Complications of Chemical Peels, Lasers, and Energy-Based Device Procedures Performed by Core Cosmetic Physicians: A Retrospective Analysis.

BACKGROUND: There has been a proliferation of physicians of different levels of experience and training offering nonsurgical cosmetic procedures. Rising demand, compounded by increasing utilization of new and existing technologies by numerous physician specialties, compels discussion of adequate standardized training and patient safety. METHODS: A retrospective chart review of patients who presented to our single site dermatology clinic for managment of complications following chemical peel, laser or energy-based device treatments performed by core cosmetic physicians between the years of 2013 and 2024 was conducted. Core cosmetic physicians included plastic surgery, facial surgery/otolaryngology, oculoplastic surgery, and dermatology. Charts were reviewed for documentation of the type of complication, procedure causing the complication, and physician credentials, and referral source. RESULTS: Twenty-five patients were identified as having complications from chemical peeling, laser treatment or energy-based devices. Devices implicated included CO2 laser (fractional or fully ablative), chemical peels, 1064 nm long-pulsed Nd:YAG laser, 1320 nm Nd:YAG laser, intense pulsed light, 595 nm pulsed dye laser, Q-switched Nd:YAG laser, radiofrequency with and without microneedling, and 1550 nm erbium-doped fiber laser. Complications included hypertrophic scarring, atrophic scarring, post-inflammatory erythema, post-inflammatory hyperpigmentation, and post-inflammatory hypopigmentation. CONCLUSIONS: Even in experienced hands, complications can arise. It is imperative that all physicians offering cosmetic treatments are equipped to recognize clinical endpoints, identify and manage complications, or make a timely referral to decrease the risk of a permanent and potentially devastating esthetic outcome for patients.

Does Systemic Metformin Have a Role in Treating Melasma?

BACKGROUND: Melasma is a common pigmentary condition that affects the patients' quality of life and all the prescribed treatment options till now are not satisfactory, especially in dark-skinned patients. OBJECTIVE: To evaluate the efficacy and safety of systemic metformin (1,000 mg and 500 mg) combined with trichloroacetic acid (TCA) peeling versus TCA alone in the treatment of melasma. PATIENTS AND METHODS: The study included 60 melasma patients divided into 3 groups: Group A received systemic metformin (1000 mg/d), Group B received systemic metformin (500 mg/d) and Group C received placebo. The 3 treatment groups were treated by TCA 25% over the whole face bimonthly for a total of 6 sessions. Melasma area and severity index (MASI), and Melasma impact Quality of life Scale (MELASQOL) were used to assess the outcome. RESULTS: There was a statistically significant decrease in the MASI, and the MELASQOL in the 3 studied groups after treatment with significantly better improvement in Group (A) than Group (C) ( p = .045). CONCLUSION: Systemic metformin is a safe and promising therapeutic option for treating melasma.

Trichloroacetic Acid With Microneedling Versus Trichloroacetic Acid Alone for Treating Melasma.

BACKGROUND: Melasma is a common acquired disorder of hyperpigmentation which is difficult to treat. OBJECTIVE: We aim to evaluate the efficacy and safety of combined microneedling with trichloroacetic acid in the treatment of melasma. PATIENTS AND METHODS: Forty women with facial melasma were included and randomly classified into 2 groups. Group A included 20 patients treated with bimonthly session of trichloroacetic acid 25% peeling (8 sessions) combined with a monthly session of microneedling (4 sessions). Group B included the other 20 patients that were treated by bimonthly trichloroacetic acid 25% peeling session (8 sessions) alone. RESULTS: After 1 and 3 months of treatment, the mean melasma area and severity index, modified melasma area and severity index, and melasma severity index scores showed significant improvement in each group (p < .05 for each). At 1 and 3 months, the mean percentages of change of all scores were significantly higher in group A than group B (p < .05). CONCLUSION: Combined trichloroacetic acid peel with microneedling is effective and a safe option for treating melasma.

Endo-radiofrequency subcision in the treatment of acne scars: a pilot investigative study.

