Peeling: indications and contraindications, complications, care

The term "peeling" comes from the English verb "to peel" - to remove the skin, to exfoliate. This is one of the old cosmetic methods. So, at home you can use grape must, fermented milk products (for example, sour cream) and other products containing acids. Currently, peeling is an integral part of almost any cosmetic procedure.

Classification of peelings

Currently, there is no single classification of peels by depth, since there is no consensus among specialists in this field.

Peels can be divided into:

• intracorneal (super-superficial);
• intraepidermal (superficial, mid-superficial, mid);
• intradermal (deep).

Superficial peeling affects only the stratum corneum, as a result of its action, the superficial rows of horny scales are carefully removed. Superficial peeling affects the entire stratum corneum. Middle-superficial peeling extends to the spinous layer of the epidermis. Actually, middle peeling damages the entire epithelium, without affecting the basal membrane, preserving areas of basal keratinocytes.

Deep peeling penetrates the dermis, affecting the papillary layer, while areas of the basement membrane are preserved in the papillae.

According to the mechanism of action, there are physical, chemical and mixed peelings. When performing physical peeling, various physical methods of action are used (mechanical, scrub, gommage, desincrustation, ultrasonic peeling, microdermabrasion, dermabrasion, laser "polishing"). To perform chemical peeling, various keratolytics (acids, phenol, resorcinol, etc.) and enzymes (the so-called enzyme peeling) are used. Mixed peeling implies the combined effect of physical and chemical factors.

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Indications for the procedure

Indications for peeling are pigmentation of various genesis (melasma, lentigo, freckles, post-inflammatory pigmentation), cicatricial changes (after acne, chickenpox, post-traumatic, etc.), age-related skin changes, multiple non-inflammatory acne (open and closed comedones). Peeling is extremely rarely used to lighten unaffected skin in extensive vitiligo lesions.

To achieve the optimal aesthetic result, it is important to choose the depth of peeling. Thus, superficial and superficial peelings are effective for hypersecretion of sebum, superficial non-inflammatory acne, hyperkeratosis, initial manifestations of photo- and biological aging, skin dehydration. Superficial-medium peeling is often used for photoaging. It is also indicated for pigment disorders, especially for the epidermal type of melasma, since the depth of its effect already implies an effect on melanocytes. Medium peeling is prescribed for dermal and mixed types of melasma, post-acne, as well as pronounced gradations of photoaging. Deep peeling is used for pronounced deep wrinkles associated with biological and photoaging, deep cicatricial changes and other pronounced cosmetic defects.

Contraindications

Contraindications for peeling are divided into absolute and relative, general and local. It should be emphasized that superficial-median, median and deep peelings are not indicated against the background of taking isotretinoin, they should be started no earlier than 5-6 months after the end of the course of therapy. In addition, topical retinoids should be discontinued 5-7 days before peeling, and epilation in the area of the effect should not be carried out for 1 week. Local application of various destructive compounds (5-fluorouracil, solcoderm, prospidin ointment) together with peeling can increase the depth of the burn. Peelings are extremely undesirable for patients with a predominance of inflammatory acne, especially pustular, due to the high risk of exacerbation of the disease.

Main contraindications for the peeling procedure

Absolute contraindications		Relative contraindications
General	Local	General	Local
Fever, infectious diseases, severe general condition, etc.	Infectious skin diseases (viral, bacterial, mycotic), chronic dermatoses (eczema, atopic dermatitis, psoriasis, etc.) in the acute stage, pustular acne, multiple nevi, hypertrichosis, individual intolerance, etc.	Phototype IV-VI, menstruation, pregnancy, thyroid pathology, isotretinoin intake, active insolation season, childhood, weather sensitivity, etc.	Increased skin sensitivity, chronic dermatoses in the remission phase, frequently recurring herpes infection, inflammatory acne, tendency to keloid scars

