TITLE: Facial Chemical Peels
SOURCE: Grand Rounds Presentation, UTMB, Dept. of Otolaryngology
DATE: March 18, 2007
RESIDENT PHYSICIAN: Jean Paul Font, MD
FACULTY PHYSICIAN: David C. Teller, MD
SERIES EDITORS: Francis B. Quinn, Jr., MD and Matthew W. Ryan, MD
"This
material was prepared by resident physicians in partial fulfillment of
educational requirements established for the Postgraduate Training Program =
of
the UTMB Department of Otolaryngology/Head and Neck Surgery and was not
intended for clinical use in its present form. It was prepared for the purp=
ose
of stimulating group discussion in a conference setting. No warranties,
either express or implied, are made with respect to its accuracy, completen=
ess,
or timeliness. The material does not necessarily reflect the current or past
opinions of members of the UTMB faculty and should not be used for purposes=
of
diagnosis or treatment without consulting appropriate literature sources and
informed professional opinion."
Intro=
duction
C= onventionally aging is defined as the process of becoming older. This traditional definit= ion was recently challenged in the new Handbook of the Biology of Aging (Academic Press, 2006), as the process of system's deterioration with time.= This definition allows for existence of non-ageing systems (when "old is as good as new"), and anti-ageing interventions (when accumulated damage = is repaired). Certainly, facial skin deteriorati= on is one of the most apparent examples of aging. For this reason combined with t= he social perception of youthfulness as a measure of outer beauty, it is not a= surprise that people are seeking more avenues for anti-ageing interventions. This demand has prompted tremendous growth in the cosmetic industry, with numerous over-the-counter products av= ailable to "reverse aging changes.”
Whether to reverse the signs of aging or to trea= t cutaneous lesions, ablative skin resurfacing is an in= tegral part of the practice of facial plastic surgery and dermatology. Chemical peeling is a technique that removes superficial lesions and improves the texture of skin by the application of a chemical exfol= iant. Peeling produces a controlled, partial-thickness chemical burn of the epide= rmis and the outer dermis. Regeneration of peeled skin from follicular and eccrine duct epithelium results in a fresh, orderly, organized epidermis. In the dermis, a new 2- to 3-mm band of dense, compact, orderly collagen is formed between the epidermis and the underlying damaged dermis, which results in effective ablation of the fine wrinkles in the skin and a reduction of pigmentation. These clinical and histological changes are long-lasting (15 to 20 years) and may be permanent for some patients.
Histology
The histological changes of the aging skin are t= ypical of actinic changes which are the photochemical effects of solar radiation exposure. These changes include a loss of orderly differentiation in the epidermis and degeneration of the elastic network, along with some mottled pigmentation and lymphocytic infiltration. Ther= e is a decrease in collagen as well as disordered degeneration of the dermal fiber= s, a flattening of the dermal-epidermal junction, and multiple actinic keratoses with atypia see= n. The number of melanocytes was increased in this act= inic skin, but they were unevenly distributed and contained variable amounts of melanin.
After a
chemical peel, the skin regenerates, from follicular and eccrine
duct epithelium results in a fresh, orderly, organized epidermis. There is =
a formation
of new bands of dermis 2- to 3-mm-thick just beneath the epidermis and lyin=
g on
top of the old elastotic dermis. The epidermis =
had
returned to orderly cellular differentiation without irregularities or
microscopic actinic keratoses. The melanocytes present contain fine, evenly distributed
melanin granules, there appeared to be impaired melanin synthesis with a
generalized bleaching effect, or hypopigmentation. Lentigines are not seen. Thin, compact, parallel coll=
agen
bundles and elastic fibers are arranged horizontally along the epidermal-de=
rmal
matrix. There is decrease
Kligman concluded th= at chemical peel reduced the development of new neoplasms= . This observation has been confirmed on further research by Litton concluding that the rate of appearance with precancerous and early cancerous lesions o= f photoaged skin was decreased after a phenol chemical = peel.
