The purpose of chemical peels – predictable skin damage and its accelerated exfoliation – achieved through targeted exposure to chemicals of a certain concentration. Cytokines and inflammatory mediators, which are produced in the skin in response to damage, provide an increase in the thickness of the epidermis and the volume of the dermis, mainly due to the active production of collagen.
Depth of penetration and degree of skin damage – factors on which the classification of chemical peels is based: superficial, medial and deep. In this article, Dr. Raul Cetto (Raul Cetto) spoke about the features of the use of median chemical peels.
Medium peels: mechanism of action and indications
Medium peeling affects the papillary and upper reticular dermis, located at a depth of approximately 0.45 mm.
Predictable and controllable damage to the skin by medium peels is achieved through the use of:
Trichloroacetic acid at a concentration of 35-50%
Can be used to correct signs of photoaging, in particular:
• actinic keratosis;
• pigmentation;
• fine wrinkles;
• Wrinkles of medium depth in the perioral region.
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TCA is not suitable for loose skin or deep expression lines – deep peels are better suited for this. TCA denatures the protein, which in turn leads to keratocoagulation and death of keratinocytes. As the skin re-epithelializes, collagenesis occurs and damaged keratinocytes are replaced with new healthy cells.
TCA concentration also determines the depth of exposure. For example, trichloroacetic acid 15-20% acts only at the level of the epidermis, while at a concentration of 45% it penetrates into the upper reticular layer of the dermis.
The light touch of TCA: the possibility of peeling without side effects
An alternative to using higher concentrations of TCA may be multiple treatments using a lower concentration of acid (for example, the same results can be obtained after 1 peel of 45% TCA and after 2 peels of 20% TCA with an interval of 6 weeks).
Medium peeling affects the papillary and upper reticular dermis, located at a depth of approximately 0.45 mm.
To improve the penetration of the peel, a preliminary course of retinoids or hydroquinone is recommended. TCA also improves penetration:
• degreasing the skin with an alcohol solution;
• application of 0.025-0.05% retinoic acid immediately before TCA.
The best results can be achieved when working with phototype II skin with signs of photoaging; although trichloroacetic acid is also effective for skin phototypes III and IV. Trichloroacetic acid does not penetrate into the bloodstream, and therefore is safe for patients with heart, liver and kidney diseases.
35% TCA + Jessner Peel
As part of Jessner Peel – resorcinol, salicylic and lactic acids, as well as ethanol. Jessner peeling disrupts the function of the epidermal barrier, destroying the desmosomes between keratinocytes. Due to this, the TCA solution (35%) penetrates the epidermis better.
This combination provides clinical improvement in:
• photoaging;
• actinic keratosis;
• wrinkles.
35% TCA + dry ice
The positive results of the combined use of TCA and dry ice were obtained in 1986. Although this combination was more effective in treating post-acne than TCA and Jessner Peel, the authors of the study (Brody and Haily) noted that it can destroy melanocytes located outside the epidermis and therefore lead to hypopigmentation, especially in patients with dark skin. skin.
It has also been noted that the inability to control the depth of penetration of the solution can cause complications. The reason for this is that the depth of action of dry ice depends on how hard it is applied to the skin – indicator that is difficult to measure and standardize.
35% TCA + 30–70% Glycolic Acid
Glycolic acid peels penetrate the skin easily and have anti-inflammatory, keratolytic and antioxidant effects. Glycolic acid is applied before TCA. You can adjust the strength of the peeling effect by changing the concentration of glycolic acid (30 & ndash; 70%). Patients generally tolerate glycolic acid peels better than Jessner peels due to less exfoliation after the procedure.
Possible complications of median peels and their elimination
Chemical peels can lead to a number of complications. Some of them are easily removed. In general, median peels tend to have fewer and fewer complications than deep peels. When using median peels, there is no risk of systemic complications.
Pigmentation changes
Reactive hyperpigmentation can occur after any chemical peel. As a general rule, patients with lighter skin have a lower risk of hyperpigmentation.
You can reduce the degree of hyperpigmentation by pre-preparing the skin: apply creams with hydroquinone and retinol to the skin a few weeks before the mid-peel.
What can a chemical peel do in skincare
Hypopigmentation is common in darker skin types and skin exposed to the sun after peeling.
Infections
Bacterial and fungal infections are rare after chemical peels. Patients with a history of herpes simplex infection should receive a prophylactic course of antiviral drugs (acyclovir or valaciclovir) during peeling and until complete re-epithelialization.
Toxic shock syndrome has been reported after chemical peels, so patients should be informed about the symptoms of this complication.
Scarring
Factors that influence the likelihood of scarring after peels are not yet fully understood. However, scarring may be preceded by slow healing and persistent erythema. Topical steroids are used to treat this complication, but they cannot prevent scarring. The most frequent localization of post-peeling scars – lower face.
Miliums
Milia after chemical peels (more often after deep peels) appear in about 20% of patients, as a rule, in the period from 8 to 16 weeks after the procedure. Milia can persist for a long time and even forever. If the complication does not resolve on its own, after re-epithelialization, epidermabrasion, soft extraction or electrodissection can be performed.
Recovery period after median peeling is 5 – 10 days.
Acneform dermatitis
This complication often occurs immediately after re-epithelialization. It may be associated with an exacerbation of acne or with the excessive use of fatty preparations. Therapy – systemic antibiotics and avoidance of fatty foods.
Phenol Facial Peel: Risks and Warnings
Absolute contraindications for medium peels
Absolute contraindications to the use of medium peels include:
• active and recent bacterial, viral, fungal or herpes infections;
• open wounds;
• taking photosensitizing drugs (such as oral contraceptives, isotretinoin) within the previous 12 months;
• inflammatory dermatoses (psoriasis, atopic dermatitis, pemphigus);
• melanoma of the skin on the face.
Medium and deep peels are not recommended for patients with a history of abnormal scarring.
The selection of the peel that is most appropriate for a particular patient depends on the skin type, medical history, cosmetic concerns, and the patient's expectations. It is important to remember that proper consultation is essential for the best results from medial peels.
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