Peeling: indications and contraindications, complications, care

The term "peeling" comes from the English verb "to peel" - peel off, exfoliate. This is one of the old cosmetic methods. So, at home, you can use grape must, sour milk (for example, sour cream) and other products containing acids. Currently, peeling is an integral part of almost any cosmetic procedure.

Classification of peelings

Currently, there is no single classification of peels in depth, since there is no unified opinion of specialists in this field.

Peelings can be divided into:

• intracorneal (superficial);
• intra-epidermal (superficial, median-superficial, median);
• intradermal (deep).

Superficial peeling affects only the stratum corneum, as a result of its action, the surface rows of horny scales are carefully removed. Superficial peeling affects the entire stratum corneum. Median-superficial peeling extends to the thorny layer of the epidermis. Actually, the medial peeling damages the entire epithelium, without affecting the basal membrane, while retaining the sites of basal keratinocytes.

Deep peeling penetrates the dermis, affecting the papillary layer, while the papillae retain the areas of the basement membrane.

By the mechanism of action, physical, chemical and mixed peels are isolated. When carrying out a physical exfoliation, various physical methods of influence are used (mechanical, go scrub, gommage, disincrustation, ultrasonic peeling, microdermabrasion, dermabrasion, laser "grinding"). To perform chemical peeling, various keratolytic agents (acids, phenol, resorcinol, etc.) and enzymes (the so-called enzyme peeling) are used. Mixed peeling implies a combined effect of physical and chemical factors.

[1], [2], [3]

Indications for conduction

Indications for the peeling are pigmentation of various genesis (melasma, lentigine, freckles, post-inflammatory pigmentation), scar changes (after acne, chicken pox, post traumatic, etc.), age-related skin changes, multiple non-inflammatory acne (open and closed comedones). It is extremely rare to use exfoliation for clarifying unaffected skin with extensive vitiligo foci.

To achieve the optimal aesthetic result, it is important to choose the depth of peeling. So, superficial and superficial peelings are effective for hypersecretion of sebum, superficial non-inflammatory acne, hyperkeratosis, initial manifestations of photo and biological aging, skin dehydration. Surface-medial peeling is often used in photoaging. It is also indicated for pigment disorders, especially in the epidermal type of melasma, since the depth of its action already implies an effect on melanocytes. Median peeling is prescribed for dermal and mixed types of melasma, post-acne, and pronounced gradations of photoaging. Deep peeling is used for pronounced deep wrinkles associated with biological and photoaging, deep scar changes and other pronounced cosmetic defects.

Contraindications

Contraindications for peelings are divided into absolute and relative, general and local. It should be emphasized that the surface-median, middle and deep peels are not indicated on the background of taking isotretinoin, they should be started no earlier than 5-6 months after the end of the course of therapy. In addition, topical retinoids should be discarded 5-7 days before the peeling, and the epilation in the area of exposure should not be performed within 1 week. Local application of various destructive compounds (5-fluorouracil, solcoderm, prospidin ointment) together with peeling can increase the depth of the burn. Peelings are extremely undesirable to patients with a predominance of inflammatory acne, especially pustular, due to the high risk of exacerbation of the disease.

The main contraindications for the peeling procedure

Absolute contraindications		Relative contraindications
Are common	Local	Are common	Local
Fever, infectious diseases, severe general condition, etc.	Infectious diseases of the skin (viral bacterial, mycotic), chronic dermatoses (eczema, atopic dermatitis, psoriasis, etc.) in the acute stage, pustular acne multiple nevi, hypertrichosis, individual intolerance, etc.	Phototype IV-VI, menstruation, pregnancy, thyroid gland pathology, isotretinoin intake, active insolation season, children's age, meteosensitivity, etc.	Hypersensitivity of the skin, chronic dermatosis in the phase of remission, often recurrent herpetic infection, inflammatory acne, a tendency to keloid scars

[4]

