Chemical peels in aesthetic dermatology: an update 2009

A 15% Trichloroacetic Acid + 3% Glycolic Acid Chemical Peel Series Improves Appearance of Hand Lentigines: An Evaluator-Blinded, Split-Hand Prospective Trial

BACKGROUND

Improving the appearance of lentigines on the hands is a key component to hand rejuvenation. Soft tissue fillers revolumize hands, but do not address pigmentary changes. OBJECTIVE: This study investigated the effiacy of a 15% trichloroacetic acid (TCA) + 3% glycolic acid (GA) combination peel in improvement of appearance of hand lentigines.

METHODS

A prospective evaluator-blinded, split-hand study was performed using a 15% TCA + 3% GA peel to treat patients with hand lentigines. Subjects received a total of 3 treatments at 4-week intervals on 1 hand, with the other hand serving as an untreated control. Final photographs were taken 12 weeks after the last treatment. Two blinded board-certified dermatologists graded improvement in hand lentigines using a 5-point scale.

RESULTS

Eighteen of 20 patients completed the study (90%). The mean age was 64.4 years (SE 1.6, range 51-71). The mean pain scores were 3.8 (SE 0.4) on a 10-point scale (1 = no pain, 10 = extremely painful). Blinded evaluators correctly identified the after-treatment photographs in 16 patients (88%). Physician and patient-graded mean improvement of lentigines was significant for treated versus control hands ( p < .01). No adverse events were noted.

CONCLUSION

A series of three 15% TCA + 3% GA peels are effective and safe in the treatment of hand lentigines.

Cosmetic Dermatology Concerns in Older Adults

It is important to understand that each layer of facial tissue, from the underlying facial skeleton to the overlying skin, undergoes significant changes during the aging process. Bony support is lost along the mandible and maxilla and the orbital aperture widens. Superficial and deep fat pads undergo volume loss and migration and the overlying skin begins to reveal signs of both intrinsic aging with skin laxity and fine rhytids as well as extrinsic aging in the form of coarse, deeper rhytids and dyspigmentation.

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.

Developing Consensus-Based Guidelines for Case Reporting in Aesthetic Medicine: Enhancing Transparency and Standardization

Clinical case reporting plays a vital role in sharing detailed patient narratives, providing insights into rare conditions, innovative treatments, and unexpected outcomes. However, existing reporting guidelines in aesthetic medicine fail to capture the specific nuances of procedures and outcomes in this field. The authors' objectives were to develop comprehensive guidelines for Case REporting in Aesthetic Medicine (CREAM). The study employed a 3-phase consensus process, including a literature review, expert interviews, and a consensus meeting. A diverse group of 10 expert participants (plastic surgeons, dermatologists, noncore specialists, evidence-based medicine expert, and research scientist) in Phase I and 30 experienced aesthetic practitioners in Phase II contributed to the research. Statistical analysis was conducted to assess agreement levels among participants and explore associations and variations within the data. The participants represented various specialties, genders, LGBTQ+ identities, and ethnic backgrounds. The research resulted in the development of the CREAM guidelines, consisting of a 16-item checklist. The guidelines covered essential aspects of case reporting, such as patient and practice information, procedure details, clinical assessment and outcomes, adverse events, and ethical considerations. Statistical analysis indicated a high level of consensus among participants, as well as significant associations between checklist items. CREAM guidelines represent a step toward enhancing transparency and standardization in case reporting in aesthetic medicine. Adhering to these guidelines will allow authors to contribute to a robust evidence base, prioritize patient safety, and drive advancements aesthetic medicine.

Combination Approaches to Hand Rejuvenation: A Review of the Literature and Discussion

BACKGROUND

Various noninvasive/minimally invasive modalities for hand rejuvenation exist, and the efficacy and safety of these procedures as both monotherapy and same-day procedures is increasingly being studied.

OBJECTIVE

To review data on the efficacy and safety of hand rejuvenation modalities and suggest a practical combination approach for these procedures.

METHODS

The PubMed database was queried for peer-reviewed articles regarding hand rejuvenation techniques, including chemical peels, laser and light sources, sclerotherapy, autologous fat transfer, and injectable volumetric fillers.

