Chemical peels: A review of current practice

Non-Facial Skin Rejuvenation of the Neck, Chest, and Hands. Part One: Using Injections

BACKGROUND

The demand for aesthetic procedures aimed at restoring and preserving a youthful appearance is growing. While numerous non-surgical facial rejuvenation techniques are available, there is a need for a comprehensive review of clinic-based procedures targeting non-facial body parts.

AIMS

This review aims to describe and evaluate clinic-based techniques for rejuvenating the neck, chest, and hands, focusing on various types of fillers and other non-invasive procedures.

METHODS

In this first part of this review, we conducted an extensive literature review on PubMed, reporting the effectiveness of different fillers, detailing their preparation, required volume per area, injection methods, durability, and any associated side effects. We also discuss the use of mesotherapy, microneedling, chemical peeling, and Profhilo in these specific body areas.

CONCLUSION

The review synthesizes the latest data on the effectiveness and safety of these procedures, highlighting the advancements in filler technology and the growing popularity of non-invasive techniques for body rejuvenation. This article serves as a valuable resource for practitioners and patients interested in non-surgical body rejuvenation, providing insights into the best practices.

Supramolecular salicylic acid combined with niacinamide in chloasma: a randomized controlled trial

BACKGROUND

Chloasma is a common skin hyperpigmentation condition, with treatment options ranging from topical agents to advanced interventions such as chemical peels and laser therapy. Salicylic acid, including its supramolecular form (SSA), has shown promise in managing chloasma. However, to date, no multicentre randomized controlled trial of SSA for chloasma is available.

OBJECTIVES

The purpose of this study was to assess the efficacy and safety of 30% SSA combined with 10% niacinamide in treating -chloasma.

METHODS

This multicentre (n = 15), randomized, double-blind, parallel placebo-controlled trial (Clinical trial registration number: ChiCTR2200065346) enrolled and randomized 300 participants (1 : 1) to either 30% SSA treatment or placebo, with 150 allocated to treatment and 150 to placebo in the full analysis set, and 144 to treatment and 147 to placebo in the per-protocol set. A Visia® Skin Analysis System was used at each visit to assess the degree of improvement in chloasma lesions. The primary endpoint was the effective rate after 16 weeks, assessed using the modified Melasma Area and Severity Index (mMASI) score [(pretreatment score - post-treatment score)/pretreatment score × 100%].

RESULTS

The total mMASI score, overall score on the Griffiths 10-point scale, and Griffiths 10 score for the left and the right sides of the face were significantly lower in the 30% SSA group than in the placebo group (all P < 0.001). One study of drug-related adverse events (AEs) and one study of drug-unrelated AEs were reported in the 30% SSA group. No AE was reported in the placebo group.

CONCLUSIONS

Among our patients, 30% SSA combined with 10% niacinamide was shown to be effective and safe for treating chloasma.

Picosecond Alexandrite Laser With Diffractive Lens Array Combined With Long-Pulse Alexandrite Laser for the Treatment of Facial Photoaging in Chinese Women: A Retrospective Study

BACKGROUND AND OBJECTIVES

Facial photoaging is a type of facial skin aging induced mainly by exogenous factors (ultraviolet radiation) and often manifests itself in the form of hyperpigmentation, telangiectasia, roughness, increase in fine lines/wrinkles, and enlarged pores. Recently, picosecond lasers have become an emerging option for the treatment of facial photoaging, and long-pulse alexandrite lasers (LPAL) have demonstrated promising potential in the treatment of photoaging-related symptoms. This study aimed to evaluate the efficacy and safety of picosecond alexandrite laser (PSAL) with diffractive lens array (DLA) combined with LPAL for facial photoaging.

METHODS

This is a retrospective study of 20 Chinese female patients with facial photoaging who received PSAL with DLA combined with LPAL during a 1-year period. All patients were treated every 4 weeks for a total of three treatments. Objective indicators of facial photoaging and patient satisfaction were evaluated before each treatment, and pain scores and adverse effects were recorded after each treatment.

RESULTS

Compared with baseline, patients showed significant differences in all facial photoaging indices (p < 0.01). After receiving three treatments, there was a 20.1% decrease in the pigmentation index, a 23.9% decrease in the erythema index, a 34.5% decrease in the texture index, a 28.4% decrease in the fine lines index, a 56% decrease in the pore index, a 9.3% elevation and a 17.1% decrease in elasticity R2 and F4, respectively, and a 55% decrease in sebum content. The mean satisfaction score for the three treatments was 4.67 (3.33, 5.00), and the mean visual analogue scale (VAS) pain score was 7.00. No serious adverse effects such as post-inflammatory hyperpigmentation (PIH), hypopigmentation, or blistering were observed at the treatment site during the treatment period.

CONCLUSION

PSAL with DLA combined with LPAL for the treatment of facial photoaging with significant efficacy, high patient satisfaction, and minimal adverse effects.

Comparing the efficacy and safety of microneedling and its combination with other treatments in patients with acne scars: a network meta-analysis of randomized controlled trials

This study aimed to analyze the efficacy and safety of microneedling (MN), both alone and in combination with other treatments, to refine the approach for treating acne scars using MN. We systematically searched Pubmed, Cochrane Library, Embase, and Web of Science for randomized controlled trials examining MN or its combinations in patients with acne scars. All statistical analyses were performed using Stata 18 software. A total of 24 studies involving 1546 participants were included. The analysis revealed that MN combined with chemical peels (CP) exhibited the best results in terms of degree of improvement, patient satisfaction, and treatment efficacy compared to other treatments examined, including MN alone, MN with hyaluronic acid (HA), MN with botulinum toxin‑A (TA), MN with platelet-rich plasma (PRP), PRP alone, CP, and laser therapy. The results for MN combined with additional treatments were obviously better than for MN alone. Side effects such as erythema, pain, and post-inflammatory hyperpigmentation showed no significant differences across all treatments assessed.