Acne vulgaris is a common condition, mostly involving teenagers. Post-acne scarring can cause many psychosocial problems. Treatments include topical agents, chemical peels, ablative lasers, fractional lasers, and more invasive approaches like subcision and surgery. We aimed to build on data regarding the efficacy and safety of endo-radiofrequency subcision in treating acne scars. This trial involved 30 patients (26 females and 4 males) suffering from acne scars. Patients were treated with endo-radiofrequency subcision. Outcomes were measured by Goodman and Baron scores (GBA), Patient's Global Assessment (PGA), and Investigator's Global Assessment (IGA). All 30 patients completed the trial. The mean baseline quantitative Goodman and Baron score was 13.2 ± 4.31, which improved to 5.37 ± 2.83 by the end of the study (P < 0.001). A significant improvement was also noted in the Goodman and Baron qualitative assessment of acne scars (P < 0.001). According to the PGA, the improvement rate was 25-50% in most patients (60%), while according to the IGA, the improvement rate was 25-49% in most patients (50%). Eleven patients (36.7%) were satisfied with the treatment process, while the other 19 patients (63.3%) were very satisfied. Side effects were minimal and transient. A single session of endo-radiofrequency subcision is a fairly safe and effective treatment, with a high satisfaction rate among treated patients.

Subcision, chemical peels, and platelet-rich plasma: Combination approaches for the treatment of striae distensae.

Striae distensae (SD) are disfiguring skin condition causing cosmetic troubles and psychological distress. The aim was to compare the efficacy and safety of platelet-rich plasma (PRP) versus its combination with subcision or medium-depth peeling (glycolic acid 70% followed by trichloroacetic acid [TCA] 35%) for SD treatment. Seventy-five female patients with SD were divided into three equal groups with the contralateral side in each patients represented the control group. Group A treated with PRP, group B received PRP + subcision while group C received PRP + combined peeling (GA 70% + TCA 35%). Primary outcome included clinical improvement, patients' satisfaction, and Dermatology Life Quality Index (DLQI). Striae measurement, skin biopsies were also assessed. Very much improvement was achieved in 28%, 44%, and 36% in groups A, B, and C respectively. The combined groups (B and C) showed significantly higher patients' satisfaction and DLQI than group A (p = 0.03), (p < 0.0001). A significant decrease in all striae measurements was achieved with all groups (p < 0.001); however, groups B and C showed more decrease (p = 0.2 and 0.4). A highly significant decrease in the mean number of sessions was found in group B (p < 0.0001). All groups demonstrated improvement in dermal collagen deposition, which was higher in the combined groups. Side effects were mild and well tolerated. The combination of PRP with subcision or peeling was more effective and offered a higher therapeutic response than PRP alone. Moreover, the subcision has superior efficacy in striae albae and safer in darker skin types.

Chemical peeling with 35% glycolic acid for the treatment of disseminated facial verruca plana: A randomized, split-face, evaluator-blinded trial.

Disseminated facial verruca plana is a chronic disorder that causes significant psychological distress. However, safe and effective treatment is lacking. This study aimed to explore the efficacy and safety of 35% glycolic acid (GA) for the treatment of disseminated facial verruca plana. A split-face clinical trial was conducted to explore the efficacy and safety of using chemical peeling with 35% GA for the treatment of disseminated facial verruca plana. One side of the face was applied with 35% GA once every fortnight for a total of three times. Adapalene gel was applied every night to the other side of the face as the control. The clearance rate of lesions was evaluated at different time points. Between June 2020 and December 2020, 30 patients with disseminated verruca plana who visited the Dermatology Hospital of Southern Medical University were enrolled. After three chemical peelings with 35% GA that was applied at 2-week intervals, 15 (50%) patients achieved >70% lesion reduction. The same effective rate in the adapalene gel-treated side of the face was documented in eight patients. Subgroup analysis showed a higher clearance rate in patients with a shorter disease duration. Moreover, concurrent improvements in facial roughness were observed in the 35% GA-treated group. Adverse effects including mild erythema and desquamation were observed during chemical peeling with 35% GA. In conclusion, chemical peeling with 35% GA could be a safe and effective option for treating disseminated facial verruca plana, especially for those who desire skin improvement.

Getting to the Core of Contemporary Therapies for Post-Inflammatory Hyperpigmentation.

Post-inflammatory hyperpigmentation (PIH) is a typical complication of inflammatory dermatoses that more frequently and severely affects people with darker skin. External insults to the skin, such as burn injuries, dermatologic treatments, and intrinsic skin disorders (eg, eczema and acne), are common causes of PIH. Individuals with darker skin are prone to develop PIH, which can cause substantial psychological suffering. PIH can be prevented or alleviated. When this happens, it is essential to point out what is causing it and treat it as soon as possible to prevent inflammation and PIH from progressing. If the inflammatory symptoms go away or there is no evidence of inflammation at the time of diagnosis, PIH treatments should be evaluated. To hasten the resolution of PIH, treatment should begin as soon as possible. Treatment begins with the care of the initial inflammatory condition. Topical medications, chemical peels, laser and light-based treatment, phototherapy, and other therapeutic modalities are offered to treat PIH. Understanding the therapy options available helps the physician in choosing the best treatment for each patient. With these backgrounds, the current review aimed to discuss the epidemiology, pathogenesis, clinical presentation, and available treatment options for the PIH. J Drugs Dermatol. 2022;21(3):276-283. doi:10.36849/JDD.6485.