Chemical peeling

This procedure is most often performed using a variety of agents that have keratolytic properties. The basic keratolitics used in dermatocosmetology include hydroxy acids (alpha, beta, polyhydroxy acids), trichloroacetic acid (TCA), vitamin A derivatives, ascorbic acid and its derivatives, phenol, 5-fluorouracil, urea (> 10%), azelaic acid, benzoyl peroxide, resorcinol, propylene glycol (> 40%), and other compounds. The depth and strength of the peeling are regulated by the concentration of the active agents, their pH, multiplicity and exposure time. For superficial peeling, enzyme preparations and fruit acids are usually used, for surface hydroxy acids, for surface-median and median hydroxy acids, trichloroacetic and other acids, for deep phenol. In fact, chemical peeling is a controlled skin damage by the type of burn. That is why against the background of application of the composition for peeling, erythema and so-called "frost" (from English frost - frost) are possible, frost is a site of coagulative necrosis of the skin of various depths, i.e., a scab. Outwardly it looks like a whitish staining of the treated area of the skin. Qualitative characteristics of the frost, such as color, uniformity, consistency, allow to determine the depth of the peeling effect.

Superficial chemical peeling is performed using various enzymes (papain, bromelain, trypsin, etc.) and less often - hydroxy acids in low concentrations. Enzymes are usually obtained from certain species of plants and fungi (pineapple, papaya, fungus Mucor Mieli, etc.), as well as from animal raw materials (for example, pancreas of pigs, cattle, etc.). Superficial and and soft impact, rarely encountered complications allow to perform super-surface pilling with sensitive skin and even at home. So, in recent years in cosmeceuticals the concept of "home clinic" (proposed by RoC) has become popular. Home peelings include enzymes, various acids or other keratolytic agents (salicylic acid 2-4%, glycolic acid, lactic acid 0.5-4%, urea 2-4%, etc.), they are easy to use, the kits often include the means for post-peeling care (Nightpeel, "Lierak", sets of Peelmicroabrasion, "Vichy Laboratories", Reel-ex radiance, "RoK", etc.). To reduce the irrational effect of hydroxy acids in recent years in the means for home care began to use their ethers (for example, cream Sebium AKN, "Bioderma"). As home-made peeling, topical retinoids (adapalene Differin) and azelaic acid (Skinoren) can be used. These means are also used for pre-peel preparation,

Subject to superficial peeling, there are no subjective sensations, erythema can be observed for several minutes. Depending on the skin type and the problem being solved, it can be done daily or several times a week.

For surface peeling, a-hydroxy acids (a-Hydroxy Acids, or AHA) are widely used in a concentration of 20-50%: glycolic, malic, lactic, tartaric, almond, cinnamon, etc. AHA are organic carboxylic acids having one alcoholic group in a -position. Their source are sugarcane, sour-milk products, fruits (often all AHA is called "fruit"), some kinds of fungi (for example, kenic acid). The most widely used in cosmetology is glycolic acid, because due to its low molecular weight, it easily penetrates deep into the skin. Natural sources of glycolic acid - sugar cane, grape juice, immature beet, but in recent years in cosmetology use its synthetic variety.

To date, information has been accumulated on the mechanism of action of a-hydroxy acids on various layers of the skin. It was shown that hydroxy acids weaken the adhesion between the corneocytes, thereby achieving the effect of exfoliation. It is believed that they are capable of stimulating the proliferation of basal keratinocytes and normalizing the processes of desquamation of the epithelium. There are data on the activation of the synthesis of free ceramides (in particular, Cl), which can positively affect the barrier properties of the skin. AHA stimulates the synthesis of type I collagen, elastin and glycosaminoglycans by activating the triggering of certain enzymatic reactions at acid pH. Low concentrations of hydroxy acids may cause swelling of cell elements and enhance hydration of the intercellular substance, which creates the effect of rapid skin smoothing. Glycolic acid stimulates the production of collagen, inhibits the synthesis of melanin; there are also indications of its antioxidant effect.

Superficial peeling does not cause pain, after it there is erythema for several hours and a slight peeling of the skin at the site of exposure for 1-3 days. The rehabilitation period takes 2-5 days. It can be done once a month, the frequency of procedures depends on the problem being solved.

