Quantitative and qualitative effects of chemical peeling on photo-aged skin: an experimental study

Trichloroacetic Acid Peeling for Treating Photoaging: A Systematic Review

Photoaging can significantly contribute to lower quality of life. Medium-deep peeling using trichloroacetic acid allows controlled keratocoagulation through the dermis and into the dermal papillary layer that is effective for skin rejuvenation. The purpose of this article is to give updates regarding the efficacy, possible adverse events, and patient satisfaction of trichloroacetic acid (TCA) peeling for skin rejuvenation by assessing various photoaging parameters. A systematic review of prospective trial articles collected from PubMed, MEDLINE, EMBASE, Cochrane, and Scopus databases was conducted on November 2, 2020. Treatment efficacy was assessed based on the photoaging parameters used by each study. Adverse events and patient satisfaction as the secondary outcome were assessed based on patients-perceived improvements. Five studies included three randomized comparison studies and two prospective cohort studies. These studies show that TCA peeling significantly improve the cosmesis of photoaged facial skin. Low concentration is effective for superficial sun damage. Medium-depth peels using a higher concentration of TCA or as combination therapy are effective as skin resurfacing agents to reduce wrinkles. Some adverse effects may occur but usually resolve within weeks. Overall patients were satisfied with the treatment result. An equivalent basic skin preparation such as topical retinoic acid skin priming prior to intervention is necessary for more objective comparison. Further research studies with a larger sample size and longer follow-up period are required. This evidence suggests that TCA peeling is effective in photoaging treatment, either as monotherapy or as combination therapy with other modalities.

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

ABSTRACT

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

Effects of different therapeutic modalities for postacne scars on circulating collagen III

BACKGROUND

Therapies for postacne scarring act through modulation of elastin and collagen, and collagen III might therefore represent a biomarker of treatment effectiveness.

PATIENTS AND METHODS

Patients (n = 70) with postacne scars and individuals without scars (n = 56) were included in this case-control study. Patients were treated with Dermaroller microneedling, trichloroacetic acid chemical reconstruction, punch excision, or scar subcision. Scar severity was graded immediately before and after treatment with a photographic quartile scale and the ECCA scale. Serum levels of collagen III were measured in control individuals and in patients, before treatment, 1 month after the first treatment session, and 4 months after the final session.

RESULTS

Circulating levels of collagen III were significantly higher in patients with postacne scarring (24.1 ± 12.5) before treatment than in control individuals (2.6 ± 0.8). Circulating levels of collagen in patients were significantly lower 4 months posttreatment (14.3 ± 8.1) than at baseline. The mean percentage change in serum collagen III was positively correlated with both the mean percentage improvement by photographic evaluation (r = .530, P < .000) and the mean percentage change in the ECCA scale (r = .632, P < .000).

CONCLUSION

Circulating collagen III is a biomarker for improvement of postacne scarring following different therapies.

Radio Peel-Synergism Between Nano-fractional Radiofrequency and 20% Trichloroacetic Acid Chemical Peeling

BACKGROUND

Microneedling fractional radiofrequency (FRF) and chemical peels are widely used for skin rejuvenation.

OBJECTIVE

The authors aimed at evaluating the efficacy and safety of FRF and trichloroacetic acid 20% (TCA20%) peel in different combinations for determining the optimal treatment protocol.

METHODS

In this prospective clinical comparison of 4 protocols (FRF alone, TCA20% alone, TCA20% before FRF [TCA→FRF], and TCA20% following FRF [FRF→TCA]), the patients underwent 3.8 ± 1.2 successive treatments of one protocol at 4- to 6-week intervals. The patients and 2 dermatologists evaluated improvement of pigmentation and dyschromia, erythema and blood vessels, laxity and wrinkling, and skin imperfections using a global aesthetic improvement scale (GAIS) and a 1 to 5 scoring system. The patients rated their satisfaction and reported adverse effects and reduced activity. Skin impedance and histological changes following the different protocols were also evaluated on 3 additional volunteers.

RESULTS

Sixty-seven patients (age range 22-80 years) were studied. TCA→FRF caused skin impedance to decrease, yielding a more superficial and less-efficient penetration of FRF energy. FRF→TCA produced more significant improvement in overall facial skin appearance (GAIS) and most evaluated skin parameters. Adverse effects and satisfaction rates were similar for all approaches.

CONCLUSION

FRF→TCA had the best synergistic effect on skin rejuvenation compared with FRF or TCA20% alone and TCA→FRF.

