ROSACEA TREATMENTS Although the Etiology Remains Unclear, Newer Combination Therapies Are Giving Clinicians More Options to Manage Rosacea

Home , Alpha hydroxy acid, Chemical peel

, LLCTMTM www.skinandaging.com April 20 11

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&AGING PRACTICAL AND CLINICAL ISSUES FOR TODAY’S DERMATOLOGIST

Advances in ROSACEA TREATMENTS Although the etiology remains unclear, newer combination therapies are giving clinicians more options to manage rosacea.

Superficial Chemical Peeling: Minimal Effort, Maximum Results Aesthetic Interventions: Sebaceous Hyperplasia Psoriasis Review

In this Issue BOARD onREVIEW page 15 SUPERFICIAL CHEMICAL PEELING: Minimal Effort, Maximum Results Calling superficial chemical peels a safe and reliable addition to the medical practice, the author provides an overview of a number of commonly used peeling agents.

JENNIFER LINDER, MD

he topical application of acids is addition to increase the practice’s bot- a physician and can reach the reticular one of the most dependable and tom line and enhance treatment results, dermis, causing deep wounding. Twidely recognized methods of im- with no downtime. Peel depth is determined by several proving the overall health and appear- factors, including type and percentage ance of the skin. The goal of a chemical DETERMINING PEEL DEPTH of acid, patient skin type and thick- peel is to regulate and enhance the cel- Chemical peel depth ranges from very ness, pre-treatment and patient history lular turnover process, a complex system superficial to deep. Very superficial of exfoliating treatments. All patients that ultimately leads to the shedding of chemical peels affect the stratum have different factors that will con- cornified cells. Over the years, it has corneum and stop penetration at the tribute to how a peel solution will been established that chemical peels granular layer. Superficial peels can pen- work for their skin. For example, thick provide added clinical benefits to the etrate through the stratum corneum to skin and increased sebum production medical practice because of their ability the basal layer. Medium depth peels are may impede penetration of a peel so- to provide patients with the results they typically performed by a physician or lution. Conversely, skin with an desire. While many aesthetic medicine under the supervision of a physician and impaired barrier function may experi- practices offer medium and deep peels, can penetrate down to the papillary der- ence accelerated depth of penetration. superficial chemical peels are a versatile mis. Deep peels should be performed by Type and percentage of the acid is the

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Figure 1: Depth of penetration of chemical peels.

merous studies have shown that all ently causes live tissue protein denatura- chemical peel solutions stimulate colla- tion upon application. gen and glycosaminoglycan production, Topical treatment with TCA stimu- regardless of depth of penetration.1 Ad- lates collagen production and smoothes ditionally, topically applied products are surface texture. It is ideal for the correc- able to absorb more effectively when the tion of rhytids, keratoses, dyschromias skin is properly exfoliated, allowing for and scarring.4 TCA also reduces hyper- accelerated results. Tricholoracetic acid, pigmented keratinocytes.5 Percentages alpha hydroxy acids, salicylic acid, mod- for superficial use range from 6% to 30%. ified Jessner’s solutions, retinoids, and A 6% TCA will produce a very superfi- blended acid peels are currently the most cial exfoliation (limited to the stratum commonly utilized superficial peeling corneum) with minimal tissue coagula- agents in the industry. tion, while a 30% TCA will produce varying amounts of necrosis of the epi- TRICHLOROACETIC ACID (TCA) dermal keratinocytes.6 This versatility is Trichloroacetic acid (TCA) is a prac- what makes TCA a mainstay in any of- tical and versatile solution used in chem- fice offering skin rejuvenation. TCA, in ical peeling. TCA was first studied in the general, is appropriate for all Fitzpatrick mid 1900s and was found to be safer and skin types; however, percentages higher primary determiner of depth and con- more predictable than deeper peeling than 10% should be avoided unless the trol (See Figure 1). Superficial peels are better suited for mild to moderate textural imperfections, Numerous studies have shown that all chemical peel rhytids, dyschromia and acne lesions. Pa- tients who desire monthly treatments are solutions stimulate collagen and glycosaminoglycan viable candidates for superficial chemical production, regardless of depth of penetration.1 peels because their lower level of exfoliation permits repeat treatments with quick re-epithelialization times. agents, such as phenol. TCA is a synthet- patient is thoroughly prepped with ically derived peeling agent made of dyschromia-controlling products. COMMONLY USED SUPERFICIAL PEELING AGENTS acetic acid and chlorine. It has become a Costs associated with straight acid TCA In addition to maintaining healthy cel- popular option for superficial and peels tend to remain constant despite the lular turnover rates, each of the most medium-depth peels because there is no percentage. Broadly speaking, TCA in the commonly used superficial peeling risk of systemic toxicity.2,3 TCA is con- superficial ranges cost $35 for a 60ml bot- agents provides ancillary benefits. Nu- sidered a chemical cauterant, as it inher- tle. Keeping in mind that application tech-