PATIENT EVALUATION
Not every patient is a good candidate for chemic= al peels. There are two classification systems that help the physician assess whether= the individual patient as a good candidate for a chemical peel and strength of = peel achieve the desire results with the least risk and complications. The clini= cian must take into account the patient's underlying skin type and the amount of= photodamage present. Fitzpatrick classifie= d the skin types and acute solar radiation response from type I to type VI. The <= span class=3DSpellE>Glogau classification system provides an objective assessment of the degree of photoaging, categor= izing the patient's skin damage into mild, moderate, advanced, or severe (groups I–IV). "The ideal patient is a thin-skinned female with fair complexion and fine rhytids."
Patients with Fitzpatrick skin type I and type I= I are generally good candidates for chemical peels. Patients with Fitzpatrick skin type III and greater are at an increased risk for post= procedure pigmentary complications.
= FITZPATRICK SUN-REACTIVE SKIN TYPES I TO VI <= o:p>
|
Type |
Color |
Tanning response=
|
|
Type I |
White |
Always burns, never tans |
|
Type II |
White |
Usually burns, tans less than average |
|
Type III |
White |
Sometimes burns mildly, tans about average |
|
Type IV |
Brown |
Rarely burns, tans more than average and with ease |
|
Type V |
Dark brown |
Very rarely burns, tans very easily |
|
Type VI |
Black |
Never burns, tans very easily |
In the Glogau classi= fication, patients in category I are often young with minimal ph= otoaging and are best managed with a superficial peel in conjunction with a good med= ical skin care program. Patients in category II or III are candidates for medium-depth peels in addition to long-term medical therapy as with retinoids or alpha-hydroxy acids. Category IV photoaging patients are best treate= d with medium or deep chemical peels, ablative lasers, or der= mabrasion, in conjunction with long-term medical skin care regimens.
|
Glogau classification=
of photoaging groups |
|||
| Group |
Classification<= o:p> |
Typical age (y)=
|
Skin characteri=
stics |
|
I |
Mild |
28–35 |
Little wrinkling or scarring and no ker=
atoses |
|
II |
Moderate |
35–50 |
Early wrinkling, mild scarring, and sallow color with early
actinic keratoses |
|
III |
Advanced |
50–65 |
Persistent wrinkling, discoloration with telangectasias
and actinic keratoses |
|
IV |
Severe |
60–75 |
Wrinkling—superficial to deep actinic keratoses
± skin cancer |
The indications for facial resurfacing are divid=
ed
into aesthetic indications and therapeutic indications. The aesthetic
indications include fine facial rhytids, atroph=
ic
changes in skin caused by excessive sun exposure, spotty or splotchy hyperpigmentation, chataigne skin
(sailor's or farmer's skin), multiple actinic and solar keratoses,
superficial acne scarring, melasma, excessively
wrinkles skin and after blepharoplasty or face-=
lift.
The therapeutic indications include multiple actinic, =
seborrheic,
and solar pigmented keratoses, Superficial
basal cell carcinomas, lentigo maligna
lentigines and Melasma
(discoloration of skin caused by pregnancy).
CONTRAINDICATIONS
Telangiectasias are = relative contraindications in that they become more apparent after chemical peels. Confirmed malignant lesions should not be treated with chemical peels unless they are very superficial basal cell carcinomas. Nevoid or nevus lesions may become darker or actually stimulated to grow, and port-wine stains, hemangiomas, and neurofibromatos= es are not effectively treated with chemical peels. Contraindications include = the presence of hepatorenal disease or cardiac dise= ase (for phenol peels), unless approved by an appropriate specialist. Patients = who are unstable psychologically should not be treated with any resurfacing modality, particularly because the postoperative care may require intense patient involvement, education, and understanding (Cummings 2005).
Absolute Contraindications
Patients who are unwilling to wear makeup to cov= er postoperative hypopigmentation are not good can= didates for this procedure. Those patients who are unwilling to decrease their sun exposure are likewise poor candidat= es for chemical peel, because the procedure does in fact reduce their melanin protection.
