Characterization of the Activity of Croton tiglium Oil in Hetter's Very Heavy Phenol-Croton Oil Chemical Peels.

BACKGROUND: Croton oil (CO) is used by dermatologists and plastic surgeons in deep chemical peels. It is mixed with phenol, water, and a soap in Baker-Gordon's or Hetter's formulas. There is controversy as to whether CO or phenol is the active agent in the dermal effect of deep chemical peels. OBJECTIVE: To better clarify the role of CO in deep peels, by identification of active compounds in commercially available CO in the United States and biological effects in vivo. MATERIALS AND METHODS: Liquid chromatography-tandem mass spectrometry on CO and a domestic pig model experiment using 3 different formulas: G1: 5% Septisol (SEP), G2: 1.6% croton oil in 35% phenol with 5% SEP, and G3: 35% phenol with 5% SEP. RESULTS: Liquid chromatography-tandem mass spectrometry indicated the presence of phorbol esters. G1 was null overall. Extent of the coagulative necrosis: G2 > G3. Vascular ectasia: G2 > G3. Inflammation pattern: intense neutrophilic inflammatory band in G2 versus mild, sparse, perivascular mononuclear cell infiltrate in G3. Neocollagenesis: pronounced in G2, negligible in G3. CONCLUSION: Coagulative necrosis of the epidermis, superficial fibroblasts, and vasculature can be attributed to the action of phenol. Phorbol esters on CO could be responsible for the dense deep acute inflammation and the distinctive neocollagenesis.

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.

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.

A Study Comparing the Efficacy of Monopolar Radiofrequency and Glycolic Acid Peels in Facial Rejuvenation of Aging Skin Using Histopathology and Ultrabiomicroscopic Sonography (UBM) - An Evidence Based Study.

BACKGROUND: Radio frequency (RF) and chemical peels have been used for nonablative skin rejuvenation. Both of these cause collagen remodeling in the dermis and neo-collagen formation resulting in facial rejuvenation. There is limited literature on the evaluation of collagen remodeling by objective methods. OBJECTIVE: To compare the benefits of monopolar radiofrequency and glycolic acid peels in facial rejuvenation with regards to histopathology and Ultrabiomicroscopic sonography (UBM). METHODOLOGY: In this study, forty patients with mild to moderate photoaging received four treatments with 3 weeks interval of monopolar radiofrequency on one side of face and glycolic acid peels in increasing concentrations (NeostrataR) on the other side. Pre and post treatment, 2 mm biopsies were taken from both preauricular areas and Ultrasonography using a 35 MHz probe was done from outer canthus of eye and nasolabial folds from both sides of face. A blinded assessment was done to measure the increase in the grenz zone and dermal thickness. RESULTS: In 35/40 patients there was a significant increase in the grenz zone on histopathology and decrease in subepidermal low-echogenic band (SLEB) on UBM of the nasolabial folds on both sides of the face (p < 0.05). CONCLUSION: Radiofrequency and chemical peels showed equal efficacy in the treatment of facial rejuvenation.

A comparative study of low-fluence 1,064 nm Q-Switched Nd:YAG laser with or without chemical peeling using Jessner's solution in melasma patients.

BACKGROUND: Although low-fluence 1,064-nm Q-switched Nd:YAG laser (QSNYL) is widely used for the treatment of melasma, multiple treatments are necessary for clinical improvement. Superficial chemical peeling using Jessner's solution has been used for treatment of melasma conventionally. OBJECTIVES: To evaluate the additional therapeutic effect and adverse effects of Jessner's peel when combined with 1,064 nm QSNYL for melasma patients in a double-blind, placebo-controlled design. METHODS: Total of 52 patients were included. Patients who received 10 sessions of 1,064 nm QSNYL plus chemical peeling with placebo (Group A) in a two-week intervals and those who received 10 sessions of 1,064 nm QSNYL plus chemical peeling with Jessner's solution (Group B) in a 2-week intervals were analyzed. Responses were evaluated using the Melasma Area and Severity Index (MASI) score, physician's global assessment (PGA) and subjective self-assessment. RESULTS: At 8 weeks, the mean MASI score decreased from 8.68 ± 4.06 to 8.60 ± 3.88 in Group A and from 8.98 ± 3.72 to 7.13 ± 2.57 in Group B, showing a significant difference (p < 0.001). But at 20 weeks, there was no significant difference on reduction of MASI, self-assessment, and PGA between the two groups. No serious adverse effects were reported with the additional Jessner's peeling. CONCLUSION: This study suggests Jessner's peel is a safe and effective method in the early course of treatment for melasma, when combined with low-fluence 1,064-nm QSNYL.