RESULTS

Chemical peels have been studied the least, with most studies evaluating the use of fillers and laser/light-based devices. Most studies reported overall good results with high patient satisfaction. Satisfaction rates were lower in laser/light-based treatments compared with other modalities. Transient erythema, edema, or pain after procedures was common; most studies did not report serious postprocedure complications. Importantly, there was no significant increase in adverse effects after same-day procedures.

CONCLUSION

Using same-day procedures allows practitioners to address hand rejuvenation from different aspects, seems to improve outcomes, and reduces time spent in the office for patients. The authors suggest a practical framework for combining cosmetic approaches to achieve the most optimal outcome for hand rejuvenation.

Methods for the Improvement of Acne Scars Used in Dermatology and Cosmetology: A Review

Acne vulgaris is a chronic skin disease that, depending on its course, is characterized by the occurrence of various skin eruptions such as open and closed comedones, pustules, papules, and cysts. Incorrectly selected treatment or the presence of severe acne vulgaris can lead to the formation of atrophic scars. In this review, we summarize current knowledge on acne scars and methods for their improvement. There are three types of atrophic scars: icepick, rolling, and boxcar. They are of different depths and widths and have different cross-sections. Scars can combine to form clusters. If acne scars are located on the face, they can reduce the patient’s quality of life, leading to isolation and depression. There are multiple effective modalities to treat acne scars. Ablative lasers, radiofrequency, micro-needling, and pilings with trichloroacetic acid have very good treatment results. Contemporary dermatology and cosmetology use treatments that cause minimal side effects, so the patient can return to daily functioning shortly after treatment. Proper dermatological treatment and skincare, as well as the rapid implementation of cosmetological treatments, will certainly achieve satisfactory results in reducing atrophic scars.

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.

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.

Management of hyperpigmentation: Current treatments and emerging therapies

Hyperpigmentation of the skin refers to a dermatological condition which alters the color of the skin, making it discolored or darkened. The treatments for hyperpigmentation disorders often take very long to show results and have poor patient compliance. The first-line treatment for hyperpigmentation involves topical formulations of conventional agents such as hydroquinone, kojic acid, and glycolic acid followed by oral formulations of therapeutic agents such as tranexamic acid, melatonin, and cysteamine hydrochloride. The second-line approaches include chemical peels and laser therapy given under the observation of expert professionals. However, these therapies pose certain limitations and adverse effects such as erythema, skin peeling, and drying and require long treatment duration to show visible effects. These shortcomings of the conventional treatments provided scope for further research on newer alternatives for managing hyperpigmentation. Some of these therapies include novel formulations such as solid lipid nanocarriers, liposomes, phytochemicals, platelet-rich plasma, microneedling. This review focuses on elaborating on several hyperpigmentation disorders and their mechanisms, the current, novel and emerging treatment options for management of hyperpigmentation.

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.

Management Pearls on the Treatment of Actinic Keratoses and Field Cancerization

Field cancerization (FC) is a chronic disease involving multiple clinical and subclinical actinic keratoses (AK) on large photo-exposed surfaces with multifocal areas of dysplasia and precancerous changes. Patients and treatment must be properly monitored and managed to avoid aggravation and progression of the disease. Management of actinic keratoses includes lesion-directed treatments, such as cryotherapy and field-directed therapies. Field-directed therapies may have the potential to address subclinical damage, reduce AK recurrence rates and potentially reduce the risk of squamous cell carcinoma development. Multiple studies have demonstrated the efficacy of field-directed treatments, including 5-fluorouracil, photodynamic therapy, imiquimod, chemical exfoliation with trichloroacetic acid and diclofenac gel, for multiple AK and FC. The choice of therapy should be based on multiple factors, such as efficacy, tolerability, patient risk profile, costs and cosmetic results. Management of AK includes not only treatment but also prevention. Medical devices, such as sunscreens containing liposome-encapsulated DNA repair enzymes, can repair DNA damage associated with chronic UV radiation and reduce the number of new AK lesions. Here we provide therapeutic pearls and expert opinions on the treatment of AK and FC (as monotherapy or in combination) with the overall aim to achieve better, faster, and well-tolerated clinical responses.

