Chemical peeling

The surge of interest in chemical peels and laser resurfacing by some cosmetic surgeons coincided with the public's desire for a more youthful appearance by restoring sun-damaged skin. Public interest was stimulated by advertising for cosmetics, over-the-counter chemicals, and treatment programs that entered the marketplace to rejuvenate skin and reverse the effects of sun damage and age.

Before consulting a dermatologist, most of these over-the-counter, do-it-yourself programs have already been tried by patients, and therefore they are ready for more intensive treatments such as chemical peels or laser resurfacing. The doctor’s job is to analyze the patient’s skin type, the degree of light damage, and recommend the right rejuvenation method that will give the best results with the least risk and complications. Dermatologists should educate patients about the full range of options available in drug therapy, cosmetics, dermabrasion, chemical peels, and lasers for selectively breaking down the skin and resurfacing it. Each of these methods should have a place in the cosmetic surgeon’s toolbox.

Chemical peeling involves the application of a chemical agent that eliminates superficial damage and improves skin texture by destroying the epidermis and dermis. To achieve superficial, medium or deep chemical exfoliation of the skin, various acids and alkalis are used, differing in the degree of destructive effect on the skin. The degree of penetration, destruction and inflammation determines the level of peeling. Light superficial peeling involves stimulating epidermal growth by removing the stratum corneum without necrosis. By exfoliation, peeling stimulates the epidermis to qualitative regenerative changes. Destruction of the epidermis is a complete superficial chemical peeling, followed by epidermal regeneration. Further destruction of the epidermis and provocation of inflammation in the papillary layer of the dermis denote medium-depth peeling. In this case, a further inflammatory response in the reticular layer of the dermis causes the formation of new collagen and interstitial substance, which is characteristic of deep peeling. Currently, all these effects are distributed based on the level of penetration for different conditions related to insolation and age-related changes. Thus, doctors have a means of eliminating skin changes that can be very superficial, moderate or severe, by applying substances that act at different depths. For each patient and skin condition, the doctor must choose the right active substance.

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Indications for chemical peeling

When evaluating patients with sun- and age-related skin changes, the skin color, skin type, and severity of the changes should be taken into account. There are different classifications, but I will present a combination of three systems to help the clinician determine the correct individual treatment program. The Fitzpatrick skin classification system describes the degree of pigmentation and tanning ability. Divided into grades I through VI, it predicts the skin’s photosensitivity, susceptibility to phototrauma, and ability to undergo additional melanogenesis (innate tanning ability). The system also categorizes skin by risk factors for complications from chemical peels. Fitzpatrick identifies six skin types, taking into account both skin color and skin response to the sun. Types 1 and 2 are pale and freckled skin, with a high risk of sunburn. Types 3 and 4 skin can burn in the sun, but typically tans olive to brown. Types 5 and 6 are dark brown or black skin that rarely burns and typically does not require sun protection. Patients with skin types I and II and significant photodamage require constant sun protection before and after the procedure. However, the risk of developing hypopigmentation or reactive hyperpigmentation after chemical peeling in these individuals is quite low. Patients with skin types III and IV after chemical peeling are at greater risk of pigment dyschromia - hyper- or hypopigmentation and may need pre- and post-treatment with not only sunscreen but also a bleaching agent to prevent these complications. The risk of pigmentation disorders is not very high after very superficial or superficial peels, but it can be a significant problem after medium or deep chemical peels. In some areas, such as the lips and eyelids, pigment disorders may occur significantly more often after exposure to a pulsed laser, which significantly changes the color in these cosmetic units. In some areas, after deep chemical peeling, changes with an "alabaster appearance" may occur. The physician should inform the patient of these possible problems (especially if the patient has skin types III or IV), explain the advantages and risks of the procedure and offer an appropriate method of preventing unwanted skin color changes.

