CHEMICAL PEELING IN PHOTO AGING

SUMMARY

Photoaging is the cumulative result of exposure of endogenously aging skin to UV and infrared rays. Clinically, dryness, irregular pigmentation, freckling, lentigines, actinic keratosis, guttate hypomelanosis, persistent hyperpigmentation, wrinkles, telangiectasia, loss of elasticity, large comedones, sebaceous hyperplasia are seen. Glogau 4 stages; Type I is early stage, no wrinkles, type 2 wrinkles with facial expressions, type 3 advanced wrinkles at rest, and type 4 severe wrinkles only. Chemical resurfacing is used in the treatment of photoaging by stimulating epidermal regeneration and dermal neocollagenesis by creating controlled damage of a chemical applied to the epidermis. While alpha and beta hydroxy acids are used alone in the early stages, trichloroacetic acid and combination treatments are preferred in moderate and advanced aging.
 

After the Second World War, the “Baby boomer” movement, which started under the leadership of the United States, spread all over the world towards the end of the 20th century and rapidly increased world population, advancing technology, advertising, marketing strategies and social communication such as facebook, instagram, which exploded after the internet. resulted in its return to the consumer society with its networks. “Living well, staying young, looking beautiful, being thin” is at the center of the consumption frenzy that “baby boomers” are attracted to. With the 21st century, the people of the world, who suffered from the consumption disease, focused on fighting against physical and mental diseases, which increased as a result of deteriorated nutrition and environmental pollution, and protecting their youth and health. Men and women of modern society have begun to take care of their skin, which is the mirror of youth, health and beauty, and apply more and more to cosmetics, dermato-cosmetological and aesthetic applications that will stop skin aging. Chemical peeling is one of the most popular dermato-cosmetological procedures that can be applied even at noon and is highly satisfactory.
In order to understand chemical peel treatments in photoaging, it is necessary to briefly recall skin aging.
Skin aging is of two types, internal and external. Photoaging is the cumulative result of chronic sun/solarium-induced UV+ infrared exposure of endogenously aging skin. Clinically, dryness, irregular pigmentation, freckling, lentigines, actinic keratosis, guttate hypomelanosis, persistent hyperpigmentation, wrinkles, telangiectasia, loss of elasticity, large comedones, sebaceous hyperplasia can be seen(1). Compared to sun-exposed skin, histologically, photodamaged epidermis shows a compact and gelatinous stratum corneum, dysplastic and atypical keratinocytes, epidermal cell vacuolization and occasional necrosis, and a decrease in the number of Langerhans cells. In chronic sun-damaged skin, loss of vertical polarity and irregularity in the alignment of epidermal cells is quite common. In the dermis, elastosis, homogenization in the upper papillary dermal structures, amorphous accumulation, and decrease in collagen fibers are observed. An increase is observed in macrophages, histiocytes and mast cells containing coarse granules. It is observed that the collagen fibers that decrease in the upper dermis over time are replaced by an amorphous substance accumulation surrounded by weakly stained increased reticular fibers (2).
In 1994, Glogau classified photoaging as 4 types (3).
Type 1: premature photoaging, “no wrinkles” Ages 20-30, slight pigmentation changes, slight wrinkles, keratosis are not observed. Light/no make-up.
Type 2: Moderate photoaging, “wrinkles with facial expressions” Late 30’s – 40’s, senile lentigos, tactile keratoses, parallel smile lines are seen. Usually uses light concealers.
Type 3: Advanced photoaging, “wrinkles at rest” Ages 50 and over, significant dyschromia, telangiectasia, visible keratoses, prominent wrinkles at rest. Always uses intense concealer.
Type 4: Severe photoaging, “just wrinkles” 60 years and older, yellow-gray color, skin cancers are seen. Normal skin structure is not observed, there are widespread wrinkles. She doesn’t wear makeup.
Chemical resurfacing is a resurfacing method that initiates epidermal regeneration and restructuring of dermal collagen by means of controlled partial/full layer damage by a chemical applied to the epidermis(4, 5, 6). From the 1980s, with the development of TCA and the discovery of AHAs, it has become one of the most popular office applications for the treatment of photoaging.
They are divided into 3 according to the effects they create on the tissues. AHA and Tretinoin act metabolically, TCA act caustic, and Phenol, Salicylic acid and Resorcin act toxicly(7). Chemical peelers are classified as superficial (very light / light), medium deep and deep according to the depth of the effect they create (table 1). While very light superficial peels reach the stratum spinosum layer, the light ones affect the entire epidermis. While medium-depth peelers reach the upper reticular dermis, phenol, which is a deep chemical peeler, can descend into the middle reticular dermis(4,5,6,8).
Treatment of photoaging with chemical peeling is planned according to the Glogau classification (Table 1). According to this;
Glogau Type 1 photoaging, superficial peels,
In Glagou Type 2 and Type 3 photoaging, medium depth peels alone or in combination protocols,
In Glogau Type 4 photoaging, deep-acting Baker-Gordon Phenol is used alone(9).