If a phenol chemical peel is to be used, special= attention must be given to cardiac, liver, and kidney function in the preoperative medical workup. Any impairment of liver or kidney function could slow the excretion of phenol, potentially increasing the bloodstream concentration a= nd leading to cardiac irregularities or even death.
Patient Preparation
Positive history of herpetic outbreaks should wa=
rrant
appropriate prophylaxis. In patients with no preceding history of fever
blisters who are undergoing a medium or deep peel, Val=
trex
is an appropriate prophylaxis at 500 mg
Before undergoing any ablative resurfacing proce= dure, the patient's skin needs to be prepared properly. Vitamin A derivative ther= apy (a retinoid or tazarotene) are given for at lea= st 4 weeks before the procedure. These product speeds epidermal healing and enhances t= he effects of the procedure and increases the depth of a chemical peel by decreasing the thickness of the stratum corneum. Patients are warned to avoid unprotected sun exposure for at least 2 months before and after the procedure.
Superficial Peels
Destruction of the epidermis defines a full superficial chemical peel inducing the regeneration of the epidermis. Super= ficial peels with TCA (10% to 25%) and many other agents improve pigmentary irregularities and may improve some minor surface changes and impart a fres= her appearance to facial skin.
Superficial peels usually cause mild erythema and desquamation, with a healing time varyin= g from 1 to 4 days, depending on the strength of the chemical agent. These agents include low concentrations of glycolic acid; 10% to 20% TCA; Jessner's solution (resorcinol, 14 g; salicylic acid,= 14 g; lactic acid, 14 mL; ethanol, 100 mL); tretinoin; 5-fluorouracil (5-FU); and salicylic= acid, a beta-hydroxy acid. Glycolic acid (50% to 70%) produces superficial peels that remove actinic keratos= es, fine wrinkles, lentigines, melasma, and seborrheic keratoses. As with other peels, the depth of penetration can be titrated by the timed duration of the application of the acid. Peels are left on the skin for 3 t= o 7 minutes and can be repeated 3 to 4 times. During application, there may be a mild stinging followed by a level I frosting, defined as the appearance of = erythema and streaky whitening on the surface. Regular washing with a mild cleanser and the use of routine moisturizers and sunscr= eens is all that is needed after the procedure. Glycolic acid can be used to peel skin of all skin types with minimal risk.=
Medium Peel
Medium-depth peels offer results that even repea=
ted
superficial peels cannot match. Necrosis of the epidermis and induction of
inflammation within the papillary dermis constitutes a medium-depth peel. I=
t is
most useful for the removal of epidermal or superficial lesions and the
improvement of skin texture in moderate photodamaged
skin (grade II Glogau phot=
oaging
skin). The procedure is performed to remove actinic ke=
ratoses,
repair mild photoaging of the skin including
Trichloracetic acid = (TCA) has been the gold standard in quantitating chem= ical peel strength and depth. TCA is naturally found in crystalline form and is mixed weight-by-volume with distilled water. It is not light sensitive, does not need refrigeration, and is stable on the shelf for more than 6 months. = In the past concentrations of TCA approaching 50% or higher were used to achie= ve injury to the superficial dermis. This concentration of TCA, though, has be= en found unreliable and associated with a higher incidence of pigmentary dyschromia, textural change, and even scarring.=
In an =
attempt
to reduce the morbidity of higher-concentration TCA, a combination of produ=
cts
has been devised that improves the absorption of the lower concentration of=
trichloracetic acid without the associated complicati=
ons. The
most common agents include a combination of 35% TCA with Jessner's
solution, 70% glycolic acid, or carbon dioxide (CO2) laser. Phen=
ol
88% by itself will give a medium-depth peel.
Brody first developed the use of solid CO
The procedure is usually performed with mild preoperative sedation and nonsteroidal anti-inflammatory agents. The patient is told that the peeling agent will s= ting and burn temporarily, and aspirin is given befor= e the peel and continued through the first 24 hours if the patient can tolerate t= he medication. Its inflammatory effect is especially helpful in reducing swell= ing and relieving pain. For full-face peels, though, it is useful to give preoperative sedation (diazepam 5–10 mg orally) and mild analgesia, <= span class=3DSpellE>meperidine 25–50 mg and hy= droxyzine hydrochloride 25 mg intramuscularly. The discomfort from this peel is not l= ong lasting, so short-acting sedatives and analgesics are all that are necessar= y. A fan to cool the patient is also helpful.
