FIGURE 20-1 A hematoxylin and eosin (H&E) stain of untreated normal bovine skin in .NET

Generating QR-Code in .NET FIGURE 20-1 A hematoxylin and eosin (H&E) stain of untreated normal bovine skin

FIGURE 20-1 A hematoxylin and eosin (H&E) stain of untreated normal bovine skin
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FIGURE 20-3 Chemical structure of glycolic acid The OH group is in the alpha position; therefore, this is in the alpha hydroxy acid family histologically in a 25% increase in skin thickness, increased acid mucopolysaccharides in the dermis, improved quality of the elastic fibers, and increased collagen density8 These findings are desirable because they imply that AHAs reverse some of the histologic signs of aging This was again illustrated in a mouse model by Moon et al, who reported that mice treated with glycolic acid showed a significant decrease in wrinkle score and an increase in the amount of collagen synthesized9 It has been well established that collagen synthesis decreases with aging (see 6); therefore, increased synthesis of collagen may help retard the aging process This increase of collagen production after treatment with AHAs has been demonstrated both in vivo and in vitro by using fibroblast cultures In fact, in a study by Kim et al, glycolic acid treatments increased fibroblast proliferation in vitro as well as collagen production10 Glycolic acid peels are sometimes used in patients with acne; however, in a study by Lee et al, application of two glycolic acid peels (30%) or Jessner s solution with a 2-week interval failed to display any effect on sebum production11 Table 20-1
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CHAPTER 20 CHEMICAL PEELS
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FIGURE 20-2 A hematoxylin and eosin (H&E) stain of bovine skin treated with a super cial chemical peel (two coats of the Pigment Peel Plus) This biopsy demonstrates a split in the spinous layer of the epidermis GLYCOLIC ACID Glycolic acid (Fig 20-3) is the AHA most commonly used in chemical peels in the offices of dermatologists and aestheticians It is popularly known as the lunchtime peel because it can be completed during the patient s lunch hour and the patient can return to work without any telltale signs The glycolic peel was one of the first superficial chemical peels to become popular because of its effectiveness and ease of use Well-designed studies have demonstrated the efficacy of AHA peels as a treatment for photoaging In 1996, Ditre showed that application of AHAs resulted
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AHAs
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AHAs are a group of naturally-occurring compounds that contain the hydroxy group in the alpha position This versatile group of acids includes glycolic acid, which is derived from sugar cane, lactic acid, from sour milk, citric acid, from citrus fruits, and phytic acid, which is derived from rice The use of hydroxy acids in skin care products dates back to ancient Egypt and Cleopatra, who was said to have applied sour milk to her face to enhance its youthfulness
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TABLE 20-1 Commonly Used Glycolic Acid Peel Brandsa PRODUCT NAME Re nity Skin Solution MD Fort Glycolic Chemical Peel Kit I MD Fort Glycolic Chemical Peel Kit II Glyderm 50% GA swab MicroPeel 20 MicroPeel 30 MicroPeel 50
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COMPANY Cosmederm Technologies Allergan Allergan ICN
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PERCENT GLYCOLIC ACID 70% 70% peel 99% peel 50%
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PERCENT FREE ACID 70% 48% glycolic and ammonium glycolate 68% glycolic and ammonium glycolate Free acid is esteri ed; as such it probably is not active 20 30 50
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NEUTRALIZED No Partially Partially
BUFFERED No Yes Yes
ADDITIVES Strontium Nitrate
1 275 225
Citric alcohol 5% 13 13 08 No No No No No No Glycerin Glycerin Glycerin
BioMedic BioMedic BioMedic
20 30 50
The amount of free acid determines the strength of the peel Esteri ed free fatty acid must be hydrolyzed to the free acid by the skin s natural esterases to be active