Punctuated 88% Phenol Peeling for the Treatment of Facial Photoaging: A Clinical and Histopathological Study

BACKGROUND

Phenol peeling is considered an important agent in the treatment of facial rejuvenation; however, its use has limitations due to its high potential for side effects.

OBJECTIVE

This article proposes a new peeling application technique for the treatment of photoaging, aiming to evaluate, clinically and histopathologically, the efficacy of a new way of applying 88% phenol, using a punctuated pattern.

METHODS

The procedure was performed in an outpatient setting, with female patients, on static wrinkles and high flaccidity areas of the face. Accompanying photographs and skin samples were taken for histopathological analysis before and after treatment.

RESULTS

It was shown that 88% phenol applied topically using a punctuated technique is effective in skin rejuvenation.

CONCLUSION

The authors thus suggest, based on this new proposal, that further studies be conducted with a larger group of patients to better elucidate the action mechanisms of 88% phenol. This new form of application considerably reduced patients' withdrawal from their regular activities, besides reducing the cost, compared with the conventional procedure.

[Chemical peels and management of skin aging]

Chemical peels are an alternative and/or a complementary treatment to the surgical procedures for skin aging. The purpose of this article is to specify the procedures and the indications of the three principal types of chemical peels: alpha-hydroxy acids, trichloracetic acid, phenol-croton oil peel. The clinical examination will determine the depth of the lesions to treat and will take into consideration counter-indications and specific limits to each patient. Chemical peel is a four step procedure: pre-peel preparation, peeling itself, recovery phase and maintenance phase. The preparation is a very important phase which requires a thorough knowledge of cosmetics. This preparation can extend to any medical or surgical treatment for aging skin. Various techniques of peelings: superficial, medium, deep, combined and mosaïc peel will be detailed. These procedures require a rigorous training and a distinct learning curve. The follow up will be specified as well as the management of the possible complications.

The Effectiveness of a 5% Retinoic Acid Peel Combined with Microdermabrasion for Facial Photoaging: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial

Background. Tretinoin has been shown to improve photoaged skin. This study was designed to evaluate the efficacy and tolerability of a 5% retinoic acid peel combined with microdermabrasion for facial photoaging. Materials and Methods. Forty-five patients, aged 35–70, affected by moderate-to-severe photodamage were enrolled in this trial. All patients received 3 sessions of full facial microdermabrasion and 3 sessions of either 5% retinoic acid peel or placebo after the microdermabrasion. Efficacy was measured using the Glogau scale. Patients were assessed at 2 weeks and 1, 2, and 6 months after treatment initiation. Results. The mean ± SD age of participants was 49.55 ± 11.61 years, and the majorities (73.3%) were female. Between 1 month and 2 months, participants reported slight but statistically significant improvements for all parameters (P < 0.001). In terms of adverse effects, there were statistically significant differences reported between the 5% retinoic acid peel groups and the control group (P < 0.001). The majority of adverse effects reported in the study were described as mild and transient. Conclusion. This study demonstrated that 5% retinoic acid peel cream combined with microdermabrasion was safe and effective in the treatment of photoaging in the Iranian population. This trial is registered with IRCT2015121112782N8.

Comparison of efficacy of chemical peeling with 25% trichloroacetic acid and 0.1% retinoic acid for facial rejuvenation

INTRODUCTION

Skin aging is a problem which negatively affects the psyche of the person, social relations, as well as work life and health and which compels the patients to find appropriate treatment methods. Numerous treatment methods have been developed in order to delay aging and to reduce the aging effects in addition to having a younger, healthier and more beautiful facial appearance.

AIM

To compare the efficiency, cosmetic results and possible adverse effects of the peeling treatment with 25% trichloroacetic acid (TCA) and 0.1% retinoic acid for facial rejuvenation in patients presenting with skin aging.

MATERIAL AND METHODS

Fifty female patients in total presenting with medium and advanced degree skin aging were subject to this study. Two separate treatment groups were formed; the first group underwent chemical skin treatment with 25% TCA while the other group was applied with 0.1% retinoic acid treatment. Following the 4 months' treatment the patients were controlled three times in total for post lesional hypopigmentation, hyperpigmentation, scars, skin irritation and other possible changes per month. The pretreatment and first follow-up visit, and final control images were comparatively evaluated by three observers via specific software.

