Chemical Peels for Melasma: A Systematic Review.

BACKGROUND: Melasma is a common chronic, relapsing pigmentary disorder that causes psychological impact. Chemical peels are a well-known therapeutic modality used for accelerating the treatment of melasma. OBJECTIVE: To review the published evidence on the efficacy and safety of chemical peels in the treatment of melasma. METHODS: A systematic review was done. A meta-analysis could not be done due to the heterogeneity of data. RESULT: The authors conducted a PubMed search and included prospective case series of more than 10 cases and randomized controlled trials (RCTs) that have studied the safety and/or efficacy of chemical peel in melasma. Out of 24 studies, 9 were clinical/comparative trials and 15 were RCTs. The total sample size was 1,075. The duration of the study varied from 8 to 36 weeks. Only 8 studies were split face. All studies used self-assessment, physician global assessment, and Melasma Area and Severity Index (MASI) for quantifying the results. Glycolic acid was found to be the most safe and effective in melasma. CONCLUSION: Chemical peels were found to be safe and effective in the management of melasma.

A 15% Trichloroacetic Acid + 3% Glycolic Acid Chemical Peel Series Improves Appearance of Hand Lentigines: An Evaluator-Blinded, Split-Hand Prospective Trial.

BACKGROUND: Improving the appearance of lentigines on the hands is a key component to hand rejuvenation. Soft tissue fillers revolumize hands, but do not address pigmentary changes. OBJECTIVE: This study investigated the effiacy of a 15% trichloroacetic acid (TCA) + 3% glycolic acid (GA) combination peel in improvement of appearance of hand lentigines. METHODS: A prospective evaluator-blinded, split-hand study was performed using a 15% TCA + 3% GA peel to treat patients with hand lentigines. Subjects received a total of 3 treatments at 4-week intervals on 1 hand, with the other hand serving as an untreated control. Final photographs were taken 12 weeks after the last treatment. Two blinded board-certified dermatologists graded improvement in hand lentigines using a 5-point scale. RESULTS: Eighteen of 20 patients completed the study (90%). The mean age was 64.4 years (SE 1.6, range 51-71). The mean pain scores were 3.8 (SE 0.4) on a 10-point scale (1 = no pain, 10 = extremely painful). Blinded evaluators correctly identified the after-treatment photographs in 16 patients (88%). Physician and patient-graded mean improvement of lentigines was significant for treated versus control hands ( p < .01). No adverse events were noted. CONCLUSION: A series of three 15% TCA + 3% GA peels are effective and safe in the treatment of hand lentigines.

Definition of refractory melasma and its treatment: a review.

Although patients with refractory melasma have been treated using various methods, there is still no precise definition or summary of the therapies. To define refractory melasma and conduct a review of the treatments, we searched for relevant publications in PubMed, Web of Science, and the Cochrane Library, and a total of 35 references were obtained. Refractory melasma can be roughly defined as an ineffective treatment for melasma, including topical bleaching agents, chemical peels, laser therapy, microdermabrasion for more than six months, or chemical peels treated more than six times. Meanwhile, physicians should be careful when treating patients with darker skin and dermal or mixed types of melasma since these individuals do not respond well to treatment. Lasers combined with other methods, especially different types of lasers or topical agents, are considered more effective than monotherapy. Oral tranexamic acid (TXA) is a prospective cure for refractory melasma. Other methods include a combination of chemical peels, microneedling, or injections with additional therapies. In conclusion, we were able to provide a rough definition of refractory melasma and list the available therapies. According to the literature, the most prevalent treatment is laser combination therapy. However, laser treatment should be considered only after topical agents and chemical peeling have failed. Considering its side effects, efficacy, and safety, oral TXA may be a better option, but more research is needed to make a firm conclusion. Moreover, maintenance therapy is required after treatment.

A Comprehensive Bibliographic Review Concerning the Efficacy of Organic Acids for Chemical Peels Treating Acne Vulgaris.

