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Chemical peels.pptx
- 1. CHEMICAL PEELS DR. ANAM MEHMOOD POST GRADUATE RESIDENT DERMATOLOGY UNIT I
- 4. What is skin peeling? METHOD OF SKIN RESURFACING • ACCELERATED EXFOLIATION BY USING IRRITANT CHEMICALS
- 5. HISTORY Since ancient times, women have been using different methods to exfoliate their skin
- 6. EGYPTIANS Ancient Egyptians used animal oils Cleopatra was reported to bathe in sour milk to rejuvenate skin
- 7. BABYLONIA AND INDIA Women used pumice stones to exfoliate the top layers of the skin
- 8. TURKS Turks would intentionally singe their skin with fire to achieve exfoliation of the skin
- 9. GREEKS AND ROMANS Used soured milk, fermented grape juice, and lemon extract to clarify their skin
- 10. GYPSIES The first group to use phenol for deep chemical peels, and they are known to have passed secret chemical peel recipes between villages and generations
- 11. Today!!! Chemical Peels are the THIRD most commonly performed noninvasive cosmetic procedure in United States with over 1,300,000 procedures performed in 2016 alone American Society of Plastic Surgeons
- 12. PEELING AGENTS Peels with metabolic action • Alpha-hydroxyl acids • Azelaic acids • Retinoic acid Peels with caustic action • Trichloroacetic acid • Jessner’s solution Peels with toxic action • Phenol • Salicylic acid
- 13. How do Peels Act? Controlled keratocoagulation and denaturation of dermal and epidermal proteins Release of proinflammatory cytokines and chemokines Targeted inflammation activates normal healing signal cascade Stimulation, development and deposition of new dermal collagen and elastin, reorganization of structural scaffold proteins and dermal connective tissue, and regeneration of new keratinocytes Results in rejuvenation and thickening of the epidermis and an increase in dermal volume Subsequent exfoliation result in improvement in superficial and medium-depth dyspigmentation
- 14. CLASSIFICATION OF PEELS DEPENDING UPON DEPTH
- 15. Factors Chemicals applied Mode of application Skin type Skin condition
- 16. Mhj
- 19. SUPERFICIAL (EPIDERMAL) Indications Improving skin texture Active comedonal acne Mild actinic keratosis Superficial dyschromias Necrosis of part or all of the epidermis anywhere from stratum granulosum to basal cell layer
- 20. Chemicals used: Glycolic acid 20-50% Salicylic acid TCA 10-25%
- 21. MEDIUM (PAPILLARY DERMAL) Indications Dys- chromias Photo damage Skin rejuvenation Solar lentigines Actinic keratosis Necrosis of epidermis and part or all of papillary dermis
- 22. • Glycolic acid 70% (3-30min) • TCA 35-50% • Augmented TCA (TCA 35% plus Jessner’s solution/ glycolic acid 70% Chemicals used:
- 23. DEEP (RETICULAR DERMIS) Indications Dyschromias Wrinkles Premalignant skin tumours Acne scars Necrosis of epidermis and papillary dermis extending to reticular dermis
- 24. Chemicals used: Phenol 88% Baker-Gordon Phenol formula Pure undiluted 88% phenol + croton oil + septisol liquid soap + water
- 25. ALPHA-HYDROXYL ACIDS Naturally ocuring compounds Glycolic acid from sugar cane Lactic acid from sour milk Citric acid from citrus fruits Phytic acid from rice
- 26. Low conc. (30%) Reduce sulphate and phosphate groups from corneocyte surface Decrease corneocyte adhesion Induce Exfoliation
- 28. LACTIC ACID Comparable efficacy with Glycolic acid Low pH Low concentration is required Exfoliation after treatment occurs for several days Re-epithelialization in 7-10 days
- 29. MANDELIC ACID Simple phenolic alpha-hydroxy acid Soluble in both water and polar organic solutions results in a more uniform penetration through lipid-rich areas of skin Results of mandelic acid peels are more subtle than that of superficial glycolic acid peels Side effects and subsequent downtime of mandelic acid are comparatively less Frequent “touch ups” and shortened intervals between treatment sessions Minimal desquamation Re-epithelialization is often complete within 3 to 5 days.
