SANTOS, Suelene da Silva [1]
SANTOS, Suelene da Silva. Alternative in the Aesthetic Treatment of the Skin Using Chemical Peeling. Multidisciplinary Scientific Journal. Edition 9. Year 02, Vol. 01. pp. 83-94, December 2017. ISSN:2448-0959
abstract
The skin undergoes an aging process that may be precocious due to various factors or physiological, however, it worries many individuals who seek expert help from the expert professional to minimize their signs. One of the resources to improve skin quality are chemical peels, using various active substances such as glycolic acid, retinoic acid, trichloroacetic acid and phenol, among others, which provide skin exfoliation and subsequent cell renewal. Depending on the concentration and the pH value in which they are used in the formulations, they trigger the superficial, medium and deep peeling. ATA, for example, has been used as a deep peeling either alone or in combination with other components of the formula that act as penetration and permeation promoters. The use of these products results in the process of intense cell renewal, normalizing the pigmentation of the skin, attenuating marks and minimizing wrinkles. We also have phenol, which due to its toxicity and indications, should only be applied by physicians, carefully according to the recommended technique, and the patient should be monitored for maximum peeling efficacy and also minimize systemic effects.
Keywords: Chemical Abrasion, Skin Aging, Chemical Assets.
Introduction
Since the antiquity that there is a concern with health and aesthetics, in this way, this habit of always seeking alternatives of esthetics has been disseminated by the cultures, from the Imperial era, Middle Ages, French Revolution, arriving until the Industrial Revolution, generating a increasing progress in the pharmaceutical and cosmetics industry, leading to the development of a series of assets aimed at hygiene, health, beauty and well-being (CORREIA, 2010).
The population has been increasingly looking for quality products and technological advances, for the treatment of the alterations that the skin has been suffering, due to several factors, which motivated in this way the pharmaceutical industries to investigate and invest in the development of products aimed at the improvement of the quality of skin (BORGES, 2006).
The skin undergoes several changes during the long years of life, which worries more and more people, because it is not only aesthetic, but also the well-being. Its main function is to protect the body against external physical threats, because it is the largest organ of the human body (VIEIRA, 2008).
The skin is subject to various types of physical and chemical aggression, being in direct contact with the external environment, an example are the spots, which usually generates deformities in the same, so are changes in the color of the skin that can appear at any age different shades. These spots can be caused by several factors such as changes in the production of skin pigmentation, infections, hormonal disorders, vascular alterations, tumors, sun exposure, acne marks, among others (NOGUEIRA, 2008).
Also we have the photo aging that is the aging of the skin, due to non-protective skin against the free radicals that leads to the degeneration of the elastic and collagen fibers, giving rise to the appearance of pigmented spots and the occurrence of pre-malignant or malignant lesions. UV radiation promotes the formation of free radicals produced and thus increases the number of unrepaired oxidative lesions that alter metabolism and are responsible for premature aging and increase the risk of skin cancer (Garcia et al. 2006).
According to Ramos (2005), the choice of the specific agent or technique to be used for chemical peeling depends on the knowledge of the depth of the lesion so that an agent that does not produce exfoliation unnecessarily deeper than the alteration itself can be treated , can be performed with several substances, this will depend on two important factors: the clinical picture presented and the cutaneous phototype.
This work will address the evolution of chemical peels, describing their function in the treatments of skin alterations, as well as their use for aesthetic purposes, focusing on the mechanisms of action and the pharmaceutical forms used for their application, as well as the vehicles used for the peelings. Seeking in this way, to know in a comprehensive way, what is chemical peeling and its complexities.
CONTEXTUALIZING:
Skin
Leaving to the physical structure of the skin, it is formed by two main layers, the epidermis and the dermis. The epidermis is subdivided into five thinner layers, extracts corneum, lucidum, granulosum, spinosum and basal, and the dermis in two thicker layers to papillary and reticular. Separating these five layers, we have what we call the basal membrane, which is responsible for the regeneration of the skin (VIEIRA, 2008).
The main function of the skin is to act as a protective barrier of the organism against the aggressions of the external environment; as well as having an important role in self-esteem, social relations and the quality of life of the human being (BORGES, 2006).
