Beauty Tips For Body Care
Given that my previous research thread was well received, I thought I would provide another one on a topic that recently piqued my interest. In this brief literature review, I describe acne scarring, chemical peels, what chemical peels can be used for, and complications. Buckle up kids, it's a long ride.What is scarring?Minor acne scarring occurs in 95% of people who suffer from acne lesions, and major scarring can be seen in up to 22%. (1) Major scarring refers to areas where “normal” skin is replaced by fibrous tissue commonly known as “scar tissue." These differences in the skin are due to changes in the extracellular matrix of the skin – this is a gel-like tissue composed of water, collagen, and other proteins and sugars that supports and adheres the overlying skin. The extracellular matrix is altered in areas of wound healing which leads to a weaker tissue that is inferior to normal skin, but still serves to provide a protective barrier defense. The difference in texture is due to a change in the composition of proteins made by the skin. Scar tissue is nearly 80% type I collagen, whereas normal skin is mainly type III collagen with only a little bit of type I collagen. (1) Atrophic scars are depressed scarring that are classified as “ice pick,” “box car,” and “rolling” scars. (1) Atrophic scars arise due to an imbalance of matrix metalloproteinases (MMPs) (enzymes that break down collagen) and tissue inhibitors of MMPs – in other words, in those areas of scarring, collagen in the extracellular matrix is broken down more. (1) Superficial “minor” acne scarring (often called post-inflammatory hyperpigmentation) does not result in long-term changes to the extracellular matrix and thus the texture of the skin is not permanently altered, but there is an altered production of melanin due to inflammation.What are chemical peels?Chemical peels (along with other newer types of “laser peels” ie. Fraxel) work by causing a controlled injury to the skin that destroys the dermis (uppermost layer of the skin that peels off) and sometimes into the dermis (for medium or deep peels). (1) This promotes skin regeneration and tissue remodeling evenly over the surface area that is treated. (1) In active and healing acne, chemical peels can work by reducing sebum (oil) production, preventing new acne lesions from forming, exfoliation, and sometimes through anti-inflammatory and antibacterial effects depending on the solution used. (1)What types of peels are available and what are they used for? (1)Salicylic Acid (SA)Best for: active acne, mild acne scarringBenefits: reduces inflammatory and non-inflammatory acne lesions, lightens PIH, prevents new acne lesions, reduces sebum production, antibacterial and anti-inflammatory effectAdverse effects: redness, drying, burning sensationSafety: excellent safety profile with ability to self-neutralize, safe to use in darker skinned patients as a superficial peeling agentHow it’s used:Acne scars – 30% repeated every 3-4 weeks for a total of 3-5 sessionsActive acne – 20% every 2 weeks (can be used concurrently with oral isotretinoin[Accutane])Glycolic Acid (GA)Best for: mild, moderate and severe nodular acne, complexion brightening and PIH lightening, fine lines and wrinklesBenefits: exfoliation, anti-inflammatory and antibacterial effect, increased dermal hyaluronic acid and collagen gene expression (plumping effect), acne patients maintain clinical results for a long periodAdverse effects: temporary hyperpigmentation and irritationSafety: most adverse effects experienced are temporary and it is generally considered a well-tolerated peel; not safe if you have contact dermatitis (active rash), glycolate hypersensitivity or are pregnantHow it’s used:10-30% for 3 to 5 minutes at 2 week intervals is safe and effective for treatment of superficial scarringIn combination with microneedling has been shown to significantly improve acne scarsPyruvic Acid (PA)Best for: acne scarringBenefits: exfoliation, antimicrobial, sebum control, new collagen production stimulationAdverse effects: transient intense stinging and burning sensation during treatmentHow it’s used:40-70% has been proposed for the treatment of moderate acne scarsLactic Acid (LA)Best for: PIH, texture improvementBenefits: exfoliation, skin lightening, moisturizing, antibacterial and anti-inflammatory effects, new collagen productionHow it’s used:92% was used in a study and showed an improvement in superficial acne scarringMandelic Acid (MA)Best for: superficial