Chemical peelings for the treatment of actinic keratosis: a systematic review and meta-analysis

BACKGROUND

Actinic keratosis (AK) is a common precancerous lesion of the skin that may be treated with chemical peelings. Despite their long-standing usage and clinical experience, no evidence-based recommendation regarding the efficacy and safety of chemical peelings for AK exists.

OBJECTIVES

To systematically review and synthesize the current knowledge on chemically exfoliative peelings as interventions for AK.

METHODS

We performed a systematic literature research in Medline, Embase and CENTRAL and hand-searched pertinent trial registers for eligible records until 5 August 2019. Results from individual studies were pooled using a random-effects model or described in a qualitative synthesis. The risk of bias was estimated with the tools provided by the Cochrane Collaboration (randomized and non-randomized trials) and the Evidence Project (single-arm trials).

RESULTS

Four randomized controlled trials, two non-randomized controlled trials and two single-arm studies with a total sample size of n = 170 patients were included. Trichloroacetic acid (TCA) plus Jessner's solution showed significantly lower participant complete clearance (RR 0.36, 95% CI: 0.14-0.90, two studies, I²  = 0%, P = 0.03) and lower lesion clearance (RR 0.92, 95% CI: 0.85-0.99, one study, P = 0.03) compared to 5-fluorouracil (5-FU) 5% cream. TCA as monotherapy showed lower lesion complete clearance (RR 0.75, 95% CI: 0.69-0.82, two studies, I²  = 7%, P < 0.001) and lower mean lesion reduction per patient compared to conventional photodynamic therapy (cPDT) (MD -20.48, 95% CI: -31.55 to -9.41, two studies, I²  = 43%, P = 0.0003). Pain was more pronounced in patients treated with cPDT in comparison with TCA (MD -1.71 95% CI: -3.02 to -0.41, two studies, I²  = 55%, P = 0.01). In the single-arm studies, 5-FU plus glycolic acid showed 92% lesion clearance and phenol peeling 90.6% participant complete clearance. All studies showed a high risk for bias.

CONCLUSIONS

Future high-quality studies and a standardization of peeling protocols are warranted to determine the value of chemical peelings in the treatment of AK.

Its written all over your face: The molecular and physiological consequences of aging skin

Perhaps the most recognizable consequences of tissue aging are manifested in the skin. Hair graying and loss, telltale wrinkles, and age spots are indicative of physiological aging symptoms, many of which are analogous to processes in other tissues as well with less visible outcomes. While the study of skin aging has been conducted for decades, more recent work has illuminated many of the fundamental molecular and physiological causes of aging in the skin. Recent technological advances have allowed for the detection and quantification of a variety of physiological triggers that lead to aging in the skin and molecular methods have begun to determine the etiology of these phenotypic features. This review will attempt to summarize recent work in this area and provide some speculation about the next wave of studies.

Effect of a new irrigant solution containing glycolic acid on smear layer removal and chemical/mechanical properties of dentin

The objective of this study was to evaluate the effects of glycolic acid (GA) (with pH 1.2 and 5) and ethylenediaminetetraacetic acid (EDTA) on the chemical and mechanical properties of dentin to investigate the potential use of GA as final irrigant in the root canal therapy. Specifically, changes in microhardness, smear layer removal, erosion, mineral content distribution, apatite/collagen ratio and flexural strength of mineralized dentin treated with GA were assessed. Saline solution was used as a negative control. Knoop microhardness (KHN) was measured on the root canal lumen of root segments. Dentin beams were used for 3-point flexural strength (σ) test. Scanning electron microscopy (SEM) images of root sections were obtained for evaluation of smear layer removal and dentin erosion on root segments and energy dispersive X-ray spectroscopy (EDS) was used for mineral content distribution. The apatite/collagen ratio (A/C) in dentin powder were examined by Fourier transform infrared (FTIR) spectroscopy. KHN, σ and A/C results were statistically analyzed with ANOVA and Tukey tests (α = 0.05). Smear layer and dentin erosion scores were analyzed with Kruskal-Wallis and Dunn tests (α = 0.05). Root dentin treated with EDTA and GA presented similar KHN regardless of the pH (p > 0.05). However, KHN was significantly reduced in EDTA and GA groups when compared to control group (p<0.001). GA showed the same ability to remove the smear layer and to cause dentin erosion as EDTA. EDS results showed that the GA and EDTA solutions did not alter the dentin mineral content distribution. The apatite/collagen ratio reduced with all irrigant solution and was the lowest with GA pH 5 (p<0.001), while σ was not significantly affected by the experimental solutions (p = 0.559). It can be concluded that GA has similar ability to remove the smear layer than EDTA. GA does not affect negatively the chemical/mechanical properties and it does not increase dentin erosion. The use of GA with low pH seems to promote less change in collagen/apatite ratio, but further studies are needed to establish an ideal clinical protocol. Therefore, this study supports the potential use of GA as an alternative final irrigation solution for root canal preparation.