Vigorous cleaning and degreasing are necessary f= or even penetration of the solution. The face is scrubbed gently with Septisol soaked gauze pads and water, then rinsed and dried. Next, an acetone preparation is applied to remove residual oils and debris. The skin is essentially debrided of str= atum corneum and excessive scale. A thorough degreasing is necessary for an even penetrant peel. The physi= cian should feel the dry, clean skin to check the thoroughness of degreasing. If= oil is felt, degreasing should be repeated. A splotchy peel is usually the resu= lt of uneven penetration of peel solution because of residual oil or stratum <= span class=3DSpellE>corneum and a result of inadequate degreasing.
Jessner’s solu= tion is applied with a painless white fine frosting resulting. On application, a faint frosting w= ill appear within 1 minute within a background of mild ery= thema. Even strokes are used to apply the solution to the unit area, covering the forehead to the cheeks to the nose and chin. The eyelids are treated last, creating the same erythema with blotchy frostin= g. After the Jessner's solution has dried, the TCA is ap= plied. The TCA is painted evenly with one to four cotton-tipped applicators that c= an be applied over different areas with light or heavier doses of the acid. Th= e perioral area and eyelids are treated, coming within = 1 to 2 mm of the lower eyelid margin. An assistant should always be on standby with sterile eye wash for irrigation in case the surgeon inadvertently spills any peel solution into the eye. It is important to note that the amount of TCA delivered to the skin surface is dependent on the number of applications, t= he degree of saturation, the amount of pressure applied to the skin, and conta= ct time with the peel solution. The cotton-tipped applicator is useful in quantitating the amount of peel solution to be applie= d. The white frost from the TCA application appears complete on the treated area within 30 seconds to 2 minutes. Even application should eliminate the need = to go over areas a second or a third time, but if frosting is incomplete or uneven, the solution should be reapplied. Before re-treating an area, howev= er, one should wait at least 3 to 4 minutes to ensure that the frosting has rea= ched its peak before determining for asymmetry.
The physician should achieve a level II to level= III frosting. Level I frosting is erythema with a stringy or blotchy frosting, seen with light chemical peels. Level II frosting is defined as white-coated frosting with eryt= hema showing through. A level III frosting, which is associated with penetration through the papillary dermis, is a solid white enamel frosting with little = or no background of erythema. A deeper level III frosting should be restricted only to areas of heavy actinic damage and thi= cker skin. Sensitive areas such as thin eyelid skin and bony prominences (which = have a high propensity for scarring) should be limited to a level II frosting. A solid white enamel frosting without an erythematous background indicates injury to the reticular dermis and is too deep for a medium peel.
Anatomic areas of the face are peeled sequential= ly from forehead to temple to cheeks and finally to the lips and eyelids. The white frosting indicates keratocoagulation or p= rotein denaturation of keratin, and at that point the reaction is complete.
Eyelid skin must be treated delicately and caref= ully. A semidry applicator should be used to carry the solution to the level of t= he superior aspect of the tarsus on the upper lid and to 2-3 mm from the lash = line on the lower lid. The patient should be positioned with the head elevated a= t 30 degrees and the eyelids closed. Excess peel solution on the cotton tip shou= ld be drained gently on the bottom before application.