A peeling agent is a caustic chemical that has a damaging therapeutic effect on the skin. It is important for the practitioner to understand the patient’s skin condition and its ability to withstand such damage. Certain skin types are more resistant to chemical damage than others, and certain skin conditions tend to potentiate the side effects and complications of chemical peels. Patients with significant photodamage may require deeper peels and repeated applications of medium-depth peeling solutions to achieve a therapeutic result. Patients with skin conditions such as atopic dermatitis, seborrheic dermatitis, psoriasis, and contact dermatitis may experience exacerbation or even delayed healing after peeling, as well as post-erythematous syndrome or contact sensitivity. Rosacea is a vasomotor instability of the skin that may be accompanied by an excessive inflammatory response to peeling agents. Other important anamnestic factors include the history of radiation therapy, since chronic radiation dermatitis is associated with a decreased ability to heal properly. In all cases, the hair in the irradiated area should be examined; its intactness indicates the presence of sufficient sebaceous pilosebaceous units for adequate healing of the skin after medium and even deep chemical peels. However, there is no direct correlation, so it is also necessary to ascertain the timing of radiation therapy and the doses used for each session. Some of our patients with severe radiation dermatitis were treated for acne dermatitis in the mid-1950s, and over time, significant degenerative changes developed in the skin.

Problems in the postoperative period can be caused by the herpes simplex virus. Patients suspected of having this infection should be given a prophylactic course of an antiviral drug, such as acyclovir or valcyclovir, to prevent herpes activation. These patients should be identified during the initial consultation and prescribed appropriate therapy. All antiviral drugs suppress viral replication in intact epidermal cells. It is important that re-epithelialization is completed after peeling before the full effect of the drug is evident. Therefore, antiviral therapy should be continued for 2 full weeks for deep chemical peeling and for at least 10 days for medium-depth peeling. The authors rarely use antiviral drugs for superficial chemical peeling, since the degree of damage is usually insufficient for virus activation.

The primary indications for chemical peels are related to the correction of actinic changes such as photodamage, wrinkles, actinic growths, pigment dyschromias, and post-acne scars. The physician may use classification systems to quantitatively and qualitatively assess the level of photodamage and to justify the use of an appropriate combination of chemical peels.

Superficial chemical peeling

Superficial chemical peeling involves the removal of the stratum corneum or the entire epidermis to stimulate the regeneration of less damaged skin and achieve a more youthful appearance. Several peeling sessions are usually required to achieve maximum results. Preparations are divided into those that produce a very superficial chemical peel, removing only the stratum corneum, and those that produce a superficial peel, removing the stratum corneum and damaged epidermis. It should be noted that the effect of superficial peeling on skin altered by age and insolation is insignificant, and the procedure does not have a long-term or very noticeable effect on wrinkles and folds. Trichloroacetic acid (TCA) in 10-20% Jessner solution, 40-70% glycolic acid, salicylic acid and tretinoin are used for superficial peeling. Each of these compounds has special characteristics and methodological requirements, so the doctor should be thoroughly familiar with these substances, the methods of their application and the nature of healing. Typically, healing time is 1-4 days, depending on the substance and its concentration. Very light peeling substances include glycolic acid in low concentrations and salicylic acid.

10-20% TCA produces a slight bleaching or freezing effect by removing the upper half or third of the epidermis. Preparation of the facial skin for peeling consists of thorough washing, removal of superficial sebum and excess horny scales with acetone. TCA is evenly applied with a gauze napkin or a sable brush; 15 to 45 seconds are usually enough for frost to form. The appearance of erythema and superficial frost stripes can be assessed as level I freezing. Levels II and III freezing are observed with medium-depth peeling and deep peeling. During the procedure, patients experience tingling and some burning, but these sensations subside very quickly and patients can return to their normal activities. Erythema and subsequent sloughing lasts 1-3 days. With such superficial peeling, sunscreens and light moisturizers are permissible, with minimal care.

