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CASE REPORT
CHEMICAL PEELING IN
ETHNIC SKIN
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. CASE REPORT
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 1b). 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 Discussion
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 CASE REPORT
ARTICLES
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. Conclusion
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. Declaration
Genop Healthcare donated the Neostrata peeling kit.
References
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 Derm1997;137:934-938 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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