Microdermabrasion assisted delivery of glycolic acid 70% peel for the treatment of melasma in dark-skinned patients.

Melasma is a disfiguring dermatologic condition and its treatment is still considered a challenge. To evaluate the efficacy and safety of microdermabrasion (MDA) combined with glycolic acid 70% (GA70%) peel versus GA70% alone in treating melasma in dark-skinned patients. This study included 30 female patients (skin type IV and V) with melasma. After cleansing the face, 3 passes of MDA were done on one side of the face. Then, GA70% was applied to the whole face in 1-2 uniform passes. Melasma area and severity index (MASI), modified MASI and hemi-MASI scores were used to assess the outcome. A significant decline of the mean MASI, mMASI and both hemi-MASI scores following treatment (p value = 0.000 for each). Furthermore, the hemi-MASI score on the MDA/GA70% treated side showed significantly greater decrease than the hemi-MASI score on GA70% treated side (p value = 0.041). MDA enhanced the improvement of GA70% peel effectively and safely.

Topical 5% tranexamic acid with 30% glycolic acid peel: An useful combination for accelerating the improvement in melasma.

Recently, topical Tranexamic acid (TXA) has been used in melasma management. On detail search of literature, this may be the first study-assessing efficacy on combining of Topical TXA with GA peel in melasma. The aim of this study is to assess efficacy, safety, and improvement in quality of life index on combining 30% GA peel with 5% TXA solution topically in melasma of epidermal type. Sixty patients of epidermal melasma were included in the study and were categorized into two groups: Combination group was treated with 30% GA peel at 2 weekly intervals with 5% TXA solution applied twice daily and Control group was treated with only 30% GA peel every 2 weeks for 12 weeks. Melasma area severity index (MASI) was used for assessing clinical improvement. Hi-MELASQOL and HRQOL scales were used to measure Melasma related quality of life and were compared between both groups. At each visit, adverse effects were noted. A significantly decreasing trend was seen regarding the MASI score when compared within the group, but the difference was statistically not significant between the two groups at 12 weeks. However, significant reduction in MASI score was attained earlier in the combination group than the control group. Similarly, there was significant improvement in Hi-MELASQOL and HRQOL in both the groups, but the difference between them was statistically not significant. Side effects experienced by patients in both groups were trivial and did not require stoppage of therapy. This study concluded that topical TXA with GA peel has comparable result with GA peel alone, but the therapeutic response was achieved in patients of combination group earlier in comparison to control group patients.

The factors influencing the unmet effects of alpha hydroxy acid peels on acne vulgaris: A single tertiary center experience.

Acne vulgaris is a common condition. Alpha hydroxy acid (AHA) peels have been previously recommended as an option for patients with intolerance to first-line treatments especially when long-term use. The safety and efficacy of AHA peels for acne have been established, but the factors influencing the ultimate effects are unknown. We recruited patients diagnosed with acne who were intolerant to or refused the first-line treatments from July 2017 to December 2019 at our hospital and retrospectively collected the medical and demographic information of patients treated with a full course of AHA peels; data collected included age, sex, treatment history, compliance status, and efficacy after treatment. The efficacy score was defined by revised scales: 2 points indicated significant improvement, 1 point indicated mild improvement, and 0 point indicated no improvement. Additionally, only efficacy scores of 2 points were classified in the satisfactory group; the others were classified in the unmet effect group. Analyses were used to evaluate the potential influencing factor(s). A total of 141 patients (120 females, 21 male) were included in the final analysis. The patients in the satisfactory group were significantly older (higher proportion aged >28 years) (47.4% vs 29.5%, P = .046) and showed better compliance (88.7% vs 54.5%, P = .001) than the patients in the unmet effect group. Multiple analyses confirmed the effects of younger age (OR 2.70, 95% CI 1.15-6.34, P = 022) and poor compliance (OR 2.74, 95% CI 1.74-4.32, P = .001) on the unmet effect. Unsatisfactory compliance and age might decrease the effects of AHA peels on acne.

Most worthwhile superficial chemical peel for melasma of skin of color: Authors' experience of glycolic, trichloroacetic acid, and lactic peel.