Is there still a place for deep chemical peels in the treatment of perioral wrinkles?

Baker-Gordon formula phenol chemical peel remains the most effective and long-lasting treatment for deep facial lines. However, this treatment is associated with risk of serious complications, such as arrhythmias and dystrophic scars. With the emergence of new and safer technologies for facial rejuvenation, such as fractionated carbon dioxide (CO2) lasers and microneedling, there has been a decrease in the use of deep chemical peels. This raises the question of whether there is still a place for deep phenol chemical peels. In this sense, we present a successful case of using Baker-Gordon formula phenol chemical peel at the perioral region for treating advanced wrinkles. This technique is called "Regional Phenol Peeling" and is safer than the use of the formula applied to the entire face, since it does not need systemic monitoring.

Skin Ageing: Pathophysiology and Current Market Treatment Approaches

Ageing is a natural phenomenon which is a fold, ridge and crease in the skin that occurs due to loss of body mass, poor hydration, disintegration of dermis and epidermis junction. The Skin ageing process involves many changes that occur due to the combination of both endogenous factors (gene mutation, cellular metabolism, and hormonal factor) and exogenous factors (U.V, pollutants, chemical, and toxins). In 1950, the number of older people were found to be almost 205 million across the globe. But this number almost got 4 times by the year 2012 and the number of older persons increased to a massive amount of 810 million. The ageing of the skin occurs due to various mechanisms like glycation, free radical, cell cycle, and cellular and molecular mechanism of skin ageing. In this review article, we have discussed the treatment, worldwide newer therapies and marketed formulation that are currently available for the reduction of skin ageing. The most promising and revolutionizing field of nanotechnology is mostly applied in the field of dermatology, cosmetics, and biomedical applications. Nanotechnology also plays a vital role in increasing the efficacy of the product.

Enhancement of exfoliating efficacy of L-carnitine with ion-pair method monitored by nuclear magnetic resonance spectroscopy

Carnitine (CAR), an amino acid derivative, has great potential as a facial exfoliating agent owing to its calcium chelating property under weakly acidic or neutral conditions. However, its application is limited by its poor transdermal penetration. To optimise its exfoliation efficacy with minimal concentration, we propose the ion-pair method. The ionic interaction between CAR and a zwitterionic substance was successfully monitored by measuring conductivity. The alterations of penetration and exfoliation efficacy for CAR addition to different types of counter ions were investigated in vitro and in vivo. We found that hydrogenated soya phosphatidylcholine (HSC), an amphiphilic counter ion, significantly increases the stratum corneum penetration and exfoliation efficacy of CAR. The changes of the CAR-HSC ionic interaction in the presence of calcium ions were also investigated by ¹H nuclear magnetic resonance (NMR) spectroscopy. The NMR spectra for amino groups of CAR first decreased with HSC and then gradually recovered and shifted as calcium ions were added. From the results, a noble exfoliating complex of CAR with high exfoliation efficacy could be proposed. Moreover, the results demonstrate that NMR spectroscopy is useful to obtain direct experimental evidence of the molecular dynamics simulations of the alteration of an exfoliating complex as it penetrates.

The use of lasers and light sources in skin rejuvenation

Smooth, wrinkle-free skin is associated with supposed attractiveness, youthfulness, and health, while rhytids have a negative impact on one's perceived appearance, image, and self-esteem. Noninvasive esthetic procedures such as laser or light therapy have been used to achieve and attain a more youthful appearance. Currently, there is a wide range of lasers and devices available for the regeneration and healing of skin. Lasers and light sources for skin rejuvenation involve the removal of aged skin tissue via thermal heat from high-powered lasers, stimulating the surrounding tissues to recover through natural wound-healing processes. In contrast, photobiomodulation, which makes use of low energy lasers or light emitting diodes, uses no heat and has shown positive effects in the reduction of wrinkles and improving skin laxity.