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?

Outcomes assessment of combination face lift and perioral phenol-croton oil peel.

BACKGROUND: Face-lift surgery when combined with perioral phenol-croton oil peel is an underappreciated tool for face rejuvenation. The procedure results in significant central face skin tightening and wrinkle reduction. METHODS: A retrospective review of 47 consecutive patients who underwent simultaneous face lift and perioral peel was performed. The objective measures used to evaluate the change in appearance of the patients included (1) a validated patient satisfaction questionnaire, (2) an evaluation of apparent age, and (3) an evaluation of perioral wrinkles by independent reviewers using a validated model. The assessment of apparent age was performed as follows: preoperative and postoperative photographs were shown randomly to six reviewers, who were asked to estimate the patient's age. The apparent age was compared with the patient's actual age, and the reduction in apparent age was calculated. Improvement in perioral rhytides was evaluated by using the Glogau classification system (range, 1 to 4). RESULTS: Survey results documented overall patient satisfaction, which was rated as 6.5 on a scale of 1 to 7 (with higher scores indicating greater satisfaction). Patients' postoperative apparent age estimate was 8.2 years younger than their real age (p=0.0002). The Glogau classification system score demonstrated a mean reduction of 1.15 (3.3 preoperatively as compared with 2.15 postoperatively, p<0.0001). CONCLUSION: Outcomes measurements, including patient satisfaction, objective evaluation of wrinkle improvement, and significant reduction in apparent age, document the power of this technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Comparative evaluation of wrinkle treatments.

BACKGROUND: Skin wrinkles are one of the most cosmetically concerning signs of aging for women, and improvements in the visual effect of wrinkles become a matter of concern that has an impact on the quality of life. Although various wrinkle treatments are being tried in the area of aesthetics and noninvasive cosmetic surgery, no guideline on how to treat wrinkles exists to date. This study evaluated the clinical effects of four wrinkle treatment methods [fractional erbium yttrium-aluminum-garnet (YAG) laser treatment, intense pulsed light (IPL) therapy, CD-atRA external application, and nutritional therapy with intake of amino acid supplements]. These four methods were selected as promising candidates in a pilot case study to improve wrinkles by following the consensus guideline (Task Force Committee for Evaluation of Anti-Aging Function, J Jpn Cosmet Sci Soc 31:411-431, 2007) for the evaluation of anti-wrinkle effects issued by the Japan Cosmetic Industry Association. METHODS: The wrinkle area fraction and skin viscoelasticity were measured by objective evaluation. Furthermore, a satisfaction survey of the subjects was conducted on the basis of subjective evaluations using the visual analog scale (VAS) method and in accordance with the guideline for the evaluation of antiwrinkle effects. RESULTS: Fractional erbium YAG laser treatment showed statistically significant improvement in both of the objective evaluations (wrinkle area and skin elasticity). The IPL method showed statistically significant improvement in both of the objective evaluations (wrinkle area and skin elasticity), and it especially demonstrated a more significant difference in skin elasticity. The CD-tretinoin external application method showed statistically significant improvement in both of the objective evaluations (wrinkle area and skin elasticity), and it especially demonstrated a more significant difference in wrinkle area. Nutritional therapy showed statistically significant improvement in wrinkle area, whereas IPL, CD-tretinoin external application, and nutritional therapy demonstrated statistically significant improvement in the degree of wrinkle. As for the subjective assessment of VAS, all four treatments demonstrated equivalent satisfaction. CONCLUSION: All four minimally invasive procedures (fractional erbium YAG treatment, IPL therapy, CD-atRA external application, and intake of amino acid supplements) showed significant improvement of wrinkles. Comparative evaluation of wrinkles using the same criteria is important. The findings clearly showed that an evidence-based approach to wrinkle treatments supported by validation of their effectiveness is required. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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.