Jessner's solution is a combination of caustic acids that has been used for over 100 years to treat hyperkeratotic skin conditions. This solution has been used in acne to remove comedones and signs of inflammation. In superficial peeling, it acts as an intense keratolytic. It is applied in the same way as TCA, with a damp gauze, sponge or sable brush, causing erythema and patchy frost deposits. Test applications are made every other week, and the coverage levels of Jessner's solution can be increased with repeated applications. The visual end result is predictable: exfoliation of the epidermis and its build-up. This usually occurs within 2-4 days, and then mild cleansers, moisturizing lotions and sunscreens are applied.

Alpha hydroxy acids

Alpha hydroxy acids, especially glycolic acid, were the wonder drugs of the early 1990s, promising skin rejuvenation when applied topically at home. Hydroxy acids are found in foods (for example, glycolic acid is naturally present in sugar cane, lactic acid in sour milk, malic acid in apples, citric acid in citrus fruits, and tartaric acid in grapes). Lactic and glycolic acids are widely available and can be purchased for medical use. For chemical peels, glycolic acid is produced unbuffered at 50-70% concentration. For wrinkles, a 40-70% solution of glycolic acid is applied to the face with a cotton swab, sable brush, or damp cloth weekly or every other week. Time is important for glycolic acid - it should be washed off with water or neutralized with a 5% soda solution after 2-4 minutes. Mild erythema with tingling and minimal flaking may be present for an hour. Repeated applications of this solution have been reported to clear benign keratosis and reduce wrinkles.

Superficial chemical peeling can be used for comedones, post-inflammatory erythema and to correct pigmentation disorders after acne, to treat skin aging associated with insolation, and also for excess black pigment in the skin (melasma).

For effective treatment of melasma, the skin should be treated before and after the procedure with sunscreen, 4-8% hydroquinone and retinoic acid. Hydroquinone is a pharmacological drug that blocks the effect of tyrosinase on melanin precursors and thus prevents the formation of new pigment. Its use prevents the formation of new melanin during the restoration of the epidermis after chemical peeling. Therefore, it is needed for peeling for pigment dyschromia, as well as for chemical peeling of skin types III-VI according to Fitzpatrick (the skin most prone to pigmentation disorders).

When performing superficial chemical peeling, the doctor must understand that repeated treatments do not add up to a medium or deep peel. A peel that does not affect the dermis will have a very minor effect on the texture changes associated with dermal damage. In order not to be disappointed with the results, the patient must understand this before the operation. On the other hand, to achieve the maximum effect from superficial peeling, repeated procedures are necessary. The procedures are repeated every week, in a total of six to eight, and are supported by appropriate therapeutic cosmetics.

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Medium depth chemical peeling

Medium-depth chemical peeling is a single-stage controlled damage of the papillary dermis with a chemical substance, leading to specific changes. The drugs currently used are complex compounds - Jessner solution, 70% glycolic acid and solid carbon dioxide with 35% TCA. The determining component of this level of peeling is 50% TCA. It has traditionally allowed to achieve acceptable results in smoothing fine wrinkles, actinic changes and precancerous conditions. However, since TCA, in concentrations of 50% and higher, causes many complications, especially scarring, it is no longer used as a monodrug for chemical peeling. Therefore, combinations of several substances with 35% TCA began to be used for peeling, which also effectively cause controlled damage, but do not have side effects.

Brody suggested treating the skin with acetone and dry ice to freeze it before applying 35% TCA. This allows the 35% TCA solution to penetrate the epidermal barrier more effectively and completely.

Monheit used Jessner solution prior to 35% TCA. Jessner solution disrupts the epidermal barrier by damaging individual epithelial cells. This allows for a more uniform application of the peeling solution and deeper penetration of the 35% TCA. Coleman demonstrated this effect with 70% glycolic acid prior to 35% TCA. Its effects are very similar to Jessner solution. All three of these combinations have been shown to be more effective and safer than 50% TCA. Uniformity of application and frost formation is more predictable with these combinations, so that the "hot spots" characteristic of high concentrations of TCA, which can cause dyschromia and scarring, are not a serious problem when a lower concentration of TCA is included in the combination solution. Monheit's modified Jessner solution-35% TCA is a relatively simple and reliable combination. This technique is used for mild to moderate photodamage to the skin, including pigment changes, freckling, epidermal growths, dyschromia and wrinkles. It is used once, with a 7-10 day healing period and is useful for removing diffuse actinic keratosis as an alternative to chemical peeling with 5-fluorouracil chemotherapy. This peel significantly reduces complications and cosmetically improves aged skin.

