بسم الله الرحمن الرحیم

1. بسم الله الرحمن الرحیم موضوع باز آموزی : پیلینگ شیمیائی دکتر رسول توکلی کیا مرکز تحقیقات پوست و سالک شانزدهم اردیبهشت نود و دو

2. Chemical peel • Aims: • Understand thedifferent depths achievedbythevarious agentsusedinchemical peeling. • Learn theindicationsfor various chemical peels. • Understand factors in patient selection. • Learn the techniques involved for predictable outcomeswith avarietyof chemical peels • Learn howto identify andtreat potential complications.

3. Chemical peeling is a popular, relatively inexpensive, and generally safe method for treatment of some skin disorders and to refresh and rejuvenate skin. • Peels can be combined with other in-office facial resurfacing techniques to optimize outcomes and enhance patient satisfaction and allow clinicians to tailor the treatment to individual patient needs. • Successful outcomes are based on a careful patient selection as well as appropriate use of specific peeling agents. • Used properly, the chemical peel has the potential to be an important therapeutic tool for dermatologist • The American Society of Plastic Surgery reported that more than one million peel procedures were performed by its members in 2008. • Chemical peels are very common in clinical practice. • Creates a controlled wound

4. Classificatiion of chemical peel • Chemical peels are classified by the depth of action into • superficial, • medium, • deep peels. • The depth of the peel is correlated with clinical changes, with the greatest change achieved by deep peels. • However, the depth is also associated with longer healing times and the potential for complications

5. Classificatiion of chemical peel

6. Classificatiion of chemical peel • Superficial peels, penetrating only the epidermis, can be used to enhance treatment for a variety of conditions, including acne, melasma,dyschromias, photodamage, and actinic keratoses. • Medium-depth peels,penetratingto the papillary dermis, may be used for dyschromia, multiple solar keratoses, superficial scars and pigmentary disorders. • Deep peels, affecting reticular dermis, may be used for severe photoaging, deep wrinkles, or scars.

7. Superficial peels • Superficial peels affect the epidermis and dermal-epidermal interface. • They are useful in the treatment of mild dyschromias, acne, postinflammatory pigmentation, and AKs and help in achieving skin radiance and luminosity • Because of their superficial action, superficial peels can be used in nearly all skin types. • After a superficial peel, epidermal regeneration can be expected within 3 to 5 days, and desquamation is usually well accepted. • Superficial peels exert their actions by decreasing corneocyte adhesion and increasing dermalcollagen. • These peels are a good method for rejuvenating the epidermis and upper dermal layers of skin.

8. Medium-depth • Medium-depth peels may be used in the treatment of dyschromias, such as solar lentigines, multiple keratoses, superficial scars, pigmentary disorders, and textural changes. • The healing process is longer, with full epithelialization occurring in about one week. • Sun protection after a medium-depth peel is recommended for several weeks. • Because of the risk of prolonged hyperpigmentation, medium-depth peels should be conducted with caution in patients with dark skin.

9. Deep peels • Deep peels may be used for severe photoaging, deep or coarse wrinkles, scars, and sometimes precancerous skin lesions. • Usually performed with phenol in combination with croton oil • Deep peels cause rapid denaturization of surface keratin and other proteins in the dermis and outer dermis and penetrate the reticular dermis, so deep peel maximizes the regeneration of new collagen. • Epithelialization occurs in 5 to 10 days, but deep peels require significant healing time usually two months or more and sun protection must always be used. • Phenol is rapidly absorbed into the circulation, potentiating cardiotoxicity in the form of arrhythmias. • Therefore, special care, such as cardiopulmonary monitoring and intravenous hydration, must be provided to address this concern. • Due to the increased risk of prolonged or permanent pigmentarychanges, deep peels are not recommended for most darkskinnedindividuals.

10. Wound healing Chemical peeling is the application of one or moreexfoliating agents to the skin, to produce controlled partial-thickness ablation Chemical peels creates a controlled wound

11. Post-Peel, Immediate

12. Post-Peel, 72 hrs

13. Post-Peel, Complete

14. Wound healing • In general, before the 20th century, it was believed that wounds healed best when left open (to allow them to breathe) and dry (to keep them ‘germ free’) as advocated by Pasteur. • This view began to change in 1958 when Odland observed that a blister healed faster when left unbroken. • Winter’s landmark study on swine in 1962 showed that superficial wounds kept moist by covering them with a film healed twice as fast as those exposed to the air • Hinmanand Maibach repeated Winter’s study in humans and found a similar increase in epithelialization rate for occluded wounds • These studies revolutionized the approach to wound care by demonstrating the importance of moist wound healing

15. Acute wounds • Acute wounds are wounds with no underlying healing defectthat heal in an orderly and timely fashion, passing through well-defined phases of an inflammatory response, granulation tissue formation, and remodeling.6 • In acute wounds, the function of dressings in maintaining a moist environment is critical in facilitating healing. • In fact, acute wounds have been shown to heal 40% faster in a moist environment than when air exposed

16. Tretinoen • α-Hydroxyacids • Sunscreens • Hydroquinone • Antiviral prophylaxis • Photography

17. Effects of a moist environment andocclusion on wound healing • Enhancement of epithelial migration • Stimulation of angiogenesis • Retention of growth factors • Facilitation of autolytic debridement • Protection against exogenous organisms • Maintenance of voltage gradient