Table 1. Classification of chemical peelers according to depth, effect and photoaging types
Superficial
Glogau type 1-2

So light
str. my spinosum
Middle
Glogau type 2-3

upper reticular dermis

Deep
Glogau type 4

         
middle reticular dermis
10-20% TCA*
Low potency AHA**(GA, MA)
BHA***
LHA****
Tretinoin 10% mask

Light
the whole epidermis
TCA 20-30%
Jessner solution
70% CI
40-50% PA*****
35-50% TCA
Jessner solution + 35% TCA
70% CI + 35% TCA
Salicylic acid + 35% TCA
Salicylic acid+ 50% PA
70% PA

Baker-Gordon Phenol

*TCA; trichloroacetic acid, **AHA; alpha hydroxy acid(GA; glycolic acid, MA; mandelic acid), ***BHA; beta hydroxy acid, ****LHA; lipo hydroxy acid, *****PA; pyruvic acid

ALPHA HYDROXY ACIDS(AHA)
Alpha hydroxy acids are used quite frequently among surface chemical peels and are known as “midday peels” with their fast recovery time(7). They perform epidermolysis and exfoliation. They must be neutralized with a basic solution such as ammonium salts, sodium bicarbonate, sodium hydroxide. Although the most commonly used and known AHA is Glycolic acid, Pyruvic acid and Mandelic acid have been used in the treatment of photoaging in recent years(5,10,11,12). Lactic acid, together with salicylic acid in Jessner’s solution, is another alpha hydroxy acid used in the treatment of moderate photoaging(13).
Studies conducted on AHAs, str. It has been shown that it causes thinning of the corneal layers, epidermal thickening by increasing the amount of epidermal mucopoisaccharides, an increase in the amount of dermal collagen, an improvement in the quality of elastic fibers, and a decrease in photocarcinogenesis (14).
Glycolic acid(GA)
GA, which has the smallest molecular weight, is frequently used in 20-70% concentrations, especially in people with skin phototypes I-VI and stage 1,2 photoaging, for regulating skin tone and removing fine wrinkles. It has no effect on deep wrinkles. It can be used together with 35% TCA at 70% concentrations in stage 3 photoaging. Although it is most commonly used in the face area, it can also be used on the hands, neck, décolleté and back. The eye area and neck are the most sensitive areas and the treatment should be kept at low concentrations (20-35%). 4-6 sessions are recommended at intervals of 2-4 weeks (4,15). It has been found to be effective and safe in the treatment of photoaging at 20-70% concentrations and repeated sessions at 10-14 days intervals in ethnic skin of Asian and African origin(8).
Mandelic Acid (MA)
The MA obtained from bitter almonds is a larger molecule than glycolic acid and has been used as a urinary antiseptic in medicine for many years. It has significant antibacterial activity against S. aerius and gram negative bacteria. It has an antiaging effect as strong as glycolic acid, and its side effects such as redness, peeling and crusting are much less than glycolic acid. It has been found to be effective on type 1-2 photoaging at concentrations of 30-50%, in all skin types, in repeated sessions at intervals of 2-4 weeks(12). Wojcik et al. In a study in which they compared the effects of 20% Azeleic acid and 40% Mandelic acid on sebum secretion in 28 female patients aged 49-71 years with moderate and advanced photoaging, they emphasized that both acids reduce the signs of aging while controlling sebum secretion(16). Mandelic acid is actually an important peeler and has not found the value it deserves in the treatment of photoaging.
Pyruvic Acid(PA)
PA, an alpha keto-acid, is a strong acid with a small molecular weight that rapidly descends into the upper papillary dermis and makes dermo-epidermal separation. It turns into lactic acid in the tissue. In addition to its keratolytic, antimicrobial and sebostatic effects at 50-70% concentrations, it stimulates the production of dermal glycoprotein, collagen and elastin fibers, and regulates skin tone(4). In the literature, in 2 studies conducted with 50% PA in the treatment of photoaging, it was found to be effective on the regulation of skin tone, fine wrinkles, and increase in elasticity in Glogau Type 1 and 2 photoaging, when applied in 4 sessions with an interval of 2 weeks (10,11). It was emphasized that severe burning and stinging was felt during the application, but prolonged erythema was not observed and it was well tolerated by the patients (10,11).
BETA HYDROXY ACIDS (BHA)
Salicylic acid (ortho-hydroxybenzoic acid) is a lipophilic, hydrophobic beta hydroxy acid. It has a keratolytic effect on intercellular lipids in the epidermis. At 30% concentrations, it stimulates corneocyte separation, proliferation in the basal layer, activation in dermal fibroblasts, and collagen production. It is quite effective on its own in the early stages of photoaging. It also has anti-inflammatory and antimicrobial effects(4,5,17,18). The feature that makes salicylic acid superior to other chemical peels is that it can be used safely in patients with skin phototype V-VI and accompanying dyschromia and acne in the treatment of photoaging without the risk of postinflammatory hyperpigmentation(8). Salicylic acid causes severe stinging and burning sensations that pass within a few minutes after application. 3 min. In applications exceeding frosting appears on the skin surface. The process is terminated with water to reduce the burning sensation and to allow the precipitation of salicylic acid salts. Normally, SA does not require an absolutely basic neutralizer such as glycolic acid.(4) Kligman et al. They applied 30% SA in 50 female patients aged 25-55 years, Glogau 1-2, Fitzpatrick I-III. In addition, 4 minutes on one half of 5 patients’ faces. They applied 70% CI and 30% SA to the other half and compared them. In conclusion, patients described more severe burning and stinging on the 30% SA side compared to the 70% CI side. All of the patients returned to their daily work after the procedure. In summary, in this study, SA peeling was found to be effective in early photoaging, being safe, effective, and requiring less sessions than 70% CI peeling(15).