Chemical peeling
According to Teixeira (2008), chemical peeling, also known as chemosensory, consists in the application of one or more exfoliating agents to the skin, resulting in the destruction of parts of the epidermis and / or dermis, followed by regeneration of epidermal and dermal tissues.
According to Ramos (2005), this type of treatment has several applications, among them: cases of wrinkles, melanosis, actinic keratoses, melasma, postinflammatory hyperpigmentation, acnes and its sequels, atrophic scars, striations, keratosis pilaris and bleaching skin. However it is contraindicated in cases of inadequate photo protection, pregnancy, neurotic stress or excoriations, use of oral isotretinoin for less than six months, poor healing or keloid formation, history of permanent postinflammatory hyperpigmentation, difficulty understanding and following guidelines provided .
Classification of chemical peeling
Chemical peeling is classified into three types: superficial, medium and deep, as described.
The superficial peeling has action in the epidermis and alpha-hydroxyacids (AHAs), beta-hydroxyacids (VELHO, MORAIS, 2010) are used as active substances.
According to Velho and Morais (2010), the desquamations must be repeated, so that they achieve better results. These superficial peeling of the skin layers activate the biological mechanisms that stimulate cell renewal and growth, which will make the appearance of the skin healthier and more beautiful. Depending on the concentration and residence time of the active in the skin, it will increase the thickness of the epidermis and increase the production of the collagen fibers. This type of peeling is indicated for the treatment of superficial spots, dilated pores, superficial wrinkles, rough texture, hyperpigmentation lighter, epidermal melasma, acne vulgaris.
The average peel has action on the papillary dermis and uses as active substances combinations of TCA with CO2, TCA with Jessner's solution, TCA with glycolic acid or only TCA and resorcinol. It is indicated for cases of acne, light aging photo hyperquerostático eczema, actinic keratosis, fine wrinkles and melasma (GOMES, 2008).
According to Souza (2011), the deep peeling has action on the reticular dermis. Active components are 50% TCA and phenol (Baker-Gordon solution), among others. They are indicated for the cases of epidermal lesions, spots, scars, actinic dyschromias, moderate wrinkles, keratoses and melasma. It is established as an extremely aggressive peeling and is indicated for the skins that need cellular renewal of the deeper layer of the dermis, such as very aged skin. In this peeling, if lesions occur in the basal layer, due to its action, can occur scars.
Types of skin that best respond to chemical peels
According to Teixeira (2008), the different forms of Peeling can benefit almost all types of skin: Type I – Without wrinkles, typically under 35, requires little makeup. Type II – Wrinkles only appear when there is movement on the face (for example, when smiling), typically between 25/35 years, yellowish color and with signs of early sun damage. Type III – Wrinkles even with the face at rest, especially around the eyes, mouth and forehead, aged between 30/65 years, discoloration, and appearance of small blood vessels. Type IV – Severe aging, with many deep wrinkles. Patients with type II and III skins are the ones that benefit most from medium and superficial peels.
Active principles used according to the classification of chemical peels
Surface Peeling
– Glycolic or lactic acids 40-50% (up to 10 minutes);
– Retinoic acid 2-5%;
– 10-25% trichloroacetic acid (one layer);
– Resorcin 20-30% (5 to 10 minutes);
– Jessner's solution (1 to 2 layers) (OLD and MORAIS2010)).
Medium Peeling
– Glycolic or lactic acids 40-70% (10 to 20 minutes);
– 10-30% trichloroacetic acid (one layer);
– Resorcinol 40-50% (30 to 60 minutes);
– Jessner's solution (4 to 10 layers) (RAMOS et al., 2005).
Deep Peeling
– 70% glycolic or lactic acids (3 to 30 minutes);
– Trichloroacetic acid above 50%;
– 35% trichloroacetic acid + Jessner's solution;
– Pyruvic Acid;
– Jessner's solution + Glycolic acid 40-70%; (RAMOS et al., 2005).
Very Deep Peeling
– Phenol with occlusion;
– Baker-Gordon solution (RAMOS et al., 2005).
