skin and chemical peeling

1. Skin Anatomy

2. Struktur Kulit

3. Epidermis
5 sub-lapisan ~ 1,5 mm
(corneum, lucidum, granulosum,
spinosum, basale)
Fungsi proteksi & imunitas
Fungsi regenerasi

4. Epidermis
Stratum spinosum = stratum Malpighi
Stratum germinativum = stratum basale

5. Dermis
folikel rambut
kelenjar keringat
kelenjar sebasea
pembuluh limfatik
pembuluh darah
ujung saraf
jaringan ikat

6. Hypodermis
Lemak/adiposa, untuk:
Body shaping
Pengatur suhu tubuh
Shock absorber
Pembuluh darah
Saraf
Sistem limfatik

7. Warna Kulit

8. Warna Kulit

9. Klasifikasi Photoaging
Klasifikasi Glogau
untuk Photoaging
Umur Derajat
photoaging
Perubahan
pigmen
Keratosis Kerutan
1
(tidak ada kerutan)
20an-30an Early Minimal Tidak ada Tidak ada atau
minimal
2
(kerutan ekspresi)
30an
akhir-40an
Early-
moderate
Early senile
lentigine
Teraba, tidak
terlihat
Smile lines
3
(kerutan diam)
50an Advanced Diskromia,
teleangiektasis
Terlihat Semakin
banyak
4
(kerutan semua)
60an Severe Kulit berwarna
keabu-abuan
Terlihat jelas,
lesi prekanker
Hampir seluruh
kulit sudah
berkerut

15. CHEMICAL PEELING

16. • Merupakan tindakan medis
• Berupa pengelupasan kulit
• Menggunakan satu atau lebih larutan kimiawi pengelupas
• Menyebabkan destruksi epidermis sampai dermis
Chemical Peeling

17. • Melepaskan lapisan sel-sel kulit mati
• Menghilangkan flek ( sampai upper reticular dermis )
• Merangsang pembentukan sel-sel kulit baru
• Memperbaiki elastisitas dan tekstur kulit (Kolagen Remodelling)
• Menambah efektivitas kerja perawatan harian
• Merangsang epidermal-dermal remodeling
Tujuan Chemical Peeling

18. • Stimulation epidermal growth :
pelepasan str. corneum  str. corneum tipis – kompak 
epidermis > tebal
• Destruction specific layers of damaged skin :
 jar. normal dengan penampilan kosmetik
lebih baik
 distribusi melanin lebih merata
• Induction of inflammation reaction :
 jumlah kolagen dan GAG di dermis me
Mekanisme Kerja Chemical Peeling

19. Penampang Kulit

20. 1. Very superficial ( exfoliation )
2. Superficial ( epidermis )
3. Medium depth ( papillary dermis sampai upper reticular
dermis )
4. Deep ( dari upper sampai lower reticular dermis )
Tingkat Kedalaman Peeling

21. 1. Very superficial :
• destruksi stratum korneum
• tidak ada luka di bawah stratum korneum
2. Superficial :
• nekrosis sebagian atau seluruh epidermis
3. Medium depth :
• nekrosis pada epidermis dan sebagian atau seluruh papila dermis sampai
upper retikular dermis
4. Deep :
• nekrosis pada epidermis dan papila dermis sampai mencapai lower reticular
dermis
Tingkat Kedalaman Peeling

22. Tingkat Kedalaman Peeling

23. Kedalaman Chemical Peeling dipengaruhi oleh :
• Priming
• Tipe kulit
• Defatting process
• Daerah yang dipeeling
• Jenis cairan peeling
• Konsentrasi cairan peeling
• Jumlah lapisan
• Lamanya kontak cairan peeling dengan kulit
• Tehnik
Tingkat Kedalaman Peeling

24. 1. Very Superficial :
• Glycolic acid 30% to 50 %
• Jessner solution applied in 1 to 3 coats
• TCA 10% applied in 1 coat
2. Superficial :
• Glycolic acid 50% to 70%
• Jessner solution applied in ± 4 coats
• TCA 15% to 30%
Classification of Peeling Agents

25. 3. Medium Depth :
• TCA 30% to 50%
• Kombinasi Jessner Modification Peel dengan konsentrasi TCA 25%
4. Deep :
• Phenol 88%
• Baker Gordon Phenol Formula
• TCA 50% atau lebih
Classification of Peeling Agents

26. 1. Seleksi pasien
2. Priming yang baik
3. Pemilihan cairan yang digunakan sesuai
dengan priming dan kondisi kulit pasien
4. Post peeling care
Syarat Peeling yang Baik

