Sadr v9n1 pages
CHEMICAL PEELING IN
Dr Gloria Mmankurata Tshukudu & Dr ZF Annandale.
Background: Chemical peeling for skin of colour arose in Egypt, Mesopotamia and other ancient cultures in andaround Africa. Egyptians bathed in sour milk to smooth the skin utilising the properties of Alpha-hydroxy acids (AHAs).1Chemical peeling agents are varied. Superficial agents are many and varied. Superficial agents include Alpha HydroxyAcids (AHAs), salicylic acid, resorcinol, and Jessner's solution and trichloroacetic acid (TCA) at 10-35%concentrations. The most feared complication is scarring. Those at risk are patients with histories of poor healing andkeloid formation, patients undergoing deep peels patient recently on Accutane therapy and those who develop infectionduring the peel.2 In ethnic or dark skin our efforts are focused on superficial and medium depth peeling agents andtechniques.
Objective: To determine the effect of chemical peeling on ethnic (dark) skin in terms of safety and tolerance Methods: 25 women of Fitzpatrick Type V-VI between 16 and 45years. Of the 25 women, twelve had acne, five had acnescarring, six had melasma and two had acne and post inflammatory hyperpigmented scarring. All information regardingthe treatment and the complication which may occur as a result of the treatment were let known to the patients. Peelingprocedure was done according to Neostrata peeling protocol. All the patients were started with a 20% and the proceededto 35% to 50%.Peeling interval was 4 weeks. Pre and post peel photos were taken.
Results :The results show improvement in the patient's condition. Marked clearing of acne and improvement in melasmawas noted in the study group.
Conclusion: In the 18 month period there was no evidence of hyperpigmentation or scarring in the study group.
Introduction and Objectives
This is especially true in the treatment of pigmentationabnormalities and actinic keratosis.
Induction of an inflammatory reaction induced by the
Chemical peeling for skin of colour arose in Egypt,
chemical agent. Activation of the mediators of
Mesopotamia and other ancient cultures in and around
inflammation is able to induce production of new
Africa. Egyptians bathed in sour milk to smooth the skin
collagen and ground substance in the dermis. Epidermal
utilising the properties of alpha-hydroxy acids.1 Chemical
wounds are capable of inducing deposition of collagen
peeling is basically an accelerated form of exfoliation
induced by use of chemical agent. Superficial peeling agentsinclude a faster sloughing of the cells in the stratumcorneum, whereas deeper peeling agents create necrosis and
Chemical peeling agents are varied. Superficial agents are
inflammation in the dermis or reticular dermis.2
many and varied. Superficial agents include Alpha HydroxyAcids (AHAs), salicylic acid, resorcinol, and Jessner's
Chemical peeling creates changes in the skin through three
solution and trichloroacetic acid (TCA) at 10-35%
concentrations.1,2,3 AHAs cosmetic effects include increased
Stimulation of epidermal growth through removal of
flexibility of the stratum corneum and decreased
stratum corneum. Even light peels that do not create
formulations of dry, flaky scales on skin surface. Applied in
necrosis of “the living dermis” can induce the epidermis
lower concentrations, AHAs promote desquamation and
temporary thinning of the corneum, eventually leading to a
Destruction of specific layers of damaged skin. By
point at which cells formed and shed at a normal rate and
destroying the layers and replacing them with normalised
pattern. AHAs are organic carboxylic acids with one
tissue, a better cosmetic result is achieved.
hydroxyl group attached to the position of the acid.
Many AHAs are non toxic and occur naturally in plants,
peel. In the melasma group a peel booster was used after the
animals or body tissues. AHAs in common clinical use
include glycolic acids and lactic acid.4 Indications forchemical peeling in darker skin include acne vulgaris; post
The number of peels per patient ranged from 6-10. Peeling
inflammatory hyperpigmentation, melasma, scarring,
was done every 4 weeks and follow up period ranged from
photodamage and pseudofolliculitis barbae.2,3 Chemical
6- 18 months. Pre - and post peel photos of each patient
peeling can be used alone or in combination with the
bleaching agents for the treatment epidermal and mixedtypes of melasma. For the epidermal melasma (checked with
Wood's lamp) even superficial peeling gives excellentresults. For the mixed types of melasma a medium chemical
The results show improvement in the patient's condition.
peeling sometimes stimulates melanogenesis resulting to a
Skin tolerance was noted after the second peel. In the acne
worsening of the hyperpigmented patches especially in dark
group, marked clearing of acne was seen (see figure 1a and
). This effect was noticed after the third peel in most of thepatients. In the melasma group improvement in patient's
The most feared complication is scarring. Those at risk are
pigmentation was seen after the fifth peel (figure 3 and 4
patients with histories of poor healing and keloid formation,
When asked to evaluate their skin in terms of mild, moderate
patients undergoing deep peels patient recently on Accutane
and significant improvement worsening of condition most of
therapy and those who develop infection during the peel.2 In
the patents reported significant improvement, while 3 of the
ethnic or dark skin our efforts are focused on superficial and
patients reported mild to moderate improvement in their
medium depth peeling agents and techniques. The objective
of this study was to determine the effect of chemical peeling,tolerance and safety on ethnic (dark) skin
Chemical peeling is largely a cosmetic procedure.