RESULTS

The healing rates of the group subject to retinoic acid were statistically higher (p < 0.05) compared to patients in the TCA group in the final follow-up visit following the treatment according to the first and second observers. On the other hand, according to the third observer, patients applied with retinoic acid presented with higher healing rates compared to those treated with TCA, however; this rate was not statistically significant (p > 0.05). The frequency of TCA- and retinoic acid-associated adverse effects was similar in both groups (p > 0.05). As a result of both treatments, a reduction in the quality of life scores as well as a pronounced recovery (p = 0.001) in the quality of life of those patients with skin aging was observed.

CONCLUSIONS

The photo aging treatment option with 0.1% retinoic acid is cheaper and more feasible for patients compared to 25% TCA, and it is also as reliable and effective as TCA.

A randomized, placebo-controlled, single-blinded, split-faced clinical trial evaluating the efficacy and safety of KLOX-001 gel formulation with KLOX light-emitting diode light on facial rejuvenation

Purpose

Many treatment modalities exist to counteract the effects of cutaneous aging. Ablative methods have been the mainstay for nonsurgical facial rejuvenation. In recent years, nonablative techniques have been developed with the aim of achieving facial rejuvenation without epidermal damage. Light-emitting diode (LED) photorejuvenation is a novel nonablative technique that induces collagen synthesis through biophotomodulatory pathways.

Materials and methods

A single-center, randomized, single-blinded, placebo-controlled, split-faced clinical trial was designed. Thirty-two patients were enrolled for a 12-week study. Patients were randomized into one of four groups: Group A, treatment with KLOX-001 gel formulation and white LED (placebo) light; Group B, treatment with a placebo/base gel (no active chromophore) formulation and KLOX LED light; Group C, treatment with KLOX-001 gel formulation and KLOX LED light; and Group D, treatment with the standard skin rejuvenating treatment (0.1% retinol-based cream). Patients received treatment at weeks 0, 1, 2, and 3, and returned to the clinic at weeks 4, 8, and 12 for clinical assessments performed by an independent, blinded committee of physicians using subjective clinician assessment scales. Tolerability, adverse outcomes, and patient satisfaction were also assessed.

Results

Analysis demonstrated that the KLOX LED light with KLOX placebo/base gel and the KLOX LED light + KLOX-001 gel formulation groups were superior to standard of care and KLOX-001 gel formulation with placebo light on subjective clinical assessment and multiple wrinkle scales, with statistically significant results obtained for brow positioning, perioral wrinkling, and total wrinkle score.

Conclusion

The study results show that KLOX LED light with KLOX-001 gel formulation and KLOX LED light with KLOX placebo/base gel are effective, safe, well-tolerated, and painless treatment modalities for skin rejuvenation.

Therapeutic response of 70% trichloroacetic acid CROSS in atrophic acne scars

BACKGROUND

Acne scarring is a common sequela of acne for which no single treatment method is uniformly effective. The chemical reconstruction of skin scars (CROSS) therapy using high-concentration trichloroacetic acid (TCA) has shown promise as a cheap, safe, and effective modality of treatment in acne scars.

OBJECTIVE

To assess the therapeutic response of 70% TCA CROSS on atrophic acne scars and to evaluate the adverse effects of this therapy.

MATERIALS AND METHODS

Fifty-three patients with postacne atrophic scars were treated with 70% of TCA focal application every 2 weeks by the CROSS technique and results evaluated on 3 parameters: physician assessment, patient assessment, and satisfaction level of patients, after a follow-up of 3 months.

RESULTS

Good or excellent improvement (>50%) was seen in 66% of patients on physician and patient assessments. The patients were either very satisfied or satisfied in 81.1% of cases. Patients with predominantly boxcar scars and higher pretreatment scar severity were associated with better treatment outcomes. Age, sex, duration of scars, or type of skin did not significantly influence the treatment outcome and adverse effects.

CONCLUSION

The study showed that 70% of TCA is a safe and effective treatment option in all types of atrophic acne scars, especially in severe boxcar scars.

Chemical reconstruction of skin scars therapy using 100% trichloroacetic Acid in the treatment of atrophic facial post varicella scars: a pilot study

Context:

Chickenpox (varicella) is a common viral disease caused by Varicella zoster virus. Facial atrophic scars after varicella infection are not uncommon and pose a cosmetic problem. Like atrophic scars of other aetiologies, they are a difficult condition to treat. There are not enough references in the literature regarding efficient treatment of post varicella scars. High strength Trichloroacetic acid (TCA), which is known to cause dermal collagen remodelling, was used to treat varicella scars in the present study.

Aims:

The study was undertaken to assess the efficiency of Chemical Reconstruction of Skin Scars (CROSS) technique using 100% TCA in the treatment of atrophic facial post varicella scars. Settings and Design: Open label, pilot study.