The procedure is usually performed under light sedation and nonsteroidal anti-inflammatory drugs. The patient is warned that the peel will sting and burn for a while; aspirin is given before and for 24 hours after the peel to reduce these symptoms, if tolerated. Aspirin's anti-inflammatory effect is particularly helpful in reducing swelling and pain. If aspirin is taken before the procedure, it may be all that is needed in the postoperative period. However, sedation (diazepam 5-10 mg orally) and light analgesia [meperidine 25 mg (diphenhydramine) and hydroxyzine hydrochloride 25 mg intramuscularly (Vistaril)] are desirable before a full-face peel. The discomfort from such a peel is short-lived, so short-acting sedatives and analgesics are required.

To achieve uniform penetration of the solution, strong cleaning and degreasing are required. The face is carefully treated with Ingasam (Septisol) (10 x 10 cm napkins), washed with water and dried. To remove residual sebum and dirt, a preparation called mazetol is used. For the peeling to be successful, deep degreasing of the skin is necessary. The result of uneven penetration of the peeling solution, due to the presence of residual sebum or horny deposits after incomplete degreasing, is a spotty peeling.

After degreasing and cleaning, Jessner solution is applied to the skin with cotton swabs or 5 x 5 cm wipes. The amount of frost formed under the influence of Jessner solution is much less than from THC, and patients usually do not feel discomfort. A weak uniform shade of moderate erythema appears under the frost.

Then, 1-4 cotton swabs are used to apply TCA evenly, the doses of which in different areas can vary from low to high. The acid is applied to the forehead and medial part of the cheeks with broad strokes of four cotton swabs. One slightly moistened cotton swab is used to treat the lips, chin and eyelids. Thus, the dose of TCA is proportional to the amount used, the number of cotton swabs used and the doctor's technique. Cotton swabs are convenient for dosing the amount of solution applied during peeling.

White frost from TCA appears on the treated area within a few minutes. Uniform application eliminates the need to treat certain areas a second or third time, but if freezing is incomplete or uneven, the solution should be applied again. Frost from TCA takes longer to form than from Baker or pure phenol, but faster than from superficial peeling agents. To ensure that freezing has reached its maximum, the surgeon should wait at least 3-4 minutes after applying TCA. Then he can assess the completeness of the effect on a particular cosmetic area and, if necessary, correct something. Areas with incomplete freezing should be carefully treated again with a thin layer of TCA. The doctor should achieve an effect of level II-III. Level II is defined as a layer of white frost with erythema shining through it. Level III, meaning penetration into the dermis, is a dense white enamel layer without an erythematous background. Most medium-depth chemical peels achieve a level II freeze, especially on the eyelids and sensitive areas. In areas with a greater tendency to scar, such as the zygomatic arches, bony prominences of the mandible and chin, the peel should not exceed a level II. Applying an additional layer of TCA increases its penetration, so a second or third application will dry the acid out even more, causing more damage. Therefore, an additional layer of acid should only be applied to areas where the peel has not been sufficiently applied or where the skin is much thicker.

Peeling of the anatomical areas of the face is carried out sequentially, from the forehead to the temples, cheeks and, finally, to the lips and eyelids. White frost means coagulation of keratin and indicates that the reaction is complete. Careful framing of the hair growth borders, the edge of the lower jaw and eyebrows with the solution hides the demarcation line between the areas that have and have not been peeled. In the perioral area, there are wrinkles that require complete and uniform covering of the skin of the lips with the solution up to the red border. This is best done with the help of an assistant who stretches and fixes the upper and lower lips during the application of the peeling solution.