First-ever HSV-1 recurrence following superficial facial chemical peel after 30-year latency following neonatal primary infection

Recurrence of orofacial herpes simplex infection is a well-known potential complication of chemical peeling procedures. Risk of reactivation is believed to correlate with depth of peel, leading to the recommendation that all patients with history of primary orofacial herpes simplex infection or recurrent herpes labialis receive prophylactic antivirals prior to and after undergoing medium and deep peels. The following is a case of herpes labialis following a very superficial peeling procedure in an otherwise healthy 30-year-old male after primary infection as a neonate with no history of herpes simplex recurrence in the intervening 30 years. This case highlights the importance of history-taking and consideration of prophylactic antivirals in peels of all depths in patients with any history of primary infection, regardless of length of disease free period.

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.

Microparticles based on natural and synthetic polymers for cosmetic applications

Most peeling products (exfoliators) available on the market, used in cosmetic and aesthetic dermatology applications, contain synthetic microbeads as abrasive agents. After being released into the natural environment, these non-biodegradable microparticles have an adverse impact on it, especially on aquatic ecosystems. Cosmetics consisting of solid plastic particles will be prohibited in the European Union from 2020. Therefore, there is a great need to develop effective abrasive substances for cosmetic industry. An alternative to synthetic beads may be beads based on biopolymers. Spherical microparticles of sodium alginate and mixture of sodium alginate and starch were obtained using encapsulator BÜCHI B-395 Pro. The obtained microparticles were added to the developed peeling formulation. Subsequently, the evaluation of skin condition after application of peelings with alginate, alginate-starch and synthetic microparticles was made, including topography, skin's barrier quality, hydration, colour, and the level of sebum. The peeling containing sodium alginate and sodium alginate with starch beads does not irritate the skin - redness of skin, itching and dryness did not appear. Microparticles of sodium alginate and sodium alginate with starch act on the skin as effectively as commercial synthetic particles, therefore they may be successfully used as abrasive ingredients in the developed recipe.

Chemical Peeling with a Modified Phenol Formula for the Treatment of Facial Freckles on Asian Skin

BACKGROUND

Chemical peeling is an efficient method for the treatment of pigment disorders. For freckles, medium-depth to deep peeling using a phenol solution is one of the most effective chemical peels, and modifications of facial skin can be observed up to 20 years after peeling. However, applying phenol to the skin may cause serious side effects. Phenol peeling has been rarely used in Asia due to its tendency to cause permanent pigmentary changes and hypertrophic scars.

METHODS

In total, 896 Chinese inpatients with facial freckles were enrolled in this study. The phenol formula was modified with crystalline phenol, dyclonine, camphor, anhydrous alcohol and glycerin and adjusted to a concentration of 73.6-90.0%. The entire peeling treatment was divided into two procedures performed separately on 2 days.

RESULTS

All patients exhibited 26% or greater improvement, and 99.66% of patients exhibited 51% or greater improvement (good and excellent). Scarring and systemic complications were not observed in any patient.

CONCLUSIONS

The modified phenol formula is very effective and safe for the treatment of facial freckles in Asian patients.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Photodynamic therapy for aesthetic-cosmetic indications

Photodynamic therapy (PDT) is a well-established, non-invasive treatment for a variety of dermatologic disorders, including actinic keratosis. Furthermore, PDT results in marked improvements in the signs of skin aging, although currently there are no standardized guidelines for PDT in skin rejuvenation. Two types of PDT are available: conventional-PDT (c-PDT) and the newly introduced daylight-PDT (DL-PDT). Both require a topical photosensitizer, a light source and oxygen, and both are comparable regarding safety and efficacy for treatment of photo-induced skin aging. Treatment is particularly effective for improvement of fine wrinkles, skin roughness, actinic elastosis and mottled hyperpigmentation. The most widely studied topical sensitizers used in PDT are 5-aminolevulinic acid (ALA) and methyl aminolevulinate (MAL). A range of pre-treatment procedures help improve skin absorption of the photosensitizer and lead to significantly improved efficacy. A variety of activating light sources can be used for c-PDT, while DL-PDT uses natural daylight, making it easier to treat larger areas of photodamaged skin. A major limitation of c-PDT is significant treatment-related pain, but DL-PDT has proved to be an almost pain-free procedure. Treatment duration is based on individual patient need but most patients receive 2 to 3 treatment cycles, with results fully evident 3-6 months post-treatment. PDT for aesthetic-cosmetic treatments has established its value in modern procedural dermatology as mono- or combination therapy. A major, unique advantage of PDT is that it is a non-invasive treatment that effectively rejuvenates photodamaged skin, while successfully treating a range of dermatologic conditions, including prevention and therapy of pre-cancerous actinic keratosis.