Revitalizing the lower face: Therapeutic insights and an innovative treatment guideline for jowl rejuvenation

BACKGROUND

The intricate mechanisms of jowl formation, which ultimately lead to loss of lower jaw definition, skin laxity, and localized fat accumulation, involve interrelated factors such as skin aging, fat redistribution, muscle dynamics, and loss of support.

AIMS

To propose a structured approach to the treatment of the jowl area that is comprehensive and tailored to the needs of each individual patient.

MATERIALS AND METHODS

This integrative review combines a meticulous analysis of the literature with practical insights from real-world clinical settings. The authors draw on their extensive clinical experience to bridge research findings with practical clinical perspectives.

RESULTS

This study presents a guideline for addressing jowl formation that starts with the major aging processes and, based on simple diagnostic questions, suggests minimally invasive interventions, including collagen stimulators, energy-based devices, lipolytic injectables, polydioxanone threads, and hyaluronic acid fillers.

DISCUSSION

The guideline emphasizes the significance of personalized treatments while also acknowledging the need for comprehensive evaluation and recognizing the ever-evolving nature of aesthetic interventions in jowl management.

CONCLUSION

This systematic approach can not only simplify diagnostic and treatment decisions for dermatologists but also enhance patient satisfaction by customizing treatment plans based on individual characteristics and expectations.

Procedural and surgical treatment modalities for acne scarring: Part II

The optimal treatment of acne scarring is challenging because several factors need to be considered, including the type and number of scars, Fitzpatrick skin type, and the amount of downtime permissible to the patient. This second article in the continuing medical education series discusses the procedural treatments available for acne scarring, including the use of chemical peels, fillers, radiofrequency microneedling, lasers, and surgical procedures. The indications for each modality, evidence for its benefits, and the adverse effects are discussed. This section aims to help guide the reader select and implement the most appropriate treatment based on the patient's preferences, acne scarring, and skin type.

A novel professional-use synergistic peel technology to reduce visible hyperpigmentation on face: Clinical evidence and mechanistic understanding by computational biology and optical biopsy

Topicals and chemical peels are the standard of care for management of facial hyperpigmentation. However, traditional therapies have come under recent scrutiny, such as topical hydroquinone (HQ) has some regulatory restrictions, and high concentration trichloroacetic acid (TCA) peel pose a risk in patients with skin of colour. The objective of our research was to identify, investigate and elucidate the mechanism of action of a novel TCA- and HQ-free professional-use chemical peel to manage common types of facial hyperpigmentation. Using computational modelling and in vitro assays on tyrosinase, we identified proprietary multi-acid synergistic technology (MAST). After a single application on human skin explants, MAST peel was found to be more effective than a commercial HQ peel in inhibiting melanin (histochemical imaging and gene expression). All participants completed the case study (N = 9) without any adverse events. After administration of the MAST peel by a dermatologist, the scoring and VISIA photography reported improvements in hyperpigmentation, texture and erythema, which could be linked to underlying pathophysiological changes in skin after peeling, visualized by non-invasive optical biopsy of face. Using reflectance confocal microscopy (VivaScope®) and multiphoton tomography (MPTflex™), we observed reduction in melanin, increase in metabolic activity of keratinocytes, and no signs of inflammatory cells after peeling. Subsequent swabbing of the cheek skin found no microbiota dysbiosis resulting from the chemical peel. The strong efficacy with minimum downtime and no adverse events could be linked to the synergistic action of the ingredients in the novel HQ- and TCA-free professional peel technology.

Practical Aspects of Acne Scar Management: ASAP 2024

Acne scars are one of the most common complications of acne. They can significantly affect the patient's quality of life. Often, several types of atrophic acne scars are observed simultaneously; therefore, consideration must be given to the type of scar while choosing the treatment modality. Effective treatment is not only important to prevent and improve acne scars but also crucial in preventing psychosocial effects. Treatment of acne scars requires an algorithmic approach that targets each component of the scars, and combination therapy on a patient-specific basis may offer the best chance for significant improvement. The goal of the current article is to discuss the practical aspects of management of atrophic acne scars using the vast modalities of treatment available. The panel of dermatologists and plastic surgeons, each one with at least 20 years of experience in acne scar treatment, participated in a series of 'Practical Aspects of Acne Scar Management' (ASAP) meetings: ASAP 2024. ASAP meetings were organized by "Scar Forum India" from March 2023 to July 2023 in four Indian cities (Mumbai, Delhi, Bengaluru, and Kolkata), each one for a duration of at least three hours. During these meetings and discussions, panelists reviewed and discussed the acne scar-related literature, their clinical experience in its management, available treatment options, along with recent advances. Consequently, a summary of the discussion and practical approach for the management of acne scars is developed. It was concluded that, though there is no specific guideline available to optimize acne scar management despite the multitude of treatment options, the best results can be achieved through the synergy of multiple treatment modalities and using the algorithmic approach.

Modern techniques in addressing facial acne scars: A thorough analysis

BACKGROUND

Facial acne scars are a prevalent concern, leading to the development of various treatment modalities.

OBJECTIVES

This review aims to explore the latest advancements in the treatment of facial acne scars, focusing on both surgical and non-surgical methods.

METHODS

The non-surgical treatments reviewed include topical medications (such as retinoids and alpha hydroxy acids) and non-invasive procedures (like microdermabrasion and chemical peels). Surgical options discussed are punch excision, subcision, and fractional laser treatments.