Some areas and pathological formations require special attention. Thick keratoses are not evenly soaked with the peeling solution. Additional application, even intensive rubbing, may be required to ensure penetration of the solution. Wrinkled skin should be stretched to achieve even coverage of the folds with the solution. In the perioral folds, up to the red border of the lips, the peeling solution should be applied with the wooden part of the cotton applicator. Deeper folds, such as expression lines, cannot be corrected with peeling, so they should be treated like the rest of the skin.

The skin of the eyelids must be treated with care and gentleness. To apply the solution 2-3 mm from the edges of the eyelids, use a semi-dry applicator. The patient should be positioned with the head raised at 30° with eyes closed. Before applying, the excess peeling solution on the cotton swab should be squeezed out against the wall of the container. Then the applicator is gently rolled over the eyelids and periorbital skin. Never leave excess solution on the eyelids, as it may get into the eyes. During peeling, tears should be dried with a cotton swab, as they can carry the peeling solution into the periorbital tissues and eyes by capillary attraction.

The peeling procedure with Jessner-TXK solution is carried out as follows:

• The skin is thoroughly cleansed with Septisol.
• Acetone or acetone alcohol is used to remove sebum, dirt and exfoliated horny epidermis.
• Jessner solution is applied.
• Thirty-five percent THC is applied before light frost appears.
• To neutralize the solution, compresses with cold saline solution are applied.
• Healing is facilitated by wetting with 0.25% acetic acid and applying an emollient cream.

When applying the peeling solution, a burning sensation immediately occurs, but it disappears after the freezing process is complete. Symptomatic relief in the peeling area is achieved by applying cold compresses with saline to other areas. After the peeling process is complete, compresses are applied to the entire face for several minutes until the patient feels comfortable. The burning sensation completely disappears by the time the patient leaves the clinic. By this time, the frost gradually disappears, giving way to pronounced peeling.

After the procedure, swelling, redness and peeling will occur. With periorbital peeling and even forehead peeling, the swelling of the eyelids can be so pronounced that the eyes will be closed. In the first 24 hours, patients are advised to apply compresses with 0.25% acetic acid (4 times a day), made from 1 tablespoon of white table vinegar and 0.5 l of warm water. Following the compresses, an emollient is applied to the peeling areas. After 24 hours, patients can take a shower and gently cleanse the skin of the face with a mild detergent-free product. After peeling is complete (after 4-5 days), erythema becomes more noticeable. Healing is complete in 7-10 days. By the end of the first week, the bright red color of the skin changes to pink, like with a sunburn. This can be hidden with cosmetics after 2-3 weeks.

The therapeutic effect of medium depth peeling is based on three factors:

• degreasing,
• Jessner solution and
• 35% THC.

The effectiveness and intensity of peeling are determined by the amount of the product applied. Differences in results may be due to the skin type of the patients and the characteristics of the areas treated. In practice, medium-depth peeling is used most often and is planned individually for almost every patient.

Medium depth peeling has five main indications:

1. destruction of epidermal formations of the skin - actinic keratosis;
2. treatment and restoration of the surface of skin moderately damaged by sun exposure up to level II,
3. correction of pigment dyschromia,
4. removal of small superficial acne scars; and
5. treatment of sun-aged skin combined with laser resurfacing and deep chemical peeling.

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Deep chemical peeling

Level III photodamage requires deep chemical peeling. This involves the use of TCA in a concentration of more than 50% or phenol peeling according to Gordon-Baker. Laser resurfacing can also be used to correct damage of this level. TCA concentrated over 45% is considered unreliable, as it often causes scarring and complications. For this reason, concentrated TCA is not included in the list of standard means for deep chemical peeling. For deep chemical peeling, the phenol composition of Baker-Gordon has been successfully used for more than 40 years.

