Skin care after chemical peeling and laser polishing

Chemical peeling, microdermabrasion, laser polishing – all these procedures imply damage of some skin layers that leads to natural development of inflammation. Incorrect assessment of initial skin condition (thickness, phototype, regeneration ability) often leads to “unexpected” reactions in post-peeling period. At the same time practice shows that most complications can be predicted and prevented.

ALL EXPECTED REACTIONS and complications that arise in the post-peeling period can be divided into following groups:

• immediate reactions (that appear in 1-14 days after the procedure);

• regeneration period reactions (2-6 weeks after the procedure);

• persistent changes that form after the regeneration period (3-10 weeks of the rehabilitation period).

Immediate expected reactions

These reactions appear as a result of epidermis integrity disturbance and are a direct consequence of inflammatory process.

Epidermis dehydration.

Damage and removal (complete or partial) of corneal layer, which is the main component of epidermal barrier, always leads to skin dehydration.

Erythema

Erythema intensity and duration can vary greatly depending on the deepness of effect, damage mechanism and chemical agent nature. For example for peeling with alpha-hydroxyacids irregular erythema of medium intensity remains for not more than 1-3 hours. At the same time peeling with Jessner’s solution (with resorcinol), trichloroacetic acid (up to 15%) causes development of bright regular erythema that remains for 1-2 days. Bright fixed eruption (3-5 days) is typical for retinoic and medium TCA peelings.

Desquamation

It is almost always observed after chemical peeling. The most comfortable procedures in this respect are superficial peelings with fruit acids: microscaled desquamation is observed on 2-3 day after the procedure that remains usually for not more than 1-3 days. All other peelings (with retinoids, resorcinol, salicylic and trichloroacetic acids) cause macroscaled desquamation for 2-7 days.

Doughy condition and cutaneous edema

Doughy and edema develop because of release of large amount of proinflammatory mediators (interleukins, histamine, bradykinin) on damage of Malphigian layer of epidermis and derma. Blood plasma “sweats” into intercellular environment because of vascular wall penetrability increase (porosity). This causes edematization of tissues and doughy condition. Doughy condition is most often observed on regions with thin skin (eyelids, neck) after peelings with retinoids and TCA in concentration that does not exceed 15% and very rarely occurs after fruit acids peeling.

Medium TCA peelings inevitably cause edema.

Skin darkening

Skin darkening is observed after combined acid-enzymatic peelings (15-25% trichloroacetic acid+papain) and among patients with skin phototype IV-V.

To reduce the intensity of expected immediate reactions post-peeling care has to include skin moistening and restoration of epidermal barrier. These two main components are necessary for normal regeneration and epithelization of skin.

Cosmetic gels or foams are most suitable for use during first days of rehabilitation period because they are easily applied and quickly absorbed without the need for additional rubbing movements. Creams are more preferable at later stages (when desquamation appears on 3-5 day of rehabilitation period).

Active epidermis moistening allows not only to decrease subjective uncomfortable sensations (tightened skin) but is also a necessary condition of normal epithelization and reduces risk of cicatrisation. Hyaluronic acid, natural moistening factor (NMF) elements (amino acids, urea, pyrrolidonecarboxylic acid, sodium and calcium ions), proteins and their hydrolyzates, alginates, hydrogels have the most intensive hydrating effect.

Purposeful restoration of epidermal barrier allows to reduce transepidermal water loss and high skin sensitivity. Thus when choosing cosmetic skin care preparations for post-peeling period it is better to choose those that contain shea nut oil, phospholipids, ceramides, omega-6-fatty acids, waxes, blackberry, evening primrose, grape seed oils and other natural elements.

Renegeration stimulators (placenta, panthenol, retinol, bisabolol) accelerate processes of wound healing and are included into skin care schemes after surface, medium and deep peelings.

Antioxidants (selenium, tocopherol, ubiquinone, pycnogenol and other bioflavonoids) that are part of makeup preparations for post-peeling care significantly reduce intensity of inflammatory reaction, prevent lipid peroxidation and reduce the risk of development of postinflammatory hyperpigmentation.

Immediate side reactions

These reactions may be classified as complications.

Herpetic infection

Herpetic infection exacerbation is most often observed after chemical peeling with retinoids or trichloroacetic acid (25—30%). In first case typical eruption localization is on red lips border and wings of the nose; medium TCA peeling causes high risk of generalized eruptions. At the same time probability of atrophic or, more seldom, hypertrophic cicatrices significantly increases. Therefore antiherpetic treatment (acyclovir, valtrex) is necessary for the patients with regular exacerbations (twice a year and more often). If prophylactic measures were not taken for some reason, antiviral pulsing therapy is prescribed in case of exacerbation according to the following scheme: acyclovir 1 g once a day for 1-5 days (depending on eruption regress speed).

Infections

Infections are caused by non-observation of asepsis and antisepsis rules during the procedure and post-peeling period. Most frequent infection is streptostaphyloderma treated with standard antibacterial therapy (kefzol, tavanic, oxycort, baneocin ointment).

