, LLCTMTM www.skinandaging.com April 20 11 ™ &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 32 A PRIL 2011 | SKIN & AGING | www.skinandaging.com CHEMICAL PEELING 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 exfo- liation 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- APRIL 2011 | SKIN & AGING | www.skinandaging.com 33 CHEMICAL PEELING Lactic acid is indicated for patients with dry or dehydrated skin, dyschro- mias or sensitive skin conditions. Lactic acid’s comparatively larger molecule also allows it to penetrate slowly, which reduces treatment-induced inflamma- tion. Its antimicrobial and anti-inflam- matory 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 gly- colic 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 per- centage 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