Salicylic acid+ 50% Pyruvic acid
20-30% salicylic acid can be combined with 50% pyruvic acid in the treatment of moderate to severe photoaging with thick epidermis. In this protocol, SA alone is applied one week before and by utilizing its keratolytic effect, PA to be applied from the next week is ensured to reach the upper dermis rapidly. After the SA application in the 2nd session, the skin is wiped with alcohol and 50% PA is applied for 1 minute. It is applied with gauze/cotton throughout. The process is terminated with neutralizer. An average of 6 sessions are applied with 3-4 week intervals. This combination was found to be successful with a synergistic effect in Glogau 3 and 4 photoaging(4).
LIPO HYDROXY ACIDS (LHA)
Capryloyl Salicylic acid (C8-LHA), the most recently defined superficial chemical peeling agent, is a lipophilic derivative of salicylic acid and has been used in the treatment of photoaging at 5-10% concentrations. It is thought that LHA, which acts without breaking the bonds between corneocytes, acts on transmembrane glycoproteins and has no effect on keratin fibers and the corneocyte cell wall. Similar to retinoic acid, it has been found to stimulate epidermal cells and extracellular matrix regeneration. Unlike many other chemical peelers, the PH value is very close to normal skin (5.5) and does not require neutralization (5,19). It is more widely used in the treatment of acne with its antibacterial, anti-inflammatory, antifungal and anticomedogenic effects(8).
JESSNER SOLUTION
While Classic Jessner contains 14% Resorcin, 14% lactic acid, 14% salicylic acid in Ethanol, Modified Jessner also contains 17% lactic acid, 17% salicylic acid, 8% citric acid in Ethanol. It is effective in mild photoaging by causing complete epidermal damage when applied alone. When applied together with 35% TCA, the damage reaches the upper reticular dermis. Together with 35% TCA, it has been found to be quite successful in moderately photodamaged skin(4,5, 8, 20).
TRIchloroacetic acid (TCA)
TCA is a caustic stripper similar to glycolic acid in molecular but several times stronger. When applied to the skin, it rapidly causes epidermal protein coagulation, necrosis and peeling, and is self-neutralized when it reaches the dermal vascular structure. It has no systemic toxicity(4,7). In low concentrations like 10-20%, Glogau type 1-2 is successful as a superficial peeling in photoaging. Histological studies have shown that epidermal polarity improves, the number of dermal fibroblasts and type 1 collagen increase in TCA-treated photodamaged skin(4). At 30-50% concentrations, Glogau type 2-3 is effective and successful in photoaging alone or in combination protocols with 70% CI and 20-30% SA. The effectiveness of TCA was found not only to be related to concentration, but also to the application time and the experience of the practitioner(5). It should be used carefully and with preliminary preparation, especially in individuals with skin type IV-V-VI, due to the risk of post-inflammatory hyperpigmentation after the procedure, and care should be taken after the procedure (8,21).
Jessner + 35% TCA
Glogau type 2-3 is the most effective and popular medium-depth peeling combination for photoaging. 3-4 following the procedure. With significant collagen production in months, improvement in fine wrinkles, decrease in dyschromia, and decrease in the number of keratosis and lentigo are observed(20).
BAKER-GORDON PHENOL
Glogau 4 is a deep-acting chemical peeling used in photoaging that causes damage to the mid-reticular dermis and is not preferred in practice due to its potential complications. Phenol can cause permanent hypopigmentation with its toxic effect on melanocytes. In addition, cardiac arrhythmia and hepatorenal toxicity may develop due to systemic absorption(4).
CONCLUSION
