The use of peelings in the fight against acne and scars

During the clinical management phase of acne treatment, it is necessary to establish a framework for treatment modifications that includes concepts such as non-pharmacological interventions using various modalities to improve efficacy and tolerability, and to optimize outcome in the treatment of acne and scars .

Non-pharmacological interventions for the treatment of acne vulgaris have been used for many years, but recently the need for such interventions has increased, leading to new concepts in the field of peeling, opening up new ways to treat acne and scars.

Conservative treatment has its own indications, and although many acne can be effectively eliminated as a result of this treatment, resistant forms and post-acne are still a significant problem for dermatologists. Recent acne research has shown that scar prevention and treatment should be carried out in some cases when patients are undergoing acne treatment, or immediately after the end of such treatment. A patient's tendency to form scars after acne can be judged by the type of inflammatory reaction that occurs during treatment. Early treatment helps avoid gradual scarring of healing wounds from inflammatory acne.

Chemical peels

In this day and age, with lasers, IPL and other energy sources being used for therapeutic purposes, chemical peels still hold a firm position as the most widely used procedure in our practice.

The technology for gradual chemical exfoliation to improve skin condition has improved over the years. Today, a number of exfoliating agents are available to us in the most incredible cocktail of formulas. Peels are primarily aimed at eliminating acne, acne scars, pigmentation, wrinkles, and improving the texture of the patient's skin (Table 1).

Table 1. The most common indications for peeling

Standard traditional peels have their advantages, but they are limited by many contraindications and unsuccessful results that satisfy neither patients nor doctors.

The limitations of glycolic acid peels are that a strong free acid cannot be used due to the potential risk of complications, and a weak acid does not provide the desired effect.

A general understanding of the mechanism by which peels act on tissue is evolving. Composition formulas at the molecular level are becoming more complex, combinations, mechanisms of action, and the concept of compatibility are changing, since the composition of each peel is selected in such a way that it is optimally effective in eliminating a specific problem. If previously peelings used one component, now they include several.

Combined peels are the most common today. Deep knowledge of the predominant molecule in a peel helps to select products that give the best results.

Peels are used in the early stages of acne treatment because they:

• help eliminate concomitant comedous and nodular acne;
• accelerate the elimination of erythema after acne;
• eliminate pigmentation at the site of removed acne;
• reduce the depth and contours of acne scars and soften them;
• contribute to the normalization of skin color;
• Externally rejuvenate the skin.

Although alpha and beta hydroxy acids and trichloroacetic acid (TCA) are the mainstays of peels, we have learned to combine them, revolutionizing peeling techniques.

The newest techniques used today are segmental, sequential, alternating peeling and timed peeling.

Current trends in optimizing the results of chemical peels to eliminate acne and scars are as follows:

• The use of peeling at the early stage of acne treatment for moderate, moderate and inflammatory acne.
• Reducing the effects of residual mild acne after drug treatment through early use in the treatment of erythematous scars.
• Good results on pigmented scars.
• Combining different types of peelings for one patient - alternating peelings or peelings with time delay.
• Widespread replacement of traditional peelings with combined ones.
• Peels with a slow release of the active substance, giving better results with fewer side effects.
• Combination with other methods of dermabrasion, laser correction, dermarollers - to improve the results of the fight against scars.

The decision to use the active peeling substance should be made after careful preliminary selection of sun protection products and provided that the patient observes all precautions and waits for real results. The effect of the main substances of the formulas differs for different indications, and this should be taken into account when choosing one or another composition.

Indications for use should be carefully selected: a patient with acne will not be suitable for the peel used for a patient with early scars after acne elimination. In patients with acne, the stage at which peeling is applied is more important. The choice of peel is also based on the predominant type of acne: comedose, nodular, inflammatory, etc. Younger skin responds better to different formulations than mature skin, and pigmentation and texture issues should always be taken into account when assessing the expected result.

Selection of peeling

Combined peelings. The use of a combination of several active ingredients in order to mutually complement their effects has become the latest trend, forming the basis of the latest concepts in the field of peeling. The depth of penetration and effectiveness of peeling are enhanced by the combination of its active ingredients. For example, peeling based on salicylic acid in combination with mandelic acid is effective in the treatment of seborrhea and residual acne, pigmented scars after stage 1 acne, and also improves skin texture. Mandelic acid has an antibacterial effect and is safe for dark skin types. Gel-based combination peels contain less free acid and therefore have fewer side effects, making them suitable for sensitive skin.

Consecutive peelings. Used sequentially, peels have a synergistic effect, provided that their components are compatible. A generally accepted technique is to apply one peel, after which the next one is applied. Then the action of the latter stops, or it is left and acts with a temporary delay with a slow release of the active substance. The most effective sequential peels are salicylic acid followed by mandelic acid and glycolic acid followed by TCA. They give a moderately deep effect.

Alternating peels. Provide for the use of various active substances for peeling alternately. You can also use these substances sequentially. For example, to eliminate comedous or inflammatory acne, you can apply a peel with salicylic acid or retinol, and then, in the next session, use a peel with glycolic, mandelic or phytic acid. This technology effectively reduces scars and improves skin structure.

