Abstract Show Chemical peeling is the application of a chemical agent to the skin, which causes controlled destruction of a part of or the entire epidermis, with or without the dermis, leading to exfoliation and removal of superficial lesions, followed by regeneration of new epidermal and dermal tissues. Indications for chemical peeling include pigmentary disorders, superficial acne scars, ageing skin changes, and benign epidermal growths. Contraindications include patients with active bacterial, viral or fungal infection, tendency to keloid formation, facial dermatitis, taking photosensitizing medications and unrealistic expectations. Physicians' qualifications : The physician performing chemical peeling should have completed postgraduate training in dermatology. The training for chemical peeling may be acquired during post graduation or later at a center that provides education and training in cutaneous surgery or in focused workshops providing such training. The physician should have adequate knowledge of the different peeling agents used, the process of wound healing, the technique as well as the identification and management of complications. Facility : Chemical peeling can be performed safely in any clinic/outpatient day care dermatosurgical facility. Preoperative counseling and Informed consent : A detailed consent form listing details about the procedure and possible complications should be signed by the patient. The consent form should specifically state the limitations of the procedure and should clearly mention if more procedures are needed for proper results. The patient should be provided with adequate opportunity to seek information through brochures, presentations, and personal discussions. The need for postoperative medical therapy should be emphasized. Superficial peels are considered safe in Indian patients. Medium depth peels should be performed with great caution, especially in dark skinned patients. Deep peels are not recommended for Indian skin. It is essential to do prepeel priming of the patient's skin with sunscreens, hydroquinone and tretinoin for 2-4 weeks. Endpoints in peels: For glycolic acid peels: The peel is neutralized after a predetermined duration of time (usually three minutes). However, if erythema or epidermolysis occurs, seen as grayish white appearance of the epidermis or as small blisters, the peel must be immediately neutralized with 10-15% sodium bicarbonate solution, regardless of the duration of application of the peel. The end-point is frosting for TCA peels, which are neutralized either with a neutralizing agent or cold water, starting from the eyelids and then the entire face. For salicylic acid peels, the end point is the pseudofrost formed when the salicylic acid crystallizes. Generally, 1-3 coats are applied to get an even frost; it is then washed with water after 3-5 minutes, after the burning has subsided. Jessner's solution is applied in 1-3 coats until even frosting is achieved or erythema is seen. Postoperative care includes sunscreens and moisturizers Peels may be repeated weekly, fortnightly or monthly, depending on the type and depth of the peel. Introduction The concept of peeling the skin to improve the texture, smoothen and beautify it has been used since ancient times. In ancient Egypt, Cleopatra used sour milk, now known to contain lactic acid, an alpha hydroxy acid while French women used old wine containing tartaric acid, to enhance the appearance of the skin. [1],[2] Chemical peeling is a common office procedure that has evolved over the years, using the scientific knowledge of wound healing after controlled chemical skin injury. [3] In spite of the advent of newer techniques and lasers, peeling has stood the test of time as a simple procedure, requiring hardly any instrumentation to rejuvenate the skin. DefinitionChemical peeling is the application of a chemical agent to the skin, which causes controlled destruction of a part or entire epidermis, with or without the dermis, leading to exfoliation, removal of superficial lesions, followed by regeneration of new epidermal and dermal tissues. Rationale and Scope These guidelines identify the indications for chemical peels, various agents that can be utilized, methodology, pre- and postpeel care, associated complications, and expected results. Indications of Chemical Peels [1],[4] Pigmentary disorders
Acne
Aesthetic
Epidermal growths
Contraindications [1],[4]
Physicians′ Qualifications 1. General
2. Specific
Prepeel Assessment A. History should include general medical history, degree of sun exposure, occupation to judge the level of sun exposure, history of herpes simplex, recent isotretinoin treatment in the last six months (for medium depth and deep peels), keloidal tendency, tendency for postinflammatory hyperpigmentation, current medications, any previous surgical treatment, immunocompromising conditions, and smoking (may delay healing in deep peels; this is not relevant for superficial peels). In patients in whom phenol peels are planned, history of systemic disease, particularly cardiac disease, should be taken. B. Detailed medical examination should include general physical and cutaneous examination including skin type, degree of photoaging, degree of sebaceous activity (oily or dry skin), presence of postinflammatory hyperpigmentation, keloid or hypertrophic scar, infection, and preexisting inflammation. C. Investigations
D. Documentation
Counseling: Proper counseling is very important and should include:
Preprocedure treatment recommendations (Priming): [1],[5],[6] Priming is essential for at least 2-4 weeks prior to the procedure. Priming helps to reduce wound healing time, facilitates uniform penetration of peeling agent, detects intolerance to any agent, enforces patient compliance and reduces the risk of complications.