RESULTS

Combination therapy, integrating both surgical and non-surgical approaches, is frequently utilized to achieve optimal results in scar improvement.

CONCLUSION

Recent advancements in the treatment of facial acne scars provide promising options for individuals seeking improvement. However, these treatments have associated risks and potential adverse effects, highlighting the importance of consulting a dermatologist before beginning any treatment regimen.

Clinical Assessment, Diagnosis, and Management of Infraorbital Wrinkles and Pigmentation

Lower eyelid skin is unique and different from that of other areas. In addition to being an area of high exposure to the sun and elements, there are anatomic considerations and specific histologic characteristics that can cause the skin in this area to be more sensitive. These attributes can readily cause under-eye wrinkling and pigmentation. This review aims to present an updated overview of the current knowledge regarding the clinical characteristics, diagnosis, and management of wrinkles and pigmentation in this area. These disorders are usually caused by different factors, such as genetics, aging, sun exposure, lack of sleep, and stress.

Chemical Peels in Treatment of Melasma

Superficial chemical peels are one of the most popular skin resurfacing procedures in a dermatologists' clinic today due to quick application process, fast recovery, good patient acceptance, and excellent cosmetic results. The role of various peeling agents like glycolic acid, salicylic acid, trichloroacetic acid, Jessner's solution, retinoic acid, and lactic acid in the management of melasma has been established as that of an additional or maintenance therapy. This article details the current evidence and recommendations for the use of chemical peels in the treatment of melasma, a chronic and recurrent hyperpigmentary disorder.

Application of clitoris exposure + episioplasty + dermabrasion + platelet-rich plasma injection + chemexfoliation in vulvar lichen sclerosus

Introduction

To investigate the therapeutic effect of clitoris exposure + episioplasty + dermabrasion + platelet-rich plasma (PRP) injection + chemexfoliation on vulvar lichen sclerosus (VLS).

Methods

Twenty children with VLS (under 14 years old) at our hospital from July 2020 to November 2022 were enrolled and treated with clitoris exposure + episioplasty + dermabrasion + PRP injection + chemexfoliation. Additionally, symptomatic changes and improvements in signs were recorded.

Results

Significant therapeutic effects were achieved in all children enrolled in this study. The Cattanco score was 8.02 ± 1.22 points before surgery, 2.21 ± 0.70 points 3 months after surgery, and 2.61 ± 0.59 points 6 months after surgery, demonstrating that the score after surgery was significantly lower than that before surgery (p < 0.05). Mild complications (one case of mild vulvar swelling, one case of minor bleeding, and one case of superficial ulcer) were observed in three children after surgery, with an overall complication incidence of 15%; all complications were improved after the intervention, and no severe adverse reactions were observed. Recurrence was observed in one child (5%) 6 months after surgery.

Conclusion

Clitoris exposure + episioplasty + dermabrasion + PRP injection + chemexfoliation is an effective approach for the treatment of VLS.

Systematic Review Registration

https://www.chictr.org.cn/searchproj.html, identifier: ChiCTR2100054787.

A Comprehensive Bibliographic Review Concerning the Efficacy of Organic Acids for Chemical Peels Treating Acne Vulgaris

Acne vulgaris stands out as the most prevalent skin disorder among teenagers and young adults, causing physical discomfort and considerable economic and psychological burdens on individuals and society. A wide range of topical and systemic therapies are available in acne treatment. Chemical peeling is a skin resurfacing technique designed to rebuild healthy skin using exfoliating substances, a simple and affordable process with various dermatological uses. Chemical peels, classified as superficial, medium, and deep, have been utilized for acne vulgaris and multiple other skin issues. In these chemical peels, a diverse range of chemical substances is employed, each with its unique mode of action. Among these, α-hydroxy and β-hydroxy acids have gathered attention for their efficacy in reducing acne lesions and enhancing overall skin appearance. Acids, such as salicylic acid, glycolic acid, or lactic acid, are commonly used in chemical peels due to their exfoliating and sebum-regulating properties. Despite the widespread use of these acids, there exists a lack of consensus regarding the most effective acid type and concentration for treating acne-prone skin. This review aims to bridge this knowledge gap by evaluating the effectiveness and safety of various organic acids used in chemical peels specifically for acne-prone skin. The findings of this comprehensive bibliographic review indicate that organic acid-based chemical peels represent effective and safe treatment options for individuals with acne-prone skin. Their adaptability sets these treatments apart; the choice of organic acid can be tailored to meet individual patient needs and tolerability levels. This personalized approach ensures that patients receive optimal care while minimizing the risks associated with the treatment. As research in this field progresses, it is anticipated that a more nuanced understanding of the ideal acid type and concentration will emerge, further enhancing the efficacy and safety of chemical peels for acne-prone skin.

Five dimensions of cleansing: A holistic view on the facets and importance of skin cleansing

