Cosmetic Interventions for Dyschromia: Chemical Peels Cosmetic Interventions for Dyschromia: Chemical Peels Dr. Neelam A. Vashi, MD, Department of Dermatology, Boston University School of Medicine, Boston Medical Center, Boston INTRODUCTION sulfur, and limestone were used later Social psychology has long shown us by the Greeks and Romans.7In the late that attractiveness ratings of images 1800s, dermatologists pioneered skin relate positively to parameters of skin peeling for therapeutic benefit publishing homogeneity.1Faces with even skin data on the removal of ephelides with color distribution attract more visual phenol.7 Today, we define chemical attention than those with greater color peeling as the application of chemical contrast illustrating the importance exfoliating agents to the skin which of skin color homogeneity with results in destruction of one or more perceptions of beauty.2,3,4Alexis et al parts of the epidermis and/or dermis showed that dyschromia was one of the with subsequent regrowth of these 5 most common diagnoses observed layers.8 at one dermatology center amongst darkly pigmented patients.5In particular, PEELING AGENTS melasma and post-inflammatory Peeling agents can broadly be classified hyperpigmentation are major concerns into different groups such asalpha- for skin of color patients. Pigment hydroxy acids and beta-hydroxy acids. deposition in the skin secondary to Other types of peeling agents include trauma from mechanical affects and/ trichloroacetic acid, retinoic acid, or inflammatory skin disease can phenol, and combination products, cause extreme dissatisfaction amongst i.e. Jessner’s solution. The following patients and therapeutic challenges discussion will focus on superficial and to the physician. The treatment of medium peels most safe and efficacious dyschromia in darkly pigmented patients in skin types III-VI. poses many challenges given the higher Alpha-hydroxy acids risk of post-inflammatory changes Alpha hydroxy acids are naturally and potentially disfiguring scarring. In occurring carboxylic acids which work addition to other modalities that include by epidermolysis within minutes of topical skin bleaching preparations, application followed by desquamation chemical peeling is one of several and epidermal melanin dispersion. This ways to successfully remove excess formulation can produce light peels pigment from the skin. This summary for uneven pigmentation depending provides a review of various peeling on formulation and percentage used. agents, indications, and practical The prototypical alpha-hydroxy acid is tips on performing safe and effective glycolic, a natural constituent of sugar chemical peeling for richly pigmented cane, and comes in both solutions and skin, defined as those with skin types gels, ranging in percentage from 30-70. III-VI in this article. Other naturally occurring alpha-hydroxy The historical beginnings of chemical acids include lactic acid (found in sour peeling lie in Africa with the ancient milk and tomato juice), malic acid Egyptians using animal oils, salt, (present in apples), citric acid (present alabaster, and sour milk to aesthetically in oranges and other fruits), and tartaric improve the skin, unknowingly utilizing acid (present in grapes). These are timed the properties of alpha-hydroxy peels and must be neutralized with water acids.6,7Poultices containing mustard, or 1% bicarbonate solution otherwise 30 April 2014 Cosmetic Interventions for Dyschromia: Chemical Peels the acid will continue keratolysis with salicylic acid (14g), resorcinol (14g) 2)Review patient ethnicity as skin subsequent desquamation. and lactic acid (85%) in ethanol (95%). type alone is not always an accurate The advantage of this formulation is assessment of how the skin will Beta-hydroxy acids 8 Salicylic acid (ortho-hyroxybenzoic that there is a synergistic effect from respond. three keratolytic agents, as well as the acid) is the naturally occurring beta- 3)Discuss risks, benefits and possible additional benefit of a phenolic skin- hydroxy acid family member used for complications and review patient lightening agent (resorcinol). Jessner’s chemical peeling,derived from the consent forms. bark of the willow tree. Salicylic acid solution can also be combined with can be formulated in many types of other peeling agents (i.e. TCA); however, 4)Set realistic expectations. caution should be taken with this peel vehicles. Ethanol solutions act as 5)Photograph full face and specific as the phenolic compound, resorcinol, excellent peeling agents for multiple areas prior to starting chemical peels. may create undesirable depigmentation dyschromias including melasma and 8 post-inflammatory hyperpigmentation.9 in darker skin types. Of note, Jessner’s 6)Start a pretreatment