A variety of chemicals is currently used in chemical peel formulations. Among them we can mention the alpha-hydroxy acids Glycolic Acid, beta-hydroxyacids, phenolic derivatives and retinoids, as well as salicylic acid, resorcinol and lactic acid, all are substances used in exfoliating formulations for the execution of chemical peeling with the main objective of to obtain a controlled skin lesion (RAMOS et al., 2005).
Contraindications and complications of chemical peels
Contraindications
Chemical peels are contraindicated in cases of pregnancy due to lack of safety studies. Background of hypertrophic and keloid scars should avoid medium and deep peels. Patients taking isotretinoin should wait at least one year after the end of the medication, as this causes re-epithelialization of the skin. Radiotherapy promotes reepithelialization reduction. Previous surgical procedure wait at least three months for peeling (laser and electrolysis). People with active acne lesions, herpes, active inflammatory processes, flat warts, seborrheic and atopic dermatitis, rosacea, immunosuppressive diseases should not be subjected to this type of feeling (RAMOS, 2005).
Complications
Alteration of pigmentation, alteration of cicatrization, alteration of texture are some of the complications generated by chemical peels, and may occur infection, toxic shock, laryngeal edema, mily, persistent erythema, cutaneous atrophy, cold hypersensitivity, cardiac arrhythmias and, finally, liver changes (RAMOS, 2005).
Purpose of performing a skin preparation or pre-peeling
The purpose of the preparation of the skin before each chemical peeling, emphasizing the superficial peeling, is to obtain a uniform absorption of the active principle used in each preparation, and with that to reduce the risks of hyperpigmentation of the same, as well as to stimulate its recovery faster, ( GARCIA et al., 2006).
According to Lacrimati (2008), the skin will depend on a preparation proportional to the depth of the aggression that will suffer, for that is used creams or other pharmaceutical forms that generate a conditioning of the skin so that it does not present spots in the post-peeling, and for that heals more easily. This preparation phase ranges from 4 (four) to 8 (eight) weeks, depending on the depth of action of each peel.
Cleansing the skin is essential for the removal of its impurities, such as sebum, makeup residues and cellular debris, and also assist in the homogenous absorption of the acids by the same. Thus, according to Lacrimati (2008). It can be cleaned with soap and water, 70% alcohol, 10% salicylic acid, Jessner's solution (14% resorcinol, 14% salicylic acid, 14% lactic acid in 100 ml ethanol), Hoffmam alcohol in parts) and also acetone.
Chemical Agents Betahidroacidos and alpha-hidroacidos
Chemical agents beta-hydroacids
- Tretinoin
It is used in pre and post-peelings, starting at concentrations ranging from 1% progressing up to 8%. It has a yellowish color that should stay in contact with the skin for 4 (four) to 6 (six) hours, and then removed with running water. Its desquamation will occur between 2 to 3 days, and can remain until the 7th day. They present advantages due to their absence of burning sensations and application uniformity, due to their coloration being easily noticed in the skin (GARCIA et al., 2006).
- Salicylic acid
It is a betahydroxy acid, used in concentrations ranging from 20 to 35%, causing an exfoliation that will occur between 3 to 5 days to the application. Applications should occur weekly in small areas, presenting mild burning and bleaching in the area, due to the crystallization of the acid (CUNHA, 2009).
Salicylic acid is a beta-hydroxy acid, which was chemically synthesized in 1860 and has been widely used in dermatological treatment as a keratolytic agent for the treatment of acne. It is a white powder soluble in alcohol, and slightly soluble in water. Its keratolytic action is due to its ability to solubilize the cell surface proteins, resulting in desquamation of the keratolytic residues of the skin. It should be used in concentrations of 3.0 to 6.0%, as above this concentration can be destructive to the skin (CUNHA, 2009).
- Tcidorichloroacetic Acid (ATA)
According to Ferreira (2000), trichloroacetic acid is a crystalline powder, highly soluble in water. When used for rejuvenating purposes they are excellent in treating damaged acne skin, as well as for deep wrinkles and scarring. It is a widely used active for superficial and medium depth chemical peels, with concentrations ranging from 10 to 75% in aqueous solutions. It is a peeling widely used by physicians, due to their absence of systemic toxicity, being requested in the formulations whose concentration varies between 10 to 80% (TEIXEIRA, 2008).