For surface-median peeling, in addition to AHA (50-70%), use of salicylic acid (refers to beta-hydroxy acids). Due to good keratolytic properties, salicylic acid promotes a faster exfoliative effect and serves as a kind of conductor in the skin for other means. The direct anti-inflammatory action of salicylic acid is also discussed. In cosmetology, combined peelings with alpha and beta hydroxy acids, polyhydroxy acids are used.

Surface-medicated peeling also uses polyhydroxy acids, retinoic acid (5-10%), trichloroacetic acid, or trichloracetic acid, TCA (up to 15%), phytic acid, Jaysner's peeling. Thus, retinoic acid, possessing the properties of vitamin A derivatives, is able to regulate keratinization and differentiation of epidermocytes, inhibit pigmentation, affect the proliferative and synthetic activity of fibroblasts, and inhibit the activity of collagenases (matrix metalloproteinases). Phytic acid, obtained from wheat seeds, acts not only as keratolytic, but also as a powerful whitening agent capable of inhibiting the activity of tyrosinase. It is known that this acid is capable of forming chelate compounds with a number of metals participating as coenzymes of certain inflammatory reactions and pigmentation processes. In recent years, also used malonovuyu, almond, azelaic acid.

A solution for Jaysner's peeling, widely used in America and Western Europe ("5th Avenue Peeling", "Hollywood Peeling", etc.), includes 14% of resorcinol, salicylic acid and lactic acid in 96% alcohol. Combinations with cinnamic acid and hydroquinone are possible in the correction of pigmentation (melasma, post-inflammatory pigmentation). Resorcinol, which is part of the Jasner solution, can cause systemic toxic effects. That's why this peeling is used on individual skin areas.

When conducting a superficial medication, not only erythema, but also uneven, white, in the form of dots or clouds of frost is possible. Subjective sensations - discomfort, mild itching, burning, less soreness of the skin. Post-peeling erythema lasts up to 2 days. With the use of TCA, swelling and swelling of soft tissues in thin skin areas is possible within 3-5 days. Peeling remains for up to 7-10 days. The rehabilitation period is up to 14 days. Can be carried out once and in courses with an interval of 1-3 months. Multiplicity of procedures depends on the problem being solved.

Median chemical peeling is carried out using trichloroacetic acid (15-30%), as well as salicylic acid (up to 30%). A combined application of TCA and carbonic acid snow is possible. During mid-peeling, in addition to erythema, a snow-white homogeneous dense frost appears. Subjectively, severe discomfort, itching, burning and even soreness of the skin are possible. Post-peeling erythema lasts up to 5 days. Peeling and individual crusts can persist for 10-14 days. The rehabilitation period is up to 3 weeks. Medial peeling is carried out once or in courses, but not more often than once in six months.

Deep peeling is done using formulations containing phenol. When carrying out a deep exfoliation, a yellowish-gray frost appears. Subjectively, there is severe soreness of the skin, so it is performed under general anesthesia. After a deep peel, crusts are formed, which gradually separate to the 10th-14th day. Post-peeling erythema persists up to 2-4 weeks. The rehabilitation period takes about 30 days. Given the depth of necrosis, the risk of infection, scarring, as well as the toxic effect of phenol, deep peeling is performed by plastic surgeons in a hospital. Not all skin is processed often, but only its individual parts. Deep chemical peeling is carried out, as a rule, once. If necessary, repeated corrective measures decide the issue of microdermabrasion, local laser resurfacing, dermabrasion and other procedures.

[5]

Physical peeling

Superficial and superficial in depth physical peeling is achieved using creams-scrubs, peeling creams, ultrasonic peeling, disincrustation, microcrystalline dermabrasion (microdermabrasion). Microdermabrasion - skin resurfacing under the action of inert crystals of aluminum oxide powder, by means of which the layers of tissues exfoliate at different depths. At the same time, the crystals touching the skin produce a mechanical removal of the tissue fragments, then the removed fragments of the tissue together with the crystals are collected in a special container. Superficial purification of the skin and improvement of blood circulation is also due to vacuum massage. These techniques can be combined with chemical peelings.