Indications depend on the patient's tolerance and wishes for
25 women of Fitzpatrick Type V-VI between 16 and 45years.
correcting the skin textural problems. Fitzpatrick skin types
Initially the group consisted of 40 women. Most of the
IV-VI have significantly increased chance of developing post
patients about 8 left after the first peel procedure, the other
inflammatory hyperpigmentation.2 It is important to know
two left because they were pregnant and one reported an
that when peeling darker skin, the peel has to be started
allergic reaction a day after the peel procedure. Of the 25
slowly and conservatively to avoid inducing additional post
women, twelve had acne, five had acne scarring, six had
inflammatory hyperpigmentation. The peel must be
melasma and two had acne and post inflammatory
neutralized at the first sign of erythema and certainly before
hyperpigmented scarring. Patients were fully informed about
epidermolysis to prevent further hyperpigmentation
the aim of the study, the possibility of side effects and the
complications.3 A pre -peel photograph was taken and was
complications of the treatment. A formal written consent to
used as a baseline. Skin tolerance was noted after the second
the chemical peeling procedure was obtained from each
peel. Maximum peel concentration that could be tolerated
patient. The clinical history was collected from each patient
was 50%. Averages of three peels were done for acne patients
on their first visit, with special attention to previous and
and six peels melasma patients and acne scarring patients. As
current dermatological therapy, occupation and allergies.
seen in (figure 2
) the patient presented with acne and post
The patients were advised to stop all topical treatment except
inflammatory hyperpigmentation scarring and a marked
for their cleanser and moisturising cream. Patients were
clearing was seen after six peels. Significant clearing of acne
strongly advised to apply sunscreen and to wear protective
was seen in the patient in (figure 1
) after three peels. Similar
results were obtained in acne patients peeled with glycolicacid. A significant improvement of coexisting post acne
Peeling procedure included AHAs from Neostrata. No pre-
superficial scarring was noted.5 Four out of five melasma
conditioning of the skin done. Peeling procedure included
patients showed a dramatic improvement in their melasma
cleansing, application of petroleum sparingly to the medial
after an average of 5 peels as seen in figure 3 and 4
and lateral canthi of the eyes, nasolabial folds commissure oflips and the lips themselves. This protected the sensitive
In a study done by Cotellessa et al
, it was found that both
areas from pooling of the glycolic acid solution. The eyes
TCA and glycolic acid peels were effective in the treatment
of cutaneous hyperpigmentation.9 Superficial improvementin skin texture, pigmentation and acne has been observed by
All the patients were started with a 20% and the proceeded
patients. Some patients reported improvement in skin texture
to 35% to 50%. Some of the patients had to be peeled twice
with minimum change in their pigmentation. This was noted
with 20% peel concentration before they could tolerate the
Figure 1A:Significant clearing of acne after 3 peels.
Figure 4: Improvement in their melasma after 5 peels
No evidence of post inflammatory hyperpigmentation orworsening of condition was observed in the study group inthe 18 months period.
The peeling agent was well tolerated and safe to use inFitzpatrick V-VI. It is illustrated in this study that there areclinically proven benefits in the use of glycolic acid peel.
Most of the patients in the study group were satisfied withthe treatment
Figure 1B: Significant clearing of acne after 3 peels.
Genop Healthcare donated the Neostrata peeling kit.
1. Roberts W.E. Chemical Peeling in ethnic/dark skin:
2. Rubin M.G., Complications. In: Manual of Chemical Peels.
Philadelphia: JB Lippincott Company, 1995; 130-153
3. Briden M.E. Alpha-Hydroxyacid Chemical peeling Agents:
Case Studies and Rationale for Safe and Effective Use:Cutis
. 2004; 73 (Suppl 2): 18-24
4. Bernstein Eric F, , Green B.A., Edison B., Wildnauer R.H. ,
Poly Hydroxy acids(PHAs): Clinical uses for the next
Figure 2: Clearing of inflammatory hyperpigmentation
generation of Hydroxy acids. Supplement to Skin & Aging.
5. Andreas D., Katsambas A., Syngros hospital. University of
Anthens, Anthens, Greece Chemical peelings for thetreatment of melasma. Luncheon discussions.WS113
6. Ghersetich I., Teofoll P. Gantcheva M. Ribuffo M Puddu P.
Chemical peeling: How, When, Why? Journal of theEuropean Academy of Dermatology and Venerology.
8 (1997) 1-11
7. Beradesca E, Distante F, Vingoli GP, Oresajo C, Green B.
Alpha hydroxy acids modulate stratum corneum barrierfunction. Brit J Derm
8. Atzori L., Brundu M.A., Orru A., Biggio P. Glycolic acid
peeling in the treatment of acne. Journal of the EuropeanAcademy of Dermatology and Venerology
Vol. 12, Issue 2,1 March 1999. 119-122
9. Cotellessa C. Peris K. Onorati M.T. Fargnoli M.C.,
Chimenti S. The Use of Chemical Peelings in the Treatment
Figure 3: Improvement in their melasma after 5 peels
of Different Cutaneous Hyperpigmentations
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