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Chemical peeling

This procedure is most often performed using various agents with keratolytic properties. The main keratolytics used in dermatocosmetology include hydroxy acids (alpha-, beta-, polyhydroxy acids), trichloroacetic acid (TCA), vitamin A derivatives, ascorbic acid and its derivatives, phenol, 5-fluorouracil, urea (>10%), azelaic acid, benzoyl peroxide, resorcinol, propylene glycol (>40%) and other compounds. The depth and strength of peeling are regulated by the concentration of active agents, their pH, frequency and exposure time. Enzyme preparations and fruit acids are usually used for superficial peeling, hydroxy acids for superficial peeling, hydroxy acids, trichloroacetic and other acids for superficial-median and median peeling, and phenol for deep peeling. In essence, chemical peeling is a controlled skin injury similar to a burn. That is why, against the background of applying the peeling composition, erythema and so-called "frost" (from the English frost - frost) are possible; frost is an area of coagulation necrosis of the skin of varying depth, i.e. a scab. Externally, it looks like a whitish coloring of the treated area of the skin. The qualitative characteristics of frost, such as color, uniformity, consistency, allow you to determine the depth of the peeling effect.

Ultra-superficial chemical peeling is performed using various enzymes (papain, bromelain, trypsin, etc.) and, less frequently, hydroxy acids in low concentrations. Enzymes are usually obtained from certain types of plants and fungi (pineapple, papaya, Mucor Mieli fungus, etc.), as well as from animal raw materials (e.g., pancreas of pigs, cattle, etc.). Superficial and gentle action, rare complications allow ultra-superficial peeling to be performed on sensitive skin and even at home. Thus, in recent years, the concept of "home clinic" has become popular in cosmeceuticals (proposed by RoC). Home peels include enzymes, various acids or other keratolytics (salicylic acid 2-4%, glycolic acid, lactic acid 0.5-4%, urea 2-4%, etc.), they are easy to use, the kits often include products for post-peeling care (Nightpeel, Lierac; Peelmicroabrasion kits, Vichy Laboratories; Peel-ex radiance, RoK, etc.). To reduce the irritating effect of hydroxy acids, their esters have been used in home care products in recent years (for example, Sebium AKN cream, Bioderma). Topical retinoids (adapalene Differin) and azelaic acid (Skinoren) can be used as a home peel. These products are also used for pre-peeling preparation,

When performing superficial peeling, there are no subjective sensations, erythema may be observed for several minutes. Depending on the skin type and the problem being solved, it can be performed daily or several times a week.

For superficial peeling, a-hydroxy acids (a-Hydroxy Acids, or AHA) are widely used in concentrations of 20-50%: glycolic, malic, lactic, tartaric, almond, kojic, etc. AHA are organic carboxy acids with one alcohol group in the a-position. Their source is sugar cane, fermented milk products, fruits (often all AHA are called "fruit"), some types of mushrooms (for example, kojic acid). Glycolic acid is most widely used in cosmetology, since due to its low molecular weight it easily penetrates deep into the skin. Natural sources of glycolic acid are sugar cane, grape juice, unripe beets, however, in recent years, its synthetic variety has been used in cosmetology.

To date, information has been accumulated on the mechanism of action of alpha-hydroxy acids on various layers of the skin. It has been shown that hydroxy acids weaken the adhesion between corneocytes, thereby achieving the exfoliation effect. They are believed to be able to stimulate the proliferation of basal keratinocytes and normalize the processes of epithelial desquamation. There is data on the activation of the synthesis of free ceramides (in particular, Cl), which can positively affect the barrier properties of the skin. AHA stimulate the synthesis of type I collagen, elastin and glycosaminoglycans due to the activation of some enzymatic reactions at an acidic pH. Low concentrations of hydroxy acids may cause swelling of cellular elements and increase hydration of the intercellular substance, which creates the effect of rapid skin smoothing. Glycolic acid stimulates collagen production, inhibits melanin synthesis; there are also indications of its antioxidant effect.

