Considerations for Laser Therapy, Microneedling, and Chemical Peels When Treating Patients With Skin of Color.

Over the past 10 years, we have seen exponential growth in the aesthetic industry. With this growth, we have also seen an influx of patients of differing ethnicities, in all varying shades of color. Some clinicians may not have the necessary knowledge and skill to appropriately treat these patients using modalities such as laser therapy, microneedling, and chemical peels. The aesthetic industry provides courses, conferences, and educational guides for helping aesthetic practitioners determine which patients are eligible to undergo these treatments. However, there is a considerable lack of information available for clinicians about treatment modalities that can be safely and effectively used on patients with Fitzpatrick skin types IV-VI. As the population of patients of various ethnic origins seeking aesthetic treatments continues to grow, it is imperative for clinicians performing these treatments to increase their knowledge and skill related to treating patients with skin of color. The purpose of this article is to educate aesthetic clinicians about appropriate treatments, procedures, and protocols for preventing adverse reactions in patients with skin of color who are undergoing aesthetic treatments using lasers, microneedling, and chemical peels.

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.

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.

Melasma: A critical analysis of clinical trials investigating treatment modalities published in the past 10 years.

BACKGROUND: Melasma is an acquired disorder of facial pigmentation which is a treatment challenge. AIMS: The aim of this article is to critically appraise the clinical trial evidence for different treatment modalities for melasma, published in peer-reviewed journals in the past 10 years. PATIENTS/METHODS: The literature review was conducted using PubMed and MEDLINE. The search was performed in July 2019, and search parameters were limited to all English language articles published in the past 10 years only. RESULTS: Eighty-nine clinical trials were found. Four clinical trials investigated topical hydroquinone, supporting its safety and efficacy as first-line treatment. Twelve studies showed tranexamic acid as very promising. Nineteen studies assessed various novel oral, injectable, and topical treatments and highlight some new potential future treatments. Forty-two studies investigated laser and light treatment in melasma: LFQS laser is still one of the best options, especially in darker skin types. However, the picosecond laser has shown excellent results. Finally, 11 studies looked at peels. Overall, peels have not been shown to be superior to the use of topical therapy alone. CONCLUSION: Topical therapy with a HQ and retinoid-based product should be first line for a minimum of 3 months with the addition of oral tranexamic acid at 250 mg BD if no contraindication. Second-line treatment with lasers includes the LFQS Nd:YAG, picosecond laser, and the pulsed dye laser in lighter skin types. Third-line therapy would be the addition of chemical peels to the above treatments, with GA or TCA peels having the most evidence for effectiveness.

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.

Efficacy and tolerability of using platelet-rich plasma versus chemical peeling in periorbital hyperpigmentation.

BACKGROUND: Various therapeutic modalities for periorbital hyperpigmentation (POH) have been proposed. OBJECTIVE: This study was designed to compare the efficacy and tolerability of autologous platelet-rich plasma (PRP) and chemical peeling in POH. SUBJECTS AND METHODS: Forty-two patients were enrolled in this study and randomly subdivided into two groups. Group A patients were assigned to receive four sessions of chemical peeling using trichloroacetic acid and lactic acid, while group B was assigned to patients who received four sessions of PRP injection with 2 weeks of intervals. Patients were assessed by digital photographs. The degree of improvement included four degrees from poor to excellent, and side effects were reported. RESULTS: Females constituted 38 out of 42 patients (mean age, 28.14 ± 3.47 years). There was a significant improvement in favor of chemical peeling over PRP. Good improvement occurred in 47.6% in the group A versus 4.8% in group B (P < 0.001). None of the PRP group had excellent improvement, while 38% of chemical peeling group did. Most of group A patients reported very pleased (47.6%) to excellent (38%) degree, in contrast to group B where 52.5% were just pleased (P < 0.001). Some of group A patients experienced itching (14.3%) and redness (14.3%), while in group B, they experienced pain (23.8%) and edema (14.3%) with nonsignificant difference between both groups (P = 0.07). CONCLUSIONS: Both PRP and chemical peeling are effective for treatment of POH; however, chemical peeling is much more effective, tolerable, and satisfying procedure than PRP.

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.

