REsurface

When aging, acne, or sun exposure leave the face with blotches, scars, wrinkles, or lines, skin resurfacing may help the skin look younger and healthier.

With "peel" (from English “to peel”), it’s defined some procedures that induce the destruction of epidermal areas and/or layers of the dermis and the subsequent tissue regeneration process, in order to treat some skin conditions and/or resolve or improve the clinical-aesthetic aspects.⁽¹⁾

The peel is mainly used in the clinical-aesthetic field⁽¹⁾ and it is possible to draw up a list of the most common cases in which the aesthetic doctor adopts this type of treatment; in particular, among others, we can mention keratosis and stretch marks, dyschromia, acne, seborrheic dermatitis, skin laxity.⁽²⁾

The peeling procedure is also a valuable method for the aged skin, photo aging, acne scars and melasma and to improve the skin vitality, tonus and texture.⁽³⁾

Peeling procedures to obtain the exfoliation are:

chemical peels
mechanical peels
physical peels

The aim is to remove excess corneocyte buildup, which in turn stimulates cell turnover, resulting in a more polished, smoother, translucent surface⁽⁴⁾.

Skin resurfacing a powerful tool that can restore a more youthful and rested appearance to the aging face. It is also used to manage other skin conditions with the aim of homogenizing pigmentation and reducing textural unevenness. Skin resurfacing ultimately aims to enhance a patient's appearance and thus, self-esteem.⁽⁵⁾

The quest to preserve a youthful appearance has persisted for centuries, and recent advances in dermatology have catalyzed the re-emergence of noninvasive techniques. Noninvasive modalities such as lasers, chemical peels, and microdermabrasion remain viable alternatives to successful noninvasive facial rejuvenation.⁽⁶⁾

^{⁽¹⁾Labrini G. et al. Peeling chimici: Linee guida. Aprile – Giugno Numero 2.}

^{⁽²⁾Molinari P. et al. L’utilizzo del peeling chimico nello studio del medico estetico. L’ambulatorio medico, settembre 2017.}

^{⁽³⁾Merita Grajqevci-Kotori and Allma Kocinaj Exfoliative Skin-peeling, Benefits from This Procedure and Our Experience Med Arch. 2015 Dec; 69(6): 414–416. doi: 10.5455/medarh.2015.69.414-416}

^{⁽⁴⁾Katie Rodan, MD, Kathy Fields, MD, George Majewski, and Timothy Falla, PhD Skincare Bootcamp: The Evolving Role of Skincare Plast Reconstr Surg Glob Open. 2016 Dec; 4(12 Suppl): e1152. Published online 2016 Dec 14. doi: 10.1097/GOX.0000000000001152}

^{⁽⁵⁾Kouris A, Platsidaki E, Christodoulou C, Efstathiou V, Markantoni V, Armyra K, Potouridou I, Rigopoulos D, Kontochristopoulos G. Patients' self-esteem before and after chemical peeling procedure. J Cosmet Laser Ther. 2018 Aug;20(4):220-222.}

^{⁽⁶⁾Meaike JD et al. Noninvasive Facial Rejuvenation. Part 3: Physician-Directed-Lasers, Chemical Peels, and Other Noninvasive Modalities. Semin Plast Surg. 2016 Aug; 30(3): 143-50.}

PEELS CLASSIFICATION.

There are three different levels of implementation the peeling procedures. Depth of peeling and the concentration of the substance used are based on the level of damage or photo damage and what is expected by the patient. There are three levels of chemical peels: superficial, medium, and deep.

Superficial peel eliminates the superficial cells of the epidermis by causing the necrosis of the epidermis from granulose to basal layer. These peels stimulate a rapid regeneration of epidermis, eliminate the spots, eliminate the fine lines and improve the wrinkles through the promotions of fibroblasts and regeneration of fibers of elastin and collagen.
Medium peel is recommended for the skin that is more damaged by radiation to penetrate deeper the product and the improvement to be seen in the middle layers of the skin.
Deep peel: this procedure is implemented to eliminate deep wrinkles, acne scars and signs of actinic keratosis. Today the application of lasers and dermabrasion procedures are most frequent and eliminate side effects. Since the deep peeling can cause hypo pigmentation or skin whitening and skin changes it is recommended to use combinations of deep and medium peeling.⁽⁹⁾

