should be used,
Electrosurgery for Cosmetic Procedures 211
Electrodes should be sterilized by autoclave to After the procedure, the patient is advised to keep
prevent cross-contamination as it has been the wound clean and dry. The healing process
shown that viral and bacterial infection can be takes at least several weeks or longer, depending
transferred on such electrodes (Matzle et al. on the size of the wound and other factors. It
2006; Pollack 2000; Sampaio and Piazza 2009; should be noted that necrotic tissue under the
Hainer2002; Bennett and Kraffert 1990). If a post-operative crust can appear to be pus and
non-sterile electrode tip is used, the potential for infection to the inexperienced electrosurgeon.
cross-contamination and subsequent infection Large, loose soggy crusts are best removed, but
would exist either from patient to patient or from dry adherent crusts should be left undisturbed.
patient to physician (Bennett and Kraffert 1990). Dryness of the post-operative site is desirable for
Disposable electrodes can be used or adapters are healing and the site is covered only for protection
available that allowed disposable metal hypoder- or cosmetic reasons. The wounds may be cleansed
mic needles to be used as electrodes. Another daily and then covered with an antibiotic ointment
significant contamination potential in the office that provides a moist environment for new tissue
setting results from the handling of electrosurgical growth. The wound may then be covered with
pencils and cords. Although the electrode may be common adhesive bandages (Pollack 1991).
changed, the handle may be subject to contamina-
tion. A disposable plastic sheath cover that
envelops the electrosurgical handpiece should be
Adverse Effects
used (Bennett and Kraffert 1990).
The greatest hazard of electrosurgery is associated
with treatment technique and involves excessive
Advantages: destruction of tissue. As a result, slow healing and
tissue necrosis can lead to an unsightly or hyper-
Simple procedure trophic scar. The surgeon must take special care to
Rapid healing avoid electrosurgical damage to adjacent areas.
Minimal or no bleeding Coagulation can cause extreme damage to
Aesthetically pleasing scars larger nerves and blood vessels, and at times can
Shorter operating time lead to delayed hemorrhage from unsuspected
Histopathology examination of surgical injury to blood vessel walls. Delayed post-
specimens operative bleeding with the sloughing of the
Fewer surgical risks and complications crust can occur, and the patient should be
Inexpensive instructed beforehand in applying direct pressure
Can be completed as an outpatient. to control any bleeding (Blankenship 1979).
212 S. Martins et al.
K O
Keloids, 83, 93, 160 Occlusion, 77–82
Keloids and hypertophic scars, 190–191 Oily skin, 26
Keratocoagulation, 64 Organic carboxylic acids, 20
Keratolysis, 64, 65
Kligman formulas, 33
Kojic acid, 156 P
Pain, 156
L control, 66
Lactic acid, 26, 35, 156 phenol peeling, 86–89
Laser toning, 30 PCIM. See Percutaneous collagen induction with
Laxity, 208 microneedles (PCIM)
Lifting effect, 74 Pearly penile papules, 191
Lipo-hydroxy acid (LHA), 147 Peculiarities of non-facial areas. See Non-facial areas
Liquid petrolatum, 68 Peel(s), 52. See also Chemical peeling
Lymphangiomas, 191 dark skin (see Dark skin, peelings)
strengths, 10–11
M Peeling, 154
Malignant lesions, 186, 187, 193 Peeling care, 59
Manual sanding, 69 Percutaneous collagen induction with microneedles
Medium-depth peels, 53 (PCIM)
Coleman combination, 59 characteristics of, 177–181
Monheit combination, 57–59 fundamentals of, 176–177
preparation for, 56–57 protocol and management, 181
tricholoroacetic acid, 55–57 Persistent erythema, 92, 155
Medium peels, 64 Petroleum jelly, 104
Melanosis, 4 pH, 167
Melasma, 4, 5, 11–12, 20, 23, 26, 36, 42, 43, 67, 133, 136, Phenol, 76–77, 102, 159, 166
142, 145, 146, 149 Phenol-croton formulas, 102, 106
Middle reticular dermis, 74 Phenol-croton oil peel, 74
Mild photodamage, 26 toxicity, 76–77
Milia, 158, 206 Phenol-croton peel treatment. See also Deep peeling,
Modified Jessner’s solution, 42, 43, 169 phenol
Molluscum contagiosum, 68, 191 absorption, 76
Monheit combination, 55 acne scars, 102
Monheit’s Jessner + TCA, 35%, 107 actinic cheilitis, 102
