Срединные и глубокие пилинги: механизм действия, показания и минимизация осложнений

The purpose of chemical peels – improve the condition of the skin of the face or body through the controlled destruction of targeted skin layers by chemicals. As a result, dead skin particles are exfoliated, and new, healthier tissue forms in their place. Repaired skin tends to be smoother, less wrinkled and less pigmented.

In aesthetic dermatology, chemical peels – widely used treatment due to its effectiveness in correcting the signs of aging such as wrinkles, sallow complexion, pigmentation disorders and skin laxity. The cosmetologist needs to understand how superficial, medium and deep chemical peels work, what precautions to take and what contraindications to take into account in order to choose a safe and effective procedure for each patient.

Classification of chemical peels: superficial, medium and deep

Chemical peels

are classified according to the depth of penetration and the skin damage they cause:

superficial peels penetrate the epidermis to the basal layer;
  • medium peels penetrate to the papillary dermis;
  • deep peels penetrate to the level of the reticular dermis.
  • The peeling solution used for the procedure does not necessarily determine the depth of the peeling effect – it depends on several factors, including:

solution concentration;
  • pH;
  • presence or absence of free acid;
  • exposure duration;
  • skin conditions;
  • application method.
  • For example, a 70% glycolic acid solution can act as a superficial (if applied for 5 minutes) or midline (if applied for 15 minutes) peel. Trichloroacetic acid, depending on the concentration, can be used as a superficial, medium or deep peel.

A separate step in the evolution of chemical peels was their combined use – sequential application of different substances, providing a synergistic effect and a lower side effect profile.

Skin preparation for medium and deep chemical peels

Before any chemical peel, including medium or deep, the patient's skin must be properly prepared. The purpose of such training – reduce the likelihood of adverse events such as post-inflammatory hyperpigmentation, provide more effective rejuvenation and identify potential problems associated with products that are used during or after the peeling procedure. To do this, use:

A low alpha hydroxy acid cleanser or moisturizer;
  • retinol/isotretinoin and/or skin lightening agent such as hydroquinone, kojic acid, etc.;
  • Sunscreens that suppress the excitability of melanocytes.
  • The duration of the skin preparation program is at least 2 weeks before the peeling procedure.

Medium peels: indications, features, results

Medium peels shown when available:

fine lines and wrinkles associated with photoaging;
  • pigmentation disorders;
  • superficial atrophic scars.
  • Traditionally, trichloroacetic acid (TCA) at a concentration of 40-60% is used in median peels. This approach is quite effective, but it comes with an increased risk of complications such as scarring and pigmentation. Similar results with less risk can be achieved by using TCA solution 35% in combination with
Jessner Peel

, glycolic acid 70% or solid carbon dioxide.

sredinnye-i-glubokie-pilingi-mekhanizm-dejstviya-pokazaniya-i-minimizatsiya-oslozhnenij

Before and After Peeling

Easy TCA, Creams Blending Bleaching Cream and DHEA. Photos: SkinTech and AestheticSource Jessner's solution and trichloroacetic acid 35%

Jessner's solution consists of 14 g salicylic acid, 14 g lactic acid and 14 g resorcinol, diluted to 100 ml with ethanol. Before applying this medium peel, the skin is cleansed and thoroughly rubbed with acetone to remove sweat and sebum. In case of hypertrophic actinic keratosis, curettage can also be performed at this stage.

Peeling is applied to cleansed and degreased skin with a cotton applicator. After reaching the end point of the procedure – the appearance of white frost and uniform reddening of the skin – a cold compress can be applied to the treated area to soothe the skin and relieve discomfort.

Jessner Peel provides a keratolytic effect and increases the permeability of the epidermal barrier of the skin, due to which the TCA solution penetrates the skin more evenly and quickly.

After the Jessner Peel is removed, an anesthetic such as EMLA or LMX – can be applied to the skin. so the TCA peel procedure will be more comfortable for the patient.

After the topical anesthetic has been removed, TCA 35% solution is applied to dry skin. To do this, use a cotton swab or a small gauze napkin. After reaching the endpoint – the appearance of a uniform white frost against the background of erythema – a cold compress is applied to the treated area in order to reduce the burning sensation that the patient feels for about 10 minutes after applying the composition. Then an occlusive ointment, such as Vaseline or Aquaphor, is applied to the skin, which eliminates dryness after peeling.

sredinnye-i-glubokie-pilingi-mekhanizm-dejstviya-pokazaniya-i-minimizatsiya-oslozhnenij

Before and after

Easy Phytic treatment and cleansing cream (Purifying Cream). Photos: SkinTech and AestheticSource Glycolic acid 70% and trichloroacetic acid 35%

This approach provides the same results as the Jessner Peel technique, however glycolic acid is used as the initial superficial peel. Glycolic acid has a keratinolytic effect and enhances the penetration of TCA 35%. As a rule, it is applied for 2 minutes, after which it is neutralized with a bicarbonate solution or cold water. Glycolic acid is not suitable for inflamed or dry skin.