- 30. GLYCOLIC ACID Most commonly used alpha-hydroxyl acid Available in various concentrations up to 70% Needs application of water or weak buffer (5% sodium bicarbonate) once desired depth has been reached
- 31. AZELAIC ACID Saturated dicarboxylic acid Naturally found in rye, wheat and barley 20% topical preparation Mainly used in acne and melasma
- 32. JESSNER’S SOLUTION 14% lactic acid, 14% salicylic acid, 14% resorcinol in ethanol Provokes stratum corneum separation only Can be used alone or in combination with TCA Depth of peel is dependent on number of coats Erythema powdery whitening of skin exfoliation lasting 8-10 days Repeated monthly
- 33. PHENOLS Direct toxicity to cell proteins, membranes and enzymatic degradation 88% conc. causes immediate coagulation of proteins upto upper reticular dermis 45-55% conc. acts as keratolytic deeper penetration to mid reticular dermis Systemic effects include cardiotoxicity Cardiac monitoring Resuscitative equipment
- 34. Indications Anti ageing Deep rhytidosis Dyschromia
- 35. SALICYLIC ACID Beta-hydroxy acid Keratolytic with high affinity for lipids preferentially acts through pores 20-30% topical preparation
- 36. Indications Comedonal and inflammatory acne Early to moderate photo damage Oily skin with enlarged pores Rosacea Post inflammatory hyperpigmentation Melasma
- 37. Does not need neutralization No concerns about timings or over peeling Preferred in Fitzpatrick skin type V and VI Systemic toxicity rare (Salicylism)
- 38. TRICHLOROACETIC ACID Analogue of acetic acid Found naturally as hygroscopic crystals Gold standard for chemical peels for many years @ conc. 10-25% Superficial peel @ conc. 30% Medium depth peel @ conc. >30% not recommended, unpredictable results
- 39. Destructive due to low pH Rapidly neutralized Coagulation of skin proteins Clinical end point of treatment is frosting Frosting is due to denaturation of proteins Replaced by erythema
- 41. BAKER–GORDON FORMULA 88% phenol , croton oil, hexachlorophene and distilled water Croton oil is a vesicant derived from the seed of the Croton tiglium plant that promotes deeper penetration and absorption of phenol Hexachlorophene is a liquid soap that increases surface tension, acts as an emulsifier and retards phenol penetration
- 42. COMBINATION PEELS 70% Glycolic acid un buffered peel followed by 35% TCA Combined Jessner’s solution (1-4 coats) and 35%TCA
- 43. -Skin rejuvenation -Photodamaged skin -Acne Vulgaris -Pigmentation -Wrinkles and scars INDICATIONS
- 44. SKIN REJUVENATION Superficial and medium depth peels Superficial peels temporary ‘refreshed ’ look Medium depth improve fine lines, wrinkles, pigmentation
- 45. PHOTODAMAGED SKIN Medium depth peels like TCA and Jessner’s solution are most popular Superficial peels not effective for solar lentigines, wrinkles
- 46. ACNE VULGARIS Comedogenic acne Acne associated hyperpigmentation Mild acne scarring Salicylic acid Glycolic acid Mandelic acid Jessner’s solution
- 47. DYSCHROMIAS Ephelides Lentigines Flat seborrhoeic keratoses Melasma Post inflammatory hyperpigmentation Repeated sessions are needed 5-6 peels at 2-3 week intervals
- 49. WRINKLES AND SCARS Medium depth and deep chemical peels Replaced by laser technology
- 50. CONTRAINDICATIONS Absolute Allergy to peeling solution/ neutralizing agent Patients with unrealistic expectations Immunosuppression Relative Use of oral isotretinoin, OCPs, Tetracyclines Pregnancy or lactation Herpes labialis Plain Warts or dermatitis Radiotherapy irradiated skin/ Photosensitivity History of scar or keloid formation
- 51. PROCEDURE
- 52. TEST-SPOT TESTING Application of the medium-depth or deep-peeling agent to a small area of skin Common areas: lateral temple, anterior hairline and pre-auricular region • Healing time • Pigmentary response • Post peel complications • Delay of treatment
- 53. PRE-PEEL PROCEDURE Counselling Identify concerns Educate regarding peeling options Potential side effects, healing time, complications Skin type Degree of photodamage Sebaceous quality of skin Look for inflammatory dermatosis Exclude skin conditions associated with koebnerization
- 54. SKIN PRIMING Target skin is primed for 2-4 weeks