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Lactic acid is indicated for patients with dry or dehydrated skin, dyschromias or sensitive skin conditions. Lactic acid’s comparatively larger molecule also allows it to penetrate slowly, which reduces treatment-induced inflammation. Its antimicrobial and anti-inflammatory properties make it effective in Figures 2A and 2B: Before (left) and 4 months after (right) receiving five blended 10% TCA and 20% lactic acid peels with the treatment of acne and sensitive skin a 10% retinol and 20% lactic acid booster treatment. conditions. Lactic acid’s mechanism of action is to dissolve the intercellular desmosomes to promote exfoliation. By nature, this AHA is hydrophilic, a humectant and a natural constituent found in muscle fiber. Similar to glycolic acid, lactic acid percentages range from 10% to 70%.12 The cost of a straight acid AHA will vary from one manufacturer to the next. Generally speaking, an AHA will cost $30 to $90 depending upon the percentage desired, based on a 60ml bottle. The average number of treatments per bottle will fluctuate due to the preferred Figures 3A and 3B: Before (right) and 2 months after (right) receiving one modified and enhanced Jessner’s treatment with 14% lactic acid, 14% salicylic acid and 3% kojic acid. application method; however, 15 to 20 treatments may be obtained from a sin- niques vary, each 60ml bottle should pro- of treatment options.2 AHA are hy- gle 60ml bottle. vide approximately 15 to 20 treatments. drophilic by nature, and have the ability to penetrate the epidermal layers. In some SALICYLIC ACID ALPHA HYDROXY ACIDS (AHA) cases, they can reach the superficial der- Salicylic acid is a keratolytic and Alpha hydroxy acids (AHA) include mal layers, depending on the percentage lipophylic substance that is considered to lactic, glycolic, citric, malic, mandelic and and patient skin condition, by breaking be the sole member of the beta hydroxy tartaric acids. Lactic and glycolic acid are up the keratinocyte cohesions.2 The stra- acid family to be used topically. Salicylic the most studied AHA for topical use. tum corneum is reduced, cellular acid has the ability to dissolve follicular AHA offer many ancillary benefits, in- turnover is increased and collagen and impactions, reducing acne lesions. Also cluding humectant moisturizing quali- elastin production is stimulated.10 suitable for sensitive skin conditions and ties, inhibition of Propionibacterium acnes In addition to the many ancillary ben- rosacea, salicylic acid provides notable bacterial proliferation, reduction of hy- efits, each AHA has a detailed specifica- anti-inflammatory exfoliation benefits.13 perkeratinization and slowing of the tion for use. Glycolic acid is best for Studies suggest that salicylic acid is also melanogenesis process.7 Some studies oilier skin types due to its degreasing beneficial when treating post-inflamma- suggest that AHA have the ability to pro- properties. Concentrations of glycolic tory hyperpigmentation, mild to moder- mote collagen synthesis in the skin while acid typically range from 20% to 70%.2 ate photodamage, lentigenes and desquamating the corneocyte cohesions It has also shown to be effective in the abnormal surface texture.14 This is a fa- just above the granular layer.8 treatment of hyperpigmentation and as a vorable option for Fitzpatrick skin types Alpha hydroxy acids prove to be an- prepping agent prior to a deeper peel, I to VI.15 Although available in higher other versatile peeling agent. AHA, in such as a high percentage TCA. Histori- percentages, salicylic acid is typically ap- general, are considered very superficial cally, glycolic acid peels have also been plied in 20% to 30% formulations. The and superficial and percentages range used to correct rhytids, sallow complex- probability of salicylic poisoning rises as vastly from 10% up to 70%.9 These acids ions, textural abnormalities and lentig- the percentage and layers increase, mak- are typically safe for Fitzpatrick skin types ines, amongst other dyschromia-related ing superficial percentages ideal for I to VI. Since AHA are derived from sug- disorders.11 The small molecular struc- use.15,16 Different from AHA, salicylic ars found in fruit carboxylic acids, they ture of glycolic acid allows for hastened acid does not need to be neutralized; are nontoxic, making them an easy addi- epidermolysis, making it more aggressive however, it is recommended to remove tion to any plastic surgeon, dermatologist and dehydrating in comparison to other the salt-crystal residue with a mild soap or other skin health professional’s arsenal forms of AHA. and lukewarm water.15