Complicaciones y manejo de procedimientos dermatoestéticos: una actualización para el dermatólogo / Complications associated with cutaneous aesthetic procedures: an update for the dermatologist

En las últimas décadas se han desarrollado nuevas técnicas e indicaciones de los procedimientos estéticos mínimamente invasivos, presentando cada vez mejores resultados con un alto nivel de seguridad, sin embargo, estos no se encuentran exentos de complicaciones, las que pueden ser transitorias o permanentes. El conocimiento, abordaje, tratamiento y prevención de las distintas complicaciones son esenciales para los dermatólogos y cirujanos plásticos. Los procedimientos más utilizados son: administración de rellenos, peeling químicos, láser, luz pulsada intensa y ultrasonido de alta frecuencia. La siguiente revisión tiene como objetivo reconocer las principales complicaciones de estos procedimientos y su manejo.

In recent decades, new techniques and indications of minimally invasive aesthetic procedures have been developed, presenting increasingly better results with a high level of safety, however these are not exempt from complications, which may be transient or permanent. The knowledge, approach, treatment and prevention of the different complications are essential for the dermatologist and plastic surgeons. The most used procedures are the administration of fillers, chemical peels, lasers, intense pulsed light and high frequency ultrasound. The following review aims to recognize the main complications of these procedures and their management.

The Evolution of Chemical Peeling and Modern-Day Applications.

Despite the growth of technically more sophisticated skin resurfacing modalities, such as those based on light, radiofrequency, and ultrasound, chemical peel procedures have risen 5 to 25 percent over the past year alone. Chemexfoliation carries historical significance and has markedly evolved since its inception in ancient times. As a result of plastic surgery and dermatologic advancements, modern-day chemexfoliation offers plastic surgeons additional safe and effective options for patients with rhytides, dyschromias, and other signs of light- and environment-induced skin damage. This review discusses the historical evolution of chemexfoliation procedures, highlights modern-day practice habits, and touches on the clinically relevant applications of chemical peels.

Effect of different types of therapeutic trauma on vitiligo lesions.

New treatment modalities for vitiligo acting by changing certain cytokines and metalloproteinases are newly emerging. The aim of this work is to To assess the efficacy of trichloroacetic acid (TCA) chemical peel, dermapen, and fractional CO2 laser in treatment of stable non-segmental vitiligo and to detect their effects on IL-17 and MMP-9 levels. Thirty patients with stable vitiligo were recruited in a randomized controlled study. They were randomly categorized into three equal groups. Group 1: TCA peel, Group 2: dermapen machine, and Group 3: Fractional CO2 laser. Skin biopsies were taken from treated areas and from control areas for which MMP-9 and IL-17 tissue levels were measured using ELISA. The 30 vitiligo patients had low basal tissue MMP-9 levels and high baseline IL-17 tissue levels. As regards the three different used modalities, all of them caused rise in MMP-9 as well as IL-17 levels and almost their levels were much more elevated with repetition of the previously mentioned traumatic procedures. TCA 25% peel proved to be the most effective modality both clinically and laboratory and it can be used prior or with other conventional therapies in the treatment of vitiligo.

Adjuvant alternative treatment with chemical peeling and subsequent iontophoresis for postinflammatory hyperpigmentation, erosion with inflamed red papules and non-inflamed atrophic scars in acne vulgaris.

The standard management of acne vulgaris in Japan includes a combination of topical treatment with benzoyl peroxide (BPO) and BPO/clindamycin (CLDM), topical adapalene and systemic antimicrobials. However, the treatment of therapy-resistant complications such as postinflammatory hyperpigmentation (PIH), erosions with inflamed red papules and atrophic scars has not been established. We performed chemical peeling with glycolic acid and iontophoresis with ascorbyl 2-phosphate 6-palmitate and DL-α-tocopherol phosphate for the treatment of PIH, erosions with inflamed red papules and non-inflamed atrophic scars in 31 patients with acne vulgaris (mild to severe severity), and evaluated the efficacy and safety of these interventions. In most of cases, there was remarkable improvement in PIH and erosions with inflamed red papules after treatment. There was also some improvement in non-inflamed atrophic scars without erythema. Mild redness and irritation was observed in four cases as adverse reactions. Early initial treatment of PIH and erosions with red papules by chemical peeling and iontophoresis is an effective and safe method to prevent the formation of atrophic scars in patients with acne vulgaris.