Allergic reactions

This complication is very rare and can be provoked with presence of êîéåâîé and ascorbic acid in the peeling solution. The range of “problem” ingredients of post-peeling care preparations is much wider. If itching, increasing hyperemia, or edema occurs, immediate injection of antihistamine or steroid preparations (tavegyl, hydrocortisone, dexamethasone, prednisolone) is recommended. Steroid creams are not effective enough in this case.

Thoroughly collected anamnesis allows to significantly reduce the risk of allergic reactions!

Prolonged inflammation

Persistent inflammatory reaction (erythema and edema of face, eyelids, neck that remain for 2-3 days and more) is a highly adverse condition. This is an indirect indication of the fact that peeling damaging effect was not in keeping with skin individual regeneration abilities. This often leads to degenerative changes in epidermis and derma, forming of high skin sensitivity, significant reduction of skin turgor and elasticity.

It is necessary to take the most active steps to stop inflammation. Antioxidants, anti-inflammatory preparations (containing zinc and glycyrrhetinic acid), voltaren, indometacin, traumeel cream or non-fluorinated steroid creams are recommended.

Regeneration period complications (2-6 weeks)

Correct assessment of skin condition (type and phototype, thickness, reparative reserves, vascular reactivity) performed prior to the procedure course allows to prevent all complications listed below.

Persistent erythema

It usually affects the patients with telangiectasia after medium and deep peelings or laser polishing. Intensification of vascular pattern is not observed if surface chemical peelings with alpha-hydroxylic acids or TCA (up to 15%) are performed correctly.

Persistent erythema can remain for 1-6 months and even a year in some cases after laser polishing. Usually persistent erythema tends to regress even without medicinal treatment.

The following recommendations should be observed:

• avoid insolation, physical loads, visiting sauna;

• do not drink alcohol (especially red wine), do not eat spicy food and marinades.

Bioactive food additives based on omega-3-fatty acids that promote increase of vascular walls elasticity and prevent new telangiectasias are recommended as a supporting therapy. They are prescribed both during pre-peeling preparation for “problem” patients and during rehabilitation period.

“Vasoconstrictive tonic” (3,0—5,0 ml of 0,1% adrenaline hydrochloride solution + 100,0 ml of distilled water) allows to quickly and effectively reduce erythema intensity so the patients feel more comfortably and can continue their day-to-day activities. The tonic is applied 1-4 times per day if necessary.

Photocoagulation is the only safe method of telangiectasia treatment (and not a cosmetic correction). It is recommended to perform photocoagulation not earlier than in 2-3 months after peeling. Light flux intensity is selected individually depending on skin phototype and sensitivity. There should be at least 3 sessions once per month.

Important parts of persistent erythema treatment are vasotonic preparations: hepathrombin ointment/gel, lioton gel, arnica cream. In some cases mesotherapy with ginkgo biloba or sweet clover extracts with rutin is recommended. Mesotherapy use is limited by significant painfulness of injections that worsens patients’ psychoemotional condition that is already difficult after medium and deep chemical peelings and laser polishing.

Microcurrent therapy improves microcirculation and lymph outflow, reduces erythema intensity, activates tissue regeneration after peelings. Microcurrent therapy sessions are recommended since first days of post-peeling period.

Post-inflammatory hyperpigmentation (PIHP)

The main cause of this complication is increase of chromatophorotropic hormone synthesis by keratinocytes. The initiating factor of this complication is the post-peeling inflammation and not excess insolation during rehabilitation as it was considered before. PIHP most often affects patients with initial predisposition for hyperpigmentation or with skin phototype IV-V after medium TCA peelings or laser polishing. At the same time this complication occurs very rarely after peelings with phytic and fruit acids, retinoids, phenol, and after dermabrasion.

According to our observations post-inflammatory hyperpigmentation can be provoked by physiotherapy (electrical lymphodrainage massage, ultrasonic) in the post-peeling period.

The following measures are recommended for PIHP prevention:

• careful selection of patients allows to exclude the high risk group. When correcting already present hyperpigmentations and chloasmas it is better to use retinoic, AHA or phenol peelings.

• one month pre-peeling preparation using tyrosinase inhibitors (retinoic acid (0.025-0.05%), kojic acid (3—5%), azelaic acid (5-20%), arbutin, glabridin, ascorbic acid (in the form of magnesium ascorbil-2-phosphate), N-acetylcysteine) is recommended for patients with skin phototype IV-V before medium TCA peelings or laser skin polishing.

Anti-inflammatory therapy (zinc preparations, bisabolol, various antioxidants) and purposeful melanogenesis depression are necessary during the post-peeling period. Preparations that contain N-acetylcysteine are recommended because it is a strong antioxidant that reduces intensity of inflammatory reaction and risk of post-inflammatory hyperpigmentation. In addition N-acetylcysteine “embeds” itself in the process of melanins synthesis and promotes synthesis of pheomelanin (light brown pigment) instead of eumelanin (dark brown pigment) thus preventing forming of dark pigmentation.