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Profitability of salicylic acid is compa- rable to that of straight AHA peels. Al- though pricing may fluctuate, on average a 60ml bottle of salicylic acid ranges from $30 to $50, depending on the strength. One can expect to perform approximately 15 to 20 treatments per bottle, as the method of application may differ from one individual to another.

MODIFIED JESSNER’S SOLUTION The modified Jessner’s solution was the first blended acid chemical peel. The Figures 4A and 4B: Before (left) and 4 months after (right) receiving five 10% TCA and 20% lactic acid peels with a 10% retinol original formula is a combination of 14% booster treatment. lactic acid, 14% salicylic acid and 14% re- sorcinol — an effective keratolytic — in an alcohol base. The original use of a Jessner’s-like solution can be dated back to the 1940s; however, the solution used today was popularized in the 1950s by Dr. Max Jessner.16 This solution offers marked improve- ments in acne, dyschromias and the ex- trinsic signs of aging. Because the peel stimulates the dermal layers to produce collagen and fibroblasts, mild to moderate rhytids can be treated.16 The modified Figures 5A and 5B: Before (left) and 3 months after (right) receiving one 6% TCA and 12% lactic acid peel. Jessner’s solution is often administered because of its ease of use, extremely low risk of toxicity and uniform peel depth.16,17 These agents assist in cellular turnover BLENDED ACID CHEMICAL PEELS This peel solution is recommended for and regulation of abnormal desquama- Blended acid chemical peels create fa- Fitzpatrick skin types I to VI.7 tion, while reducing the incidence of vorable changes within the skin without The cost of a modified Jessner’s solu- corneocyte cohesion.18 Science also sug- inducing large amounts of inflammation, tion is relatively low, making it a favorable gests that retinoids have the capacity to limiting complications. A multitude of option for office use. On average, a 60ml reduce the activation of matrix metallo- ingredients can be combined to treat bottle of a modified Jessner’s solution is proteinase enzymes, such as collage- many skin conditions and all Fitzpatrick between $65 and $100. As mentioned nase.8,19 Retinoids are melanogenesis skin types, making these peels an all-in- previously, the number of treatments per inhibitors that stimulate the production clusive treatment option. Blended peels bottle will depend upon the desired ap- of collagen and discourage hyperkera- typically offer a combination of the plication method, but one can expect 15 tinization within the follicle.19,20They are aforementioned acids, as well as melano- to 20 treatments per 60ml bottle. also safe for all Fitzpatrick skin types I to genesis inhibitors, hydrating agents, and VI, although retinoic acid may induce anti-inflammatory and antioxidant in- RETINOIDS significant amounts of topical irritation. gredients. These types of ingredients help Retinoids include all forms of vita- If surface irritation is a concern, retinol to enhance the exfoliating benefits of su- min A. The forms used most often in is an effective alternative.20 perficial chemical peels by targeting spe- professional products are retinoic acid, Retinoic acid tends to be an expen- cific skin concerns, including acne, retinaldehyde and retinol. Retinoic sive solution to compound. Although rosacea, hyperpigmentation and visible acid is typically compounded using a pricing may vary, a 60ml bottle of com- aging for accelerated results. 0.3% solution with ethanol alcohol. pounded 0.3% retinoic acid is approxi- Peel blends have been administered for Retinol and retinaldehyde are both mately $120. Since compounded well more than 20 years; however, re- produced synthetically but have the retinoic acid does not dry on the skin cently there has been a noticeable spike capacity to convert to retinoic acid like other peel solutions; one layer per of interest in the industry. This level of within the skin. Percentages of retinol treatment offers satisfactory results. Gen- treatment can be a lucrative addition for and retinaldehyde vary up to 10% in erally speaking, a 60ml bottle should a practice, as blended peels can be per- topical products. provide 25 or more treatments. formed quickly and safely by an aestheti-

