The Use of Chemical Peels in the Rejuvenation of Ethnic Skin

Aurora Badia, DO

Considerations of Ethnic Skin

• Pigmentary changes are more common and persistent

• Response to peeling agents can be unpredictable

• Demarcation lines are common

Considerations of Ethnic Skin

• Increased risk of hypertonic scars and keloids

• Psychosocial distress common due to marked changes in skin color

Ethnic Skin Considerations

• Greater intrinsic photoprotection due to increased dermal melanin

• Photodamage, actinic keratoses, rhytides, skin cancers less common in deeply pigmented skin

• Dyschromia more common; melanocytesshow exaggerated response to cutaneousinjury

Chemical Peel Indications

Skin Types I-III• Fine wrinkles, rhytides• Solar keratoses• Photodamage• Melasma• Postinflammatory

hyperpigmentation• Acne vulgaris• Rosacea• Superficial scarring

Skin Types IV-VI• Postinflammatory

hyperpigmentation• Melasma• Acne vulgaris• Oily skin• Textural changes• Acne scarring• Fine wrinkles• Pseudofolliculitis barbae

Chemical Peel Depth

General Patient Preparation for Ethnic Skin Peeling

• Detailed history and physical examination• Standardized photos• Topical skin preparation

– Retinoids/alpha hydroxy acid– Hydroquinone/bleaching agent– Sunscreen

• Antivirals

Retinoids

• Topical retinoids used 2-6 weeks before peeling– Thin stratum corneum and enhance epidermal

turnover– Decrease epidermal melanin and expedite

epidermal healing– Enhance penetration and depth of chemical peel

Retinoids

– Should be discontinued 1-2 weeks pre-peel to avoid complications

– Can be resumed post-peel after skin re-epithelializes

– Topical alpha hydroxy acid is less aggressive version of retinoids

Hydroquinone

• Use of hydroquinone 4% or higher 4-6 weeks pre-peel to reduce epidermal melanin– Inhibits conversion of tyrosine to melanin– Degrades melanosomes– Causes structural change in melanocyte

organelles• Decreases formation of melanosomes• Increases degradation of melanosomes

Hydroquinone

• Hydroquinone only prevents formation of new melanin

• Other bleaching agents include azelaic, kojicacid, arbutin, licorice

• Can be resumed post-peel after peeling and irritation subside

Other Pre-Peel Strategies

• Broad spectrum sunscreen (UVA & UVB) use daily

• Antivirals if prone to herpetic outbreak

Peeling Agents Commonly Used

• Glycolic acid• Salicylic acid• Jessner solution• Tricholoroacetic acid (TCA)• Tretinoin

Glycolic Acid Peels

• Alpha hydroxy acid• Improve skin surface by thinning stratum

corneum, promoting epidermolysis, dispersing basal layer melanin, and increasing collagen synthesis in dermis

Song JY, Kang HA, Kim MY et al. Damage and recovery of skin barrier function after glycolic acid chemical peeling and crystal microdermabrasion. Dermatol Surg2004; 30: 390-394.

Common AHA’s

• Glycolic acid• Lactic acid• Mandelic acid• Pyruvic acid

Glycolic Acid

• Strengths utilized range from 20-70%• Formulations

– Buffered– Partially neutralized– Esterified

Glycolic Peel Indications for Skin Types IV-VI

• Dyschromias– Melasma– Post-inflammatory hyperpigmentation from acne

or burns

Contraindications

• History of allergy to solution, neutralizing agent

• Photosensitization from medication• Extensive sun exposure• Smoking • Poor health• History of herpetic outbreak

Complications/Side Effects

• Hyperpigmentation• Hypopigmentation• Scarring

Glycolic Acid Clinical StudiesSarkar R et al. The combination of glycolic acid peels with a topical regimen in the

treatment of melasma in dark-skinned patients: a comparative study. DermatolSurg 2002;28:828-832.

• Comparison of efficacy of 3 series 30% glycolic peels and 3 series 40% glycolic peels in combination with modified Kligman bleaching formulation (5% hydroquinone, 1% hydrocortisone, 0.05% tretinoin) and with bleaching alone

• 40 subjects per group

Glycolic Acid Clinical Studies

• Both groups had statistically significant improvement in Melasma Area Severity Index (MASI) score at 21 weeks

• Maximum improvement occurred in combination peel and topical bleaching formula

Glycolic Acid Clinical StudiesJavaheri SM et al. Safety and efficacy of glycolic acid facial peel in Indian women

with melasma. Int J Dermatol 2001;40:354-357.