Deep chemical peels are labor-intensive procedures that should be taken as seriously as any major surgery. Patients require preoperative intravenous sedation and hydration. Typically, a liter of fluid is given intravenously before surgery and another liter intraoperatively. Phenol is cardiotoxic, hepatotoxic, and nephrotoxic. Therefore, attention must be paid to the serum concentration of phenol during its absorption through the skin. Methods to limit this include:

• Intravenous hydration before and during the procedure to wash out phenolic compounds from the blood serum.
• Stretching the application time for peeling the entire face for more than 1 hour. Before applying the solution to the skin of each subsequent cosmetic unit, an interval of 15 minutes is observed. Thus, the treatment of the forehead, cheeks, chin, lips and eyelids gives a total of 60-90 minutes.
• Monitoring the patient: If any electrocardiographic changes occur (e.g. premature ventricular or atrial contractions), the procedure is stopped and the patient is closely monitored for other signs of intoxication.
• Oxygen therapy: Many doctors believe that oxygen therapy during the procedure can help prevent rhythm disturbances.
• Proper patient selection: All patients with a history of cardiac arrhythmia, renal or hepatic insufficiency, or taking medications that predispose to arrhythmia should be refused Baker-Gordon phenol peel.

Patients undergoing deep chemical peels should be aware of the significant risks and potential complications associated with this procedure, so that the potential benefits must be weighed against the specific risk factors. In the hands of those who perform this procedure regularly, it is a safe and reliable way to rejuvenate skin with severe photodamage, deep perioral wrinkles, periorbital and crow's feet lines, forehead lines and folds, and other textural and morphological changes associated with severe sun-induced aging.

There are two methods of deep chemical peeling: occlusive and non-occlusive Baker phenol peels. Occlusion is accomplished by applying a waterproof zinc oxide tape, such as 1.25 cm Curity tape. The tape is applied immediately after each cosmetic unit has been phenol treated. Tape occlusion enhances the penetration of the Baker phenol solution and is especially good for deeply striated, “windburned” skin. Occlusive phenol peels create the deepest damage in the mid-reticular dermis and this form of chemical peel should only be performed by the most knowledgeable and experienced cosmetic surgeons who understand the dangers of over-penetrating and damaging the reticular dermis. Complications include hyper- and hypopigmentation, textural changes such as “alabaster skin,” and scarring.

The non-occlusive technique, as modified by McCollough, involves more skin cleansing and application of a larger amount of peeling solution. Overall, this technique does not provide as much deep exfoliation as the occlusive method.

The Baker-Gordon formulation for this peel was first described in 1961 and has been used successfully for over forty years. This formulation penetrates deeper into the dermis than undiluted phenol, as the latter is believed to cause immediate coagulation of the keratin proteins of the epidermis, thereby blocking its own penetration. Dilution to approximately 50-55% in Baker-Gordon solution causes keratolysis and keratocoagulation, facilitating deeper penetration of the solution. Hibiclens liquid soap is a surfactant that reduces the surface tension of the skin and ensures more uniform penetration of the peeling preparation. Croton oil is a vesicant epidermolytic that improves the absorption of phenol. The freshly prepared formulation is not miscible, so it must be shaken in a transparent glass medical container immediately before application to the patient's skin. Although the composition can be stored briefly in a dark glass bottle, this is usually not necessary. It is preferable to prepare the composition fresh each time.

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Chemical peeling technique

Before anesthesia, the patient is seated and the face is marked, with landmarks such as the angle of the lower jaw, chin, anterior auricular groove, edge of the orbit and forehead. This is done in order to perform peeling strictly to the borders of the face and slightly beyond the edge of the lower jaw, creating an unnoticeable transition in skin color. This peeling necessarily requires sedation. To do this, the anesthetist administers an intravenous anaesthetic such as a combination of fentanyl citrate (Sublimaze) and midazolam (Versed) and observes the patient. It is helpful to numb the supraorbital nerve, infraorbital nerve, and mental nerve with bupivacaine hydrochloride (Marcane), which should provide local anesthesia for about 4 hours. The entire face is then cleansed and degreased with a keratolytic agent such as hexochlorophene with alcohol (Septisol), with particular care in sebaceous areas such as the nose, hairline, and midcheeks.