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4. Harmon CB, et al. Trichloroacetic acid. In: Tosti A, et al. eds. Color Atlas of Chemical Peels. New York, NY: Springer-Verlag; 2006:59-68. 5. Perez-Bernal A, Munoz-Perez MA. Manage- ment of facial hyperpigmentation. Amer J Clinic Dermatol. 2000; 1:261-268. 6. Collins PS Trichloroacetic acid peels revisited. J Dermatol Surg Oncol. 1989; 15:933-40. 7. Inan S, et al. Histopathological and ultrastruc- tural effects of glycolic acid on rat skin. Acta His- tochemica 2006; 108:37-47. 8.Clark CP. Office-based skin care and superficial Figures 6A and 6B: Before (left) and 3 months after (right) after receiving six modified and enhanced Jessner’s treatments with 14% peels: The scientific rationale. Plast Reconstr Surg. lactic acid, 14% salicylic acid, 2% hydroquinone and 3% kojic acid. 1999; 104:854-64. 9. Leu D, Yoo SS. Epidermal and color improve- 21,22 cian, medical assistant or nurse. The and each has a place within the industry. ment in ethnic skin: Microdermabrasion and Su- treatments are more controlled than By offering a multitude of chemical perficial Peels. In: Alam M, et al, eds. Cosmetic straight acid chemical peels, and there- peeling solutions, including blended Dermatology for Skin of Color. New York, NY: Mc- fore do not need to be administered by acids and various percentages of differ- Graw-Hill, Inc.; 2009:29-33. the physician. In addition, patients seem- ent acids, providers and their staffs are 10. Vanscott E, and Yu R. Hyperkeratinization, Corneocyte Cohesion, and Alpha Hydroxy Acids. ingly are becoming more interested in able to enhance treatment plans for JAAD.1984; 11:867-79. no-downtime procedures that improve more comprehensive outcomes. Al- 11. Ditre CM. Alpha hydroxy acid peel. In: Rubin the skin gradually. though straight acid peels will not be- MG, Dover JS, Alam M, eds. Chemical Peels. This type of treatment simultaneously come obsolete in a physician’s office, Philadelphia, PA: Elsevier Saunders; 2006: 27-45. induces exfoliation while also infusing blended acid peels tend to provide an- 12. Brody HJ. Chemical Peeling. St. Louis: Mosby Year Book; 1992. the skin with added beneficial ingredi- cillary benefits with little to no down- 13. Grimes PE. The safety and efficacy of salicylic ents. These added ingredients often make time to the patient. This variety and acid chemical peels in darker racial-ethnic it unnecessary to neutralize the acid, opportunity for treatment customization groups. Dermatol Surg. 1999; 25:18-22. which can also be advantageous. Straight encourages optimal patient outcomes 14. Maya V. Salicylic scid peels. Ind J Dermatol, AHA peels, for example, require neutral- and profitability for the physician. n Venerol, Leprol. 2004; 17: 136-138. 15. Grimes PE. Salicylic acid peels. In: Rubin 23,24 ization. If not neutralized, the acid MG, Dover JS, Alam M, eds. Chemical Peels. could potentially collect in the upper Dr. Linder, a board- Philadelphia, PA: Elsevier Saunders; 2006: 47-55. portions of the skin and cause surface ir- certified dermatologist 16. Fulton Jr JE. Jessner's Peel. In: Rubin MG, ritation or burns. Neutralization, while and fellowship-trained Dover JS, Alam M, eds. Chemical Peels. Philadel- necessary in this instance, can release Mohs skin cancer sur- phia, PA: Elsevier Saunders; 2006: 57-71. 