Is There an Association Between Hyperbaric Oxygen Therapy and Improved Outcome of Deep Chemical Peeling? A Randomized Pilot Clinical Study

Background

Phenol chemical peeling (PCP) treatment is associated with prolonged recovery and sustained adverse events. Hyperbaric oxygen therapy (HBOT) is known to accelerate wound healing. The purpose of the current study was to evaluate the effect of HBOT on PCP recovery period and adverse events.

Methods

This is a pilot randomized controlled clinical study. Women following PCP underwent 5 consecutive daily HBOT sessions, compared with PCP alone. Pain, pruritus, erythema, crusting, scaling, and edema were daily evaluated up to 28 days following PCP. Photographs taken on days 14 and 35 following PCP were assessed. Confidence to appear in public was assessed 14 days following PCP.

Results

Eight participants equally assigned to HBOT and control groups. Lower severity scores for erythema, scaling, and pruritus were documented in the HBOT group (mean difference 1.19, P = .006; .84, P = .04; and 2.19, P = .001, respectively). Photographic assessment severity score was higher for skin tightness, edema, erythema, crusting, and scaling in the control group on day 14 post PCP (P < .05) and for erythema on day 35 post PCP (P < .05). Epithelialization percentage was higher in the HBOT group on day 14 post PCP compared with controls (98.5% ± 1% vs 94.2% ± 1%; P = .021). The HBOT group scored higher in confidence to appear in public (20.8 ± 1.7 vs 14.5 ± 1.3; P = .029).

Conclusion

Hyperbaric oxygen therapy following PCP is associated with faster recovery as assessed by both patients and caregivers. So far, HBOT was mainly used in the treatment of problematic or chronic wounds. Our study suggests expanding the indications in which hyperbaric oxygen treatment is applicable and recommended.

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.

Noninvasive Facial Rejuvenation. Part 3: Physician-Directed-Lasers, Chemical Peels, and Other Noninvasive Modalities

A proper knowledge of noninvasive facial rejuvenation is integral to the practice of a cosmetic surgeon. Noninvasive facial rejuvenation can be divided into patient- versus physician-directed modalities. Patient-directed facial rejuvenation combines the use of facial products such as sunscreen, moisturizers, retinoids, α-hydroxy acids, and various antioxidants to both maintain youthful skin and rejuvenate damaged skin. Physicians may recommend and often prescribe certain products, but patients are in control with this type of facial rejuvenation. On the other hand, physician-directed facial rejuvenation entails modalities that require direct physician involvement, such as neuromodulators, filler injections, laser resurfacing, microdermabrasion, and chemical peels. With the successful integration of each of these modalities, a complete facial regimen can be established and patient satisfaction can be maximized. This article is the last in a three-part series describing noninvasive facial rejuvenation. Here the authors review the mechanism, indications, and possible complications of lasers, chemical peels, and other commonly used noninvasive modalities.

Oral isotretinoin in photoaging: objective histological evidence of efficacy and durability

BACKGROUND

The off-label use of oral isotretinoin in photoaging is a therapeutic tool that has been used by dermatologists. There are few studies to corroborate its effectiveness and durability.

OBJECTIVES

To assess, both clinically and histologically, the changes caused by the use of oral isotretinoin in skin photoaging as well as the duration of the effects.

METHODS

20 female patients, aged 45-50 years, with phototypes II-VI, none of whom had experienced menopause, were treated with 20mg oral isotretinoin, 3 days a week, for 12 weeks. They underwent clinical analysis and skin biopsies in the pre-auricular region, while histologic cuts enabled assessment of the solar elastosis level and morphologic analysis.