Acne vulgaris stands out as the most prevalent skin disorder among teenagers and young adults, causing physical discomfort and considerable economic and psychological burdens on individuals and society. A wide range of topical and systemic therapies are available in acne treatment. Chemical peeling is a skin resurfacing technique designed to rebuild healthy skin using exfoliating substances, a simple and affordable process with various dermatological uses. Chemical peels, classified as superficial, medium, and deep, have been utilized for acne vulgaris and multiple other skin issues. In these chemical peels, a diverse range of chemical substances is employed, each with its unique mode of action. Among these, α-hydroxy and ß-hydroxy acids have gathered attention for their efficacy in reducing acne lesions and enhancing overall skin appearance. Acids, such as salicylic acid, glycolic acid, or lactic acid, are commonly used in chemical peels due to their exfoliating and sebum-regulating properties. Despite the widespread use of these acids, there exists a lack of consensus regarding the most effective acid type and concentration for treating acne-prone skin. This review aims to bridge this knowledge gap by evaluating the effectiveness and safety of various organic acids used in chemical peels specifically for acne-prone skin. The findings of this comprehensive bibliographic review indicate that organic acid-based chemical peels represent effective and safe treatment options for individuals with acne-prone skin. Their adaptability sets these treatments apart; the choice of organic acid can be tailored to meet individual patient needs and tolerability levels. This personalized approach ensures that patients receive optimal care while minimizing the risks associated with the treatment. As research in this field progresses, it is anticipated that a more nuanced understanding of the ideal acid type and concentration will emerge, further enhancing the efficacy and safety of chemical peels for acne-prone skin.

Demystifying the mechanism of action of professional facial peeling: In-vivo visualization and quantification of changes in inflammation, melanin and collagen using Vivascope® and ConfoScan®.

Professional peeling using chemicals (chemical peeling) is a popular non-surgical procedure commonly used for the treatment for photoaging, pigmentary disorders, scarring, fine lines, and wrinkles. The objective of our case study was to elucidate the mechanism of action of professional peels/peeling. For proof-of-concept, we used a commercial blended peel containing trichloroacetic acid and lactic acid. The facial peeling was performed by a physician on four subjects. These subjects were followed over time in the clinic to take clinical pictures and monitor surface and anatomical changes in inflammation, melanin, and collagen at regular intervals post-peel (5 min, 48 h, and day 9). Dermoscope and Vivascope® were used to image surface and subsurface anatomical changes, respectively, and ConfoScan® was used to quantify aforementioned anatomical changes. Based on Vivascope and ConfoScan analysis, we could see clear visual clinical evidence of controlled injury-healing mechanism of peel's action: immediate but transient onset of inflammation within 5 min (indicate injury response by skin), followed by melanin redistribution evident at 48 h (indicate activation of skin's defense system), and remodeled fibrous collagen network without any inflammatory cells on day 9 (healing response). To our knowledge, this is the first ever clinical study to deconvolute the mysterious mechanism of action of peels, in-vivo.

Long-term effect of azelaic acid peel on sebum production in acne.

Seborrhea and the associated oily skin are undoubtedly the problem of women and men around the world. The pathogenesis of acne vulgaris involves excessive activity of sebaceous glands, as well as disturbances in the composition of sebum. The aim of the study was to assess the severity of seborrhea in a group of acne vulgaris patients and to determine the effect of a 20% azelaic acid solution on the activity of sebaceous glands. Twenty seven women, aged 19-25 years, underwent a series of six treatments with the application of a 20% solution of azelaic acid to the face. The mean values of sebum level showed a decreasing tendency. On the forehead, the results were as follows-195.5 before the treatment and 162.7 2 weeks after the last treatment. Measurements of the right cheek decreased from 175.3 to 141.3 The measurements taken 3 months after the study were 151.3 on the forehead and 138.9 on the cheek. Similarly, the values determining the total number of acne lesions and the severity of the disease according to the IGA scale also changed significantly. Chemical peel with 20% azelaic acid shows long-term sebostatic action, which inhibits the formation of new acne lesions.