The chemical compound is then applied successively to the skin of six aesthetic units: the frontal, perioral, right and left cheek, nasal and periorbital areas. Each cosmetic area is treated for 15 minutes, which in total makes up 60-90 minutes for the entire procedure. Cotton swabs are used for application, in the same way as described in the section on medium-depth peeling with Jessner-35% TCA solution. However, the preparation is applied in smaller quantities, since freezing occurs much faster. The immediate burning sensation is present for 15-20 seconds and then passes; however, the pain returns after 20 minutes and bothers for 6 to 8 hours. The last area of peeling is the periorbital skin, to which the solution is applied only with moistened cotton swabs. In no case should drops of the peeling solution be allowed to come into contact with the eyes and tear fluid, since the solution mixed with tears can penetrate the eye by capillary attraction. It is important to remember that diluting the peeling compound in water may enhance its absorption; therefore, if the chemical gets into the eye, it should be flushed with mineral oil rather than water.

After the solution has been applied, frost will appear on all areas and an occlusive peel tape may be applied. Ice packs may be used to increase comfort after the peel is complete; and petroleum jelly may be used if the peel is non-occlusive. A biosynthetic dressing such as Vigilon or Flexzan is applied for the first 24 hours. Patients will return for their first postoperative visit after 24 hours to remove the tape or biosynthetic dressing and to monitor the healing process. At this time, patients are instructed in the use of compresses and occlusive dressings or ointments. It is important to prevent the skin from scabbing over.

Following a deep chemical peel, there are four stages of wound healing. These are (1) inflammation, (2) coagulation, (3) re-epithelialization, and (4) fibroplasia. Immediately following completion of the chemical peel, an inflammatory phase occurs, beginning with a marked dark erythema that progresses over the first 12 hours. The pigmented lesions on the skin become more accentuated as the epidermis is separated during the coagulation phase, serum exudates, and pyoderma develops. During this phase, it is important to apply cleansing lotions and compresses, as well as occlusive soothing ointments. This will remove the sloughing necrotic epidermis and prevent the serum exudate from drying out to form crusts and eschar. The authors prefer to use 0.25% acetic acid compresses (1 teaspoon white table vinegar, 500 ml warm water) because they have an antibacterial effect, especially against Pseudomonas aeruginosa and other gram-negative microorganisms. In addition, the slightly acidic reaction of the solution is a physiological environment for the healing granulation tissue and gently washes the wound, dissolving and washing away necrotic material and serum. When examining the skin daily for complications, we prefer to use emollients and soothing agents such as Vaseline, Eucerin or Aquaphor.

Re-epithelialization begins on the 3rd day and continues until the 10th-14th day. Occlusive dressings promote rapid healing. The last stage of fibroplasia continues for a long time after the primary closure of the wound and consists of neoangiogenesis and the formation of new collagen for another 3-4 months. Erythema can persist from 2 to 4 months. Long-term persistence of erythema is usually not observed and is associated with individual sensitivity of the skin or contact dermatitis. The formation of new collagen during the fibroplasia phase can continue to improve the texture of the skin for up to 4 months.

Complications of chemical peeling

Many peel complications can be recognized early in the healing process. The cosmetic surgeon should be familiar with the normal appearance of a healing wound at different stages after peels of varying depths. Prolongation of the granulation stage beyond 7-10 days may indicate delayed wound healing. This may be the result of a viral, bacterial, or fungal infection; contact dermatitis that interferes with healing; or other systemic factors. The red flag (granulation) should prompt the surgeon to perform a thorough examination and prescribe appropriate treatment to prevent irreparable damage that may cause scarring.