Cleansing is an important human ritual practised for hygiene, well-being and relaxation over centuries. As part of body care it is often taken for granted, yet its relevance cannot be underestimated. Although cleansing the skin may seem trivial to some, it is accepted, that this fundamental function of skin cleansing products is highly complex, diverse and crucial for a variety of reasons in the personal, public, healthcare and dermatological settings. Employing a comprehensive and strategic approach in viewing cleansing and its rituals, supports innovation, understanding and development. Apart from being a fundamental function, as far as we know, there is no comprehensive presentation of skin cleansing with all its effects besides 'removing dirt'. To our knowledge, comprehensive analyses on the multi-dimensional facets of skin cleansing are either rare or not published. Against this background, we examine the importance of cleansing in terms of function, relevance and concepts. First, the key functions and efficacies of skin cleansing were investigated by literature research. Based on this survey, the functions were analysed, sorted and merged and a novel approach to skin cleansing 'dimensions' was developed. Herewith, we took into consideration the evolution of skin cleansing in terms of concept evolution, complexity and testing methods for cleansing products and their claims. Several multi-dimensional functions of skin cleansing were identified and then established into five skin cleansing dimensions, namely: hygienic and medical importance; socio-cultural and interpersonal relevance; mood, emotion and well-being; cosmetic and aesthetic function; corneobiological interactions. It became obvious, that these five dimensions with their corresponding 11 sub-dimensions, are influenced by each other throughout history by culture and society, technical progress, scientific knowledge and consumer trends. This article presents the enormous complexity of skin cleansing. Skin cleansing has evolved from basic care up to a highly complex and diverse cosmetic product category in terms of technology, efficacy and usage routine(s). In view of future challenges, such as the effects of climate and associated lifestyle changes, the development of skin cleansing will remain an exciting and important topic and thus will finally, again, further increase the complexity of skin cleansing itself.

MALDI Mass Spectrometry Imaging and Semi-Quantification of Topically Delivered Lactic Acid

BACKGROUND

Lactic acid is a common active ingredient in many topical skincare products; however, measuring its delivery into the skin is challenging due to the presence of a large level of endogenous lactic acid. In this study, matrix-assisted laser desorption/ionization mass spectrometry imaging (MALDI-MSI) was used to quantitatively and qualitatively measure the delivery of lactic acid into the skin from a range of topical skincare products.

MATERIALS AND METHODS

Porcine skin samples were treated with various skincare products containing lactic acid. After 24 h, skin samples were sectioned and treated via H&E staining or prepared for MALDI-MSI using chemical derivatization. Samples were then analyzed by MALDI-MSI imaging to obtain lactic acid distribution in the entire skin section.

RESULTS

Due to the high level of endogenous lactic acid in the skin, a "triple isotope" of lactic acid (L-Lactic acid-13 C3 ), was needed to provide full resolution from the skin's background signal with MALDI-MSI. With this approach, the topically delivered lactic acid could be quantitatively and qualitatively analyzed from a variety of skincare products.

CONCLUSIONS

The combination of L-Lactic acid-13 C3 and MALDI-MSI was successfully used to quantitatively and qualitatively measure the topical delivery of lactic acid from a variety of skincare products. This approach could be used in future work to better understand the mode of action of lactic acid as an active ingredient in skincare products.

Molluscum Contagiosum in HIV Patient Treated with 20% Topical Glycolic Acid After Resistance with Topical Tretinoin

Molluscum contagiosum (MC) is a benign papular skin infection caused by Molluscum contagiosum virus (MCV). Over the past 30 years, the incidence of MK has continued to increased association with sexually transmitted infections and human immunodeficiency virus (HIV) infection. The incidence of MC in HIV patients is quite high at 5-8%. Until now there is no standard therapy used for the treatment of MC in patients with HIV. In HIV patients, anti retro viral therapy (ARV) is the main therapy with several other additional therapies such as cantaridin, chemical peeling agents such as glycolic acid (20-70%) and trichloroacetic acid (20-100%), cryosurgery, electrosurgery, incision, lactic acid, laser surgery, podophyllin, retinoic acid, and urea. There have been no studies regarding the administration of topical 20% glycolic acid in MC patients. We report a case of MC in an HIV patient who was treated with 20% topical glycolic acid after failing treatment with topical tretinoin. The diagnosis was made clinically, cytologically, and histopathologically, a white mass was found on compression of the lesion and Henderson-Paterson bodies. The lesions on the face, arms, and legs were given glycolic acid lotion 20% which was applied once a day at night. The lesions started to show responses to the treatment at week 6th as some of the MC papules became hyperpigmented macules. The side effects of therapy that appeared were itching and hyperpigmentation. Topical 20% glycolic acid can be used for MC therapy with minimal side effects, easy to apply and safe.

Insights on in-office scar revision and resurfacing procedures

Objective

Many facial plastic surgery procedures can be performed in an office-based setting, ranging from simple chemical peels to reconstructive surgeries to assist with scar revision. The aim of this review is to summarize the current state of facial plastics in-office surgical procedures, including scar revision, dermabrasion, lasers, and chemical peels.

Methods

A literature review was conducted with the PubMed search engine with the following keywords: facial plastics, scar revision, dermabrasion, lasers, chemical peels, face, office, and outpatient. The literature was surveyed for relevance, with a focus on realistically which procedures were performed in a facial plastics surgery outpatient clinic. These were then used to compile a review of the current state of this field.

Results and Conclusions

There are various scar revision procedures that can be performed in the office setting, including z-plasty, w-plasty, and geometric broken line closure techniques, as well as various nonmedical treatment options to improve the appearance of a scar. Dermabrasion can also be performed to assist with elevated scars. Various lasers are available to enhance cell turnover in the field of facial rejuvenation, scarring, and sun damage. Chemical peels are also available to assist with facial rejuvenation. With the appropriate counseling of the patient and medical staff, these can be safely performed in the office.

Disorders of Facial Hyperpigmentation

Disorders of hyperpigmentation are common and challenging conditions which can arise due to a myriad of etiologic factors. Many of them can present across skin types but are more common in skin of color individuals with Fitzpatrick skin types III-VI. Facial hyperpigmentation, in particular, can have a significant impact on the quality of life of affected individuals due to its increased visibility. This article provides a comprehensive review of disorders of facial hyperpigmentation including epidemiology, pathogenesis, diagnostic considerations, and treatment approaches for these conditions.