provides a list of the most commonly used glycolic acid peel brands Glycolic acid peels are inexpensive and easy to use However, unlike many other peels, glycolic acid must be neutralized after use so as to prevent burning For this reason, it is difficult to use on large areas of the body It is best used in a small area on which application can be quickly applied and quickly neutralized LACTIC ACID Lactic acid (Fig 20-4) is a popular AHA that is found in many athome products and prescription moisturizers It is usually not used as an inoffice peel Lactic acid is hypothesized to be part of the skin s natural moisturizing factor which plays a role in hydration12 (see 11) Several studies on the activity of buffered 12% ammonium lactate lotion (LacHydrin ) have documented its moisturizing ability13 Lactic acid also has been shown to impart antiaging benefits similar to those seen with glycolic acid One study demonstrated an increase in skin firmness and thickness and improvement in skin texture and moisturization using 5% and 12% lactic acid These effects were limited to the epidermis as no effect on dermal firmness or thickness was seen14 OTHER EFFECTS OF AHAs Aged skin, in addition to manifesting wrinkles and pigmentation abnormalities, is generally dryer than younger skin Most cosmetic dermatologists forget that AHAs are also effective moisturizing agents because they have humectant properties (see 32) Interestingly, lactic acid is one of the few ingredients in the United States that is available in the same strength over the counter (OTC) and in prescription form LacHydrin is actually an FDA-approved drug for use in dry skin, but not for photoaged skin AHAs are beneficial in dry skin because they function as humectants, causing the skin to hold onto water They also
enhance desquamation thereby normalizing the SC by getting rid of the clinging keratinocytes that make the skin look rough and scaled Once the desquamation is enhanced, the skin is more flexible and better able to reflect light Although many patients with sensitive skin are afraid to try AHAs, the irritation induced by some of these acids has been shown to be related to the formulation rather than the AHA itself15 In fact, AHAs have actually been demonstrated to reduce the irritation experienced when known irritants are placed on the skin It is thought, but not proven, that AHAs can actually increase skin barrier function In one study, glycolic acid, lactic acid, tartaric acid, and gluconolactone were compared in a double-blind, vehicle- and negative-controlled randomized trial It was found that all of these AHAs protected the skin from irritation caused by a 5% sodium lauryl sulfate challenge patch test as measured by resulting erythema and changes in transepidermal water loss (TEWL) In fact, this study showed that TEWL is not altered by application of AHAs It is interesting that AHAs are able to cause a sheet-like separation of the SC that is not associated with compromise of the barrier function7 The exact mechanism of action of how AHAs impart this protection is currently unknown; however, these agents may prove useful in the management of skin diseases associated with diminished barrier function and a susceptibility to irritant contact dermatitis
FIGURE 20-5 Chemical structure of salicylic acid new agent it had a long history of effectiveness before it was labeled as a BHA Most physicians use preparations of 20% or 30% SA for in-office peels Such peels have been shown to fade pigment spots, decrease surface roughness, and reduce fine lines,16 with similar results to those seen with AHAs In the early 1990s, Swinehart reported satisfactory results using 50% SA on the hands and forearms of patients exhibiting actinically induced pigmentary changes in those areas4 These effects are likely caused by increased exfoliation and an accelerated cell cycle, as seen with AHAs However, unlike AHAs, BHA affects the arachidonic acid cascade and, therefore, exhibits anti-inflammatory capabilities These properties may allow SA peels to be effective while inducing less irritation than AHA peels A 1997 double-blind consumer-perception study of neurosensory discomforts after 3 weeks of use confirmed that SA is perceived by patients as being milder than glycolic acid Of subjects treated with glycolic acid, 20% reported subjective adverse reactions, while 4% to 7% of the SA group reported such reactions17 The lower incidence of perceived irritation caused by SA has contributed to the great popularity of in-office peels and home products that contain BHA The anti-inflammatory effects of BHA make it a very useful peel in patients with acne and rosacea (Fig 20-6) It can be combined with traditional acne therapy to speed the resolution of comedones and red inflamed papules (see 15) SA peels may have a whitening effect in patients with darker skin types In a study of 24 Asian women who were treated with bi-weekly facial peeling with 30% SA in absolute ethanol for 3 months, some lightening of skin color was seen18 These peels can also lead to postinflammatory hyperpigmentation The risks of skin lightening or darkening should be explained to patients with darker skin types prior to their use The trick is to use a strong enough peel to be
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