peeling for skin rejuvenation and lightening, mild to moderate acne treatmentBenefits: skin lightening, some PIH fading, exfoliation, antibacterial and anti-inflammatory effect, new collagen productionSafety: very safe due to large molecular size it has a very slow skin penetrationHow it’s used:20-50% can be usedSMP (20% SA and 10% MA)Best for: active acne and post acne scarring; combination peels can be more effective than each solution alone (may have an additive and synergistic effect) - see SA and MA for details about eachJessner’s Solution (14% SA, 14% resorcinol or citric acid, 14% LA in 95% ethanol)Best for: PIH, superficial scarring, active acneBenefits: exfoliation, reduced sebum production, antibacterial effect, new collagen productionSafety: can’t be used if you have active inflammation, rash, or infection of the areaTrichloroacetic Acid (TCA)Best for: acne scar treatment (one of the most effective procedures) including atrophic scarsBenefits: low cost, increase in dermal volume of collagen, glycosaminoglycans, and elastin, can be combined with other procedures for maximal efficacy, some antibacterial effectAdverse effects: more risk of permanent hyperpigmentationSafety: not indicated for use in people with dark skin due to high risk of hyperpigmentation (up to medium-depth peels may still be used in people with darker skin)How it’s used:Can be used as a superficial, medium or deep peel depending on the concentration usedNew technique – CROSS method: uses high concentrations of TCA (50-100%) applied to isolated atrophic acne scars for a few seconds until white frosting appears within the scar; repeated at 4 week intervals and is particularly useful for “ice pick” scarring. May be safe for use in darker skinned patients.PhenolBest for: acne scarsBenefits: exfoliation, antibacterial, new collagen synthesisAdverse effects: potential systemic toxicitySafety: caution must be taken to systemic absorption that can cause heart toxicity, kidney toxicity, and respiratory depressionHow it’s used:Very deep peeling agent that is very effective at treating acne scarringWhat type of peel to use when?This is decided based on your skin type, acne type, age, previous or concurrent treatments, etc. by a certified professional (a dermatologist, plastic surgeon, or GP with fellowship training in cosmetic dermatology)In general, more superficial peels are for less severe acne and acne scarring, and deeper peels are for more severe acne and acne scarring (1)Chemical peels in general should be avoided for 6 months following a course of Accutane except for SA peels, which have been shown to be safe and effective while using Accutane (1)What kind of adverse effects or complications can be expected?(2)SwellingOccurs more often with deeper peelsExpected in most peels, and appears between 24-72 hours afterwards and make take a few days to resolveUsually mild, can be enough to cause eyes to swell shutIce, antihistamines and proper wound care can helpSteroids may be prescribed for people who have severe swelling, but should be avoided if possible because they will slow wound healingPain and burningExpected and very ordinary outcome of medium and deep peelsIntensity can vary from low to very high depending on the solution, concentration, and pain thresholdTopical analgesics (lidocaine) may be used for some peels to decrease sensitivity without affecting peel penetrationDeep peels can have pain and burning that lasts for 8-12 hours after the procedureProlonged sun exposure, deficient sunscreen, or using a topical retinoid or glycolic acid immediately after peels can exacerbate this side effectImmediate ice application reduces pain and burning, calamine lotion can help and emollients to moisturize skinFor deep peels, potent analgesics may be necessary as well as topical steroids to reduce inflammation (hydrocortisone, fluticasone)Persistent rednessRedness is common after all types of peelsMedium and deeper peels can lead to more prominent and prolonged rednessSuperficial peels usually don’t have redness beyond 3-5 days post procedure; 15-30 days can be expected for medium peels, and 60-90 days for deep peelsSome known causes of persistent redness are:Use of topical tretinoin immediately before and after the peelAccutane within 6 months preceding the peelAlcoholic beverage consumptionContact dermatitis (rash reaction)Some pre-existing conditions (rosacea, eczema, lupus)must be treated with potent topical steroids for 1-2 weeks, hats and sunscreens and continued moisturizing to prevent