0.5-5% Supramolecular Salicylic Acid Hydrogel is Safe for Long-Term Topical Application and Improves the Expression of Genes Related to Skin Barrier Homeostasis in Mice Models

Background

As a keratolytic, salicylic acid (SA) can be topically applied in various formulations and doses in dermatology. Supramolecular SA hydrogel, a new SA formulation with higher bioavailability, is developed and commercially available nowadays. However, there still remain concerns that the long-term and continual application of SA at low concentrations may jeopardize the cutaneous barrier properties.

Aim of the Study

To reveal the long-term effects of 0.5-5% supramolecular SA hydrogel on the skin barrier in normal mice models.

Materials and Methods

The 0.5%, 1%, 2%, and 5% supramolecular SA hydrogel or hydrogel vehicle without SA was applied to mice's shaved dorsal skin once per day respectively. Tissue samples of the dorsal skin were harvested on day 14 and 28 of the serial application of SA for histopathological observation and transcriptomic analysis.

Results

Following topical supramolecular SA hydrogel therapy with various concentrations of SA (0.5%, 1%, 2%, and 5%) for 14 days and 28 days, there were no obvious macroscopic signs of impaired cutaneous health and no inflammatory or degenerative abnormalities were observed in histological results. Additionally, the transcriptomic analysis revealed that on day 14, SA dramatically altered the expression of genes related to the extracellular matrix structural constituent. And on day 28, SA regulated gene expression profiles of keratinization, cornified envelope, and lipid metabolism remarkably. Furthermore, the expression of skin barrier related genes was significantly elevated after the application of SA based on RNA-seq results, and this is likely to be associated with the PPAR signaling pathway according to the enrichment analysis.

Conclusion

Our findings demonstrated that the sustained topical administration of the 0.5-5% supramolecular SA hydrogel for up to 28 days did no harm to normal murine skin and upregulated the expression of genes related to the epidermal barrier.

Chemical peels for atrophic acne scarring: Evolution of peel types and methods

Acne vulgaris is a common condition among those of adolescent age. Prolonged inflammation associated with the disease can result in substantial scaring which is detrimental to both the physical and psychological well-being of the patient. Chemical peels are a commonly used treatment modality for acne scarring that is widely available and can be administered with a low associated cost. This article aims to illustrate the current best practice and highlight new advances in chemical peeling in the treatment of acne scarring.

Demystifying the mechanism of action of professional facial peeling: In-vivo visualization and quantification of changes in inflammation, melanin and collagen using Vivascope® and ConfoScan®

Professional peeling using chemicals (chemical peeling) is a popular non-surgical procedure commonly used for the treatment for photoaging, pigmentary disorders, scarring, fine lines, and wrinkles. The objective of our case study was to elucidate the mechanism of action of professional peels/peeling. For proof-of-concept, we used a commercial blended peel containing trichloroacetic acid and lactic acid. The facial peeling was performed by a physician on four subjects. These subjects were followed over time in the clinic to take clinical pictures and monitor surface and anatomical changes in inflammation, melanin, and collagen at regular intervals post-peel (5 min, 48 h, and day 9). Dermoscope and Vivascope® were used to image surface and subsurface anatomical changes, respectively, and ConfoScan® was used to quantify aforementioned anatomical changes. Based on Vivascope and ConfoScan analysis, we could see clear visual clinical evidence of controlled injury-healing mechanism of peel's action: immediate but transient onset of inflammation within 5 min (indicate injury response by skin), followed by melanin redistribution evident at 48 h (indicate activation of skin's defense system), and remodeled fibrous collagen network without any inflammatory cells on day 9 (healing response). To our knowledge, this is the first ever clinical study to deconvolute the mysterious mechanism of action of peels, in-vivo.

A Comprehensive Review of Non-Energy-Based Treatments for Atrophic Acne Scarring

Scarring is a dire consequence of acne vulgaris. Particularly, atrophic acne scarring is highly prevalent among young adults, and its physical and psychological effects can persist throughout their lives if left untreated. This literature review will analyze various non-energy-based approaches to treating atrophic acne scarring, emphasizing recent advances within the last 5 to 10 years. To accomplish this, we performed a PubMed search for various acne scar treatments such as chemical peels, dermabrasion, microdermabrasion, subcision, microneedling, punch techniques, dermal fillers, and thread lifting. Our findings and analysis show that there is no panacean solution to treating atrophic acne scars, which explains the evolving trend towards developing unique combinatorial treatments. Although a fair comparison of each treatment approach is difficult to achieve due to the studies’ varying sample sizes, strength of evidence, treatment execution, etc, there still remains a level of consensus on what treatments are well suited for particular scar types.

A prospective, randomized, split-face study of concomitant administration of low-dose oral isotretinoin with 30% salicylic acid chemical peeling for the treatment of acne vulgaris in Asian population

BACKGROUND

Acne vulgaris (AV) is a common dermatosis. For moderate to severe AV, isotretinoin is the first-line treatment. Chemical peeling with supramolecular salicylic acid (SSA) was developed with water solubility and advanced skin penetration properties. In the present study, we investigated the efficacy and safety of oral low-dose isotretinoin combined with 30% SSA chemical peeling.

METHODS

Thirty-three moderate-to-severe acne patients were enrolled and received oral low-dose (0.2-0.4 mg/kg/d) isotretinoin and were then randomly assigned to receive 30% SSA or not on each side of the face with 2-week intervals for four sessions. Photos, the number of lesions, GAGS score, skin indices (melanin, erythema, pore, and texture), hydration, and transepidermal water loss (TEWL) were assessed at 0, 2, 4, 6, and 10 weeks. Side effects, efficacy, and satisfactory rates were recorded.