17. Rubin MG. Manual of Chemical Peels: Superfi- more free carboxylic groups and reduce geon,is a volunteer Clin- cial and Medium Depth. Philadelphia: J.B. Lippin- the pH of the skin even further, increas- ical Instructor in the cott; 1995. ing stimulation and inflammation. By Department of Derma- 18. Varani J, Warner RL, Gharaee-Kermani M et using several acids blended together, each tology at the University al. Vitamin A antagonizes decreased cell growth can be used at a lower percentage, Jennifer Linder, MD of California, San Fran- and elevated collagen-degrading matrix metallo- proteinases and stimulates collagen accumulation thereby maximizing outcomes and min- cisco. Dr. Linder is currently in private practice in naturally aged human skin. J Invest Dermatol. imizing the risk of pooling in the epi- in Scottsdale,AZ. 2000; 114:480–486. dermis and other side effects.24 19. Griffiths C, et al. Restoration of collagen Blended acid peels tend to increase Disclosures: Dr. Linder is Chief Scientific Officer, formation in photodamaged human skin by profitability because the patient can PCA SKIN, is National Instructor, Dermik Aes- tretinoin (Retinoic Acid). The NEJM 1993; 323: 530-535. safely tolerate monthly treatments, in- thetics (Sculptra), and National Instructor, Allergan Facial Aesthetics. 20. Draelos ZD. Retinoids in cosmetics. Cosmet creasing repeat business. Generally speak- Dermatol. 2005; 18:3-5. ing, a 60ml bottle of a blended acid peel 21. Roberts WE. Chemical peeling in ethnic/dark will cost $65 to $75. Depending on the References skin. Dermatol Ther. 2004; 17:196-205. layers needed and the application tech- 1. Eskild LW, Hansson, V. Vitamin A functions in 22. Zakopoulou N, Kontochristopoulos G. Super- the reproductive organs. In: Blomhoff R, ed. Vita- ficial chemical peels. J Cos Der., 2006; 5:246-253. niques, a 60ml bottle can provide up to min A in Health and Disease. New York, NY: Mar- 23. Draelos ZD. Glycolic acid and other super- 20 to 30 treatments. cel Dekker; 1994:531-559. ficial peels. In: Lowe NJ, ed. Textbook of Facial 2. Mangat D, et al. Current chemical peels and Rejuvenation: The Art of Minimally Invasive Com- CONCLUSION other resurfacing techniques. Facial Plast Surg. bination Therapy. London, England: Martin Superficial chemical peels are a safe 2011; 21:35-49. Dunitz; 2002: 49-59. 3. Stagnone G J, Orgel, MG, Stagnone JJ. Cardio- 24. Dewandre L. The Chemistry of peels and a and reliable addition to the medical vascular effects of topical 50% trichloroacetic acid hypothesis of action mechanisms. In: Rubin MG, practice. Each of the aforementioned and Baker's phenol solution. J Dermatol Surg ed. Chemical Peels. Philadelphia, PA: Elsevier peeling agents provides unique benefits 1987; 13:999-1002. Saunders; 2006: 1-12.

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