Reagents
Equipment
Peeling Agents
Classification of peels according to the histological depth of necrosis: [5] A. Very Superficial light peels : Necrosis up to the level of stratum corneum. Agents used: TCA 10%, GA 30-50%, Salicylic acid 20-30%, Jessner′s solution 1-3 coats, Tretinoin 1-5% B. Superficial light peels : Necrosis through the entire epidermis up to basal layer. Agents used: TCA 10-30%, GA 50-70%, Jessner′s solution 4-7 coats C. Medium depth peels : Necrosis up to upper reticular dermis. Agents used: TCA 35-50%, GA 70% plus TCA 35%, 88% phenol un-occluded, Jessner′s solution plus TCA 35%, solid CO 2 plus TCA 35% D. Deep peels : Necrosis up to mid-reticular dermis. Agents used: Baker-Gordon phenol peel Recommendations Anesthesia: Anesthesia is not required in superficial and medium depth peels. Mild tranquilizers or anxiolytics may be used in anxious patients. Safety Precautions before peeling : The label on the bottle must be checked before applying the peel; the head should be elevated to 45° . To avoid accidental spillage, the open bottle or the soaked applicator should not be passed over the face. A syringe filled with water or saline should be kept ready for irrigation of the eyes in case of accidental spillage. Skin preparation before peeling
Procedure for Superficial Peels [1],[4],[8]
Medium Depth and Deep Peels Medium depth peels should be done with great caution in dark skinned patients because of the high risk of prolonged hyperpigmentation. [1],[31] Deep phenol peels are not recommended for dark skins of types IV-VI because of high risk of prolonged or permanent pigmentary changes, [1] although modified phenol peels are being used in types III-IV Asian skins. [28],[29],[30] Postoperative Care The aim of good postoperative care is to prevent or minimize complications and ensure early recovery. This is most important in dark skinned patients in whom pigmentary alterations are common. A careful maintenance program is essential to maintain the results of chemical peeling in most patients.
Complications [1],[32],[33],[34],[35] Proper patient selection, adequate counseling, priming the skin and supportive medical therapy in addition to good intra- and postoperative care, are essential for satisfactory cosmetic results. The best way to avoid complications is to identify patients at risk and use lighter peels. The deeper the peel, the greater is the risk of complications. The patients at risk are those with a history of postinflammatory hyperpigmentation, keloid formation, heavy occupational exposure to sun such as field workers, uncooperative patients and patients with a history of sensitive skin who are unable to tolerate sunscreens, hydroquinone etc.
Combination Peels and Procedures A. combination of peeling agents enhances the depth of the peel without using a higher concentration of the peeling agent. However, these medium depth peels should be used cautiously in darker skinned patients because of the risk of uneven depth of peeling and increased risk of side effects, such as postinflammatory hyperpigmentation and scarring.
B. Two procedures can also be combined to blend cosmetic units and avoid demarcation lines: [38],[39],[40]
Conclusions Chemical peeling is a simple office procedure used for the treatment of dyschromias, photoaging, and superficial scarring that can lead to excellent cosmetic improvement, when repeatedly performed in carefully selected patients. Although various depths of peels have been described, superficial and medium depth peels are safer for Indian patients. Deep chemical peels should be avoided because of the risk of permanent pigmentary changes. The type, depth and concentration of the peel should be selected according to the pathology of the condition [Table - 1]. Chemical peels are not one-time procedures and should be repeated with maintenance peels to achieve maximum improvement and prevent recurrence. With the advent of lasers and newer techniques, the use of chemical peels has declined; however, its simplicity as an office procedure, minimal morbidity, easy availability and cost-effectiveness ensure that it still holds an important place as a tool to treat dyschromias and photoaging. Careful patient selection, priming of the skin, standardization of peels, postpeel care and maintenance programs are essential to achieve excellent cosmetic results. References
Who is not suitable for chemical peels?Your doctor might caution against a chemical peel or certain types of chemical peels if you: Have taken the oral acne medication isotretinoin (Myorisan, Claravis, others) in the past six months. Have a personal or family history of ridged areas caused by an overgrowth of scar tissue (keloids) Are pregnant.
Are chemical peels safe for brown skin?Chemical peels are safe for people with darker skin, result in few side effects and complications. Summary: Results from a new study indicate that, when performed appropriately, chemical peels can be a safe treatment option for people with darker skin.
Are chemical peels safe for all skin types?People with skin types 1, 2, or 3 have a lower risk of a chemical peel changing the color of their skin or causing scarring. This means that any type of peel may be safe. People with skin types 4, 5, or 6 have a higher risk of a peel causing severe skin discoloration or scarring.
Who is suitable for chemical peel?This choice may be best if you have moderate lines and wrinkles, extensive sun-damaged skin, deep acne scars, blotchy skin, and/or precancerous growths called actinic keratosis. A deep chemical peel requires pretreatment for up to eight weeks. Your doctor will provide specific instructions.
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