27. • Initial consultation
• Establishing a relationship
• Identifying the patient’s concern
• Identifying contra indication
• Evaluating the patient’s acceptance of risk and down time
• Educating the patients
• Setting the ground rule
Seleksi Pasien

28. • Pasien dengan priming yang tidak adekuat
• Dermatitis pada wajah
• Acne inflamasi
• Pasien masih dengan eritema (karena proses peeling sebelumnya)
• Pasien dalam kondisi tidak stabil mentalnya (stress, Body Dysmorphic Disorder)
• Pasien pasca face lift/eyelift (3 bulan)
• Alergi dengan bahan2 yg terdapat dalam cairan peeling
Kontraindikasi MUTLAK

29. • Priming dengan sunprotection inadekuat
• Hamil
• Riwayat baru trauma di kepala – leher
• Riwayat radiasi di daerah peeling
• Riwayat skar, keloid, herpes labialis
• Luka terbuka, acne nodulo kistik / konglobata
• Ekskoriasi neurotik
• Riwayat penggunaan isotretinoin dengan dosis standard (hanya
berlaku utk deep peel)
• AIDS
Kontraindikasi RELATIF

30. • Veruka plana
• H. Simplex
• D. seborrhoik
• D. atopi
• Perioral dermatitis
• Acne
• Rosacea
• Facial teleangiectasis
Dapat Dieksaserbasi oleh Peeling

31. GROWTH FACTOR

33. PREBIOTICS, PROBIOTICS AND
POSTBIOTICS

34. Prebiotics : fuel for the good bacteriaon your skin’s surface. They
provide energy for probiotics and allo your microbiome to flourish.
Work to nurture and enrich the microbiome.
Probiotics : good bacteria that support the skin’s moisture barrier
function. Work on the skin’s surface to visibly renew the skin
Postbiotics : metabolites left behind by probiotics. When applied
topically, postbiotics renew the skin for a smooth and glowing skin

35. GLYCOLIC ACID, LACTIC ACID , MANDELIC
ACID

40. Ukuran partikel dari yang paling besar :
1. Mandelic Acid ( twice that of glycolic acid (152 Daltons), so it penetrates the skin
more slowly. ) = Salicylic acid
2.Lactic acid ( less skin penetration )
3.Glycolic acid (smallest of the alpha hydroxy acids, weighing in around 76 Daltons,
its small molecular weight, it works on both the epidermal and dermal layers,
increasing collagen and hyaluronic acid synthesis in the skin )
4.

41. Glycolic acid
It is a colorless, odorless AHA derived from sugarcane.
It is the most effective among all other AHAs, which can penetrate deeper into the skin layers
even at low concentrations.
It is the smallest and simplest AHA in terms of chemical structure, and is also a highly
hydrophilic molecule with the greatest bioavailability of all the AHAs.
When properly used, superficial exfoliation with glycolic acid at concentrations of 30 to 50%
has demonstrated excellent clinical efficacy in the treatment of superficial hyperpigmentation,
mild-to-moderate chrono- and photoaging, and fine rhytides.
For superficial chemoexfoliation, most concentrations range from 20 to 50%, with higher
concentrations (70%) entering the medium-depth category.

42. Lactic acid,
which is structurally identical to glycolic acid with the exception of an additional methyl group
at the β-carbon end, has a lower pKa and thus a lower pH than glycolic acid at equivalent
concentrations, allowing for efficient chemoexfolation at lower concentrations.
Lactic acid has a lower pH than glycolic acid, a lower concentration ( 10–30% ) is often used
to achieve an equivalent depth of keratocoagulation compared to glycolic acid, which allows a
favorable side effect profile and recovery time.

43. Mandelic acid
Peels are more subtle than that of superficial glycolic acid peels; however,
the side effects and subsequent downtime of mandelic acid are
comparatively less, which allows more frequent “touch ups” and shortened
intervals between treatment sessions.
Mandelic acid has demonstrated efficacy in the treatment of superficial
erythema and dyspigmentation, as well as efficacy in the reduction of
cutaneous sebum production.
Patients often experience minimal desquamation, and reepithelialization is
often complete within 3 to 5 days.

44. Salicylic acid
has a chemical structure similar to that of mandelic acid.
given its low pKa and small molecular size, salicylic acid demonstrates easy,
rapid, and deep penetration through the lipid barriers of the epidermis.
30% salicylic acid is often considered the “gold standard” superficial
peel for the treatment of acne and has demonstrated excellent clinical
efficacy for the treatment of mild-to-moderate inflammatory
papulopustular acne vulgaris and comedonal acne
Exfoliation after treatment typically occurs over several days, and
reepithelialization is complete within 7 to 10 days