Materials and Methods:

A total of 16 patients with atrophic facial post varicella scars were treated by focal application of 100% TCA solution by pressing down upon the scar surface by a toothpick (CROSS technique). Total 4 sittings were given at 2 weekly intervals and the results evaluated after 3 months of follow-up. Statistical analysis was carried out using Fischer's exact t-test.

Results:

All of the 13 patients who completed the study showed good clinical improvement, with 69% patients grading the response as excellent (>75%) improvement, whereas the rest 31% patients reporting good (51-75%) improvement. No significant complications were seen in any patient.

Conclusions:

CROSS technique using 100% TCA is a safe, cheap and effective therapy for the treatment of post varicella scars.

Skin anti-aging strategies

Skin aging is a complex biological process influenced by a combination of endogenous or intrinsic and exogenous or extrinsic factors. Because of the fact that skin health and beauty is considered one of the principal factors representing overall "well-being" and the perception of "health" in humans, several anti-aging strategies have been developed during the last years. It is the intention of this article to review the most important anti-aging strategies that dermatologists have nowadays in hand, including including preventive measurements, cosmetological strategies, topical and systemic therapeutic agents and invasive procedures.

A review of minimally invasive cosmetic procedures

In today's society the desire to maintain a youthful appearance has driven the development of minimally invasive dermatological procedures that are designed to rejuvenate the ageing face. The aim of this review is to present evidence for the use of techniques which can easily be incorporated into outpatient dermatology practice with low overhead expenditure. For this reason, laser and light-based treatments have been omitted. This review will instead focus on chemical peels, intradermal fillers and botulinum toxin. These techniques address the main aspects of facial ageing, namely photodamage, volume loss and dynamic lines, which correlate anatomically to skin, subcutaneous fat and muscle. A combination of such techniques will provide the practitioner with a reasonable portfolio of treatments for a balanced, holistic result.

Histometric and histochemical analysis of the effect of trichloroacetic acid concentration in the chemical reconstruction of skin scars method

BACKGROUND

Atrophic scars can be induced by various causes, including severely inflamed acne, chicken pox, and trauma. Many treatment modalities are used for reconstructing and improving the appearance of scars with various treatment results.

OBJECTIVE

A recent report shows the clinical efficacy of the chemical reconstruction of skin scars (CROSS) method, which consists of the focal application of trichloroacetic acid (TCA) in a higher concentration. Histometric analysis of the CROSS method, however, has not yet been established.

METHODS

In this study, five hairless mice were used to evaluate the effect of the CROSS method and to analyze the difference between the CROSS method and simple TCA application.

RESULTS

Similar histologic changes were observed in the two methods, including epidermal and dermal rejuvenation with new collagen deposition. These changes, however, were more prominent in the CROSS method-treated areas, particularly when 100% TCA was used.

CONCLUSION

The results of this study suggest that treatment of atrophic scars using the CROSS method is more effective than simple application of TCA in activating fibroblasts in the dermis and increasing the amount of collagen.

Evaluating cutaneous photoaging by use of multiphoton fluorescence and second-harmonic generation microscopy

The photoaging process of facial skin is investigated by use of multiphoton fluorescence and second-harmonic generation (SHG) microscopy. We obtain the autofluorescence (AF) and SHG images of the superficial dermis from the facial skin of three patients aged 20, 40, and 70 years. The results show that areas of AF increase with age, whereas areas of SHG decrease with age. The results are consistent with the histological findings in which collagen is progressively replaced by elastic fibers. The AF and SHG changes in photoaging are quantified by a SHG to autofluorescence aging index of dermis (SAAID). Our results suggest that SAAID can be a good indicator of the severity of photoaging.

Trichloroacetic acid peeling versus dermabrasion: a histometric, immunohistochemical, and ultrastructural comparison

BACKGROUND

Trichloroacetic acid (TCA) chemical peel and dermabrasion are beneficial methods for treatment of photoaged skin.

OBJECTIVE

In this study, we evaluated the changes induced by these therapies on various structures of facial skin of nine dark-skinned patients (Fitzpatrick types IV-V; TCA, five patients; dermabrasion, four patients) demonstrating different degrees of photodamage.

METHODS

Routine histopathology coupled with histometric computer-assisted image analysis was used to assess epidermal changes. Alcian blue stain was used to evaluate changes in glycosaminoglycans. Immunoperoxidase techniques with antibodies against types I and III collagen and elastin were used to evaluate quantitatively changes in collagen and elastic fibers, and their ultrastructure was examined by transmission electron microscopy.