RESULTS

A total of 29 patients completed the study. Oral isotretinoin combined with SSA decreased response time compared to isotretinoin monotherapy, with significantly improved GAGS score, count of lesions, and efficacy (%) at 4-6 weeks. Skin indices of melanin, erythema, pore, and texture evaluated at week 10 were improved as well. Oral isotretinoin with or without SSA was effective by the lesion clearance; only SSA significantly improved the TEWL. All the side effects were temporary and tolerable, and no adverse effects were observed.

CONCLUSION

Oral low-dose isotretinoin combined with 30% SSA is safe and effective, which advanced the onset of action and improves lesion clearance.

Subcision, chemical peels, and platelet-rich plasma: Combination approaches for the treatment of striae distensae

Striae distensae (SD) are disfiguring skin condition causing cosmetic troubles and psychological distress. The aim was to compare the efficacy and safety of platelet-rich plasma (PRP) versus its combination with subcision or medium-depth peeling (glycolic acid 70% followed by trichloroacetic acid [TCA] 35%) for SD treatment. Seventy-five female patients with SD were divided into three equal groups with the contralateral side in each patients represented the control group. Group A treated with PRP, group B received PRP + subcision while group C received PRP + combined peeling (GA 70% + TCA 35%). Primary outcome included clinical improvement, patients' satisfaction, and Dermatology Life Quality Index (DLQI). Striae measurement, skin biopsies were also assessed. Very much improvement was achieved in 28%, 44%, and 36% in groups A, B, and C respectively. The combined groups (B and C) showed significantly higher patients' satisfaction and DLQI than group A (p = 0.03), (p < 0.0001). A significant decrease in all striae measurements was achieved with all groups (p < 0.001); however, groups B and C showed more decrease (p = 0.2 and 0.4). A highly significant decrease in the mean number of sessions was found in group B (p < 0.0001). All groups demonstrated improvement in dermal collagen deposition, which was higher in the combined groups. Side effects were mild and well tolerated. The combination of PRP with subcision or peeling was more effective and offered a higher therapeutic response than PRP alone. Moreover, the subcision has superior efficacy in striae albae and safer in darker skin types.

Chemical Peels as Field Therapy for Actinic Keratoses: A Systematic Review

BACKGROUND

Actinic keratoses (AKs) are a common premalignant cutaneous neoplasm and can progress to squamous cell carcinoma. A variety of treatment options are available for field therapy of diffuse AKs.

OBJECTIVE

This review systematically analyzes the use of chemical peels for treatment of AKs.

MATERIALS AND METHODS

A systematic review of PubMed was performed searching from 1946 to March 2020 to identify the literature on chemical peels for AKs.

RESULTS

Of the 151 articles identified, 5 met inclusion criteria for review. Four of the reviewed articles demonstrated the efficacy of chemical peels in reducing AK count and minimal adverse effects. In some studies, chemical peels exhibited potential to prevent additional AK formation and development of keratinocyte carcinomas.

CONCLUSION

Chemical peels are an efficacious and affordable treatment option for field treatment of AKs. With improved patient tolerance and adherence, chemical peels are an attractive option for field therapy of AKs for both dermatologists and patients.

Skin Preparation for Photodynamic Therapy, Chemexfoliation, and Ablative Laser Resurfacing: a Systematic Literature Review

BACKGROUND

Photodynamic therapy, chemexfoliation, and ablative laser resurfacing are common practices for dermatologists, yet no formal protocols exist regarding preprocedural skin preparation.

OBJECTIVE

To review and summarize the skin preparation protocols for photodynamic therapy, chemexfoliation, and ablative laser resurfacing available in the literature.

METHODS

Data Sources A systematic review of English and non-English articles using the PubMed database was performed. A manual search of bibliographies from relevant articles was also performed to collect additional studies. Study Selection Only articles in the English language with full texts available that pertained to skin preparation for photodynamic therapy, chemexfoliation, and ablative laser resurfacing were included. Data Extraction Article selection was performed by one author, and relevant sources were verified by other authors using predefined inclusion and exclusion criteria.

RESULTS

There is a paucity of scientific research regarding efficacy and safety of dermatologic preprocedural skin preparation agents. Only 2 studies have compared various cleansing agents for these measures. Yet, strong statements regarding the importance of degreasing are published without supportive data.

CONCLUSION

Consensus guidelines for preprocedural protocols are lacking for photodynamic therapy, chemexfoliation, and ablative laser resurfacing. Further studies are warranted to explore the efficacy and safety of various preprocedural cleansing agents.

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.

Most worthwhile superficial chemical peel for melasma of skin of color: Authors' experience of glycolic, trichloroacetic acid, and lactic peel

Glycolic acid (GA), lactic acid (LA) and trichloroacetic acid (TCA) peels have been used in various combinations for treating melasma patients, but none of the studies have compared their therapeutic efficacy and improvement in quality of life (QOL) index with these three peeling agents in melasma. Our study aims to compare the clinical efficacy, safety, tolerability and improvement in QOL index between 30% GA, 92% LA, and 15% TCA peeling in epidermal melasma. Ninety patients were divided into three groups with 30 in each. First group was treated with 30% GA peel, second with 92% LA peel, and third with 15% TCA peel at every 2 weeks interval for 12 weeks. Melasma area severity index (MASI) and QOL index (Melasma quality of life and Health related quality of life index) were used for clinical evaluation. Patients were observed for side effects and tolerability. The mean MASI score after therapy was significantly lower in patients treated with GA and TCA peels as compared with the group receiving LA peel. However, there was no significant difference in the mean MASI scoring at 12 weeks between GA peel and TCA peel groups. The improvement in QOL index was higher among patients undergoing GA peel followed by TCA and LA peel. Adverse effects were noted mostly with TCA peels followed by GA and LA peel. Thus, GA and TCA peels were equally efficacious and more effective than LA peels. LA peel had minimum side effects and better tolerability than GA and TCA peels.