Skin Preparation for Photodynamic Therapy, Chemexfoliation, and Ablative Laser Resurfacing: a Systematic Literature Review.

BACKGROUND: Photodynamic therapy, chemexfoliation, and ablative laser resurfacing are common practices for dermatologists, yet no formal protocols exist regarding preprocedural skin preparation. OBJECTIVE: To review and summarize the skin preparation protocols for photodynamic therapy, chemexfoliation, and ablative laser resurfacing available in the literature. METHODS: Data Sources A systematic review of English and non-English articles using the PubMed database was performed. A manual search of bibliographies from relevant articles was also performed to collect additional studies. Study Selection Only articles in the English language with full texts available that pertained to skin preparation for photodynamic therapy, chemexfoliation, and ablative laser resurfacing were included. Data Extraction Article selection was performed by one author, and relevant sources were verified by other authors using predefined inclusion and exclusion criteria. RESULTS: There is a paucity of scientific research regarding efficacy and safety of dermatologic preprocedural skin preparation agents. Only 2 studies have compared various cleansing agents for these measures. Yet, strong statements regarding the importance of degreasing are published without supportive data. CONCLUSION: Consensus guidelines for preprocedural protocols are lacking for photodynamic therapy, chemexfoliation, and ablative laser resurfacing. Further studies are warranted to explore the efficacy and safety of various preprocedural cleansing agents.

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.

Modified Jessner's Solution Combined With Trichloroacetic Acid 20% Versus Glycolic Acid 70% Combined With Trichloroacetic Acid 20% in the Treatment of Melasma.

BACKGROUND: Melasma is an acquired challenging pigmentary skin problem, which commonly affects the face. A wide range of therapeutic modalities is available, yet none is satisfactory. OBJECTIVE: To compare efficacy and safety of trichloroacetic acid (TCA) 20% peeling with either modified Jessner's solution (MJs) or with glycolic acid (GA) 70% peeling in the treatment of melasma. PATIENTS AND METHODS: Thirty adult Egyptian women with melasma were recruited in the study. After cleansing the face, MJs was applied on one side of the face and GA 70% on the other side. Then, TCA 20% was applied in one uniform coat on both sides of the face. Assessment of the clinical response was guided by calculating the melasma area, severity index (MASI), modified MASI, and hemi-MASI scores before and after the end of treatment. RESULTS: Both combinations showed significant reduction in MASI, modified MASI, and hemi-MASI scores (p value = .000, for each). Moreover, the hemi-MASI score after MJs and TCA20% showed a significant decrease compared with GA70% and TCA20% (p value = .013). CONCLUSION: Both modalities are successful, safe options for treating melasma. Moreover, combining MJs with TCA 20% is more efficacious.

Effectiveness of water as the neutralising agent for glycolic acid peels in skin phototypes IV-V.

The aim of the study is to evaluate the effectiveness of water as a substitute for sodium bicarbonate plus solution in the neutralisation process of chemical peeling using a 35% glycolic acid solution. This randomised, double-blind, split-face, controlled trial was conducted in an outpatient setting. A total of 126 healthy patients with skin phototypes IV-V aged between 18 and 60 years old were recruited. Chemical peeling was performed with 35% glycolic acid solution. One side of the face was neutralised with water, and the other side of the face was neutralised with a sodium bicarbonate plus solution. The main outcome of this study was measured by the degree of erythema, pruritus and pain scores. Significant difference in the pain score immediately after the neutralisation process of the chemical peeling with glycolic acid was seen. However, there were no significant differences in the degree of erythema or the pruritus score. These results indicate that water can be used as a substitute for sodium bicarbonate plus solution in the neutralisation process of chemical peeling with 35% glycolic acid in patients with skin phototypes IV-V.

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.

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.

Site-oriented depigmentation in vitiligo patients using Q-switched Nd:YAG laser (1,064/532 nm), cryotherapy and chemical peels: A comparative study.