Superficial peeling does not cause pain, after it there is erythema for several hours and slight peeling of the skin at the site of action for 1-3 days. The rehabilitation period takes 2-5 days. It can be carried out once a month, the frequency of procedures depends on the problem being solved.

For superficial-medium peeling, in addition to AHA (50-70%), salicylic acid is used (refers to beta-hydroxy acids). Due to its good keratolytic properties, salicylic acid promotes a faster exfoliative effect and serves as a kind of conductor into the skin for other products. The direct anti-inflammatory effect of salicylic acid is also debated. In cosmetology, combined peelings with alpha- and beta-hydroxy acids, polyhydroxy acids are used.

For superficial-median peeling, polyhydroxy acids, retinoic acid (5-10%), trichloroacetic acid, or trichloracetic acid, TCA (up to 15%), phytic acid, and Jessner peel are also used. Thus, retinoic acid, having the properties of vitamin A derivatives, is able to regulate keratinization and differentiation of epidermocytes, inhibit pigment formation, affect the proliferative and synthetic activity of fibroblasts, and suppress the activity of collagenases (matrix metalloproteinases). Phytic acid, obtained from wheat seeds, acts not only as a keratolytic, but also as a powerful bleaching agent capable of inhibiting tyrosinase activity. It is known that this acid is capable of forming chelate compounds with a number of metals that participate as coenzymes in some inflammatory reactions and pigment formation processes. In recent years, malonic, mandelic, and azelaic acids have also been used.

The solution for the Jessner peeling, widely used in America and Western Europe (the "5th Avenue peeling", "Hollywood peeling", etc.), includes 14% resorcinol, salicylic acid and lactic acid in 96% alcohol. Combinations with kojic acid and hydroquinone are possible when correcting pigmentation (melasma, post-inflammatory pigmentation). Resorcinol, which is part of the Jessner solution, can cause a systemic toxic effect. That is why this peeling is used on individual areas of the skin.

When performing superficial-median peeling, not only erythema is possible, but also uneven, white frost in the form of dots or clouds. Subjective sensations are discomfort, moderate itching, burning, and less often skin soreness. Post-peeling erythema lasts up to 2 days. When using TCA, pastosity and swelling of soft tissues in areas of thin skin are possible for 3-5 days. Peeling persists for up to 7-10 days. The rehabilitation period is up to 14 days. It can be performed once or in courses with an interval of 1-3 months. The frequency of procedures depends on the problem being solved.

Medium chemical peeling is performed using trichloroacetic acid (15-30%) and salicylic acid (up to 30%). Combined use of TCA and carbonic acid snow is possible. During medium peeling, in addition to erythema, a snow-white homogeneous dense frost appears. Subjectively, severe discomfort, itching, burning and even skin soreness are possible. Post-peeling erythema lasts up to 5 days. Peeling and isolated crusts can persist for 10-14 days. The rehabilitation period is up to 3 weeks. Medium peeling is performed once or in courses, but not more often than once every six months.

Deep peeling is performed using compounds containing phenol. When performing deep peeling, a yellowish-gray frost appears. Subjectively, there is pronounced skin pain, so it is performed under general anesthesia. After deep peeling, crusts are formed, which gradually separate by the 10th-14th day. Post-peeling erythema persists for up to 2-4 weeks. The rehabilitation period takes about 30 days. Given the depth of necrosis, the risk of infection, scarring, as well as the toxic effect of phenol, deep peeling is performed by plastic surgeons in a hospital setting. Often, not all of the skin is treated, but only individual areas. Deep chemical peeling is usually performed once. If repeated corrective measures are necessary, the issue of microdermabrasion, local laser resurfacing, dermabrasion and other procedures is decided.

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Physical peeling

Superficial and superficial physical peeling is achieved by using scrub creams, peeling creams, ultrasonic peeling, desincrustation, microcrystalline dermabrasion (microdermabrasion). Microdermabrasion is skin polishing under the action of inert crystals of aluminum oxide powder, which exfoliates tissue layers at different depths. In this case, crystals in contact with the skin mechanically remove tissue fragments, then the removed tissue fragments together with the crystals are collected in a special container. Superficial skin cleansing and improved blood circulation also occurs due to vacuum massage. These methods can be combined with chemical peels.