Paradigms in Complex Facial Scar Management

The process of scar formation is a sequela of the healing following soft tissue injury extending to, or through, the reticular dermis. Scars, within the head and neck in particular, may be physically disfiguring with resultant psychosocial implications. Mitigation of excessive scar formation during the healing process following surgery, or in the setting of trauma, begins with meticulous soft tissue handling and reconstructive technique. The reconstructive surgeon's armamentarium must therefore include techniques that minimize initial scar formation and revision techniques that address unfavorable outcomes. With this in mind, this article reviews both conservative nonsurgical and surgical treatment modalities that mitigate scar formation or address mature scar formation.

Effectiveness of water as the neutralising agent for glycolic acid peels in skin phototypes IV-V

The aim of the study is to evaluate the effectiveness of water as a substitute for sodium bicarbonate plus solution in the neutralisation process of chemical peeling using a 35% glycolic acid solution. This randomised, double-blind, split-face, controlled trial was conducted in an outpatient setting. A total of 126 healthy patients with skin phototypes IV-V aged between 18 and 60 years old were recruited. Chemical peeling was performed with 35% glycolic acid solution. One side of the face was neutralised with water, and the other side of the face was neutralised with a sodium bicarbonate plus solution. The main outcome of this study was measured by the degree of erythema, pruritus and pain scores. Significant difference in the pain score immediately after the neutralisation process of the chemical peeling with glycolic acid was seen. However, there were no significant differences in the degree of erythema or the pruritus score. These results indicate that water can be used as a substitute for sodium bicarbonate plus solution in the neutralisation process of chemical peeling with 35% glycolic acid in patients with skin phototypes IV-V.

Trichloroacetic acid 35% as a therapeutic line for localized patchy alopecia areata in comparison with intralesional steroids: Clinical and trichoscopic evaluation

BACKGROUND

Intralesional corticosteroids (ILCs) is the first-line therapy for patients older than 10 years having patchy alopecia areata, however some patients do not respond effectively.

AIMS

To evaluate the efficacy of a chemical peel trichloro acetic acid (TCA 35%) in comparison to ILCs.

PATIENTS/METHODS

Twenty-two patients with two patches of alopecia areata were included. Two treatment modalities with ILCs and topical TCA 35% were performed in two randomly selected patches. Three sessions were done, 3 weeks apart and were followed-up for three months. Evaluation was done using Mac Donald Hull and Norris grading system and by counting trichoscopic parameters in each patch.

RESULTS

Both ILCs and TCA 35% treated patches showed measurable improvement with no statistically significant difference between the results of the two modalities (p>0.05) at different times of the study. Yellow dots, black dots, exclamation marks and dystrophic hair were all reduced by 100%, 82.0%, 100% and 88.3% in ILCs treated patches and by 70.4%, 69.1%, 100% and 75.0% in TCA treated patches, respectively.

CONCLUSION

Topical TCA 35% is an effective and safe treatment for the treatment of AA without serious side effects, despite the slower response when compared to ILCs.

A spray containing extracts of oat plantlets and Uncaria tomentosa relieves pain associated with chronic inflammatory skin diseases and dermatological procedures

BACKGROUND

Inflammation from skin conditions such as psoriasis, eczema-like atopic dermatitis (AD) and hand eczema (HE) and following dermatological procedures (post-acts) can result in intense itching and cutaneous pain. Dermo-cosmetics containing plant extracts have been shown to reduce or alleviate these symptoms.

OBJECTIVES

Assessment of the tolerability and efficacy of a spray containing Rhealba\xAE Oat plantlets and Uncaria tomentosa extracts in adults and children with inflammatory skin diseases and after dermatological procedures.

METHODS

Data from five open label studies were analysed (Study 1: adults with AD; Study 2: children with AD; Study 3: adults with psoriasis; Study 4: adults with HE; Study 5: adults who had undergone a dermatological procedure: laser, intense pulsed light, glycolic acid peeling, photodynamic therapy or cryotherapy procedure). In all studies, subjects could use the test product up to six times per day for symptom relief. Physical and functional signs of inflammation, treatment-emergent adverse events (TEAEs), soothing effect, changes in quality of life, cutaneous pain and cosmetic acceptability were compared pre- and postapplication.

RESULTS

A total of 176 subjects were enrolled across the five studies. Overall, investigators judged the dermatological tolerance of the test product containing Rhealba\xAE Oat plantlets extract and Uncaria tomentosa as good to excellent. All studies showed significant improvements in physical signs, reduction in itching and feeling of pain (P < 0.05). The soothing effect was evident after the first application. TEAEs were mostly mild, transient and occurred within the first few days of treatment. The majority of subjects reported improved QoL across the studies.

CONCLUSIONS

The dermo-cosmetic spray containing Rhealba\xAE Oat plantlets extract and U. tomentosa was well tolerated and efficacious in providing relief of symptoms associated with cutaneous pain from inflammatory skin diseases and following dermatological procedures; however, further studies are needed to rule out alternative explanations of symptom reduction such as natural history and response biases.

Clinical and trichoscopic evaluation of trichloroacetic acid 35% vs phenol 88% peels in treatment of alopecia areata

BACKGROUND

Among alopecia areata (AA) treatments, contact irritants (anthralin) and topical immunotherapies (diphenylcyclopropenone) have been successfully used. Chemoexfoliation can potentially be utilized, acting as irritants and consecutively immunomodulators. Peels via therapeutic wounding provoke growth factors and cytokines that may induce hair regrowth.