Median physical peeling is achieved by microdermabrasion, dermabrasion and erbium laser (laser "polishing" of the skin). Dermabrasion is the removal of the epidermis and part of the dermis by contact of the skin with rotating abrasive nozzles, the speed of rotation of which is 40-50 thousand rpm. Laser "polishing" of the skin is carried out using an erbium laser, the main physical principle of which is the selective photothermolysis. For deep peeling, use dermabrasion and CO2 laser (on individual skin areas). In addition to the above indications, additional indications for the appointment of medium depth and deep peeling are tattoos. It should also be emphasized that all types of dermabrasion and deep "polishing" of the skin with the help of a laser are performed in the conditions of specialized cosmetology facilities by physicians who have been trained accordingly.

Complications of peelings

Early and late complications of peeling are distinguished by the timing of the onset. Early complications include secondary infection (pustulization, impstiginization), exacerbation of herpetic infection and allergic dermatitis, marked skin sensitivity, persistent edema (more than 48 hours) of soft tissues. Often there is exacerbation of acne, rosacea, seborrheic dermatitis and other chronic dermatoses. To late complications include persistent erythema of the face, hyperpigmentation, depigmentation, scar formation (after a medial and deep peelings). Important timely diagnosis of these diseases and conditions and the appointment of appropriate therapy. It is necessary to emphasize once again the need for a thorough elucidation of the allergic anamnesis, especially in atopic patients. An important role in the prevention of a number of complications is played by pre-peel preparation and post-peeling care.

[6], [7], [8]

Pre-peel preparation and post-peeling care

The goal of pre-peel preparation is to reduce the overall thickness of the stratum corneum and local keratotic layers. This is what will contribute to better penetration of the drug for peeling deep into the skin. Pre-peeling preparation can also be aimed at adapting the sensitive skin to the subsequent peeling. Usually, cosmetic preparations are used, including acids in low concentrations, which are prescribed daily, at night. The most popular alpha-, beta- and polyhydroxy acids, azelaic acid (Skinoren gel) can be used. At the stage of pre-peeling preparation, adequate photoprotection should be provided, patients are advised to refrain from staying in the sun or in a solarium. The duration of preparation depends on the depth of the expected peeling. When planning superficial peelings, it is recommended to prepare for 7-10 days. Before midline and deep peelings, preparation is shown, occupying the duration of the renewal of the epidermis, ie 28-30 days. When carrying out surface and surface-median peels for bleaching, it is desirable to use not only preparations containing hydroxy acids, but also substances that reduce the synthesis of melanin by melanocytes (azelaic acid, ascorbic acid, topical retinoids, glabridine, resorcinol, benzoyl peroxide, etc.).

Post-peeling care is aimed at restoring the barrier properties of the skin, reducing the severity of skin sensitivity, erythema, as well as preventing the formation of scars, secondary infection and other negative effects. To restore the barrier properties of the skin, moisturizers are used. When choosing a moisturizing cream consider its composition. So, for example, the inclusion of unsaturated fatty acids, ceramides and their precursors in the cream will help restore intercellular lipids. It is also advisable to take medications that include omega-fatty acids (El-theans idr.).

When skin sensitivity and persistent erythema appear, people use basic care products designed for sensitive skin. Moisturizing creams for daily care can include substances that affect the condition of the skin vessels (Roselyan, Urjazh, Rosaliac, La Rosh-Pose, Apizans Anticuperoz, Lierac, Dyrozale, Aven, etc.). From the physiotherapy procedures, microcurrent therapy is shown in the lymph drainage regime.

For the prevention of secondary pigmentation, active photoprotection is recommended by special means (for example, Photoderm laser, "Bio-derma"). Patients are contraindicated with ultraviolet irradiation, including in the solarium. It is for this reason that peelings are recommended to be carried out during the non-sunny season.