• 25 Indian women with melasma treated with 50% glycolic acid peels monthly for 3 months

• Improvement in 91% of subjects with maximal clearing in patients with epidermal melasma

Glycolic Peel Results

Salicylic Acid

• Beta hydroxy acid• Lipophilic compound that removes

intercellular lipids that are linked to cornifiedenvelope surrounding epithelial cells

• Well tolerated in all skin types

Salicylic Formulations

• 50% ointment formula• 10%, 20%, 30% ethanol formula

Salicylic Acid Indications in Ethnic Skin

• Acne vulgaris• Melasma• Post-inflammatory hyperpigmentation• Texturally rough or uneven skin

Contraindications

• Salicylate allergy or sensitivity• Active inflammation or infection• Viral infection• Pregnancy• Isotretinoin therapy 3-6 months prior to

procedure

Complications/Side Effects

• Mild in nature for the most part• Erythema• Dryness• Salicylic acid toxicity (rare)

Salicylic Acid Clinical StudiesGrimes PE. The safety and efficacy of salicylic acid chemical peels in darker racial-

ethnic groups. Dermatol Surg 1999;25:18-22.

• 25 patients in darker racial ethnic groups treated with 20% and 30% salicylic peels for acne vulgaris, melasma, and post-inflammatory hyperpigmentation

• Substantial efficacy and minimal side effects

Salicylic Acid Clinical StudiesLee HS, Kim IH. Salicylic acid peels for the treatment of acne vulgaris in Asian

patients. Dermatol Surg 2003;29:1196-1199.

• 35 Korean patients with facial acne were treated biweekly for 12 weeks with 30% salicylic acid

• Inflammatory and noninflammatory lesions significantly improved

Salicylic Acid Results

Jessner Peels

• Mixture of salicylic acid, resorcinol, and lactic acid

• Causes loss of corneocyte cohesion and induces intracellular edema

• Wound induced to papillary dermis

Jessner Formulation

• Standard– 14 g resorcinol, 14 g salicylic acid, 14 g lactic

acid mixed with ethanol to make 100 ml solution• Modified

– 17% lactic acid, 17% salicylic acid, 8% citric acid mixed with ethanol to make 100 ml solution

Jessner Indications in Ethnic Skin

• Acne• Melasma• Post-inflammatory hyperpigmentation

Contraindications

• Active inflammation• Infection in treatment area• Isotretinoin within 6 months of treatment• Pregnancy• Allergy to resorcinol, salicylic acid, lactic

acid

Complications/Side Effects

• Increased exfoliation• Thyroid dysfunction related to resorcinol

toxicity (rare)

Jessner Results

Trichloroacetic Acid (TCA)

• Precipitates epidermal proteins, causing sloughing and necrosis

• Concentration dependent• Can be used in darker skin, but incidence of

post-inflammatory hyperpigmentation much higher in skin types V and VI

• Sometimes used in combination with other acids as superficial peeling agent

Combination TCA/Salicylic Acid

• 20% or 30% salicylic acid followed by low strength TCA (10-15%)

Combination TCA Indications

• Melasma• Acne• Photodamage

Contraindications

• Salicylate allergy• Active inflammation• Viral infection• Pregnancy• Isotretinoin within 6 months of treatment• Poor wound healing

Side Effects/Complications

• Erythema• Longer desquamation period

Combination Results

Tretinoin Peels

• Increases epidermal thickness of granular cell layer, decreases melanin content, improves stratum corneum compactness

Tretinoin Indications

• Poor skin texture• Melasma

Tretinoin Clinical StudiesKhunger N et al. Tretinoin peels versus glycolic acid peels on the treatment of

melasma in dark-skinned patients. Dermatol Surg 2004;30:756-760.

• 10 patients with melasma treated weekly• Split-faced trial

– Glycolic acid 70%– 1% tretinoin left on face 4-6 hours

• Significant decrease in MASI scores noted at 6-12 weeks• No difference in between responses for each peel• Suggests tretinoin well tolerated in darker skinned patients

Medium-Depth Chemical Peels

• TCA 35%-50%• Glycolic acid 70% applied 3-30 minutes• Combination peels

– Jessner + TCA 35%– Glycolic acid 70% + TCA 35%

Indications for Medium Depth Peels

• Actinic keratoses• Blotchy hyperpigmentation• Post-inflammatory hyperpigmentation• Recalcitrant melasma• Fine to medium rhytides• Superficial acne scars

Medium Depth Peels

• Used sparingly in darker-skinned patients due to increased risk of post-inflammatory hyperpigmentation and scarring

• Risks do not outweigh the rewards

Ethnic Skin ChemicalPeel Summary

• Safe peels– Glycolic acid 35%-55%– Mandelic acid 30%-50%– Salicylic acid 20%-30%– TCA 10%-15%

Ethnic Skin Chemical Peel Summary

• High Risk Peels– Jessner– TCA 25%-35%– Jessner + 35% TCA– Glycolic acid 70% + 35% TCA

• Peels to Avoid– Phenol

Chemical Peel Summary

• Pre-peel preparation extremely important 4-6 six weeks before treatment in darker skin types to reduce risk of complications– Bleaching agent– Retinoid– Broad spectrum sunscreen

Chemical Peel Summary

• Post peel care extremely important in darker skin types – Avoid sun exposure– Use broad spectrum sunscreen– Avoid picking, rubbing, peeling skin– Start priming agents to prevent post-

inflammatory hyperpigmentation