Clinical comparison of salicylic acid peel and LED-Laser phototherapy for the treatment of Acne vulgaris in teenagers.

Acne vulgaris treatments usually cause sensitivity, teratogenicity and bacterial resistance. Investigations of other therapeutic techniques, such as phototherapy, are highly relevant. Thus, we compared the effectiveness of two Acne vulgaris treatments in adolescents: peeling with salicylic acid (SA) and phototherapy. Teens were randomly divided into: group I, treatment with SA peels (10%) and group II, treatment with phototherapy (blue LED and red laser lights). Photographs were taken before and after ten sessions of each treatment, carried out weekly, and compared. To compare the differences between the treatments, the Student t-test was used. P values < 0.05 were considered significant. Both techniques are effective therapies for the treatment of acne in teenagers since the number of comedones, papules and pustules decreased significantly at the end of the session. However, when the two treatments were compared, phototherapy showed a significant difference in reducing the number of pustules. The combined use of red and blue lights due to their anti-inflammatory and wound-healing properties is a more efficient alternative for treating Acne vulgaris in relation to SA and proves more reliable and without side effects, improving the adolescents' skin health.

Preventing, identifying, and managing cosmetic procedure complications, part 2: lasers and chemical peels.

Part 1 of this series highlighted some of the potential complications that have been associated with soft tissue augmentation and botulinum toxin injections. In part 2, tips for how dermatology residents may prevent, identify, and manage complications from lasers and chemical peels for optimal patient outcomes are provided.

Complications in the Cosmetic Dermatology Patient: A Review and Our Experience (Part 2).

BACKGROUND: Over recent decades, the options available to patients for cosmetic rejuvenation have expanded dramatically. The range of options commonly available to patients now includes neuromodulators, fillers, sclerotherapy, chemical peels, lasers, lights and other energy devices, and liposculpture and continues to grow. Like all therapeutic interventions, these cosmetic dermatologic procedures are not without risk. Timely recognition of complications and intervention are paramount for optimal patient outcomes. OBJECTIVE: Part 1 of this review focused on the common complications that may result from injectable cosmetic procedures. The second part will discuss the complications of chemical peels, lasers, light and energy devices, and fat removal/sculpture procedures. MATERIALS AND METHODS: A MEDLINE search was performed on cosmetic dermatology complications from 1989 to 2015, and results are summarized. Practical considerations of these complications are also provided. RESULTS: Reports of complications after neuromodulator, injectable hyaluronic acid, calcium hydroxylapatite, poly-L-lactic acid, polymethylmethacrylate, sclerotherapy, fat transfer, liposuction, cryolipolysis, chemical peels, lasers, and light sources, such as Q-switched laser, intense pulsed light, and nonablative and ablative resurfacing lasers, were found. CONCLUSION: Review of the literature revealed multiple management options for potential complications of the multitude of cosmetic dermatology procedures now available to patients.

Chemical peels: panel discussion.

Edwin Cortez, Fred Fedok, and Devinder Mangat address questions for discussion and debate. Do you agree or disagree, and why, with the following: "The best method to improve moderate to deep rhytids is the croton oil-phenol peel." "There are no problems with cardiotoxicity with croton oil-phenol peels if done appropriately." "Do not do spot testing with chemical peel agents." How do you handle peels in advanced Fitzpatrick skin types III, IV, V? What is the main factor for rate of reepithelialization: (1) depth of peel, (2) depth of laser, (3) depth of dermabrasion? How has your approach to or technique in chemical peels evolved over the past several years?

Split-face comparative study of 1550 nm fractional photothermolysis and trichloroacetic acid 15% chemical peeling for facial melasma in Asian skin.

Fractional photothermolysis (FP) therapy and chemical peels have been reported to be effective in patients with recalcitrant melasma. However, there is little information to compare the efficacy of single treatment session in Asian women. The aim of this study was to examine the efficacy, long-lasting outcomes and safety of a single session of 1550-nm erbium-doped FP in Asian patients, compared with trichloroacetic acid (TCA) peel with a medium depth. Eighteen Korean women (Fitzpatrick skin type III or IV) with moderate-to-severe bilateral melasma were randomly treated with a single session of 1550-nm FP on one cheek, and with a 15% TCA peel on the other cheek. Outcome measures included an objective melasma area severity index and subjective patient-rated overall improvement at 4 and 12 weeks after treatment. Melasma lesions were significantly improved 4 weeks after either treatment, but melasma recurred at 12 weeks. Post-inflammatory hyperpigmentation developed in 28% of patients at 4 weeks but resolved in all but one patient by 12 weeks. There was no difference between FP treatment and TCA peeling with respect to any outcome measure. FP laser and TCA peel treatments were equally effective and safe when used to treat moderate-to-severe melasma, but neither treatment was long-lasting. We suggest that multiple or periodic maintenance treatments and/or supplemental procedures may be required for the successful treatment of melasma in Asian women.