- 55. MORE UNIFORM PENETRATION OF PEELING AGENT TO SHORTEN HEALING PHASE TO REDUCE RISK OF POST INFLAMMATORY HYPERPIGMENTATION SKIN PRIMMING
- 56. SKIN PRIMING • Topical Retinoids For pigmentary disorders: Stopped 1 week before peeling procedure • Topical hydroquinone • Kojic acid • Azelaic acid • Arbutin • Liquorice
- 57. CONSENT & PHOTO DOCUMENTATION Whole procedure After care Informed consent Before and after peel photos Sun avoidance for 14 days after peel
- 59. PEELING PROCEDURE Careful examination of Skin Thin skin requires lower concentration Thick skin requires higher concentration Greasy skin gives better results than dry skin
- 60. EQUIPMENT Fan Alcohol Gauze sponge Cotton-tipped swabs Spray bottle Mild cleanser Bland moisturizer Neutralizing agent
- 61. TECHNIQUE
- 62. TECHNIQUE Remove make up; wash face Supine at 45 degrees Topical anesthesia can be used medium depth peels Sedation and analgesia for deep peels Degreasing for uniform penetration
- 63. Vaseline applied to sensitive areas Cotton tipped applicators; sponge applicators; gauze pads; brush Performed craniocaudally starting from Forehead, proceeding inferiorly Applied clockwise or anticlockwise from forehead to chin and back Eyelids and periocular areas last Peeling chemical applied to every single anesthetic unit
- 64. COSMETIC SUBNITS Solid blue lines Forehead Peri-orbital area Nose Cheeks Mentum Red dots Danger areas of face
- 66. SAFETY PRECAUTIONS Always check label by yourself Write down the date of prepared formula on the bottle Always shake or tilt the bottle before use Always ask patient to close eyes before the procedure Watch for tears, dry immediately, tears running down can create streak of peeling Never pass open container over patient’s face
- 67. TIPS Rubbing using gauze is better than painting Apply to small dark areas first then to the whole skin Continue to the hairline Continue for 1cm below the hairline and neck (feathering) For treating wrinkles around eyes, skin is stretched During the peeling process skin is cooled with a fan continuously
- 68. GLYCOLIC ACID Conc. Range from 15% to 70% Concentration of solution and contact time determines results
- 69. Start with 15- 30% and 3-5 min Skin primed; degreased with alcohol Watch for Erythema, Epidermolysis Neutralized End point depends upon desired results Neutralized with Sodium bicarbonate solution Wash with cold Water Bland emollient Sunscreen Performed at 3-4 weekly
- 71. JESSNER’S SOLUTION No Neutralizati on washed with Water Moisturizer Multiple coats white Frosting from tissue coagulation Powdery whitening because of precipitation of chemicals Faint erythema Degreasing Application done evenly
- 72. SALICYLIC ACID 20-30% Sol applied 2nd coat to papaules and pustules Tingling and burning sensation White frost of crystalline precipitation of Salicylic acid After 3-5 min Face washed Moisturizer Repeated at 2-3 week interval
- 73. TRICHLOROACETIC ACID TCA rubbed into skin with 4x4cm guaze Even redness or Frost appear Wait at least 60s for froth to appear before another coat Light frost Level 1 Superficial epidermal Peel Light frost with erythema Level 2 Full Epidermal Peel Solid frost/ fridge white Papillary Level 3 dermal peel Face washed with water after reaching desired amount Emollients
- 76. POST PEEL Look and feel tight Look terrible for 7-10 days after a medium depth peel During the first 2 days skin is slightly pink During day 3 and 4 skin darkens By day 5 skin starts peeling in sheets Erythema may last upto 2 weeks
- 79. POST-PEEL CARE DEPENDS UPON THE PEELING AGENT BEING USED
- 80. POST-PEEL CARE Superficial chemical peel No special care required Bland emollient 2-4 times/day for 1-2 days When skin appears normal patient can restart skin care
- 81. POST-PEEL CARE Medium depth and Deep chemical peel Necrotic, exfoliated skin, erythema and edema Measures to keep necrotic skin layer in place Bland emollient or ointment dabbed Keep skin moist; mild soap Avoid picking, scratching or rubbing to prevent premature peeling Avoid spraying water directly to the face For exudative areas ; acetic acid compresses or antibiotic ointment Re-epithelization in 5-7 days