Short review on face rejuvenation procedures: focus on preoperative antiseptic and anesthetic delivery by JetPeel™-3 (a high pressure oxygen delivery device).

AIM: Nowadays there is great attention in trying to slow and reverse the facial aging process. Esthetic medicine has been primarily based on the surgical approach for many years, but now, in order to solve the problem of aging skin, there is an increasing interest into non-invasive, possibly painless, procedures that can guarantee the patient a quick recovery. In this perspective the use of chemical peeling and dermabrasion, to achieve skin rejuvenation, is growing worldwide. These techniques are also relevant to treat skin pigmentation irregularities and to remove keratoses, lentigines, acne and other skin related conditions. One of the most interesting, safe and painless devices, useful for the effective antiaging face treatment, is JetPeel™-3. The aim of this study was to assess the device efficacy starting from a short review on face rejuvenation procedures. METHODS: The basic action mechanism of this medical device is a constant high pressure air flux delivery, including oxygen, mixed with different chemical compounds such as peeling molecules, antioxidants, vitamins and hyaluronic acid, which are mechanically forced across the skin surface. Here we report a new approach in the clinical use of JetPeel™-3, tested in 20 adult volunteers, consisting in the addition to the standard protocol of an anesthetic, carbocaine and a sterilizing and disinfectant agent, that is chlorexidine. In fact disinfection and sterilization of the skin surface is a peculiar step for every antiaging or therapeutic procedure. The procedure has been completed with multiple hyaluronic acid injections of the skin in order to achieve face rejuvenation. The anesthetic power of the JetPeel™-3-carbocaine protocol has been compared to the Emla cream one. RESULTS: The spontaneous pain sensation perceived by the patients in the hemiface treated with JetPeel™-3 was significantly lower compared to the hemiface treated with Emla cream (P<0.001) showing, consequently, that JetPeel™-3-carbocaine protocol had the best anesthetic performance either in dermal, subdermal or subcutaneous injections compared with Emla cream. CONCLUSION: JetPeel™-3 has proved to be a good non-invasive approach and its use is recommended since it induces local anesthesia in a short time.

Postinflammatory hyperpigmentation: etiologic and therapeutic considerations.

Postinflammatory hyperpigmentation (PIH) is a reactive hypermelanosis and sequela of a variety of inflammatory skin conditions. PIH can have a negative impact on a patient's quality of life, particularly for darker-skinned patients. Studies show that dyschromias, including PIH, are one of the most common presenting complaints of darker-skinned racial ethnic groups when visiting a dermatologist. This is likely due to an increased production or deposition of melanin into the epidermis or dermis by labile melanocytes. A variety of endogenous or exogenous inflammatory conditions can culminate in PIH and typically most epidermal lesions will appear tan, brown, or dark brown while dermal hypermelanosis has a blue-gray discoloration. Depigmenting agents target different steps in the production of melanin, most commonly inhibiting tyrosinase. These agents include hydroquinone, azelaic acid, kojic acid, arbutin, and certain licorice (glycyrrhiza) extracts. Other agents include retinoids, mequinol, ascorbic acid (vitamin C), niacinamide, N-acetyl glucosamine, and soy, and these products depigment by different mechanisms. Certain procedures can also be effective in the treatment of PIH including chemical peeling and laser therapy. It is important to note that these same therapeutic modalities may also play a role in causing PIH. Lastly, those lesions that are not amenable to medical or surgical therapy may experience some improvement with cosmetic camouflage.

Current chemical peels and other resurfacing techniques.

The currently available methods for resurfacing will be addressed in this article, which has been divided into three areas of focus: chemical peels, lasers, and dermabrasion. Emphasis will be placed on chemical peels, a technique with a long history that provides a very reliable method of resurfacing and that every facial plastic surgeon should be familiar with.