AIM

To evaluate and compare trichloroacetic acid (TCA) 35% and phenol 88% peels effectiveness and tolerability in patchy AA.

PATIENTS/METHODS

This comparative, randomized, double-blind study included 20 patients with multifocal patchy AA. In each patient, 2 patches were selected and randomized into group I (20 patches: TCA 35%) and group II (20 patches: phenol 88%). A session was performed every 3 weeks for 9 weeks. Response was assessed by two blinded observers as regards percentage of clinical improvement, severity of alopecia tool (SALT), and trichoscopic scaled scores for dystrophic and terminal hairs, respectively. Patients were scheduled for follow-up visits over 6 months past treatment cessation.

RESULTS

A total of 19 patients completed the study and showed significant reduction in SALT score. TCA- and phenol-treated patches demonstrated significant improvement in the percentage of clinical improvement, trichoscopic scale of dystrophic and terminal hairs. However, TCA was superior to phenol as it showed significant more reduction in trichoscopic score of dystrophic hairs and significant higher increase in terminal hairs. Phenol yielded significant higher discomfort than TCA. No relapse was detected.

CONCLUSIONS

Trichloroacetic acid 35% and phenol 88% peels can be considered effective therapeutic modalities for patchy AA. TCA 35% represents a treatment of choice in terms of the efficacy and tolerability.

Striae distensae in adolescents: A mini review

Striae distensae or stretch marks are mainly a cosmetic concern. They commonly occur in adolescence and in pregnant women. Although, generally more common in females; physiological striae atrophicae of adolescence are more common in males. The pathophysiology is multifactorial with mechanical stretching of the skin being the most important. Despite of an abundance of treatment modalities none is 100% effective. (www.actabiomedica.it)

The rise of Chemical Peeling in 19th-century European Dermatology: emergence of agents, formulations and treatments

BACKGROUND

Considering the increasing number of chemical peeling applications, also the interest in the history of chemical peelings and agents, has grown in dermatology. Research ascribes the first use of phenol as a chemical peeling agent to William Tilbury Fox (1836-1879) in 1871. Furthermore, Ferdinand von Hebra (1847-1902) is said to describe the properties of various peeling agents in 1874, and Paul Gerson Unna (1850-1929) adds resorcinol and trichloroacetic acid in 1882.

OBJECTIVE

To identify the first mentions of chemical peeling applications and agents in 19th-century dermatology.

METHODS

Nineteenth-century dermatologists were identified by an examination of literature of the last 30 years on the history of chemical peeling. Systematic examination of the medical textbooks of Hebra, Fox and Unna was conducted. It was proved whether the mentioned agents were used for chemical peeling applications.

RESULTS

The skin peeling property of phenol was already discovered by its first describer, the chemist Friedlieb Ferdinand Runge (1795-1867) in 1834. The Viennese dermatologist Hebra described phenol as a chemical peeling agent in 1860. Hebra and his associate Moriz Kaposi (1837-1902) stated that 'Lotio carbolica' was already used in London. Fox used phenol mostly as a disinfectant and not for chemical peelings since 1869. Unna described the chemical peeling property of salicylic acid in 1882 and gave the most comprehensive account of chemical peels of the 19th century in 1899. Unna also introduced the Gutta-percha plaster with salicylic acid and phenol. Around 1900, Unna was famous for his peeling paste with resorcinol in Germany.

CONCLUSIONS

A new chronology of the introduction of chemical peeling in dermatology can be drawn from the results. The German-speaking dermatology pioneered the treatment of skin diseases with chemical peelings as well as for aesthetical purposes 21 years earlier than hitherto known.

[Chemical peeling in dermatology]

In this article, a comprehensive, yet introductory overview on chemexfoliation is given. The molecular mechanisms for selected indications are exemplified and the prerequisites, necessary precautions as well as potential complications are addressed. Finally, selected available superficial peeling substances are presented and the principal peeling procedure is outlined briefly.

Jessner's Solution with Trichloroacetic Acid Chemical Peel: Optimizing Outcomes and Safety

Trichloroacetic acid (TCA) is a versatile agent, efficacious in treating a spectrum of facial rhytids and dyschrommias at varying concentrations. TCA is commonly used in a 30%-35% concentration to achieve a medium-depth peel into the upper reticular dermis. The addition of Jessner's solution before the TCA peel application leads to partial removal of epidermis, allowing for deeper penetration of the TCA. This combination is beneficial, as lower concentrations of TCA can be used for the same depth of peel, minimizing complications such as scarring.

Effective treatment of disseminated superficial actinic porokeratosis with chemical peels - customary treatment for a rare disease

Background: Disseminated superficial actinic porokeratosis (DSAP) is a rare dermatologic disorder of the epidermis. Often misdiagnosed as chronic UV-damage or actinic keratoses, patients are treated for years with different therapeutic options with little success. Current treatment options include imiquimod, ingenol mebutate, cryosurgery, photodynamic therapy and topical or systemic therapy with retinoids. Since those approaches show only little success or come along with major side effects, therapeutic alternatives are strongly requested. Methods: We report a series of five female patients with history of DSAP that were successfully treated with chemical peels. Results: All patients suffered from the disease for 14.4 years on average and all were refractory to at least two therapeutic options, mostly imiquimod and topical tretinoin. Patients were treated with glycolic acid 50% and salicylic acid 25% in a two-layer-technique. After a mean of three cycles every 6 weeks a clear reduction in lesion was assessed by physicians. Patients were highly satisfied with outcome and rare occurrence of side effects as assessed by TSQM questionnaire. Conclusion: Chemical peels are safe and well tolerated treatment options for patients with refractory porokeratosis. As characteristic for chronic diseases, frequent repetition of treatment is needed in order to control disease activity.