A comparative study on efficacy of high and low fluence Q-switched Nd:YAG laser and glycolic acid peel in melasma.

BACKGROUND: Melasma is acquired symmetric hypermelanosis characterized by light-to-deep brown pigmentation over cheeks, forehead, upper lip, and nose. Treatment of this condition is difficult and associated with high recurrence rates. With the advent of newer therapies, there is interest in the use of glycolic acid peels and Q-switched Nd:YAG laser (QSNYL) in high and low fluence for this disorder. AIMS: To compare the therapeutic efficacy of low fluence QSNYL, high fluence QSNYL, and glycolic acid peel in melasma in three study groups of 25 patients each. METHODS: Seventy-five Indian patients diagnosed as melasma were included. These patients were randomly divided in three groups (Group A = 25 patients of melasma treated with low-fluence QSNYL at weekly intervals, Group B = 25 patients of melasma treated with glycolic acid peel at 2 weeks intervals, Group C = 25 patients of melasma treated with high-fluence QSNYL at 2 weeks intervals). Study period and follow-up period was of 12 weeks each. Out of the 75 patients included, 21 patients in Group A, 19 patients in Group B, and 20 patients in Group C completed the study. Response to treatment was assessed using melasma area and severity index score. RESULTS: Significant improvement was recorded in all the three groups. The improvement was statistically highly significant in Group A as compared to Group C (P<0.005), significant in Group A as compared to Group B (P<0.05), and also in Group B when compared to Group C (P<0.05). Low-fluence QSNYL was associated with least side effects. CONCLUSIONS: This study shows the efficacy of low-fluence QSNYL and glycolic acid peel in melasma. These could be an effective treatment options compared to conventional methods for the treatment of melasma.

Chemical face peeling.

Chemexfoliation is an excellent method to reduce facial rhytids. For 25 years, we have used the traditional formula as described by T. J. Baker but with a moist healing technique rather than a tape mask. We have found the peel to be inexpensive and easy to perform, with results that are excellent and consistent, with minimal side effects.

595-nm long pulsed dye laser and 1450-nm diode laser in combination with intralesional triamcinolone/5-fluorouracil for hypertrophic scarring following a phenol peel.

Hypertrophic scars and keloids are a therapeutic challenge because of the low response to treatment and recurrences after treatment. A variety of treatment regimens have been used with different degrees of success, with no universally accepted treatment protocol resulting in their complete and permanent resolution. We offer this case to demonstrate a combination approach for the treatment of hypertrophic scarring. A 75-year-old woman (with Fitzpatrick skin type II) presented with a 4-month history of scarring, which had developed following a phenol peel for perioral rhytides. The patient underwent 10 treatment sessions with the 595-nm long-pulsed dye laser followed immediately by the 1450-nm diode laser in combination with intralesional triamcinolone and 5-fluorouracil. After the fifth treatment session, about 90% improvement was noted; at the last treatment session, greater than 95% overall improvement was noted. Two and a half years after the last treatment session, the patient and treating physician noted no regression. A limitation of this therapy is that the combination approach makes it difficult to determine what individual contributions each treatment modality had on the final result. We have illustrated a successful multifaceted treatment regimen for hypertrophic scars and keloids using a combination approach.

Croton oil peels.

This author discusses the utility and versatility of the modern croton oil peel, which, unlike older formulations, may be used for all ages and skin types for effective and long-lasting skin resurfacing. He provides the rationale for various croton oil concentrations, focusing on avoiding complications while achieving a desirable clinical result and includes a comprehensive guide to application, appropriate formulas, and the perioperative process. Of significance is that this is a procedure with a distinct learning curve; the goal for the experienced practitioner is to control the application process, proceeding slowly enough to be able to stop at the appropriate depth.