18. Protection against exogenous organisms • Although the bacterial count is higher in occlusive dressings than non-occlusive dressings, this does not predispose to infection. • Overall infection rate is 2.6% for occlusive dressings versus 7.1% for non-occlusive dressings. • Occlusion is also associated with the presence of higher levels of lysozymes and globulins. • Lastly, occlusion maintains a mildly acidic pH,whichis inhibitory to the growth of some bacteria, especially Pseudomonas and Staphylococcus spp.14

19. It is misleading to classify chemical peeling solutions as light or deep solutions based on their concentrations since there are many factors that affect peel depth. • Acid concentration, the number of coats applied, skin thickness, skin preconditioning, and, in some cases, the duration of contact of the acid on the skin are the main variables.

20. Keratolytics are acids that disrupt the adhesion between the keratinocytes, thus causing shedding of these layers. • The two main acids used for exfoliative procedures are glycolic and salicylic acid. • These are oftentimes referred to as lunchtime peels as these exfoliative acids have the benefit of little to no downtime for the patient; in addition, there is no anesthesia requirement, and they are easy

21. Contraindications • Contraindications include patients with • active bacterial, viral or fungal infection • tendency to keloid formation • facial dermatitis • taking photosensitizing medications • unrealistic expectations.

22. Glogau Classification

23. Preparing the skin for chemical peeling • It is important to match the skin pathology to the chemical agent. • Preparation of the skin prior to chemical peeling is extremely important. • The skin-care program consists of patient education regarding sun avoidance, the use of effective sunscreenon a daily basis, and pretreatment with tretinoin and or AHAs

24. Pretreatment with tretinoin for chemical peels • Tretinoin improves skin texture and reduces fine wrinkling and mottled hyperpigmentation. • Topical tretinoin pretreatment accelerates wound healing after medium-depth and deep-depth chemical peels. • In a double-blind, placebo-controlled, prospective, randomized study, 16 males with actinically damaged skin were treated dailywith tretinoin 0.1% versus placebo cream to the left and right sides of the face,, and hands 14 days before a 35% TCA peel.Post-peel healing was evaluated on days 3, 5,7, 9,11,and14

25. Pretreatment with tretinoin for chemical peels • In 94% of patients, the sloughing occurred earlier and was more uniform, regardless of body location, in skin pretreated with tretinoin than with placebo-treated skin. • Maximalhealing of the tretinoin-treated facial skin was evident after 5 days (68% vs 52%; P < 0.005).

26. Pretreatment with tretinoin for chemical peels • The American Academy of Dermatology (AAD) Guide lines Outcomes Committee developed‘Guidelines of Care for Chemical Peeling’ in an effort to enhance quality of care for patients having cosmetic procedures. • This AAD committee recommended tretinoinpretreatment as preparation for skin that is undergoing chemicalpeeling. • The committee also recommended postoperative tretinointo enhancewound healing and to maintain results.

27. Superficial peeling agents • Trichloroacetic acid 10–25% (35%; one coat) • Jessner’s solution: resorcinol/salicylic acid/lactic acid. • Modified Unna’s resorcinol paste. • Solid CO2 slush. • Salicylic acid. • AHAs. • Tretinoin solution.

28. Advantages of superficial peels • Excellent safety record. • May be used on all Fitzpatrick skin types. • Rapid healing, minimal downtime. • Repeated peels provide cumulative effects. • Amplifieseffects of topical rejuvenating agents. • Can be combined with laser modalities. • Affordable. • No anesthesia needed.

29. Jessner’s solution formula • Resorcinol 14 g • Salicylic acid 14 g • Lactic acid 14 g • Ethanol 95% qs ad 100 mL1

32. Patient evaluation to optimize outcomes • Physician–patient relationship. • Patient’s realistic expectations. • Fitzpatrick skin type. • Active infection. • Tobacco use. • Medications:minocycline, isotretinoin. • History of herpes simplex virusinfection • History of keloid formation • History ofprevious radiation exposure. • History of immunosuppression. • History ofpostinflammatory hyperpigmentation. • History of Recent facial surgery.

33. Limitations of superficial peels • Little clinical effect with one peel. • Multiple superficial peels do not provide the same results as one mid-level or deep peel. • Media has created unrealistic patient expectations • Minimaleffect on medium to deep rhytides. • Return to before-peel condition within 2years without topical agents.

34. Deep Chemical Peel • Face is divided into six aesthetic subunits • Forehead, perioral region, bilateral cheeks, nose, and periorbital region • 15-minute time interval between units • White frost that is carried 2 to 3 mm across the vermilion border • Lower eyelids need to be treated to within 1 to 2 mm of the ciliary margin • Upper eyelid above supratarsal fold

35. Medium Peel • White frost appears complete on the treated area within 30 seconds to 2 minutes • Before re-treating an area one should wait at least 3 to 4 minutes before determining for asymmetry • Eyelid skin and bony prominences have a high propensity for scarring (limited to a level II frosting) • An assistant standby with sterile eye wash in case agent spills into the eye