Transcript Chemical peeling is the application of one or more exfoliating

‫بسم هللا الرحمن الرحیم‬
‫موضوع باز آموزی ‪ :‬پیلینگ شیمیائی‬
‫دکتر رسول توکلی کیا‬
‫مرکز تحقیقات پوست و سالک‬
‫شانزدهم اردیبهشت نود و دو‬
Chemical peel
• Aims:
• Understand the different depths achieved by the
various agents used in chemical peeling.
• Learn the indications for various chemical peels.
• Understand factors in patient selection.
• Learn the techniques involved for predictable
outcomes with a variety of chemical peels
• Learn how to identify and treat potential
complications.
• Chemical peeling is a popular, relatively inexpensive, and
generally safe method for treatment of some skin disorders
and to refresh and rejuvenate skin.
• Peels can be combined with other in-office facial resurfacing
techniques to optimize outcomes and enhance patient
satisfaction and allow clinicians to tailor the treatment to
individual patient needs .
• Successful outcomes are based on a careful patient selection as
well as appropriate use of specific peeling agents.
• Used properly, the chemical peel has the potential to be an
important therapeutic tool for dermatologist
• The American Society of Plastic Surgery reported that more
than one million peel procedures were performed by its
members in 2008.
• Chemical peels are very common in clinical practice.
• Creates a controlled wound
Classificatiion of chemical peel
• Chemical peels are classified by the depth of
action into
• superficial,
• medium,
• deep peels.
• The depth of the peel is correlated with clinical
changes, with the greatest change achieved by
deep peels.
• However, the depth is also associated with longer
healing times and the potential for complications
Classificatiion of chemical peel
Classificatiion of chemical peel
• Superficial peels, penetrating only the epidermis, can
be used to enhance treatment for a variety of
conditions, including acne, melasma,dyschromias,
photodamage, and actinic keratoses.
• Medium-depth peels,penetrating to the papillary
dermis, may be used for dyschromia, multiple solar
keratoses, superficial scars and pigmentary disorders.
• Deep peels, affecting reticular dermis, may be used
for severe photoaging, deep wrinkles, or scars.
Superficial peels
• Superficial peels affect the epidermis and dermalepidermal interface.
• They are useful in the treatment of mild dyschromias,
acne, postinflammatory pigmentation, and AKs and
help in achieving skin radiance and luminosity
• Because of their superficial action, superficial peels can
be used in nearly all skin types.
• After a superficial peel, epidermal regeneration can be
expected within 3 to 5 days, and desquamation is
usually well accepted.
• Superficial peels exert their actions by decreasing
corneocyte adhesion and increasing dermalcollagen.
• These peels are a good method for rejuvenating the
epidermis and upper dermal layers of skin.
Medium-depth
• Medium-depth peels may be used in the treatment
of dyschromias, such as solar lentigines, multiple
keratoses, superficial scars, pigmentary disorders,
and textural changes.
• The healing process is longer, with full
epithelialization occurring in about one week.
• Sun protection after a medium-depth peel is
recommended for several weeks.
• Because of the risk of prolonged hyperpigmentation,
medium-depth peels should be conducted with
caution in patients with dark skin.
Deep peels
• Deep peels may be used for severe photoaging, deep or coarse wrinkles,
scars, and sometimes precancerous skin lesions.
• Usually performed with phenol in combination with croton oil
• Deep peels cause rapid denaturization of surface keratin and other proteins
in the dermis and outer dermis and penetrate the reticular dermis, so deep
peel maximizes the regeneration of new collagen.
• Epithelialization occurs in 5 to 10 days, but deep peels require significant
healing time usually two months or more and sun protection must always be
used.
• Phenol is rapidly absorbed into the circulation, potentiating cardiotoxicity in
the form of arrhythmias.
• Therefore, special care, such as cardiopulmonary monitoring and
intravenous hydration, must be provided to address this concern.
• Due to the increased risk of prolonged or permanent pigmentary changes,
deep peels are not recommended for most darkskinned individuals.
Wound healing
Chemical peeling is the application of one
or more exfoliating agents to the skin, to
produce controlled partial-thickness
ablation
Chemical peels creates a controlled wound
Post-Peel, Immediate
Post-Peel, 72 hrs
Post-Peel, Complete
Wound healing
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In general, before the 20th century, it was believed that wounds
healed best when left open (to allow them to breathe) and dry (to
keep them ‘germ free’) as advocated by Pasteur.
This view began to change in 1958 when Odland observed that a
blister healed faster when left unbroken.
Winter’s landmark study on swine in 1962 showed that superficial
wounds kept moist by covering them with a film healed twice as
fast as those exposed to the air
Hinman and Maibach repeated Winter’s study in humans and
found a similar increase in epithelialization rate for occluded
wounds
These studies revolutionized the approach to wound care by
demonstrating the importance of moist wound healing
Acute wounds
• Acute wounds are wounds with no underlying
healing defect that heal in an orderly and timely
fashion, passing through well-defined phases of an
inflammatory response, granulation tissue
formation, and remodeling.6
• In acute wounds, the function of dressings in
maintaining a moist environment is critical in
facilitating healing.