RESULTS

Clinically, patients, as well as the researching and the assessor physicians, noticed improvement in skin quality. One patient presented severe solar elastosis, 11 manifested the moderate form, while 8 presented the discreet type. According to histological analysis, 65% of the patients revealed alteration in the distribution and thickness of the elastic fibers, which can be interpreted as a histological improvement, while 60% showed an increase in collagen density. We observed an increase in collagen density, from 51.2% to 57.4%, (p=0.004). At the end of the 12-week follow-up period, this density decreased to 54.7% (p=0.050). There was an increase in the density of elastic fibers, from 26.5% to 31.3%, (p=0.02), which had dropped to 27.5% at the end of the 12-week follow-up period.

CONCLUSIONS

The study confirmed the role of oral isotretinoin in remodeling the extracellular matrix against photoaging, as well as its durability after 12 weeks, especially when we consider collagen fibers.

Overview of Facial Plastic Surgery and Current Developments

Facial plastic surgery is a multidisciplinary specialty largely driven by otolaryngology but includes oral maxillary surgery, dermatology, ophthalmology, and plastic surgery. It encompasses both reconstructive and cosmetic components. The scope of practice for facial plastic surgeons in the United States may include rhinoplasty, browlifts, blepharoplasty, facelifts, microvascular reconstruction of the head and neck, craniomaxillofacial trauma reconstruction, and correction of defects in the face after skin cancer resection. Facial plastic surgery also encompasses the use of injectable fillers, neural modulators (e.g., BOTOX Cosmetic, Allergan Pharmaceuticals, Westport, Ireland), lasers, and other devices aimed at rejuvenating skin. Facial plastic surgery is a constantly evolving field with continuing innovative advances in surgical techniques and cosmetic adjunctive technologies. This article aims to give an overview of the various procedures that encompass the field of facial plastic surgery and to highlight the recent advances and trends in procedures and surgical techniques.

Facial primer provides immediate and long-term improvements in mild-to-moderate facial hyperpigmentation and fine lines associated with photoaging

BACKGROUND

Photoaged skin results from various environmental factors, most importantly chronic sun exposure. Dyschromia and fine lines/wrinkles are common clinical manifestations of photodamaged skin.

PURPOSE

This single-center clinical trial was conducted to assess the efficacy and tolerability of a new multifunctional facial primer (camouflage, broad-spectrum SPF 50, and a treatment for hyperpigmentation) when used by females with mild-to-moderate facial hyperpigmentation and fine lines due to photoaging over a course of 12 weeks.

PATIENTS AND METHODS

Subjects were provided test material (Even Up-Clinical Pigment Perfector) and supporting products to use on their face and neck. Products were used according to specific application instructions. Clinical grading for efficacy and tolerability assessments were performed by an expert grader at baseline, baseline (post-application primer), week 4, week 8, week 12, and week 12 (post-application primer). Standardized digital photographs were taken, and self-assessment questionnaires were conducted.

RESULTS

Twenty-eight female subjects completed the 12-week trial. The facial primer improved scores for the appearance of hyperpigmentation and other photoaging parameters immediately after the first application. The treatment also showed a progressive improvement in the clinical assessment of hyperpigmentation and other photoaging parameters over the 12-week trial. These long-term benefits can be attributed to an improvement in the underlying skin condition. The facial primer was well tolerated. Subject questionnaires showed that the product was highly rated at all visits.

CONCLUSION

The facial primer was shown to be effective and well tolerated for immediate and long-term improvement in the appearance of mild-to-moderate hyperpigmentation and fine lines associated with photodamage when used over a 12-week period.

Accidental Trichloroacetic Acid Burn in a Gynecology Office

BACKGROUND

Trichloroacetic acid is routinely used by gynecologists to treat anogenital diseases, and accidental exposure to the health care providers may result in serious burns. This case serves to raise awareness of accidental exposure of trichloroacetic acid and describes preventive, first aid, and treatment recommendations that may limit the incidence and severity of burn injury among gynecologists.