Peels with slow release of active substance. Some peels operate on a new principle of controlled release of the active substance and are called “slow release peels.” In these peels, the active substance is gradually released, which ensures complete penetration and effective action of all components of the solution. For example, a peeling consisting of three hydroxy acids and phytic acid. The AHAs (alpha hydroxy acids) included in the peeling - glycolic, lactic and almond - are released and act gradually, so the doctor does not need to neutralize them.

The depth of penetration of these three AHAs into the epidermis is different. Phytic acid present in the solution is a large inositol hexaphosphoric acid molecule that neutralizes free radicals. Thanks to this, peeling promotes regeneration, but during this process it also separates harmful free radicals. Phytic acid prevents cell degeneration caused by free radicals.

Frost should not occur during the procedure. If frost occurs (this can happen when using retinol or an exfoliating active), you need to be very vigilant for any abnormalities with any peel. Peeling based on phytic acid has a good effect on residual damage after acne, with early erythematosis and on pigmented scars in stages 1 and 2. Glycolic acid, which is part of the peel, promotes skin regeneration, mandelic acid has an antibacterial and anti-inflammatory effect, and lactic acid is moisturizer and has a rejuvenating effect.

TCA. Trichloroacetic acid peels are important for improving the appearance of most types of scars. The depth of the peel can be controlled, and in most cases, 4 sessions of peeling at a concentration of 15-25%, with appropriate preliminary preparation and treatment of the skin, will noticeably reduce the depth and soften the contours of rectangular scars.

The crossover technique consists of focal application of the highest concentration of trichloroacetic acid, from 40 to 65%, focusing on the entire area affected by acne scars. This technique is called Chemical Reconstruction of Skin Scars (CROSS).

• It is used for fibrous and superficial scars, as well as deep chipped and rectangular scars, demonstrating significant improvement after just 3-5 sessions, carried out at intervals of 1 month.
• Several regular sessions of CROSS peeling will destroy atrophic depressions by restructuring and tightening the collagen of the dermis.
• This type of peeling gives the best results for fibrous, chipped, rectangular scars and enlarged pores.

The CROSS method with parallel use of a dermaroller is another way to improve the condition of the skin with 2nd and 3rd degree scars. The CROSS technique is used before and after using a dermaroller, in cycles of 4-5 sessions with an interval of 1 month.

Often, interference with the skin structure leads to side effects and complications (Table 2). Therefore, during the peeling process you need to be especially careful, since the cause of most side effects is insufficient preliminary preparation of the skin, failure to follow the rules for peeling, the use of inappropriate peeling, etc. When working with colored skin, special care is required, since it is necessary to prevent the appearance of unwanted pigmentation. Therefore, careful preparation should be carried out and the depth of penetration of the peeling should be correctly calculated. To do this, you need to determine the correct end point of the peel.

Table 2. Complications after peeling

The good thing is that for better results, chemical peels can be combined with other procedures such as comedone extraction, microdermabrasion, subcision, dermaroller, fractional laser and skin tightening.

Combination of peeling with other techniques

The use of peeling based on salicylic acid (20–30% concentration) or TCA-based (30–50% concentration) after extracting comedones helps not only eliminate retinol-resistant comedones, but also prevents their reappearance and inflammation. The use of oral antibiotics and topical antibiotics after extraction prevents pustular inflammation.

The best results were achieved when microdermabrasion was combined with chemical peels: absorption was improved and uniform penetration of the active ingredients of the peel was achieved. Microdermabrasion should be performed a week before a chemical peel. It is used before peeling based on phytic acid, in which there is a slow release of glycolic acid. TCA-based peels should not be used in this regimen, as they carry the potential risk of over-penetration and excessive absorption, as well as subsequent inflammatory pigmentary changes, which are especially common in skin of color.

For best results, you can combine microdermabrasion a week before the peel and a dermaroller after the peel. You can also extract comedones before peeling using salicylic acid or retinol. After peeling, fractional lasers or fillers can be used after complete re-epithelialization and cessation of the inflammatory process. However, the basis for success is the doctor’s diagnostic intuition when individually selecting the appropriate combination of procedures for each specific patient.

Conclusion

Almost all types of severe acne scars and moderate acne scars can be eliminated using different types of procedures in combination with acne treatments. The use of different treatment methods in the early stages prevents the development of gradual scarring in patients with inflammatory acne. The choice of appropriate treatment and combination of various techniques depend on the individual characteristics of the patient, and responsibility for the safety, effectiveness and economy of the chosen method of treating acne and eliminating scars rests with the doctor.

Literature:

Shehnaz Z. Arsiwala is an MD in dermatology and venereology, consultant dermatologist, cosmetologist, dermatosurgeon, practicing at Saifee Hospital, Prince Aly Khan Hospital (Mumbai, India).

KOSMETIK international journal, No. 3 (49), 2012