• In fact, acute wounds have been shown to heal 40%
faster in a moist environment than when air exposed
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Tretinoen
α-Hydroxy acids
Sunscreens
Hydroquinone
Antiviral prophylaxis
Photography
Effects of a moist environment and
occlusion on wound healing
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Enhancement of epithelial migration
Stimulation of angiogenesis
Retention of growth factors
Facilitation of autolytic debridement
Protection against exogenous organisms
Maintenance of voltage gradient
Protection against exogenous
organisms
• Although the bacterial count is higher in occlusive
dressings than non-occlusive dressings, this does not
predispose to infection.
• Overall infection rate is 2.6% for occlusive dressings
versus 7.1% for non-occlusive dressings.
• Occlusion is also associated with the presence of
higher levels of lysozymes and globulins.
• Lastly, occlusion maintains a mildly acidic pH,which is
inhibitory to the growth of some bacteria, especially
Pseudomonas and Staphylococcus spp.14
• It is misleading to classify chemical peeling
solutions as light or deep solutions based on
their concentrations since there are many
factors that affect peel depth.
• Acid concentration, the number of coats
applied, skin thickness, skin preconditioning,
and, in some cases, the duration of contact of
the acid on the skin are the main variables.
• Keratolytics are acids that disrupt the adhesion
between the keratinocytes, thus causing shedding of
these layers.
• The two main acids used for exfoliative procedures
are glycolic and salicylic acid.
• These are oftentimes referred to as lunchtime peels
as these exfoliative acids have the benefit of little to
no downtime for the patient; in addition, there is no
anesthesia requirement, and they are easy
Contraindications
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Contraindications include patients with
active bacterial, viral or fungal infection
tendency to keloid formation
facial dermatitis
taking photosensitizing medications
unrealistic expectations.
Glogau Classification
Preparing the skin for chemical peeling
• It is important to match the skin pathology to
the chemical agent.
• Preparation of the skin prior to chemical
peeling is extremely important.
• The skin-care program consists of patient
education regarding sun avoidance, the use of
effective sunscreen on a daily basis, and
pretreatment with tretinoin and or AHAs
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Pretreatment with tretinoin for
chemical peels
• Tretinoin improves skin texture and reduces fine
wrinkling and mottled hyperpigmentation.
• Topical tretinoin pretreatment accelerates wound
healing after medium-depth and deep-depth chemical
peels.
• In a double-blind, placebo-controlled, prospective,
randomized study, 16 males with actinically damaged
skin were treated daily with tretinoin 0.1% versus
placebo cream to the left and right sides of the face,,
and hands 14 days before a 35% TCA peel.Post-peel
healing was evaluated on days3, 5,7, 9,11,and14
Pretreatment with tretinoin for
chemical peels
• In 94% of patients, the sloughing
occurred earlier
and was more
uniform, regardless of body location,
in skin pretreated with tretinoin
than with placebo-treated skin.
• Maximal healing of the tretinoin-treated
facial skin was evident after 5 days
(68% vs 52%; P
<
0.005).
Pretreatment with tretinoin for
chemical peels
• The American Academy of Dermatology (AAD)
Guide lines Outcomes Committee
developed‘Guidelines of Care for Chemical Peeling’
in an effort to enhance quality of care for patients
having cosmetic
procedures.
• This AAD committee recommended tretinoin
pretreatment as preparation for skin that is
undergoing chemical peeling.
• The committee also recommended postoperative
tretinoin to enhance wound healing and to
maintain results.
Superficial peeling agents
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Trichloroacetic acid 10–25% (35%; one coat)
Jessner’s solution: resorcinol/salicylic
acid/lactic acid.
Modified Unna’s resorcinol paste.
Solid CO2 slush.
Salicylic acid.
AHAs.
Tretinoin solution.
Advantages of superficial peels
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Excellentsafety
record.
May be used on all Fitzpatrick skin types.
Rapid healing, minimal downtime.
Repeated peels provide cumulative effects.
Amplifies effects of topical rejuvenating agents.
Can be combined with laser modalities.
Affordable.
No anesthesia needed.
Jessner’s solution formula
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Resorcinol
Salicylic acid
Lactic acid
Ethanol 95%
14
14
14
qs
g
g
g
ad
100 mL1
Patient evaluation to optimize outcomes
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Physician–patient relationship.
Patient’s
realistic expectations.
Fitzpatrick skin
type.
Active infection.
Tobacco
use.
Medications:minocycline, isotretinoin.
History of herpes simplex virus infection
History of keloid formation
History of previous radiation exposure.
History of immunosuppression.
History of postinflammatory hyperpigmentation.
History of Recent facial surgery.
Limitations of superficial peels
• Little clinical effect with one peel.
• Multiple superficial peels do not provide the
same results as one mid-level or deep peel.
• Media has created unrealistic patient
expectations
• Minimal effect on medium to deep rhytides.
• Return to before-peel condition within 2 years
without topical agents.
Deep Chemical Peel
• Face is divided into six aesthetic
subunits
– Forehead, perioral region, bilateral
cheeks, nose, and periorbital region
– 15-minute time interval between
units
• White frost that is carried 2 to 3 mm
across the vermilion border
• Lower eyelids need to be treated to
within 1 to 2 mm of the ciliary
margin
• Upper eyelid above supratarsal fold
Medium Peel
• White frost appears complete on
the treated area within 30
seconds to 2 minutes
• Before re-treating an area one
should wait at least 3 to 4
minutes before determining for
asymmetry
• Eyelid skin and bony prominences
have a high propensity for
scarring (limited to a level II
frosting)
• An assistant standby with sterile
eye wash in case agent spills into
the eye