- 82. RE-PEELING Very superficial peels once a week Superficial peels once every 2 weeks Medium depth peels once every 3-4 weeks Never repeat a peel in patients who have sensitivity or persistent erythema from a previous peel
- 84. COMPLICATIONS
- 85. INFECTIONS Staphylococcus Streptococcus prophylactic antibiotics? Pseudomonas Signs of infection Necrotic crust Persistent redness/pain Erosions
- 86. Reactivation of herpes simplex Pain and erosions (no blisters) Prophylactic antiviral 24 hours before to 5 days after peel in medium depth peels Active lesions need treatment
- 87. ERYTHEMA • Normally fades in 7 days • Abnormal if >30 days in SCP and >60 days in MDCP • Seen in patients of rosacea • Those on topical tretinoin • Before/ after peel persistent localized erythema impending scar
- 88. CHEMICAL BURNS • Can occur if increased contact time • Localized • Heal with post inflammatory hyperpigmentation
- 89. MILIA • Seen during healing phase • Due to occlusive effects of the ointment used after treatment • Seen 3 weeks after peeling • Treat by gentle scrubbing or tretinoin cream
- 90. ACNEFORM ERUPTIONS • During the healing phase post peel • Tender, red follicular papules • Respond to topical acne medication • Resolve in 1-2 weeks
- 91. ALLERGIC CONTACT DERMATITIS • GA and TCA are not sensitizers commonly • Resorcinol in Jessner’s solution is a common sensitizer
- 92. PREMATURE PEELING • Medium depth and deep chemical peels • Early removal of necrotic layer • Fragile healing skin may not re- epithialize • Persistent erythema post peel pigmentation/ scarring • Treat with topical antibiotic ointment • Apply vaseline until re- epithelialization • Avoid picking crusts
- 93. POST-INFLAMMATORY HYPERPIGMENTATION Unprotected sun exposure More frequent in skin of colour 1-4 weeks after treatment; up to 8 weeks Prime with topical hydroquinone Sun protection/avoidance
- 94. POST-INFLAMMATORY HYPOPIGMENTATION Due to melanocyte destruction in both hair follicles and reticular dermis Phenol peels May last 2-3 months Can be permanent Cosmetic camouflage
- 95. SCARRING At risk Exaggerated inflammatory response History of poor/delayed wound healing Tendency of keloid/hypertrophic scar Deep peels Inadequate time between peels Infection post peel On oral isotretinoin 6 months before peel Focal persistent erythema Indurated erythematous patches/plaques
- 96. SYSTEMIC TOXICITY Resorcinol, salicylic acid, phenol applied on skin can be absorbed systemically Phenol Tachycardia followed by arrhythmias Laryngeal edema Toxic shock syndrome Resorcinol Pallor, cold sweating, tremors, collapse Anti thyroid activity
- 97. Salicylic acid Tinnitus Anxiety Diaphoresis Difficulty concentrating; hallucinations
- 98. CHEMICAL PEELS IN SKIN OF COLOUR (ASIANS) Skin dyschromias Acne vulgaris Superficial acne marks/scars Textural changes superficial peels Oily skin Fine wrinkles Pseudofolliculitis barbae
- 99. PEELS IN PATIENTS WITH SKIN OF COLOUR Pre-peel priming Hydroquinone (2-4 weeks pre-peel) Stop topical retinoids 1 week pre-peel Superficial peeling agents Post peel Sun avoidance Sunscreens Apply topical retinoids for 1 week after peel Continue with topical skin whiteners until skin is healed
- 100. COMBINATION TECHNIQUES Microdermabrasion Micro needling Botulinum toxin-A injections (BTX-A) Dermal fillers Ablative laser resurfacing
- 101. According to Illustrated guide to Chemical peels
- 102. INDICATION: Multiple deep, pitted scars on cheeks
- 104. POST-PEEL PRE-PEEL
- 105. INDICATION: Hyper and hypo pigmented patches, Solar lentigines, Wrinkles
- 107. PRE-PEEL POST-PEEL
- 109. REFRENCES Rook's Textbook of Dermatology, 9th Edition Christopher Griffiths (Editor), Jonathan Barker (Editor), Tanya Bleiker (Editor), Robert Chalmers (Editor), Daniel Creamer (Editor) Connor A, Lowe P, Shumack S. Chemical peels: A review of current practice. Australasian Journal of Dermatology (2018) 59, 171–181 Illustrated Guide to Chemical Peels: Basics - Indications - Uses (Aesthetic Methods for Skin Rejuvenation) by Mark G. Rubin (2014) Soleymani T, Lanoue J, Rahman Z. A Practical Approach to Chemical Peels: A Review of Fundamentals and Step-by-step Algorithmic Protocol for Treatment. J Clin Aesthet Dermatol. 2018;11(8):21–28.
- 111. THANK YOU