^{⁽¹⁾Rendon MI, Berson DS, Cohen JL, Roberts WE, Starker I, Wang B. Evidence and considerations in the application of chemical peels in skin disorders and aesthetic resurfacing. J Clin Aesthet Dermatol. 2010 Jul;3(7):32-43.}

^{⁽²⁾Alicia A O'Connor, Patricia M Lowe, Stephen Shumack, Adrian C Lim Chemical peels: A review of current practiceFirst published:24 October 2017 https://doi.org/10.1111/ajd.12715}

^{⁽³⁾Labrini G. et al.Peeling chimici: Linee guida. Aprile – Giugno Numero 2.}

^{⁽⁴⁾Weissler JM, Carney MJ, Carreras Tartak JA, Bensimon RH, Percec I. The Evolution of Chemical Peeling and Modern-Day Applications. Plast. Reconstr. Surg. 2017 Nov;140(5):920-929.}

^{⁽⁵⁾Reserva J, Champlain A, Soon SL, Tung R. Chemical Peels: Indications and Special Considerations for the Male Patient. Dermatol Surg. 2017 Nov;43 Suppl 2:S163-S173. [PubMed]}

^{⁽⁶⁾Chen X, Wang S, Yang M, Li L. Chemical peels for acne vulgaris: a systematic review of randomised controlled trials. BMJ Open. 2018 Apr 28;8(4):e019607. [PMC free article] [PubMed]}

^{⁽⁷⁾Castillo DE, Keri JE. Chemical peels in the treatment of acne: patient selection and perspectives. Clin Cosmet Investig Dermatol. 2018;11:365-372.}

^{⁽⁸⁾Kaminaka C, Yamamoto Y, Yonei N, Kishioka A, Kondo T, Furukawa F. Phenol peels as a novel therapeutic approach for actinic keratosis and Bowen disease: prospective pilot trial with assessment of clinical, histologic, and immunohistochemical correlations. J. Am. Acad. Dermatol. 2009 Apr;60(4):615-25.}

^{⁽⁹⁾Merita Grajqevci-Kotori and Allma Kocinaj Exfoliative Skin-peeling, Benefits from This Procedure and Our Experience Med Arch. 2015 Dec; 69(6): 414–416. doi: 10.5455/medarh.2015.69.414-416}

CHEMICAL PEELS ARE ALSO RECOMMENDED TO PREPARE THE SKIN BEFORE ANY AESTHETIC MEDICINE PROCEDURE

CHEMICAL PEELS.

Chemical peel, also known as chemexfoliation or chemical exfoliation, is a procedure where a chemical substance applied to the skin causes controlled destruction of the epidermis with or without part of the dermis, leading to skin regeneration and remodeling.

Chemical peels can be used to treat various skin conditions, such as acne vulgaris, photodamage, pigmentary disorders, and scars.⁽¹⁾

Chemical Peel consists in the application of one or more chemical substances, in immediate or delayed sequence, able to induce the destruction of epidermal areas and/or layers of the dermis and the subsequent tissue regeneration process, to treat some skin conditions and/or resolve or improve the clinical-aesthetic aspects.⁽²⁾

The effects of the chemicals range from simple detachment of the corneum layer to considerable inflammatory reactions of the dermis; they depend on various factors and on some variables, able to determine the uniformity of the penetration effect, the levels of attainable depths and a more or less marked exfoliative reaction.⁽³⁾

Chemical peels are commonly classified based on their depth of skin penetration into superficial, medium, and deep peels. The factors affecting the depth of peeling, and thus the degree of its therapeutic effects, include the properties of the chemical agent used (e.g., concentration and pH), the physician's application technique, and the patient's skin condition and sensitivity.⁽⁴⁾

When performing a chemical peel, proper patient evaluation, and execution of a comprehensive treatment plan can produce safe, reliable, and satisfactory outcomes.

Various indications for using chemical peeling as a technique for skin resurfacing exist, including ^{(5),(6),(7),(8)}:

Facial rejuvenation of the aging skin to address issues such as enlarged pores and rhytides
Inflammatory disorders including acne vulgaris, pseudofolliculitis barbae, rosacea, and post-acne scarring
Pigmentary disorders such as melasma, ephelides or freckles, lentigines, and post-inflammatory pigmentation
Epidermal proliferation and pre-cancerous lesions including sebaceous and actinic keratosis

MECHANICAL PEELS.

Microdermabrasion is a minimally invasive cosmetic procedure consisting of two components: an abrasive component and a vacuum component.

