What you need to know about phenol peeling?

Irina Karnus,

dermatologist, leading specialist of the clinic

aesthetic medicine "Leomed"

Everything is poison, nothing is without poison,

just one dose makes the poison invisible

(Paracelsus)

Historical excursion

In 1865, the English surgeon Lister used a solution of carbolic acid to combat wound suppuration in open fractures. At the beginning of the 20th century, phenol was described in a pharmaceutical publication as an anesthetic and antiseptic (about 5% in aqueous, oily and alcoholic solutions). During the First World War, the doctor La Gase discovered that after treating wounds with phenol, the skin became smoother and lighter. His daughter brought this discovery - phenol peeling to America, and this became the beginning of the cosmetological use of phenol.

In the 30s, phenol began to be used in cosmetology to treat acne; in addition, it was noticed that after its use, the skin became uniform in texture, thickened and tightened. In the 40s, phenol became a sensation in cosmetology, and from that moment on the search for the “ideal formula” began. In 1961, the American doctor Lytton published the results of using phenol peeling on 50 patients. He kept his peeling formula (50% phenol, glycerin, croton oil) a secret. Many other dermatologists followed his example, creating their own formulas and also keeping them secret.

In those same years, American doctors Baker and Gordon, having obtained the recipe for phenol peeling, published it in full. Their formula consisted of 3 ml of 88% phenol, 2 ml of distilled water, 8 drops of Septisol liquid soap and 3 drops of croton oil. The first studies of the effectiveness of this peeling were only clinical observations, but in 1985, Kligman, Baker and Gordon published the first morphological studies of skin changes after applying a phenol peeling. The Baker-Gordon peeling formula penetrates the skin better than undiluted phenol. After the procedure, layers of “fresh” elastin up to 3 mm thick were found in the women’s skin. Further studies showed that in the absence of an occlusive coating, phenol penetrates deeper, with an increase in concentration from 50% to 88%, while the severity of peeling will be relatively weak. After applying the phenol peel, the occlusive film was left in place for 24 hours; the film increased penetration, but at the same time promoted hypopigmentation, which caused the skin to acquire a “porcelain” color.

The search for the perfect formula continued. Aronson developed a glycerol phenol formula that included 88% phenol dissolved in anhydrous glycerol and a few drops of alcohol. This formula was used without occlusion and did not produce as deep an effect as the Baker-Gordon peel. Iris received a medium peel by mixing phenol and trichloroacetic acid. These two formulas are not used today, because a mid-peel can be performed with trichloroacetic acid, which is potentially non-toxic. The Baker-Gordon formula remained the gold standard for many years.

The main complications that doctors encountered when using phenol peeling:

• systemic - heart attacks, arrhythmia, renal and liver failure due to intoxication;
• localized - exacerbation of herpes, infection, pathological scarring, increased allergic reactions, formation of spots of atypical color.

Research and improvement continued. In 1986, Israeli dermatologist Yoram Fintsi proposed his composition of phenol peel Exoderm Lift. The formula included liquid phenol 91%, crystallized phenol, resorcinol, salicylic acid, olive, glycerin, sesame, croton oils, distilled water, septisol, ethanol, citric acid, buffer. Dr. Fintsi has done a lot of work with more than 20 thousand patients in 35 countries, after which the interest of science and medicine in phenol peeling has once again increased greatly.

In 1996, the Spanish doctor Philippe Dupre presented his phenol peeling formula Lip&Eyelid formula (phenol concentration 63%, a complex of oils that improve penetration) and proposed the possibility of carrying out the procedure in a dermatologist’s office, subject to local application of its composition only to the periorbital and/or perioral areas with with or without occlusion. Subsequently, peeling compositions were developed for application to the entire face with a phenol concentration of less than 40%, intended for mid-depth and median exposure, which allows their use not in a hospital, but in a dermatologist’s office.

Evidence-based research

In 2000, American doctors (including Michael Yaremchuk) published an article on the topic: “Quantitative and qualitative effectiveness of chemical peels for skin photoaging. Experimental research". The study was conducted in vivo on hairless laboratory mice, which were exposed to ultraviolet irradiation for 14 weeks, then the animals were divided into five groups:

Group 1 - control;
Group 2 - 50% glycolic acid;
Group 3 - 30% trichloroacetic peeling;
Group 4 - 50% trichloroacetic peeling;
Group 5 - phenol peeling (Baker-Gordon formula).
Peeling compounds were applied to the dorsal area (back), then biopsy samples were taken from this area several times for histological and biochemical analysis. Glycosaminoglycan levels were measured on days 14, 28 and 60 (Figure 1), collagen levels on days 3, 7 and 28 (Figure 2). A significant increase was observed in the 30% TCA, 50% TCA and phenol group (p less than 0.04). A significant increase in glycosaminoglycans was observed in the 50% TCA and phenol group (p less than 0.02). Under polarized light on day 60, all study groups except the control group showed reorganization of collagen in the reticular and papillary dermis. Signs of elastosis were evident in the control group, and reorganization of elastin fibers in the dermis was observed in the peeled groups. This effect was deeper and more pronounced in the 50% TCA and phenol groups, and significant thickening of the dermal matrix was also observed in these groups.