An immediate burning sensation is felt with the application of the TCA peel, but this begins to dissipate with the onset of frosting and is typically resolved by the time of discharge. Cool saline compresses are placed over the face for 5 to 6 minutes after the peel until= the patient is comfortable. On completion of the peel, a brawny, dusky erythema will progress over the first 12 hours. For t= he first 24 hours, the patient is instructed to soak four times a day with a 0= .25% acetic acid compress made of 1 tablespoon white vinegar in 1 pint of warm water. A bland emollient is applied to the desquamating areas after soaks. After 24 hours, the patient can shower and clean gently with a mild nondetergent cleanser. Mild to moderate edema soon fo= llows and can be severe over the thin eyelid skin and forehead regions. As the ed= ema begins to resolve, dark crusts appear that peel off during the subsequent 5= to 7 days to reveal a new, erythematous epithelium= . The redness will soon fade to a pink color that resembles a sunburn and can typically be camouflaged with makeup by the 10th day after the peel. The patient can begin using sunscreens as tolerated. He or = she should wait at least 3 months before resuming regular aesthetic skin care services such as superficial chemical peels or microde= rmabrasion. Cleansing facials can begin as early as 4 to 6 weeks after the peel. Repeat medium-depth chemical peel should not be performed for at least 1 year. Sev= eral studies have demonstrated microscopic improvement of collagen thickness progressing over a 6- to 13-month period.
Deep Chemical Peel =
The more advanced changes seen with deeper groov= es and wrinkles, pebbly appearance of the skin, and more pronounced gravitational changes of Glogau III and IV photoaging skin require either deep chemical peeling or laser resurfacing. Deep peels = are usually performed using the Baker-Gordon solution. This preparation includes phenol, = water, Septisol, and croton oil. Septisol acts as a surfactant which results in more even penetration. Croton oil is a vesicant epidermolytic agent that enhances the absorption of p= henol (phenol applied alone results in only a medium-depth injury). This depth can also be achieved with a 50% or greater TCA peel; however, the high risk of scarring and pigmentation problems have resulted in a trend away from these concentrations.
Phenol itself at concentrations greater than 80%, carbolic acid is a keratocoagulant precipitatin= g the surface protein, thus preventing further penetration of the peel solution. Phenol produces an extremely rapid denaturization and irreversible coagulation. Further penetration of the phenol is prevented wh= en the keratin protein binds to the phenol, creating large molecules that cann= ot penetrate further. Concentrations of phenol less than 50%, it becomes keratolytic, interrupting sulfur bridges in the kerat= in layer, and can then produce deeper penetration and more destruction than desired. Therefore, as one decreases the concentration of phenol, the depth= and therefore wounding of tissue becomes more severe. Occlusion of the peeling solution with tape increases its penetration, creating injury to the mid-re= ticular dermis. The unoccluded technique involves more = cleansing of the skin and the application of more peel solution.
Preoperative antibiotics such as cephalexin
(Keflex) (500 mg bid) are started 24 hours befo=
re the
procedure and continued for 1 week. Patients are offered a sedative to help
them sleep the night before the procedure. Patients are given 5 mg of diaze=
pam
(Valium)
Facial subunits are addressed one at a time with 15-minute time interval between units.&nbs= p; This is done to avoid buildup of phenol to toxic levels in the blood= . One needs to obtain a white frost that is carried 2 to 3 mm across the vermilion border. When treating the lower eyelid, it is important to use a semidry applicator rolled once across the skin. The lower eyelids need to be treate= d to within 1 to 2 mm of the ciliary margin. On the = upper eyelid, one must be very judicious about treating below the supratarsal fold, and most surgeons do not breach this boundary.
Erythema may take mo= nths to resolve. Pigmentary changes and scarring are also more frequently seen with deep peels. The skin continues to improve over several months as collagen remodeling takes place. A remarkable degree of improvement= is to be expected.
Phenol is rapidly absorbed into the circulation = and may cause cardiac arrhythmias. Phenol, the active agent, is known to have cardiac toxicity and has hepatic and renal elimination. These effects necessitate a more in-depth workup and usually include a monitored setting for the application= . An anesthetist or anesthesiologist= is required to administer sedation and analgesia while monitoring the patient’s cardiac status, pulse-oximetry,= and blood pressure. Any patient who has a history of cardiac arrhythmias or is taking medications that are potentially arrhythmia precipitating may not be= a good candidate for Baker's phenol peeling. Additionally, patients with poor renal or hepatic function are poor candidates. To preve= nt toxicity, volume loading with intravenous fluids before, during, and after phenol peeling. Botta recommend maintain= ing a fluid load to force diuresis with 20 mg of furosemide given 10 minutes before the application of phenol. Waiting as much as 20 to 30 minutes between treatment of each area = and not peeling more than 50% of the face at one time minimizes the risk of phe= nol toxicity in most patients.