An inert crystal like aluminum oxide or sodium chloride is accelerated from the handpiece toward the skin. The interaction between the skin and crystals creates a gentle mechanical abrasion that removes the superficial layers of the skin.

The spent crystals and skin debris are then collected by the vacuum and deposited in a waste receptacle.⁽¹⁾

This dual action will resurface the skin and stimulate the blood flow, encouraging the skin to rejuvenate itself.

Microdermabrasion is used to remove the stratum corneum and the epidermis. After several treatments there is thickening of the epidermis and increase in collagen and elastic fibers.⁽²⁾

Microdermabrasion therapy has been advocated for treatment of photoaging (i.e., wrinkles, dyspigmentation), acne, acne scars, and striae distensae.⁽³⁾

^{⁽¹⁾Spencer J M. Microdermabrasion. Am J Clin Dermatol. 2005;6(2):89–92.}

^{⁽²⁾Zaidi, Zohra, Hussain, Khalid, Sudhakaran, Simi Treatment of Skin Diseases: A Practical Guide 2019/01/01 doi:10.1007/978-3-319-89581-9}

^{⁽³⁾Karimipour D J, Karimipour G, Orringer J S. Microdermabrasion: an evidence-based review. Plast Reconstr Surg. 2010;125(1):372–377.}

PHYSICAL PEELS.

The laser, an acronym for light amplification by stimulated emission of radiation, is employed for a variety of medical indications.⁽¹⁾

The use of high-power lasers and skin peeling by heat generation is one of the methods for skin rejuvenation.⁽²⁾

Lasers resurfacing of skin as peeling could remove fine wrinkles of skin although, however potentially have the advantages to treat deep wrinkles by collagen making stimulation.⁽¹⁾ Skin healing in deep peeling and laser resurfacing is known as like wound healing mechanism and depends on the depth of the lesion.⁽³⁾

Different types of lasers for skin rejuvenation are ablative lasers, non-ablative lasers, and fractional lasers:⁽²⁾

Ablative lasers have been used to treat scars, pigmentations, and rhytides by removing the epidermis and heating dermis. Ablative lasers are generally used for skin resurfacing and rejuvenation. For severe facial wrinkles, pigmentation, and skin challenges, ablative lasers are often the preferred treatment.⁽⁵⁾
Non-ablative lasers have become the treatment of selection for a broad range of aesthetic indications. This type of laser is less aggressive than the optical laser and due to the stimulation of collagen in the dermis, it makes the skin firm. They have been used for patients with moderate photoaging.
Fractional lasers, by virtue of rapid healing, provide a means to reduce the complications and downtime associated with ablation lasers, while maintaining a laser thermal effect superior to that of non-ablative rejuvenation (NAR) lasers. Therapeutic effects of non-ablative fractional lasers (NAFL) are achieved by irradiation of multiple micro-treatment zones on the skin. Fractional lasers are effective for both aging facial skin rejuvenation and scar improvement.⁽⁵⁾

^{⁽¹⁾Meaike JD et al. Noninvasive Facial Rejuvenation. Part 3: Physician-Directed-Lasers, Chemical Peels, and Other Noninvasive Modalities. Semin Plast Surg. 2016 Aug; 30(3): 143-50.}

^{⁽²⁾Hazhir Heidari Beigvand, Mohammadreza Razzaghi, Mohammad Rostami-Nejad, Majid Rezaei-Tavirani, Saeed Safari, Mostafa Rezaei-Tavirani, Vahid Mansouri and Mohammad Hossein Heidari Assessment of Laser Effects on Skin Rejuvenation J Lasers Med Sci. 2020 Spring; 11(2): 212–219 Published online 2020 Mar 15. doi: 10.34172/jlms.2020.35}

^{⁽³⁾Nguyen AT, Ahmad J, Fagien S, Rohrich RJ. Cosmetic medicine: facial resurfacing and injectables. Plast Reconstr Surg. 2012;129(1):142e–153e. doi: 10.1097/prs.0b013e3182362c63.}

^{⁽⁴⁾Preissig J, Hamilton K, Markus R. Current laser resurfacing technologies: a review that delves beneath the surface. Semin Plast Surg. 2012;26(3):109–16. doi: 10.1055/s-0032-1329413}

^{⁽⁵⁾Park, Seung Fractional Laser; NAFL and AFL Medical Lasers 2015/06/30 doi: 10.25289/ML.2015.4.1.1}

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