- Resorcin
It is a caustic agent of the phenol group, used as an exfoliating agent in paste form in concentrations ranging from 10 to 70%, or associated with other substances as in Jessner's solution. It is indicated for treatment of acne, alteration of skin color (dyschromia) and rough skin, post-inflammatory hyperpigmentation, can be used in darker skins, with a tendency to hyperpigmentation (TEXEIRA, 2008).
Chemical agents Alpha-hydro acids
The term alpha-hydroxyacid was first introduced in the dermatological market in 1974 and is used for the topical treatment of ichthyosis. Currently, many topical products that are on the market contain one or more alpha-hydroxy acids as the primary components of the formulation (RAMOS ET AL, 2005).
The alpha hydroxy acids are acids of nature, so when used in the formulations they need to be neutralized to reach a pH range of 3 to 5 in order to approach the pH of the skin surface ranging from 4, 2 to 5,6 because it is believed that the topical efficacy of the formulation is directly related to its desired pH, (RAMOS ET AL, 2005)
The topical efficacy of a formulation containing an alpha-hydroxy acid depends on two main factors: the bioavailable concentration, which is the fraction of the unchanged active that reaches the site of action and the vehicle used. The carrier is very important in the topical efficacy of an alpha-hydroxy acid, both for cosmetic use and for dermatological indications. Some alpha-hydroxy acids such as glycolic acid, lactic acid, tartaric acid, malic acid and citric acid, are highly water soluble, creams and or lotions made from oil-in-water emulsions, others are more soluble in lipids, which is the in the case of mandelic acid and benzylic acid, which are highly soluble in ointments or water-in-oil emulsions (RAMOS et al, 2005).
According to Ramos et al (2005) the alpha-hydroxy acids are responsible for the water retention of the epidermis, thus accelerating the cell renewal process, for this to occur, the pH of the formulation should stabilize around 3.8. Glycolic acid, citric acid, lactic acid, mandelic acid, pyruvic acid and tartaric acid belong to this group. Within these, we have some that are most commonly used as a chemical peeling in the office:
- Glycolic acid
Glycolic acid is found in natural foods such as sugarcane, has good absorption in different layers of the skin, and acts as a solvent for the intercorneocyte matrix reducing excessive keratinization. It is a peeling that depending on its concentration can be smooth, which acts promoting the thinning of the horny extract, which is useful in renewing the epidermis and visible reduction of facial lines. It should be applied locally to stimulate cell renewal, and also act as a hydrophilic bleach, which increases skin hydration and elasticity. The increased elasticity of the skin is due to direct stimulation in the production of collagen, elastin and mucopolysaccharides in the deeper layers of the skin. Glycolic acid peeling is used to treat facial skin damaged by acne, ichthyosis, melasma, warts, among other problems (HENRIQUES et al., 2007).
According to Henrique et al. (2007), glycolic acid allows us to perform superficial, medium and deep peels, depending only on their concentration and time of exposure of the agent to the skin. The surface peeling is performed with the corresponding 30 to 50% of the final amount of the formulation, the average peeling uses the corresponding of 50 to 70%, and the deep peeling uses concentrations greater than 70% of the formulation.
- Lactic acid
Extracted from sour milk, through bacterial fermentation, responsible for promoting skin hydration. At high concentrations it promotes exfoliation and renewal of the skin, always maintaining its PH of stability from 3.5 to 4.5, reaching a concentration of 85% (SHARQUIE ET AL, 2006)
- Mandelic Acid
Obtained by the hydrolysis of bitter almond extract. According to studies, mandelic acid is useful for treating non-cystic inflammatory acne and rejuvenating and aged photo skin, in addition to being used in pre-peeling and prevention of bacterial infections in post-peeling.