Glycolic acid (GA), lactic acid (LA) and trichloroacetic acid (TCA) peels have been used in various combinations for treating melasma patients, but none of the studies have compared their therapeutic efficacy and improvement in quality of life (QOL) index with these three peeling agents in melasma. Our study aims to compare the clinical efficacy, safety, tolerability and improvement in QOL index between 30% GA, 92% LA, and 15% TCA peeling in epidermal melasma. Ninety patients were divided into three groups with 30 in each. First group was treated with 30% GA peel, second with 92% LA peel, and third with 15% TCA peel at every 2 weeks interval for 12 weeks. Melasma area severity index (MASI) and QOL index (Melasma quality of life and Health related quality of life index) were used for clinical evaluation. Patients were observed for side effects and tolerability. The mean MASI score after therapy was significantly lower in patients treated with GA and TCA peels as compared with the group receiving LA peel. However, there was no significant difference in the mean MASI scoring at 12 weeks between GA peel and TCA peel groups. The improvement in QOL index was higher among patients undergoing GA peel followed by TCA and LA peel. Adverse effects were noted mostly with TCA peels followed by GA and LA peel. Thus, GA and TCA peels were equally efficacious and more effective than LA peels. LA peel had minimum side effects and better tolerability than GA and TCA peels.

Common Dermatologic Procedures and the Associated Complications Unique to Skin of Color.

BACKGROUND: The skin of color (SOC) population in the United States continues to grow, and these patients are undergoing various cosmetic and surgical procedures at increasing rates. There is a paucity of data on the potential complications associated with surgical and cosmetic procedures in this patient population. OBJECTIVE: We aim to educate dermatologic surgeons and clinicians on surgical and cosmetic procedures in patients of color and increase awareness of the potential complications unique to this patient population. MATERIALS AND METHODS: A thorough PubMed literature search was performed to conduct this review. RESULTS: There are a number of complications in SOC that require special attention, including keloids, postoperative infections, postinflammatory hyperpigmentation, and hypopigmentation. There are also various precautions to consider when performing cosmetic procedures, such as neurotoxin and filler injections, laser therapy, microneedling, and chemical peels. CONCLUSION: Dermatologists should be aware of the potential cosmetic and surgical complications of this growing patient population to provide optimal evidence-based medical care.

Chemical Peels as Field Therapy for Actinic Keratoses: A Systematic Review.

BACKGROUND: Actinic keratoses (AKs) are a common premalignant cutaneous neoplasm and can progress to squamous cell carcinoma. A variety of treatment options are available for field therapy of diffuse AKs. OBJECTIVE: This review systematically analyzes the use of chemical peels for treatment of AKs. MATERIALS AND METHODS: A systematic review of PubMed was performed searching from 1946 to March 2020 to identify the literature on chemical peels for AKs. RESULTS: Of the 151 articles identified, 5 met inclusion criteria for review. Four of the reviewed articles demonstrated the efficacy of chemical peels in reducing AK count and minimal adverse effects. In some studies, chemical peels exhibited potential to prevent additional AK formation and development of keratinocyte carcinomas. CONCLUSION: Chemical peels are an efficacious and affordable treatment option for field treatment of AKs. With improved patient tolerance and adherence, chemical peels are an attractive option for field therapy of AKs for both dermatologists and patients.

The Use of Tranexamic Acid to Prevent and Treat Post-Inflammatory Hyperpigmentation.

The risk of post-inflammatory hyperpigmentation (PIH) in patients undergoing dermatologic procedures is well known. It is especially common after laser procedures and chemical peels but can be seen with any procedure. PIH is also a sequela of acne, burns, and other trauma. High-risk patients are thought to have excessive production and abnormal distribution of melanin within the skin that triggers PIH, but the exact pathophysiology is unknown.1 We define high-risk patients as Fitzpatrick skin types 3–5, those with existing PIH, or a history of PIH.1,2 Tranexamic acid (TXA) is an antifibrinolytic medication prescribed to treat bleeding and is also used off-label to treat melasma. TXA is contraindicated in patients with hypercoagulable conditions, renal impairment, vision impairment disorders, pregnancy, breast-feeding, or on hormone therapies.3,4,5 From 2015–2020, we have used TXA off-label to successfully treat and/or prevent PIH in approximately 82 high-risk patients after injuries or prior to procedures that disrupt the epidermis. We also have used TXA to prevent PIH after acute injuries such as irritant dermatitis, thermal burns, and abrasions. We now consider TXA treatment for all at risk patients prophylactically before undergoing microneedling, cryotherapy, cryolipolysis, chemical peels, and laser treatments. J Drugs Dermatol. 2021;20(3) doi:344-345. 10.36849/JDD.5622.