priming regimen At lower concentrations (3-5%), it solution must be stored in a dark bottle 2-4 weeks prior to peeling which functions as a keratolytic agent allowing to prevent photo-oxidation. includes: photoprotection (UVA/UVB the penetration of other peeling agents. sunscreen SPF 30 or greater), gentle Newer Peels cleansing, and application of a lightening At higher concentrations (20-30%), it Newer peels not previously discussed agent (i.e. hydroquinone, azelaic acid, functions as a peeling agent. It also include pyruvic acid, ferulic acid, and and/or kojic acid). functions as a comedolytic agent given mandelic acid. Pyruvic acid has diverse its lipophilic properties being able to properties acting as a keratolytic and 7)Consider doing a small test area prior produce desquamation of the upper antimicrobial agent that has been shown to the series of peels,especially when lipophilic layers of the stratum corneum. to be effective for treating pigmentary treating dyspigmentation. Beta-lipohydroxy acid is a new derivative disorders in light-skinned patients.10, 12 of salicylic acid with an additional fatty Ferulic acid is a hydroxycinnamic acid. Procedure acid chain, creating increased lipophilic It is an organic phenolic phytochemical 1)Choose your peel wisely. When behavior and, therefore, producing a found in plant cell wall components. The choosing your peel, think about skin greater keratolytic effect.10It is available combination of ferulic acid and phloretin type and ethnicity while determining at concentrations of up to 10% that (a dihydrochalcone which is a type the depth of the wound to be created has antibacterial, anti-inflammatory, of natural phenol found in apple tree (superficial or medium only in darker skin antifungal, and anticomedogenic leaves and Manchurian apricots) has types). The key factors in determining properties.10, 11 been used for antioxidant and peeling the depth of the wound include: the effects. Mandelic acid is a newer peel agent used, the concentration of the Trichloroacetic acid agent being used, the amount of agent Trichloroacetic acid (TCA) is an inorganic and is one of the largest alpha-hydroxy used, the method of defatting, the compound that is present in crystalline acids. It is able to provide a slow and amount of pressure applied to the skin form and causes coagulative necrosis of uniform penetration of epidermis and 10 during the peel, and the duration of cells through protein denaturation and dermis. The combination of mandelic time that the peeling is in contact with structural cell death. Degree of necrosis acid with quick penetrating salicylic acid the skin. Any of these key factors can depends on the concentration used. It has been showing to be effective in the be manipulated to achieve a lighter or is self-neutralizing and can create a treatment of pigmentary disorders such 13 heavier peel. Minor fluctuations can be white frost on the skin, an undesirable as melasma. Further testing is needed purposefully utilized to the physician’s effect in richly pigmented skin. Thus, in to show safety and efficacy of these advantage; however, take great caution skin of color, the desired results can be newer peels, especially in skin types III- as they can also produce unwanted accomplished using a superficial peel VI. side effects. with lower percentage solutions (10- PRACTICAL TIPS 2)Degrease the skin. The purpose of 25%). Patient selection and preparation degreasing or defatting the skin is to Patient selection is incredibly important Retinoic acid remove excels oils in order to allow prior to performing chemical peels. Tretinoin (all-trans retinoic acid) is a for an even penetration of the peeling Patient assessment is essential when synthetic vitamin A analogue which has agent. The skin can be degreased with establishing and setting reasonable been shown to improve pigmentary isopropyl alcohol in triplicate, acetone, expectations, choosing the most suitable abnormalities.12It has been used in or chlorhexidine. The more the skin peel, and avoiding complications. varying concentrations of 1-9%. The is degreased, the more the peel will higher percentage has been used as a 1)Obtain a medical history with penetrate. mask for a period of 8 hours allowing for particular attention to a history of 3)Prepare the patient and peel. Prepare 10 a gentle peel that lasts 3-4 days. delayed wound healing, hypertrophic the patient by removing hair from the scar formation, prior herpes simplex face, applying an occlusive ointment to Combination peels virus infection (HSV), drug intake, and Combination peels allow synergy of the lips, placing cotton balls to bilateral smoking. Smoking slows the healing different acids and utilization of lower ear openings, and instructing the patient