Medium physical peeling is achieved by microdermabrasion, dermabrasion and erbium laser (laser skin "polishing"). Dermabrasion is the removal of the epidermis and part of the dermis by contact of the skin with rotating abrasive attachments, the rotation speed of which is 40-50 thousand revolutions per minute. Laser skin "polishing" is carried out using an erbium laser, the main physical principle of which is selective photothermolysis. For deep peeling, dermabrasion and CO2 laser (on individual areas of the skin) are used. In addition to the indications listed above, additional indications for prescribing medium depth and deep peeling are tattoos. It should also be emphasized that all types of dermabrasion and deep skin "polishing" using a laser are carried out in specialized cosmetology institutions by doctors who have undergone appropriate training.

Complications of peelings

Depending on the time of occurrence, early and late complications of peeling are distinguished. Early complications include secondary infection (pustulization, impostigmization), exacerbation of herpes infection and allergic dermatitis, severe skin sensitivity, persistent edema (more than 48 hours) of soft tissues. Exacerbation of acne, rosacea, seborrheic dermatitis and other chronic dermatoses is not uncommon. Late complications include persistent erythema of the face, hyperpigmentation, depigmentation, scarring (after medium and deep peeling). Timely diagnosis of these diseases and conditions and prescription of appropriate therapy are important. It should be emphasized once again that a thorough allergy history is necessary, especially in atopic patients. Pre-peeling preparation and post-peeling care play a significant role in preventing a number of complications.

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Pre-peeling preparation and post-peeling care

The purpose of pre-peeling preparation is to reduce the overall thickness of the stratum corneum and local keratotic deposits. This will facilitate better penetration of the peeling preparation deep into the skin. Pre-peeling preparation can also be aimed at adapting sensitive skin to subsequent peeling. Usually, cosmetic products are used that include acids in low concentrations, which are prescribed daily, at night. The most popular are alpha-, beta- and polyhydroxy acids; azelaic acid (Skinoren gel) can be used. At the stage of pre-peeling preparation, adequate photoprotection should be ensured; patients are advised to refrain from exposure to the sun or solariums. The duration of preparation depends on the depth of the intended peeling. When planning superficial peelings, it is recommended to carry out preparation for 7-10 days. Before medium and deep peelings, preparation is indicated that takes the same duration as the renewal of the epidermis layer, i.e. 28-30 days. When performing superficial and superficial-median peelings for the purpose of whitening, it is advisable to use for 3-4 weeks not only preparations containing hydroxy acids, but also substances that reduce the synthesis of melanin by melanocytes (azelaic acid, ascorbic acid, topical retinoids, glabridin, resorcinol, benzoyl peroxide, etc.).

Post-peeling care is aimed at restoring the skin's barrier properties, reducing the severity of increased skin sensitivity, erythema, and preventing scarring, secondary infection, and other negative effects. Moisturizers are used to restore the skin's barrier properties. When choosing a moisturizer, consider its composition. For example, the inclusion of unsaturated fatty acids, ceramides, and their precursors in the cream will help restore intercellular lipids. It is also recommended to take products containing omega fatty acids (El-teans, etc.) orally.

When skin sensitivity and persistent erythema of the face appear, basic care products intended for sensitive skin are used. Moisturizing creams for daily care may include substances that affect the condition of the skin vessels (Rozelyan, Uriage, Rosaliac, La Roche-Posay, Apizans Anticouperose, Lierac, Diroseal, Avene, etc.). Microcurrent therapy in the lymphatic drainage mode is indicated among physiotherapeutic procedures.

To prevent secondary pigmentation, active photoprotection with special means is recommended (for example, Photoderm laser, Bio-derma). Patients are contraindicated in ultraviolet radiation, including in a solarium. It is for this reason that peelings are recommended to be performed in non-sunny times of the year.