If post-inflammatory hyperpigmentation has already appeared, the following measures are taken to clear the skin:

• additional chemical peelings with retinoids (2—5%) or a combination of hydroxiacetic (50%) and kojic acids,

• phonophoresis or mesotherapy with preparations of ascorbic acid (10—20%), external application of hydroquinone preparations (2—4%).

Seborrhea, miliums, acne exacerbation.

Intensive inflammatory reaction that activates sebocytes is an initiating agent. These complications most often occur after medium and deep peelings, dermabrasion and laser polishing among patients with sebaceous skin or compromised anamnestic record (seborrhea, acne in puberty age). What is to be done?

Sometimes simple dynamic observation of patients is enough.

In 90% of cases sebum production decrease occurs in 2-3 months after the procedure.

Sebosuppressors can be prescribed if necessary: aevitum (1 capsule 2 times a day for 1-3 months), zincteral or zincite (1 pill 2 times a day for 1-2 months).

The least traumatic way of milium removal is the mechanical one with the help of a needle for intramuscular injections.

Electric, radio-wave or laser coagulation during the post-peeling period can cause appearance of “stamped” cicatricles.

If inflammatory acne elements appear, standard therapy is recommended (with the help of systemic and topical antibacterial preparations, sebosuppressors, etc.)

Retinoic ointment and basiron AC are not recommended during the post-peeling period.

Higher skin sensitivity

Repeated medium or deep peeling on the same region of skin can very likely cause higher skin sensitivity for 6-12 months for the patients with thin skin or decreased regeneration reserves.

Active measures for restoring of epidermal barrier, moistening and regeneration stimulation (placenta extract as an external preparation or mesotherapy preparations), and microcurrent therapy are recommended to correct this condition.

Line of demarcation

Line of demarcation most often affects patients with thick, porous skin after medium-deep and deep peelings, dermabrasion and laser polishing. In such cases distinct border between peeling region and adjacent skin becomes noticeable. Additional surface-medium peelings (TCA 15%. Jessner peeling) and microcrystal dermabrasion are performed to reduce it after complete skin restoration.

Mottled skin

Mottled skin is caused by irregular melanocytes death as a result of cytotoxic action of phenol or too deep laser polishing. It is most noticeable among patients with skin phototype IV-V. Unfortunately mottled skin cannot be corrected with cosmetic means. Surface and surface-medium peelings are recommended to make skin color more even.

Enlarged pores

Persistent enlarged pores are related to degenerative derma changes and significant decrease of skin elasticity after too deep peelings/skin polishing. This complication often affects patients afflicted with seborrhea after laser polishing or dermabrasion. It cannot be corrected with cosmetic means.

Persistent skin changes

These changes are formed in 3-10 weeks after the procedure.

Hypo- and depigmentation

These complications occur after deep phenol peelings and very rarely after laser skin polishing. The only way of correction is to use masking decorative makeup (dermablend). Permanent makeup in such cases requires highest professional competence and high quality dyes.

Cicatrices treatment with steroid preparations injections requires extraordinary caution because in case of triamcinolone ingress into derma and/or subcutaneous fat atrophy forming is possible in 80-100 % of cases. Preparations are injected only into scar tissue by small amounts until papules with diameter not bigger than 1 mm are formed.

Hypertrophic and keloid scars

They are formed after deep chemical peelings (ÒÑÀ 50%, phenol 88%) and in case of medium TCA peelings (with acid concentration 25-30%) technology errors when the patient is prone to hypertrophic and keloid scars, secondary infections, or exacerbation of herpetic infection.

Bucky therapy can be used to prevent pathologic scarring. If the scar has already formed, injections of triamcinolone (kenalog or diprospan) can be recommended. Depending on the scar intensity the preparation is mixed with physiological solution in the proportion of 1:1 – 1:5. Injections are made not more often than once in 10-14 days.

Cryodestruction allows to effectively decrease scar tissue volume. Optimal results are achieved if cryodestruction is combined with triamcinolone injections (once in 3-4 weeks).

Ozone therapy is a safe and effective alternative to steroid injections. Injections of oxygen and ozone mixture (ozone concentration is 5-7 mg/mole) are made every other day for 10-15 sessions.

Preparations for external application (silicone plasters, hydrogels, Dermatix, Contractubex) significantly reduce the probability of hypertrophic and keloid scars forming and are recommended as an addition for the methods listed above.

Ectropion

Ectropion (eyelid turning out) is a rare complication that is typical only for deep chemical peelings (50% ÒÑÀ, 88% phenol). Ectropion should be corrected with surgical intervention.

In summary it should be noted that probability of complications depends on professional competence of the specialist, observation of the procedure methods and, most important, correct selection of patients for a certain procedure.