RESULTS

Similar histologic, immunohistochemical, as well as ultrastructural changes were observed in the two groups, including epidermal and dermal rejuvenation with new collagen deposition and normalization of the elastic tissue. However, these changes were more prominent in patients treated with dermabrasion than those treated with TCA.

CONCLUSION

The results of this study suggest that beneficial effects of such modalities on facial skin were accomplished primarily by increasing the amounts of collagen I and collagen III and improving the morphologic appearance of collagen and elastic fibers.

Biological effects of glycolic acid on dermal matrix metabolism mediated by dermal fibroblasts and epidermal keratinocytes

Glycolic acid (GA), one of the alpha-hydroxy acids, is widely used as an agent for chemical peeling. Although there are several reports about the clinical effects of GA in the literature, its biological mechanism remains mostly unclear, and there are only a few reports about its effects on skin rejuvenation mediated by keratinocytes. The aim of this study was to investigate the effect of GA on the dermal matrix metabolism of keratinocytes and fibroblasts using in vitro and ex vivo systems. Our study shows that GA not only directly accelerates collagen synthesis by fibroblasts, but it also modulates matrix degradation and collagen synthesis through keratinocyte-released cytokines. We confirm that IL-1alpha is one of the primary mediators for matrix degradation released from keratinocytes after GA treatment. These results suggest that GA contributes to the recovery of photodamaged skin through various actions, depending on the skin cell type.

Review of nonablative photorejuvenation: reversal of the aging effects of the sun and environmental damage using laser and light sources

This review article outlines all the latest light or electromagnetic radiation based technologies used for nonablative skin rejuvenation. While many technologies have been available for a number of years, emerging technologies are also discussed, which may play a role in treatment of photoaged skin in the very near future. The principles behind these technologies are discussed in detail.

Skin rejuvenation regimens: a profilometry and histopathologic study

OBJECTIVE

To quantitatively examine the effects of skin rejuvenation regimens in treating photodamaged skin.

METHODS

Fourteen patients with photodamaged skin were considered for analysis. Skin rejuvenation regimens were as follows: (1) 10 weeks of treatment with topical 0.05% tretinoin emollient cream, (2) 10 weeks of treatment with 0.05% tretinoin emollient cream and topical ascorbic acid lotion, (3) 6 superficial trichloroacetic acid peels, and (4) a combination of the topical treatments and superficial peels. Comparisons of the treatments were analyzed using profilometry and histologic findings.

RESULTS

Profilometry analysis provided quantification of the changes from each treatment group and among the treatment programs. Each group showed improvements from baseline. Trichloroacetic acid peels combined with application of the topical products improved skin topography to a greater extent than the less aggressive regimens. Histologic changes correlated well with the skin replica findings.

CONCLUSIONS

A 10-week skin rejuvenation regimen objectively improved photodamaged facial skin. Significant changes are noted when combining topical treatments with superficial peels. Hence, use of a combination of trichloroacetic acid peels, 0.05% tretinoin emollient cream, and ascorbic acid lotions is well tolerated and superior to either component alone as part of a comprehensive skin care and sun protection program.

Focal treatment of acne scars with trichloroacetic acid: chemical reconstruction of skin scars method

BACKGROUND

Acne scarring is a common complication of acne and yet no appropriate and effective single treatment modality has been developed. We suggest a technique consisting of the focal application of higher trichloroacetic acid (TCA) concentrations by pressing hard on the entire depressed area of atrophic acne scars. This technique is called chemical reconstruction of skin scars (CROSS) by the authors.

OBJECTIVE

To evaluate the clinical effects of CROSS on atrophic acne scars in dark-complexioned patients.

METHODS

An analysis was conducted of 65 patients with atrophic acne scars who were treated with CROSS in our hospitals between July 1996 and July 2001. Thirty-three patients were treated with 65% TCA CROSS and 32 patients were treated with 100% TCA CROSS. All patients had Fitzpatrick skin types IV-V.

RESULTS

Patient treatment data indicated that 27 of 33 patients (82%) (the 65% TCA group) and 30 of 32 patients (94%) (the 100% TCA group) experienced a good clinical response. All patients in the 100% TCA group who received five or six courses of treatment showed excellent results. Good satisfaction rates in the 65% and 100% TCA groups were recorded. There were no cases of significant complication.

CONCLUSION

CROSS is a safe and very effective single modality for the treatment of atrophic acne scars with no significant complications.