Photoaging is caused by the accumulated effect of UV and Infrared rays that come into contact throughout life. In fact, it is a preventable, haltable and reversible process and, if left untreated, progresses with the formation of precancerous keratoses that can progress into non-melanoma skin cancers. Chemical peeling, on the other hand, can be applied in the treatment of photoaging in office conditions, even in the afternoon. It is a practical, cheap and safe treatment method that does not reduce the quality of life of the patient, heals quickly, gives quick results.
Glycolic acid is the most widely used peeling agent and is used safely in patients with skin phototypes I-III in early-stage photoaging. Its combination with 35% TCA at 70% concentrations has been found to be successful in the treatment of severe photoaging. However, the need for neutralization has started to give way to Salicylic, Mandelic and Pyruvic acids in recent years due to the risk of post-inflammatory hyperpigmentation in dark and ethnic skins. These three peelers were found to be very successful in early photoaging in all skin types, and effective in stopping and regressing the progression of the disease in repetitive sessions in moderate photoaging. Trichloroacetic acid, on the other hand, has been considered effective in moderate and severe photoaging in moderate and combination treatments alone. However, in patients with skin phototype III and above, necessary precautions should be taken in terms of post-inflammatory hyperpigmentation before and after the application. Phenol applications in severe photoaging have not been applied at all in recent years due to melanotoxicity and systemic toxicity and seem to have left their place to TCA combination treatments/laser applications. The reason why Salicylic acid is the most preferred acid in combination treatments is that it is both an anti-inflammatory and a strong keratolytic agent. In treatment protocols to be continued with other acids, peeling can be done with salicylic acid at 10-20% concentrations in one session to prepare the skin. Mandelic acid is preferred in early photoaging in both seborrheic and rosaceic skin types because of its strong antimicrobial activity and low risk of irritation and neovascularization. Pyruvic acid, as a small molecule, can quickly descend into the dermis and show its effect by turning into lactic acid. It can be effective in mild to moderate photoaging in a short time at 50% concentrations, and is used alone or in combination with 20% SA as a medium deep peeler at 70% concentrations. Salicylic acid can allow pyruvic acid to penetrate deeper into the dermis and control dermal inflammation that may occur with its anti-inflammatory effect. In severe photoaging this combination can be successful. However, although pyruvic acid is at least as inflammatory as glycolic acid, it does not cause erythema and icing response in the tissue. Therefore, it is recommended to keep the time short during the application and neutralizer is needed.
When we look at the literature on chemical peeling in photoaging, it is remarkable that chemical peeling studies in photoaging treatment focus on the “face” region. Yes, the “face” is a prominent and featured area in terms of aesthetics, but non-melanoma skin cancers and precancerous lesions, which are the most important results of photoaging, can also be seen frequently on the hands, décolleté, shoulders, back, and lower extremities. The fact that the efficacy of old and new generation peels (such as salicylic acid, lipohydroxy acid, mandelic acid, pyruvic acid) in “non-facial” photoaging areas has hardly been discussed in comparative studies. Therefore, there is a need for new comparative and evidence-based studies in this area.
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