Rice. 1. The effect of chemical peels on the quantitative content of glycosaminoglycans in the skin. Measurements on the 7th, 14th, 28th and 60th days

Rice. 2. The influence of chemical peels on the quantitative content of collagen in the dermis. Measurements on days 3, 7, 14, 28 and 60

The rejuvenating effect of phenol on the skin is very effective, and this mechanism is provable (Fig. 3, 4). Research and extensive experience (over 100 years) of use allows us to minimize the number of complications and side effects.

Rice. 3. Histological examination. Biopsy samples are stained with hematoxylin and eosin and examined under polarized light, demonstrating reorganization of collagen fibers. A - phenol, B - 50% TCA, C - 30% TCA, D - 50% glycolic peel, E - control group

Rice. 4. Verkhoev staining of the biopsy samples under study demonstrates the reorganization of elastin fibers after exposure to chemical peels. A - Baker-Gordon phenol peel, B - 50% TCA, C - 30% TCA, D - 50% glycolic peel, E - control group

Mechanism of action of phenol peeling

The pharmacological effect of a carbolic acid solution is protein coagulation and, as a result, an antiseptic and exfoliating effect. After soaking the connective tissues with it, they experience a feeling of numbness for several hours. This property is used therapeutically for pain relief. It has also proven useful for modifying other peeling formulations: the phenol in TCA peels relieves pain during application (for example, Skin Tech Pain Control).

When a concentrated solution is applied to the skin, the disulfide bonds between keratin and corneodesmosomes are broken - these proteins are destroyed. The complex, consisting of a denatured protein with carbolic acid, due to its large size, penetrates the stratum corneum less well and is less soluble in the lipids of the intercellular space. This explains the fact that diluted phenol, having a less denaturing effect, penetrates the skin better than concentrated phenol.

Each component in peeling formulas also serves specific purposes. Septisol causes keratolysis and promotes penetration. Croton oil enhances phenol penetration, causing epidermolysis while improving skin healing. Olive or other oils improve and slow down penetration.

Aesthetic indications

1. Photoaging.

Surgery cannot affect the quality, color or texture of the skin. Phenol influences this, promoting a complete restructuring of the dermis down to the reticular layer. Dry, wrinkled and atonic skin responds to deep peeling with significant retraction, increased elasticity due to stimulation of neocologenesis, hydration due to increased levels of glycosaminoglycans, and in some cases, even a decrease in the manifestation of rosacea, since phenol strengthens the vascular walls of lysis.

The effectiveness of phenol peeling depends on your skin type and type of aging.

Fitzpatrick identified 6 skin phototypes:

• Phototype I (0-6 points) - pale skin, blond or red hair, blue eyes, freckles. Such skin quickly burns in the sun, but is not prone to the formation of pigment spots;
• Phototype II (7-13 points) - white, light skin, blond or red hair, blue, green or light brown eyes. People with this type of skin usually get sunburned with minimal tanning;
• III phototype (14-20 points) - light cream skin, with any color of hair and eyes, a common type. This type of skin rarely burns badly, the tan is even;
• IV phototype (21-27 points) - moderately brown skin, typical Mediterranean type. Rarely burns, always tans well;
• V phototype (28-34 points) - dark brown skin, Middle Eastern skin type. Very rarely burns, tans very easily.
• VI phototype (35+ points) - deeply pigmented brown or black skin. Never burns, tans very easily.

The use of deep phenol peeling is not recommended for rejuvenation of phototypes III, IV and V due to the risk of disruption of melanocyte function and, as a consequence, the occurrence of dyschromia.

Types of skin aging according to Glogau:

• aging type 1 - up to 30 years, no wrinkles, minimal or no dyschromia, no hyperkeratosis, no makeup required;
• aging type 2 - 30-40 years, wrinkles are noticeable during facial movements (ischemic wrinkles), local hyperpigmentation (early “sew lentigo”), visible hyperkeratosis is absent, but can be felt by palpation, symptoms of photoaging are from subtle to moderately pronounced, light makeup is used;
• aging type 3 - 40-60 years, hyperkinetic wrinkles, hyperpigmentation and telangiectasia, keratomas and other benign neoplasms, symptoms of photoaging, severe hyperkeratosis, heavy makeup required;
• aging type 4 - after 60 years, deep numerous wrinkles and thermal folds. yellowish or grayish tint of the skin, pronounced symptoms of photoaging - dyschromia spots, keratomas, possible neoplasms, including malignant ones, makeup emphasizes age-related changes.