Solid carbon dioxide and TCA 35%

This technique consists of applying solid carbon dioxide coated with acetone. The substance is applied to the skin in order to damage the epidermis. The depth of epidermal damage, penetration and effect of the TCA solution depends on the time of exposure to CO2

. Thus, areas that require deep peeling (for example, deep wrinkles, scars, thick actinic keratosis) can be exposed to a longer exposure to the composition. 

Mechanism of action of medium peels

The main active ingredient of medium peels – TCA – leads to protein denaturation. Trichloroacetic acid is water soluble and cannot easily penetrate sebum-rich skin. Therefore, the task of preliminary skin preparation and superficial peeling, which is applied before TCA, is to thin and increase the permeability of the stratum corneum, as well as to remove fat from the surface of the skin.

This provides a deeper and more uniform penetration, as well as uniform protein denaturation in depth.

Results of medium peels

Immediately after a median chemical peel, swelling and tightness of the skin may be observed. Some practitioners recommend applying occlusive ointments regularly (several times a day) to the skin after the procedure, as they shorten the recovery period and reduce redness of the skin after median peels.  

The epidermis above the level of chemical damage separates from the underlying skin from about the third day, resulting in a serous exudate and a crust on the skin. The skin begins to exfoliate from the perioral region, this process ends on the forehead.

Patients are advised not to slough off the flaking epidermis, as this may lead to scarring. In this case, it is allowed to cut off the exfoliated skin with scissors. Moisturizer can be applied to the skin 5 days after the procedure, the exfoliation process itself can take up to 10 days.

After peeling off the epidermal layer, patients usually notice that the new skin looks more radiant, its color is more even; the severity of pigmentation and other skin imperfections is noticeably reduced, fine lines and wrinkles are smoothed out. During the remodeling of the dermis, neocollagenesis is triggered after about 6 weeks, which improves the quality of the skin.

Depending on the degree of photodamage and aging, for more effective rejuvenation, the doctor may recommend repeated peeling procedures. 3 weeks after the initial peel, the skin can be prepared again for the next treatment.

Three weeks after the first medium peel, the skin can be prepared again for the next procedure.

sredinnye-i-glubokie-pilingi-mekhanizm-dejstviya-pokazaniya-i-minimizatsiya-oslozhnenijBefore and after treatment

Easy Phytic, DHEA-Phyto and Re-Nutriv ACE Lipoic Complex. Photos: SkinTech and AestheticSource Deep peels: mechanism of action, performance, results

TCA is also used as a deep peel at concentrations above 50%, but the frequency of complications in such cases makes

phenol peel

a more attractive alternative.

Mechanism of action of phenol peeling

Like TCA, phenol penetrates the skin and results in protein denaturation and coagulation at a certain depth in the dermis. At the same time, unlike TCA, phenol penetrates the skin quickly, reaching the reticular dermis layer. Therefore, phenol peels are fast, but it is impossible to control the depth of their penetration as effectively as in the case of TCA.

Phenol deep peels are fast, but the depth of penetration cannot be controlled as effectively as with TCA.

When using  of any phenol peeling composition, the result is protein coagulation in the reticular dermis, therefore, indications for the use of deep peels are:

moderate to deep wrinkles;

    dyschromia;
  • post-acne.
  • Due to epidermolysis, which also affects the papillary dermis, deep peels achieve better results in eliminating wrinkles and pigmentation than median peels, which only penetrate to the papillary dermis.

sredinnye-i-glubokie-pilingi-mekhanizm-dejstviya-pokazaniya-i-minimizatsiya-oslozhnenijBefore and 8 months after melanoma treatment with peeling

CosMedix Benefit Peel x3, Peeling Timeless Rx Peel x1 and Peeling Deep Sea Peel x1. Photo: Medico Beauty Deep phenol peels carry more risks than medium peels because:

the likelihood of scarring increases due to greater depth of dermal damage, prolonged healing, post-inflammatory hyperpigmentation and hypopigmentation;

    phenol enters the bloodstream and has a cardiotoxic effect, thus increasing the risk of heart failure.
  • The degree of risk depends on the amount of phenol. If the procedure is performed on the entire face, the solution is applied alternately in zones. When treating the entire face with phenol, cardiac monitoring is strongly recommended in an appropriate clinical setting.

Phenol peels

cause considerable discomfort and are therefore sometimes performed under general anesthesia. Before, during and after the procedure, the patient is at least sedated.

Before the procedure, the skin is cleansed and degreased in the same way as before the median peels.