scarring; intense pulsed light can also be usedItchinessdue to new skin formation and usually begins in the first two weeks after treatment and continues for about one monthmore common after medium and deep peelsif it happens with increased redness or acne pustules it could be due to a contact allergy to the cream used in wound careif bothersome, can be treated with oral antihistamines and topical hydrocortisone as needed (but used sparingly)Eye injuriesthis is why an experienced and accredited professional should be the only person applying peels to your faceit is advisable that they have a prep kit for spills and flushes for the eyesphenol peels have a risk of some eye complicationsAllergic reactionsmore common with resorcinol (Jessner peels), salicylic acid, kojic acid, and lactic acidany peel can cause irritant inflammation especially if used too frequently, at high concentrations, or in cases of vigorous skin prepcan be resolved with antihistaminesBlisteringmore typical in younger patients with loose skin around the eyesdeeper peels, particularly using AHAs (like GA) can cause blistering in delicate areas like the nasolabial folds and around the mouththese areas can be protected with petroleum jelly to prevent thisFolliculitis and acneusually due to emollient creams used immediately after the peel and can be difficult to treat since most topical agents are irritating to the skinoral antibiotics can be usedBacterial infectionvery unusual because most agents used are antibacterialcan be made more susceptible by prolonged application of thick ointments, poor wound careproper wound care instruction and follow through is essential (especially for deeper peels) and for people who are susceptible they may be given an intranasal topical antibiotic (most of the bugs come from inside your nose!)managed with antibioticsYeast (Candida) infectionuncommon and difficult to distinguish but may see superficial pustulespredisposing factors: recent oral antibiotics, immunocompromised individuals, diabetics, or prolonged steroid usemanaged with antifungalsHerpes outbreaks (cold sores)onset may vary in duration from 5-12 days after the proceduredon’t appear like normal herpes “blisters”treat with antiviralsusually resolve without scarringBruisingusually below the eyes, and is a rare complicationassociated with severe swelling and resolves spontaneouslyHypopigmentation (loss of pigmentation)slight lightening is expected due to exfoliationusually noticed in jaw-neck region where untreated skin on the neck appears differentmelanin will increase in the new skin and it should balance out graduallypermanent hypopigmentation can occur in dark-skinned patients and occurs more frequently when there is an uneven penetration of the peelinfection and scarring can cause hypopigmentationHyperpigmentationcan occur any time after a peel, but usually between 4 days to 2 monthsmost common complication of TCA and can persist if not treatedrisk factors: darker skinned individuals, intense exposure, use of photosensitizing agents, early exposure to sunlight without broad spectrum sunscreens, estrogen-containing medications (oral contraceptives and hormone replacement therapy), pregnancy within 6 months after a peeltreated with hydroquinone 4-6%, vitamin C or azelaic acidSpider veinsmakes them more noticeable/brings them to the surfaceintense pulsed light, electrosurgery or vascular lasers can clear themSkin texture changestemporarily enlarged poresinappropriate technique or response to peeling agentmicrodermabrasion or re-peeling may helpMiliareported in up to 20% of patients after chemical peelsemerge in first few weeks of recoveryusually regress spontaneously but can be treated with retinoic acid post-healingcan also be extracted by needle, lancet, or electrodessicationDemarcation linesdifference between peeled and unpeeled skinpeel should be feathered around the eyes and the jawline (done by an experienced practitioner)Scarringunusual complication, but the hardest one to treatpersistent redness can predict early scarringusually have a history of poor wound healing and scarringother risk factors: Accutane use in the last 6 months, smoking, recent dermabrasion or other peelsReferences:Kontochristopoulos G, Platsidaki E. Chemical peels in active acne and acne scars. Clinics in Dermatology. 2017;5(2):179-182.Costa IMC, Damasceno PS, Costa MC, Gomes KGP. Review in peeling complications. J Cosmet Dermatol. 2017;00:1-8. https://doi.org/10.1111/jocd.12329
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