CASE

A 32-year-old female gynecologist incurred a deep second-degree, 12×14-cm, work-related chemical burn by unintentionally spilling a container of approximately 20 mL of 80% trichloroacetic acid onto her right thigh during an outpatient procedure. First aid included removal of her soaked clothing, 5 minutes of soap and cold water irrigation, and liberal placement of petroleum-based ointment onto the injury site. Treatment consisted of topical silver sulfadiazine cream twice a day, coverage with silver-impregnated silicone foam dressing, and a circumferential soft bandage to minimize sheer forces along the wound. A 9-month follow-up demonstrated a well-healed, mildly hypopigmented, aesthetically favorable wound with return of sensation.

CONCLUSION

Accidental trichloroacetic acid burns are a potential hazard in a gynecology office. Health care workers should be familiar with prevention, first aid, and appropriate treatment that often can result in acceptable long-term outcomes.

Severe hyperpigmentation and scarring following glycolic acid peel treatment in combination with low-dose isotretinoin

BACKGROUND

The application of systemic isotretinoin in the treatment of cutaneous photoaging has been well investigated. In addition, well-recognized topical antiaging therapies such as superficial chemical peeling (CP) with α-hydroxy acids have been shown to be more helpful when combined with low-dose oral isotretinoin. Even though the combination of systemic isotretinoin and medium to deep CP has been associated with serious side effects such as delayed wound healing and enlarged incidence of scarring, to date superficial CP and concomitant systemic isotretinoin have been considered safe.

CASE PRESENTATION

In this report, we present the case of a patient receiving low-dose oral isotretinoin therapy who developed severe painful erythema and erosions that led to permanent hyperpigmentation and scarring of her face and neck after undergoing superficial CP with glycolic acid.

CONCLUSIONS

There is a potential risk of hyperpigmentation and scarring with the use of a combination of low-dose oral isotretinoin and glycolic acid peeling.

Glycolic acid peel therapy - a current review

Chemical peels have been time-tested and are here to stay. Alpha-hydroxy peels are highly popular in the dermatologist’s arsenal of procedures. Glycolic acid peel is the most common alpha-hydroxy acid peel, also known as fruit peel. It is simple, inexpensive, and has no downtime. This review talks about various studies of glycolic acid peels for various indications, such as acne, acne scars, melasma, postinflammatory hyperpigmentation, photoaging, and seborrhea. Combination therapies and treatment procedure are also discussed. Careful review of medical history, examination of the skin, and pre-peel priming of skin are important before every peel. Proper patient selection, peel timing, and neutralization on-time will ensure good results, with no side effects. Depth of the glycolic acid peel depends on the concentration of the acid used, the number of coats applied, and the time for which it is applied. Hence, it can be used as a very superficial peel, or even a medium depth peel. It has been found to be very safe with Fitzpatrick skin types I–IV. All in all, it is a peel that is here to stay.

Topical treatment of hyperpigmentation disorders

Hyperpigmentation has traditionally been a relatively difficult condition to treat, especially in darker racial ethnic groups. Multiple topical agents available act upon different steps of the pigmentation pathway. We review these topical agents, their mechanisms of action, and their effectiveness as monotherapy and in combination with other compounds. Ultimately, combination therapy is the most efficacious when considering overall depigmentation as well as treatment time required to achieve clinical improvement.

Photodamage: treatments and topicals for facial skin

This article provides an overview of current therapies for photodamaged facial skin and their efficacy, with particular focus on studies that use the objective, quantitative evaluation methods discussed in the previous article. The role of topically applied agents including prescription drugs and cosmetics is discussed. From this information, a schema for the relative effectiveness of therapeutic modalities in reducing perceived age is presented. This information assists the facial plastic surgeon in evaluating patient expectations and selecting the most effective program.

[Side effects in aesthetic medicine. Spectrum, management and avoidance]

Aesthetic medicine has become increasingly popular in the last two decades. The same trend has occurred in dermatology. Aesthetic dermatology prefers minimally invasive procedures. Nevertheless, even these procedures are not free of possible adverse effects. The spectrum of possible adverse effects, their management and prevention are discussed for four popular procedures in aesthetic dermatology, i.e. chemical peels, mesotherapy, botulinum toxin, and dermal fillers. Aesthetic procedures should only be performed by well-educated, well-trained medical doctors with an excellent medical background, never by lay persons.