Depigmentation emerges as a feasible solution for vitiligo universalis and refractory cases of vitiligo vulgaris that hinder patients' quality of life. A range of depigmenting modalities has previously been developed. However, each has its own limitations. Based on skin sensitivity, this study sets out to compare the efficacy and tolerability of "trichloroacetic acid (TCA) peels 25% and 50% and Qs Nd:YAG laser (1,064/532 nm)" for facial depigmentation and "cryotherapy, phenol 88% and Qs Nd:YAG (1,064/532 nm)" for extrafacial skin depigmentation. Forty vitiligo patients were examined and equally divided into facial & extrafacial groups. Regular sessions were performed. Patients' responses were assessed after 3 months or when excellent/complete depigmentation was attained through assessing "depigmentation grade", "extent of depigmented skin", "patient satisfaction" and "overall response". Patients were observed for a six-month follow-up period. In facial depigmentation, Qs Nd:YAG showed the highest significant response followed by TCA 50% and 25%. In extrafacial depigmentation cryotherapy, phenol 88% and Qs Nd:YAG laser displayed positive outcomes without significant difference. Among the modalities tested Qs Nd:YAG yielded superior results in facial residual pigmentation in vitiligo when compared to TCA 50% and 25%, whereas in extrafacial sites Qs Nd:YAG, cryotherapy and phenol were equally effective.

"Chemical" surgery in treating basal cell carcinoma in elderly.

The incidence of basal cell carcinoma (BCC) has been increasing in the last decades due to population aging and precise diagnosis. The difficulty that physicians face frequently is related to the treatment decision for BCC; when treating BCC, correct and personalized choices must be taken into consideration by selecting from a large variety of therapeutic options such as: surgical excision ("the golden standard therapy"), electrodessication, cryosurgery, radiation therapy, laser, photodynamic therapy, curettage, topical treatment (imiquimod, 5-fluorouracil, vismodegib), or combining different treatments. The present authors present series of cases of patients diagnosed with BCC, highlighting that "chemical surgery" using 70% trichloroacetic acid could be a valuable option in the treatment of nonaggressive BCC of the face.

Radio Peel-Synergism Between Nano-fractional Radiofrequency and 20% Trichloroacetic Acid Chemical Peeling.

BACKGROUND: Microneedling fractional radiofrequency (FRF) and chemical peels are widely used for skin rejuvenation. OBJECTIVE: The authors aimed at evaluating the efficacy and safety of FRF and trichloroacetic acid 20% (TCA20%) peel in different combinations for determining the optimal treatment protocol. METHODS: In this prospective clinical comparison of 4 protocols (FRF alone, TCA20% alone, TCA20% before FRF [TCA→FRF], and TCA20% following FRF [FRF→TCA]), the patients underwent 3.8 ± 1.2 successive treatments of one protocol at 4- to 6-week intervals. The patients and 2 dermatologists evaluated improvement of pigmentation and dyschromia, erythema and blood vessels, laxity and wrinkling, and skin imperfections using a global aesthetic improvement scale (GAIS) and a 1 to 5 scoring system. The patients rated their satisfaction and reported adverse effects and reduced activity. Skin impedance and histological changes following the different protocols were also evaluated on 3 additional volunteers. RESULTS: Sixty-seven patients (age range 22-80 years) were studied. TCA→FRF caused skin impedance to decrease, yielding a more superficial and less-efficient penetration of FRF energy. FRF→TCA produced more significant improvement in overall facial skin appearance (GAIS) and most evaluated skin parameters. Adverse effects and satisfaction rates were similar for all approaches. CONCLUSION: FRF→TCA had the best synergistic effect on skin rejuvenation compared with FRF or TCA20% alone and TCA→FRF.

Comparative Efficacy of a 35% Glycolic Acid Peel Alone or in Combination With a 10% and 20% Trichloroacetic Acid Spot Peel for Melasma: A Randomized Control Trial.