Cryopeeling versus trichloroacetic acid peeling in the treatment of solar lentigines: Effect on epidermal Langerhans cells.

Trichloroacetic acid (TCA) peeling may be effective in solar lentigines, but with concerns regarding potential tumorigenesis. Cryopeeling would be better with improving the whole sun-damaged skin. We aimed to compare the efficacy and safety of cryopeeling and TCA 35% peeling for treatment of solar lentigines and assess their influence on the number of epidermal Langerhans cells (LC). Twenty-five patients were treated with TCA 35% and cryopeeling on the right and left hands, respectively. Two sessions were done 3 weeks apart. Evaluations were scheduled at weeks 0, 3, and 6. Skin biopsies, taken before and after treatment, were evaluated histologically and immunohistochemically for the number of CD1a + epidermal LCs. Lentigines decreased after cryopeeling from the first session (p < .001), but after the second session with TCA peeling (p = .004). Cryopeeling produced significant lightening, compared with TCA (p = .015). Blistering, hyper/hypopigmentation were reported with cryopeeling, whereas only hyperpigmentation was noted after TCA peeling. The LCs remained at about the pretreatment number after cryopeeling (p = .058), though they decreased after TCA (p = .002). Cryopeeling provided faster and superior improvement of lentigines compared with TCA peeling. Furthermore, TCA seems to suppress LCs raising the concern for carcinogenic potential.

Depth Map for Face and Neck Deep Chemical Peel Resurfacing.

BACKGROUND: Chemical peels are applied to the face and neck to improve rhytides and the photoaged appearance of the skin. Peels can be applied to different skin depths depending on the types of chemicals, the volume of solution, and the amount of pressure or friction applied. If a peel is applied too superficially, rhytides will not be removed. If a peel is applied too deeply, scarring or hypopigmentation could occur. OBJECTIVE: To create face and neck depth maps for chemical peeling, which can guide safety when removing rhytides and improving the skin's appearance. MATERIALS AND METHODS: A multicenter retrospective review of records was conducted of patients who underwent phenol-croton oil peeling, from January 1, 2018, to December 31, 2018. Information was collected on facial and neck cosmetic units peeled, peel formula and strength used, outcomes, and complications. RESULTS: A total of 410 patients received deep peels. Two depth maps were created that corresponded to the most common patterns of deep chemical peel applications. CONCLUSION: Different areas of the face and neck are treated with different chemical peel application depths to safely improve rhytides and appearance. Depth maps are created to balance safety and efficacy.

[Chemical peeling for treatment of Melasma, pigmentary disorders and hyperpigmentation : Indications, effectivity and risks]. / Chemical Peelings zur Behandlung von Melasma, Pigmentstörungen und Hyperpigmentierungen : Indikationen, Effektivität und Risiken.

Pigmentary disorders and hyperpigmentation are widespread. Dark skin types in particular show a tendency to formation of melasmas and to hyperpigmentation. Light skin types have a tendency to ephelides and solar lentigines. In addition to topical treatment with lightening substances, superficial chemical peeling as well as combined procedures of topical treatment with chemical peeling play an important role in the treatment of hyperpigmentation. A strict avoidance of UV light and consequent daily application of sun protectíon factor 50+ are mandatory for successful treatment.

Advanced chemical peels: Phenol-croton oil peel.

Once considered the standard for deep facial resurfacing, the classical Baker-Gordon phenol-croton oil peel has largely been replaced by formulas with lower concentrations of phenol and croton oil. The improved safety profile of deep peels has ushered in a new era in chemical peeling. Wrinkles can be improved and skin can be tightened with more subtle and natural results. No longer does a deep peel denote "alabaster white" facial depigmentation with complete effacement of wrinkles. Gregory Hetter's research showed that the strength and corresponding depth of penetration of the phenol-croton oil peel can be modified by varying the concentration of croton oil. This second article in this continuing medical education series focuses on the main historical, scientific, and procedural considerations in phenol-croton oil peels.

Basic chemical peeling: Superficial and medium-depth peels.

Chemical peeling, or chemexfoliation, has been used for centuries to improve signs of ultraviolet light-induced sun damage. Over the last 30 years, the science behind chemical peeling has evolved, increasing our understanding of the role of peeling ingredients and treatment indications. The depth of peels is directly related to improved results and to the number of complications that can occur. Key principles for superficial and medium depth peeling are discussed, as well as appropriate indications for these treatments.