Phenol Chemical Feeling
Phenol or Carbolic Acid is derived from coal tar, physically presented as needle-shaped crystals, ranging from colorless to rosy, with a characteristic odor. When heated becomes liquid and when exposed to air and the light has a dark coloration. Phenol is a chemical agent that produces bacteriostatic effects when it is in presentations with minimum concentrations of 1%, and above this concentration presents bactericidal action. It acts as a local anesthetic in nerve endings and produces the coagulation of proteins. As a chemical compound, it is soluble in oils and fats, and can be easily removed from the skin through the use of glycerin, vegetable oils or 50% ethyl alcohol (CORREIA, 2010).
For Velasco et al. (2005), Phenol in the concentration of 88% penetrates the upper reticular dermis and is keratocoagulant, preventing its penetration in the deeper layers. Thus, the more concentrated the phenol is, the greater the coagulation of keratin, the lower its penetration and the lower its toxicity. Its application to the skin induces a chemical burn action, which over time results in skin rejuvenation, if applied for a longer period of time causes penetration into the upper dermis, resulting in the formation of a stratified collagen layer. Skin regeneration begins 48 hours after application. It should be noted that phenol peeling is used for the following cases: skin whitening, wrinkles, hyper pigmentation or heterogeneous pigmentation, acne treatment, scars, actinic lentigines and solar and seborrheic keratoses. Thus, the most well known formulation used in the composition of phenol is that of Baker-Gordon (1962), where the phenol used is diluted in concentrations ranging from 45 to 55%.
According to Velasco (2005), the crtonic oil in the formula is the component that increases the phenol's ability to coagulate the skin's keratin, acting as a promoter of the skin penetrations increasing the vascularization of the site. It is highly toxic to the skin, causing edema and erythema.
Water is the vehicle used to achieve the desired concentration of phenol in the formulation, without it to the uncontrolled concentration of the phenol could cause undesirable reactions to the skin, proportional to its concentration.
Phenol at 88% concentration has the ability to penetrate the upper reticular dermis and is keratocoagulant, which prevents its penetration at deeper levels. Thus, the phenol diluted in the formulation acts as a keratolytic agent, breaking the sulfur bridges of keratin and penetrating deeper. Thus, the more concentrated the phenol in the formulation, the greater the coagulation of keratin and the lower its penetration (Velasco, 2005).
When applied to the skin, according to Corrêa (2010), phenol induces a chemical burn, which over time results in skin rejuvenation. Its application for a longer period causes penetration into the upper dermis, resulting in the formation of a new layer of collagen, regeneration begins 48 hours after application of the formulation and is completed within 10 days. Phenol peeling is recommended in the following cases: skin whitening, wrinkles, hyper pigmentation or heterogeneous pigmentation, acne treatment, scars, actinic lentigines, solar and seborrheic keratoses.
Vehicles currently used in preparations of chemical peels
- Gel
Gels are considered emulsions, which have a high percentage of water in their composition, and a low concentration of oil. They have a hydrophilic colloidal stabilizing agent and a consistency donor. The gel-cream can be obtained by mixing in suitable proportions a gel and a traditional emulsion. In order to obtain a preparation that does not present the unwanted properties of a gel, and at the same time ensure the reduction of the oily sensation of an emulsion, always evaluating the compatibility of this vehicle as the active employed, since this gel-cream system has a lower stability than the separate gel or cream system (GARCIA, 2006).
- Creme or Creamy Lotion
Cream or lotion is defined as liquid or semi-solid lotions of oil-in-water or water-in-oil type. Pharmaceutical cosmetic vehicles are highly regarded for the incorporation of various types of assets. In their practice, doctors and patients prefer creams ointments due to their ease of application, and in cases of oil-in-water emulsion creams, for their practical removal of the skin (GARCIA ET AL, 2006).
Due to its particular characteristic of having a greater penetration in the tissues of the skin, reaching deeper layers, the liquid creams or lotions are highly used for the incorporation of actives with exfoliating and depigmenting action, used in the cellular renewal and skin exfoliation, thus guaranteeing , that these assets reach deeper layers of the epidermis (GARCIA ET AL, 2006).
- Transparent or Creamy Gel Soap
According to Garcia et al. (2006), clear or creamy gel soaps are considered one of the most suitable vehicles for the incorporation and exfoliating agents, allowing in combination with the active tensions, a deeper cleaning action. Its main feature should be the softness, so as not to irritate the skin that is on the action of an abrasive agent.