Rejuvenation using deep phenol peeling is recommended for types 3 and 4 of aging, since it makes no sense to use such a procedure in case of mild age-related changes.

2. Hyperpigmentation.

Phenol disables melanocytes, even not always completely destroying them, thus its effect on dyschromia is very effective. Therapeutic indications: lentigo, lentigo maligna, both diseases are histologically characterized by an increase in the number of melanocytes (in the case of lentigo maligna they are atypical), mainly in the basal layer. Since melanocyte proliferation occurs at the intradermal level, phenol peeling therapy is very justified.

Melasma, chloasma : for these diseases, if the pigment lies intradermally (diagnosis using a Wood's lamp), then one of the therapeutic indications will be the application of phenol peeling.

Pigmented form of keratosis : manifested by multiple limited dense foci of hyperkeratosis, differentiated from other forms of keratosis by brown keratotic spots.

Scars : Due to its coagulating effect, phenol peels help improve the appearance and condition of scars.

Contraindications

Contraindications to phenol peeling are heart failure, arrhythmias, renal and liver failure, infectious diseases, exacerbations of herpes, a tendency to keloid scars, exacerbation of skin diseases, severe central nervous system diseases, diabetes mellitus, pregnancy and lactation, age under 18 years. Intense sunbathing, using retinoid-based products, and laser procedures should be stopped six months before the procedure.

Carrying out the procedure

It should be noted the difference between “large phenol” and the currently existing modified formulations, in which the concentration of phenol is no more than 40% or they are intended for local application to the periorbital and perioral zone. When it comes to “large phenol” (concentration greater than 60% and applied to the entire face), it can only be carried out by experienced doctors in a hospital setting. The patient is connected to vascular and cardiac monitoring and is under intravenous anesthesia or local anesthesia. The face is thoroughly degreased with a mixture of acetone and alcohol, divided into five zones, the composition is applied to the zones at intervals of at least five minutes - during this time, phenol, reaching the capillaries in the deep reticular dermis and entering the bloodstream, manages to be neutralized by the liver. Thus, the application of one layer occurs within 25-30 minutes. Both the patient and the doctor performing the procedure must be protected from inhaling phenol vapor.

Application of modified formulations: since these formulations are adapted for use in a dermatologist's office, they are applied only to the periorbital and perioral zones (for example, Lip&Eyelid Formula Skin Tech) or to the entire face, while the concentration of the composition is no more than 35%. This amount of phenol is not toxic to the patient. Application also occurs in zones, at intervals, the burning sensation is felt only for 12 seconds, then phenol exhibits its analgesic properties.

Phenol is applied in no more than two layers, the third application can only be applied locally on particularly deep wrinkles. Then, depending on the peeling technology, the doctor may apply an occlusive film for 24 hours or immediately apply special products to protect and relieve the feeling of tightness.

It is also recommended to use bismuth subgalate powder as a protection and antiseptic throughout the entire period until the scabs are removed. It is also possible to prescribe painkillers in the first three days after the procedure, and drinking plenty of fluids is recommended. For the next seven days, the patient is under the supervision of a doctor. If the procedure was performed with occlusion, it is removed the next day. On the third day, the doctor conducts a follow-up examination to check for infection or herpes in the peeling area. If necessary, antibiotics or antibacterial drugs are prescribed. Further rehabilitation is much easier, pain and swelling go away. On the 7-8th day, as a rule, the crusts are rejected - the doctor generously applies Vaseline to the peeling area, and over the next day the crusts come off.

Side effects and complications

After the phenol peeling procedure, side effects and complications are possible:

• herpes and bacterial infection in the peeling area - they can be dealt with by preventive administration of antiviral drugs and timely administration of antibiotics;
• long-term erythema - as a rule, erythema after deep peeling can persist for up to six months, and its resolution should be facilitated by special means (creams, masks);
• hyperpigmentation - for prevention, patients should be prescribed bleaching agents (containing hydroquinone, retinol, kojic acid, etc.). It is imperative to explain to the patient the importance of constant use of SPF protection.

Rare complications and side effects include:

• the appearance of a demarcation line - a clear boundary between the treated and untreated skin;
• ectopion - deformation of the lower eyelid;
• scar formation.

All of them arise when the doctor does not follow the application technique and peeling technology, or when the patient does not comply with the doctor’s prescriptions and recommendations during the rehabilitation period.

Rice. 5-6. Before and after using phenol peeling

Rice. 7-8. Before and after using phenol peeling

Doctors must undergo special training and be as responsible and professional as possible when carrying out the deep peeling procedure. And then the amazing results of skin rejuvenation will delight patients for many years (Fig. 5-8).

This article is part of the special project "PEELINGS"

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SPECIAL PROJECT.PEELINGS.