BACKGROUND: To study and compare the therapeutic efficacy and side effects of a 35% glycolic acid (GA) full face peel alone or in combination with a 10% or 20% trichloroacetic acid (TCA) spot peel for facial melasma. METHODS: Thirty patients with facial melasma were randomly divided into 3 equal Groups A, B, and C. Group A was treated with a 35% GA full-face peel, Group B and C with 35% GA full-face peel followed by a 10% and 20% TCA spot peel respectively once every 15 days. Four peels were performed once every 15 days. The response to the treatment was evaluated by the percentage reduction in melasma area severity index (MASI) scoring. RESULTS: All 3 groups had significant reduction of MASI, but there was no significant difference between the groups. Group A had minimum side effects. CONCLUSION: Chemical peels with GA alone or in combination with TCA do result in a significant improvement in melasma, but the combination of the peels in the same sitting does not seem to have any additive or synergistic effect while they may increase the side effects.

Microneedling (Dermapen) and Jessner's solution peeling in treatment of atrophic acne scars: a comparative randomized clinical study.

Background: Atrophic acne scarring is a permanent complication of acne vulgaris. It has a high prevalence and significant impact on the quality of life. We compared between the efficacy and safety of microneedling (dermapen) and superficial chemical peeling by Jessner's solution for treatment of atrophic acne scars. Materials/Methods: Sixty patients who had atrophic acne scars were divided randomizely into three groups. Group Ι included 20 patients and were treated with dermapen, group ΙΙ included 20 patients and were treated with Jessner's solution peeling, and group ΙΙΙ included 20 patients and were treated with dermapen and Jessner's solution. Clinical assessment of patients was done according to Goodman and Baron scarring global quantitative grading system before and after the end of treatment. Results: There was a significant clinical improvement of acne scars in group ΙIΙ than in group Ι and group ΙΙ, and boxcar scars showed the best clinical improvement in all studied groups. There was statistically negative correlation between the degree of improvement of acne scars and duration of lesions and age of patients. Conclusions: The combined technique (dermapen and Jessner's solution peeling) showed the best clinical improvement with the least number of sessions followed by the microneedling technique and lastly the jessner's solution peeling for treating atrophic acne scars.

An Advanced, Physician-Strength Retinol Peel Improves Signs of Aging and Acne Across a Range of Skin Types Including Melasma and Skin of Color

Background: Facial chemical peels are highly sought after by patients with photodamage, acne, and melasma. An advanced, physician-strength superficial peel, containing 3% retinol with other firming and volumizing ingredients was developed to exfoliate, improve the appearance of fine lines and wrinkles, and plump and firm skin, while promoting a bright, even complexion. Objective: A clinical study was conducted to evaluate the tolerability, safety, and efficacy of the 3% retinol peel with a supportive homecare regimen across a range of peel candidates, females aged 18-65 years, with photodamage, acne, hyperpigmentation or melasma, and skin of color, over a series of 2-4 peels. Method: The 3% retinol peel formulation was administered under physician direction in 6-week intervals. Subjects with photodamaged skin, acne, hyperpigmentation/melasma, or skin of color (Fitzpatrick skin types IV-VI) received 2-4 peels along with a supportive homecare regimen. Dermatologist grading, self-assessment, and digital photography documented tolerability and efficacy parameters. Results: 24 subjects participated in the study with a total of 78 peels administered (Photodamage group, n=14 [with an Acne subgroup, n=5]; Melasma group, n=5; Skin of Color, n=5). The 3% retinol peel along with the homecare regimen was well tolerated under physician direction in all skin types and conditions assessed. Obvious peeling was noticeable in many subjects 3 days post-peel and resolved by day 7. In the photodamaged group, dermatologist clinical grading of fine lines, wrinkles, pore size, laxity, mottled pigmentation, lack of clarity/radiance, and overall photodamage was significantly improved (P<0.05). Benefits were observed in all groups and supported by self-assessment. Digital photography demonstrated tolerability in the days immediately post-peel, along with benefits to photodamage. Conclusion: The 3% retinol superficial peel was well tolerated and an efficacious cosmetic treatment under physician supervision in subjects of all skin types to firm skin, improve fine lines and wrinkles, and promote a bright, even complexion. J Drugs Dermatol. 2019;18(9):918-923.