The phenol solution is applied to the skin using folded gauze. After treatment of one zone, the solution is washed off, then proceed to its application to the next area. The endpoint of a deep peel is a grey-white frost consisting predominantly of coagulated protein; the disappearance of erythema in the frost area means that the peeling has penetrated deeper into the vascular loops of the papillary dermis.

Results of using deep phenol peels

The recovery period after deep phenol peeling is quite long. For the first 48 hours after the procedure, an occlusive waterproof bandage is applied to the face. At this stage, the skin needs careful care – application of thymol iodide several times a day for a week.

Interesting: 

Phenol peeling. Features of composition and application

The first 7 days after the procedure, as a result of the mobility of the perioral area, cracks may form on the treated area, so patients are advised to consume liquid food through a straw. Re-epithelialization is observed approximately on the ninth day after deep peeling, during this period warm water compresses and emollients can be carefully applied. Erythematism and swelling of the newly formed skin after very deep peels can be observed for up to four weeks.

The result of using phenol peels – visible and long-term smoothing of wrinkles on the face, elimination of pigmentation and improvement of skin texture.

sredinnye-i-glubokie-pilingi-mekhanizm-dejstviya-pokazaniya-i-minimizatsiya-oslozhnenijBefore and 10 months after acne treatment with CosMedix

Purity Peel x5 peels for acne , Blueberry Jester x2, Timeless Peel x2 and Deep Sea Peel x1. Photo: Medico Beauty Possible complications after medium and deep chemical peels While medium chemical peels provide excellent results, there are a number of complications that can occur after their application. Careful selection of patients, the correct choice of peel, preliminary preparation of the skin and careful observation of the end points of the procedure reduce the incidence of complications.

Erythema after midline chemical peels – This is normal and should resolve within 3-4 weeks. In some cases, the redness may linger for a longer time, indicating contact sensitization existing before the procedure for skin disease (rosacea/eczema) or spontaneous penetration of the peel deeper than expected.

Scarring after median chemical peels is rare, but it can appear several months after the procedure. This complication can be identified by areas of intense and prolonged erythema and induration. In this case, early and appropriate treatment with topical steroids can give good results.

Herpetic lesions in
    patients with a history of this disease are quite common. Therefore, it is necessary to carefully study the patient's history before the procedure and prescribe prophylactic antiviral therapy to patients at risk. Some practitioners prescribe antiviral drugs to all patients undergoing chemical peels.
  1. Infections after median chemical peels develop infrequently, and in this case, their early identification in the recovery period is very important. Indicators of infection may be: more pronounced than expected, erythema, pustules, pain.
  2. Careful selection of patients, correct choice of peel, preliminary preparation of the skin and careful observation of the endpoints of the procedure reduce the incidence of complications.
  3. Permanent hypopigmentation – a complication that most often occurs in owners of dark skin types after deep peels. This phenomenon may be associated with other complications, such as infection during the recovery period.
Post-inflammatory hyperpigmentation, like hypopigmentation, occurs more often after deep peels and in patients with pre-existing pigmentation disorders. This risk can be reduced by properly preparing the skin for the procedure and, if such a complication occurs, hydroquinone 4% is applied to the skin.

The doctor should identify risk factors associated with complications in a timely manner and refuse to perform peels on patients in case of:
  1. tobacco smoking;
  2. poorly controlled diabetes;

weakened immunity;

    recent skin lift;
  • laser skin resurfacing;
  • history of recent or existing herpes simplex virus infections;
  • History of hypertrophic and/or keloid scars.
  • Using isotretinoin 6-12 months prior to peels is associated with an increased likelihood of scarring.
  • Medium and deep chemical peels: choice of ingredients
  • The first step in choosing a rejuvenation treatment for a particular patient is a consultation, during which an assessment is made of the degree of photoaging and the desired results. For this, two scales are used: the Glogau scale for assessing the degree of photoaging and the Fitzpatrick classification of skin types.
Glogau Scale – indicator of the degree of damage, by which you can determine the correct type of peeling. For example, for types II and III, medium peeling is suitable; for types III and V – deep peeling.

The Fitzpatrick classification

of skin is based on skin color and response to solar radiation, which is a good indicator of melanocyte behavior and a predictor of post-inflammatory hyperpigmentation, hypopigmentation, and scarring. Darker skin types are more prone to these complications, so peels should be done with extreme caution.

The patient's history is also of great importance as there are a number of contraindications that make deeper peels impossible, such as liver and kidney dysfunction, history of scarring, previous surgery or radiation therapy. Due to the cardiotoxicity associated with phenol peels, a detailed history of cardiac disease should also be obtained.

Read also:

Pathophysiology of chemical peels: from superficial to deep

The patient should also be explained how important pre- and post-procedure care is to get the best results from peels.

The patient should also be informed about the safety and efficacy profile of medium and deep peels. Thus, phenol peels provide more pronounced results than median peels, but at the same time they are associated with more risks.

Adapted from Aesthetics.

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