Postoperative Care
The patient is given 10 mg of dexamethasone IV intraoperatively and me= thylprednisolone postoperatively to reduce swelling. The patient is asked to return to the office on the third postoperative day to assure the physician that the woun= d is being cleaned as instructed. The patient is then again evaluated in 3 to 4 = days to observe the amount of wound healing and residual crusting. After 7 to 10 days, the patient can begin to apply makeup if epithel= ialization is complete. The use of sunscreens and sun avoidance is critically importan= t. Sunscreen with an SPF of 30 or greater is advised. The patient is not allow= ed any direct sun exposure for 6 weeks and is told to minimize sun exposure fo= r up to 6 months. To reduce the possibility of hyperpigment= ation, estrogens should be withheld 4 weeks before the peel and for at least 6 to 8 weeks postoperatively. As the erythema is fadin= g, pigmentation abnormalities are possible, and estrogen may increase the risk= of this abnormality. The patient returns for an office visit at 2 weeks and ag= ain 6 weeks later for evaluation of the early development of splotchy hyperpigmentation. If splotchy pigmentation develops,= a combination of Retin A, hydroquinone (Eldoquin Forte), and triamcinolo= ne (Aristocort) may provide an improvement. The pa= tient is seen again at the 3-month, 6-month, and 1-year period postoperatively.
Complications
Pigmentation changes are = by far the most common sequela seen with chemical peel= s. Pigmentary changes include hyper= pigmentation, hypopigmentation and depig= mentation. The most common is Hypopigmentation. Persistence of rhytids, prolonged eryt= hema, persistent texture change of skin, hypertrophic= subepidermal healing, milia, skin pore prominence, increased prominence of telangiectasias, and darkening and growth of preexist= ing nevi are other well known sequela of Chemical p= eel.
Complications
of chemical peels include=
skin infection, lower ey=
elid ectropion,
cardiac arrhythmias, r=
enal
failure, toxic shock syndrome, and facial scarring.
References
Deb= orshi R. Ablative Facial Resurfacing Dermatologic Clinics. = 23(3), July 2005
Gary D. M. MEDIUM-DEP=
TH
CHEMICAL PEELS. Dermatologic Clinics.
19(3), July 2001
Langsdon, P. Com= parison of the Laser and Phenol Chemical Peel in Facial Skin Resurfacing.
Brody HJ. Chemical Peeli=
ng.
Brody HJ: Chemic=
al
Peeling and Resurfacing.
Monheit GD: Advances in chemical peeling. Facial Plast Surg Clin
North Am 2:5–9, 1994
Monheit GD: The Jessner's-TCA pe=
el.
Facial Plast Surg <=
span
class=3DSpellE>Clin North Am 2:21–22, 1994
Monheit GD,
Rubin M: Manual =
of
Chemical Peels.
Stegman SJ: A comparative histologic
study of the effects of three peeling agents and derma=
brasion
on normal and sundamaged skin. Aesthetic Plast Surg 6:123–13=
5, 1982
Cummings: MANAGEMENT OF AGING SKIN. Otolaryngology: Head &a= mp; Neck Surgery, 4th ed, 2005. Chapter 29
Tse Y, Ostad A, Lee HS, et al. A Clinical and histologic evaluation of two medium-depth peels: glyc= olic acid versus Jessner's tric= hloroacetic acid. Dermatol Surg= . 1996;22:781-786
Kligman A.M= . Long-term histologic follow-up of phenol face p= eel. Plast Reconstr = Surg (1985) 75 : pp 65= 2-659
Halaas YP Medium Depth
Peels, Facial Plastic Surgery Clinics of