Mottled pigmentation, 26 actinic keratoses, 102
Mucocele, 191 atrophic, 102
Mycotic infection, 85, 95 BTxA, 102, 108–110
chemical peel, 106–108
N croton oil, 102
Necrosis, 160, 186 deep wrinkles, 102
Necrotic epithelium, 89–90 dermal fillers, 110
Nerve blocks, 66 ear lobe cleft repair, 102
Neutralization, 11, 14–15 elastosis, 102
Nicotinamide, and topical hyaluronic acid, 106 excretion, 77
Non-facial areas, 116 LASER, 112
blood supply, 116 lax skin, 102
chemical agent (see Chemical agents) metabolism, 77
complications, 126 phenol-croton formulas, 106
contra-indication, 116 photoaging, 102
degree of desquamation and small crusts formation, 116 poly-L-lactic acid, 111
epidermis’s thickness, 116 toxicity, 74
healing period, 116 verruca plana, 102
previous skin preparation, 117 xanthelasma, 102
rigorous medical history, 116 Phenol peel. See Deep peeling, phenol
skin surface, extension of, 116 Phenol peeling
supporting treatment, 117 complications, 91–96
Index 217
contraindications, 83 post-procedure, 21
general care, 85 pre-procedure, 21
pain with, 86 procedure, 21
Phorbol esters, 102 Salicylism, 36
Photoaged skin, 74 Saline compresses, 104
Photoaging, 10, 20, 36, 52, 64, 67, 142, 143, 147, 154, 171 Scalp, 70
Photodamage, 3, 4, 6, 26, 48 Scarring, 160
Photoprotection, 66 Scars, 92–94, 154
Photosensitizers, 36 Sebaceous hyperplasia, 191, 201
Phototype, 167 Seborrheic keratosis, 191–192, 201, 206
Pigmentary disorders, 52 Sebum, 167
Pigmentation, 157 Sedation, 86–87
Plume, 210 Shot glass, 166
Porokeratosis, 191 Skin appendages, 66
Post-inflammatory hyperpigmentation (PIH), 5, 26, 36, Skin depth, 52
46–47, 68, 91, 103, 135, 154, 167 Skin preparation, 13–14
Post-peel care, 15 Skin resurfacing, 89
Post-peeling erythema, 90 Skin retraction, 74
Post-peel period, 155 Sodium bicarbonate, 27
Postponed healing, 161 Solar lentigo, 192
Pregnant patients, 67 Solid CO2, 59
Prepeel assessment, 13 Sponges, 169
Pre-peeling preparation, 84–85 Spot peel, 135
Pruritus, 156 Spotted leucoderma, 26
Pseudofolliculitis barbae, 135 Sun exposure, 38
Pyogenic granulomas, 191, 201 Sunscreen, 38
Pyruvic acid, 25, 26, 43, 64, 166 Superficial chemical peels, 142, 143, 149–150
alpha-hydroxy-acids, 145
alpha-keto-acid, 146–147
Q beta-hydroxy-acid, 147
Q-switched laser, 33, 102 beta-lipohydroxy-acid, 147
contraindications, 144
fluor-hydroxy peel, 149
glycolic acid, 145–146
R history, 142–143
Radiant skin, 4 indications, 143–144
Radiation exposure, 36 Jessner solution, 144–145
Rayon large applicators, 168 lactic acid, 146
Reepithelization, 90, 92, 96 patient selection, 144
Rejuvenation, 3, 4 phytic acid, 146
skin, 83, 175 pre-peeling preparation, 144
Resorcinol, 35, 64, 65, 156 salicilic-mandelic acid, 149
Retinoic acid, 4, 6, 64, 134, 135, 166 side effects and managements, 150
Rhinophyma, 202, 208 special care, 144
Risks, chemical peel, 53 thioglycolic acid, 148
Rosacea, 4, 6, 64, 67 tretinoin, 145
trichloroacetic acid, 145
Superficial peeling, 6
S Superficial peels, 64, 67
Sable-hair brush, 27 Superficial scarring, 26
Safety, peeling room, 171 Surface characteristics, 52
Salicylic acid, 35, 42, 47, 64, 65, 133, 156, 166 Syringoma(s), 192, 201, 208
intoxication, 36 Systemic toxicity, 76
Salicylic acid (SA) peel, 20
complications and management, 21–22
definition, 20 T
formulations, 20 TCA. See Trichloroacetic acid (TCA)
indications and contraindications, 20 Techniques, non-facial areas. See Non-facial areas
218 Index
Telangiectasia, 4, 6, 157 V
Temperature, 167 VaselineTM, 33, 104
Textural changes, 159 Vehicles, 167
Topical/infiltrative anesthesia, 66 Venous lakes, 192
Topical steroids, 168 Verrucous nevus, 208
Toxicity, phenol, 76 Very superficial peels, 64, 67
Tranexamic acid, 33 Viral warts/condyloma acuminate, 190
Treatments, 175, 179, 181 Vitamin C, 106
Tretinoin, 4, 5, 42, 47, 65, 103 Vitamin E, 106
Trichloroacetic acid (TCA), 16, 33, 64–65, 102, 134, 156,
166, 167
disadvantage, 65 W
features, 65 Wooden toothpicks, 169
and glycolic acid, 59 Wound healing. See Healing
and Jessner’s solution, 57 Wrinkles, 4, 154, 208
medium-depth peels, 55
medium peels, 67–68
superficial and very superficial peels, 67 X
Trichoepitheliomas, 201 Xantelasma, 192, 201, 206
medium-depth peels, 55 Xeroderma pigmentosum, 68