The causes of complications may be intraoperative or postoperative. Two common errors that lead to intraoperative complications are (1) incorrect selection or application of the preparation and (2) accidental application of the preparation to undesirable sites. The physician is responsible for the correct application of the solution at the correct concentration. The volume-weight concentration of TCA should be determined, as this is the measure of the depth of peeling. The expiration dates of glycolic and lactic acids, as well as Jessner's solution, should be checked, as their potency decreases with storage. Alcohol or water may undesirably increase the effect, so the preparation time of the solution should be clarified. The peeling solution should be applied with cotton-tipped applicators. For medium and deep peeling, it is best to pour the solution into an empty container, rather than taking it from the bottle in which it was stored, squeezing cotton swabs on the walls of its neck, since crystals that have fallen on the walls can increase the concentration of the solution. It is necessary to apply the solution to the appropriate places and not to carry a wet applicator over the central parts of the face, where drops can accidentally fall on sensitive areas, such as the eyes. To dilute TCA or neutralize glycolic acid, in cases of their incorrect application, physiological saline and sodium bicarbonate solution should be on hand in the operating room. Also, for phenol peeling according to Baker, you need to have mineral oil. Postoperative complications are most often associated with local infection and contact dermatitis. The best means of containing local infection is the use of lotions to remove crusts and necrotic material. Streptococcal or staphylococcal infections may develop under thick occlusive dressings. The use of 0.25% acetic acid lotions and judicious removal of ointment when applying them will slow down the progression of infection. Staphylococcus, Escherichia coli, and even Pseudomonas infections may result from improper wound care and should be treated with an appropriate oral antibiotic.

Early recognition of a bacterial infection requires frequent patient visits to the doctor. It may manifest itself as delayed healing, ulceration, formation of necrotic material in the form of excess films and crusts, purulent discharge and odor. Early recognition allows the skin to be treated and prevents the spread of infection and scarring.

The viral infection is the result of reactivation of the herpes simplex virus in the skin of the face and especially in the perioral area. A history of herpes infection requires prophylactic oral administration of an antiviral drug. Such patients can be treated with 400 mg of acyclovir three times a day for 7-14 days, depending on the depth of the procedure, starting on the day of peeling. The mechanism of action of acyclovir is to suppress viral replication in unchanged epithelial cells. This means that the drug will not have an inhibitory effect until re-epithelialization of the skin occurs, i.e., until the 7th-10th day after medium or deep peeling. Previously, the antiviral drug was discontinued after 5 days, and clinical infection manifested itself by the 7th-10th day.

Active herpes infection is easily treated with antiviral medications. Scarring is usually not present if treatment is started early.

Slow wound healing and prolonged erythema are signs that normal tissue repair after peeling is not occurring. To recognize inadequate healing, the cosmetic surgeon must be familiar with the normal duration of each stage of the healing process. Delayed wound healing can be accelerated by wound debridement, if infection is present, corticosteroids, and removal of the dermatitis-causing substance that maintains allergic reactions and irritation, as well as protection with a biosynthetic membrane such as Flexzan or Vigilon. Once the diagnosis is made, the patient should be monitored daily, changing the dressing and observing changes in the healing skin.

Persistent erythema is a syndrome in which the skin remains erythematous longer than is considered normal for a particular type of peel. After a superficial peel, erythema resolves in 15-30 days, after a medium-depth peel within 60 days, and after a deep chemical peel within 90 days. Erythema and/or itching that persists longer than this time are considered abnormal and indicate this syndrome. This may be contact dermatitis, contact sensitization, exacerbation of a pre-existing skin disease or a genetic predisposition to erythema, but such a situation may also indicate possible scarring. Erythema is the result of angiogenic factors stimulating vasodilation, which also occurs in the fibroplasia phase, stimulated over a long period of time. Therefore, it may end in thickening of the skin and scarring. This condition should be treated immediately with adequate doses of steroids, both locally and systemically, and with skin protection from irritants and allergens. If thickening and scarring become evident, daily silicone sheeting and pulsed dye laser therapy to target vascular factors may be helpful. With proper intervention, scarring is often reversible.

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