COSMETIC DERMATOLOGY: PRINCIPLES AND PRACTICE in .NET

Generator QR Code ISO/IEC18004 in .NET COSMETIC DERMATOLOGY: PRINCIPLES AND PRACTICE

COSMETIC DERMATOLOGY: PRINCIPLES AND PRACTICE
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Also known as salicylic acid (SA), BHA is another commonly used type of inoffice chemical peel used by aestheticians and cosmetic dermatologists These formulations are also available in OTC home products that have lower concentrations of acids (usually 05% 2%) than those used in the office (usually 20% 30%) Derived from willow bark, wintergreen leaves, and sweet birch, SA is the only member of the BHA family, so named because the aromatic carboxylic acid has a hydroxy group in the beta position (Fig 20-5) This is actually a misnomer because the carbons of aromatic compounds are traditionally given Arabic numerals (1, 2, etc) rather than the Greek letter designations typical for the nonaromatic structures It is likely that SA was labeled as a BHA at the time BHA peels were introduced in order to market the products and benefit from the popularity of AHAs Although BHA is a newer category of chemical peels, SA is hardly a
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FIGURE 20-4 Chemical structure of lactic acid
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BOX 20-1 It is important to note that the frost seen in a BHA peel represents precipitated SA, while the frost in a TCA peel represents precipitated skin proteins These skipped areas seen in a TCA peel should not be touched up as they can be with a BHA peel, because the TCA peel frosting time depends on the concentration used Lower concentrations take longer to frost BHA peels frost in 2 minutes Retouching the unfrosted areas of a TCA peel could result in burning the patient and should be strongly discouraged
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CHAPTER 20 CHEMICAL PEELS
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FIGURE 20-6 Beta hydroxy acid peels can be used to treat acne and photoaging on any part of the body This patient was treated with BHA for acne and postin ammatory hyperpigmentation on the back effective but not strong enough to induce inflammation If in doubt use a lower strength peel and titrate to stronger peels in future sequential treatments Another difference between AHAs and BHA is that BHA is lipophilic, which enables it to penetrate the sebaceous material in the hair follicle and exfoliate the pores18 AHAs, which are watersoluble, do not exhibit this comedolytic characteristic19 (Table 20-2) Kligman evaluated this phenomenon in a study that compared the number of microcomedones seen in biopsies of women treated with 2% SA to those from women treated with 8% glycolic acid The glycolic formulation did not decrease the density of microcomedones, whereas a statistically significant (p 005) decrease was seen after BHA application17 Therefore, because of its lipophilic nature, BHA confers a stronger comedolytic effect than do AHAs
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Although there is a wealth of evidence that suggests that AHAs stimulate collagen production, there are no published data examining the effects of BHA on collagen synthesis Many authors postulate, however, that the increased collagen synthesis seen with AHAs and retinoids may be due in part to the resulting inflammation, which may stimulate collagen synthesis If this is true, one would expect that SA would also increase collagen synthesis BHA also differs from the AHAs insofar as it does not need to be neutralized and the frost is visible once the peel is complete (Box 20-1) The practitioner can readily observe the uniformity of application of a BHA peel because of the white precipitate of SA that forms (Fig 20-7)
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TABLE 20-2 Comparison of AHAs and BHA AHAS Useful in photoaging Useful in acne Useful in melasma Useful for dry skin Speeds cell cycle Enhances exfoliation Lipophilic Inhibits arachidonic acid Anesthetic properties Anti-in ammatory properties Must be neutralized Visible frost Risk of salicylism Variety of available concentrations FDA-approved for prescription use Shown to increase collagen synthesis Useful in pregnancy/ breast feeding Yes Yes Yes Yes Yes Yes No No No Maybe Yes No No Yes Yes (dry skin) Yes Yes BHA Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes (low) A few No No No FIGURE 20-7 The white frost appears 2 minutes after application of the salicylic acid peel and signals that the peel is complete
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effective moisturizer in combination with BHA products to prevent this problem SA is currently a popular component of many in-office peels using a combination of ingredients Examples include the Jessner s Peel, the PCA Peel by Physician s Choice, and the Pigment Plus Peel by Biomedic DISADVANTAGES OF HYDROXY ACIDS AHAs are a significant set of options in an antiaging armamentarium; however, it is important for patients to have realistic expectations Superficial chemical peels are only able to produce subtle changes in the skin with each peel It is the cumulative benefits of the peels that yield the most noticeable changes in the skin At least four superficial peels are usually necessary before patients can begin to see amelioration of photodamage, solar lentigos, and melasma Those with more severe damage may require eight or more If this is not explained to patients, they will become discouraged after one or two chemical peels and will not be compliant with the prescribed regimen Patients must also be told that superficial peels are unable to correct moderate to severe wrinkles and scars even though many OTC cosmetic products promise these unrealistic changes If patients expectations are realistic, they will be pleased with the results that superficial peels can provide (Figs 20-8 and 20-9) Although AHAs are very popular as ingredients in daily cleansers and moisturizers, some experts have suggested that continued use of hydroxy acids may lead to a decrease in efficacy with continued use because of accommodation of the skin It is postulated that this occurs because the skin becomes a better acid buffer and is able to more efficiently neutralize the effects of the acids14 At this time there is no published evidence to support this claim, but this possibility should be kept in mind It may be beneficial to have patients stop their hydroxy acid preparations periodically to enhance the efficacy of these products when used long term Although AHAs are well known to make the SC appear more compact, this effect has not been associated with the use of SA in the literature However, it is likely that BHA has the same effect AHAs, but surprisingly not BHA, were under scrutiny in the past because of the fear that AHAs thinned the skin This has not been proven There is concern that the thinner SC will provide less of a barrier to harmful environmental factors
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