Final considerations
It was concluded that chemical peels have satisfactory results in the following skin disorders: acne, rejuvenation, melasma, acne scar and maintenance of dermatoses, and the agents used to perform these procedures are: Jessner's solution, salicylic acids, retinoic acid, mandelic, glycolic, lactic, trichloroacetic and phenol. However, studies have shown few criteria for evaluations, and few have described the type of skin used in the treatments, since it is known that certain acids would not be indicated for all biotypes, so it would be interesting if the studies were more specific in relation to their way of present their methodologies and results.
Reference
BORGES, FS. Therapeutic Modalities in Esthetic Dysfunctions. Phorte. São Paulo: 305-23. 2006.
CORREIA, D. L. Phenol Peeling Rejuvenation. Curitiba – PR.2010.
CUNHA, MN. Experience with 30% salicylic acid peeling in the treatment of acne. Journal of the Brazilian Society of Aesthetic Medicine. June. 2009. Available at: http://www.sbme.org.br/portal/download/revista/14/06_peeling_de _acido_Salicilico.pdf. Accessed on April 10, 2017.
DEFFERARI, R. PEELING – Healthy Body. 2008. Available at: <http://www.corposaudavel.com.br>. Accessed on: April 19, 2017.
GARCIA, B. G. B. C. et al. Pharmaceutical Dermatological Manual. Cosmiatry. 1. ed. However,
HERRIQUES, B. G. et al. Development and Validation of Analytical Methodology for the Determination of Glycolic Acid Content in Raw Material and in Formulations. Dermocosmetics. Revista Brasileira de Ciências Farmacêuticas. Sao Paulo. V. 43, n. 1, Jan / Mar.2007.
Lima, PRESSI. Skin blemishes – Health 2006. Available at: <http://www.saudetotal.com/artigos/dermatologia/tvescola_manchaspele.asp>. Accessed on: April 19, 2017.
LACRMANTI, LM. Course of aesthetics – volume 2. Yendis. São Paulo: 51-2. 2008.
WALNUT. THE SKIN. – Good health. 2006. Available at: <http://www.boasaude.uol.br>. Accessed on: April 19, 2017. Available at: http://amsdottorato.cib.unibo.it/587/1/tesi_de_padova.pdf Access April 10, 2017.
ROTTA, O. Guide to Dermatology: Clinical, Surgical and Cosmic. Manole. São Paulo: 689-97. 2008.
SHARQUIEKE, Al-Tikreety MM, Al-Mashhadani SA. Lactic acid chemical peels as a new therapeutic modality in melasma in comparison to Jessner's solution chemical peels. Dermatol Surg. 2006; 32 (12): 1429-36.
TEIXEIRA, C.M. CHEMICAL PEELING – Bio Body Modulation. 2008. Available at: <http://www.biomodulacaocorporal.com.br/peeling_quimico.htm>. Accessed on: April 19, 2017.
OLD, PENF; Moraes AM. Superficial chemical peeling for the maintenance treatment of rosacea. Soc Bras de Dermatol. 2010 Available at: http://www.surgicalcosmetic.org.br/public/artigo.aspx?id=1 06. Accessed on April 15, 2017.
VIEIRA. Anatomy of the skin – med students. May 31, 2008. Available at: <http://www.med.students.com.br/content/resumo_medstudents20060531_01.doc>. Accessed on: April 20, 2017.
RAMOS, T. R; et al. Validation of an analytical method for the determination of active substances in pharmaceutical formulations used in chemical peels. Rev. Bras. Pharmaceutical Sciences, apr / jun 2005, vol. 41, no. 2, p. 229-235.
ROTTA, O .; et al. Guide to dermatology: clinical, surgical and cosmic. 1st ed. Barueri, SP: Manole, 2008. P. 689-696.
VELASCO, M. V.; et al. Skin rejuvenation by chemical peeling: focus on phenol peeling. An. Bras. Dermatol. jan./fen. 2005, vol. 79, no. 1, p. 91-99.
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