1. Dr. Tzermias Christopher GREECE
What are the long and short benefits of Retinoic Acid, AHAS and Chemical Peels
Dr. Tzermias Christopher
GREECE

2. Tretinoin - Retinoic Acid
The most consistent and significant improvement within 4-10 months of therapy are:
Skin texture
Mottled hyperpigmentation
Fine wrinkles
The use of 0.05% and 0.1% tretinoin cream
for 6 months leads to an increase in epidermal
and granular layer thickness.

3. Complication The most important complication of retinoic acid is its tendency to cause skin dryness, therefore new emollient formulations have been produced.
Clinical improvement of fine wrinklin
Histologically
After 24 weeks of use, reversal of stratum corneum compaction and epidermal and granular thickness is observed
After 48 weeks of use melanin content decreases and epidermal mucin increases

4. Alpa Hydroxy Acids ( AHAS )
AHAs are linear organic carboxylic acids with an attached hydroxyl group and can be derived in natural foods; hence the common name, fruit acids.
Glycolic acid ( in sugar cane) the simplest and most popular one is available in concentrations ranging from 5% to 15%. Higher concentrations of this acid are used in chemical peels.
Other fruit acids are:
Lactic acid from sour milk
Citric acid from citric fruits
Tartaric acid from grapes
Malic acid from apple

5. The increased skin thickness is attributed to increased synthesis of:
The use of AHAs has been shown to reverse histologic sings of photoaging by:
Increasing epidermal thickness
Reversing basal cell atypia
Dispersing melanin pigmentation and
Normalising the rate pattern of the dermoepidermal junction
The increased skin thickness is attributed to increased synthesis of:
Glycosaminoglycans
Collagen
Elastic fibers

6. Chemical peels are categorized into
The process of chemical peeling involves the application of a caustic agent on the skin to produce a controlled, partial-thickness inlury.
Chemical peels are categorized into
Superficial peels
Medium depth peels
Deep depth peels

7. Superficial Peels
Superficial peels penetrate the epidermis down to the dermal- epidermal junction
Some superficial peeling agents are:
Jessner’s solution
Glycolic acid at concentrations of 20% to 70%
Trichloacetic acid at concentrations of 15% to 35%
Obagi “blue peel”

8. Jessner’s solution Jessner’s solution is a combination of Resorcinol
Salicylic acid
Lactic acid
In an alcohol solution
Triple layer application produces
stratum corneum separation with upper intraepithelial and intercellular edema.

9. Glycolic acid Glycolic acid at concentrations of 20% to 70%
Glycolic acid Glycolic acid at concentrations of 20% to 70%. The effect of the peel depends on the length of time it is left on the skin . Therefore it has to be neutralized either with water of sodium bicarbonate to prevent deeper dermal penetration
Usually are performed in a series of 4 to 6 treatments at 1 to 6 week intervals in order to improve
Skin shallowness
Dyspigmentation
Fine wrinkles
Mild photodamage
For the last two an initial application of 70% unbuffed glycolic solution is recommended for a duration of 4 to 8 min.

10. Trichloacetic Acid TCA CAUSES Necrosis
Exfoliation of normal and actinically damaged cells
Percipitation of epidermal proteins
Therefore application of TCA causes:
Transient frosting
Erythema
A great advantage of TCA is that it is nontoxic systematically and is neutralized by serum in superficial dermal blood vessels.

11. Obagi “blue peel”
Obagi, “blue peel” contains a non ionic base with glycerin and saponine in order:
To slow the rate of TCA action and
To gauge the depth of peel
A light blue endpoint signifies exfoliation to the stratum corneum while a dark blue endpoint denotes coagulation to the basal layer of the epidermis
Superficial peels are desirable because:
All skin types can be treated
Have a minimal recovery time
Minimize serious adverse sepuale

12. Medium Depth Peels
Produce an injury depth down to the upper dermis and are best in use in:
• Actinic keratoses
Dyschromia
Mild wrinkling

13. TCA 40% to 60% TCA 60% to 75% can cause: Epidermal necrosis Edema
Homogenization of the papilary dermis
Sparse lympholytic infiltration in the midretieular dermis within 3 days after application
TCA 60% to 75%
Recommended only for spot treatment of localized keratoses
50% of TCA may be applied either:
in a rapid fashion over the entire face without overcoating of
In a slow controlled manner to each cosmetic unit
Eyelids are peeled with 20% to 35% TCA

14. In an attempt to decrease the risk of complications ( hypochromia) a superficial agent is used initially. After decreasing the skin with acetone either dry ice or Jenssen’s solution can be applied to initiate an epidermal injury. This then enables the 35% TCA to penetrate more readily. These two deepest medium depth peels dry ice and TCA are not recommended for skin types V and VI due to the visit of hypopigmentation. A newer combination is the use of 70% unbuffered aqueous glycolic solution to soapclean skin without prior decreasing with acetone. Left on for 2 min this solution causes epidermolysis enabling deeper penetration of subsequent 35% TCA solution application.

15. Deep Peels Baker’s formula
Indication for their use include:
Deep rhytides secondary to photodamage
Severe or extensive actinic keratoses
Baker’s formula
Baker’s formula is the most common one.
It is composed of mixture containing:
3ml 88% phenol US8
3 drops croton oil (augments phenol penetration causing epidermolysis)
8 drops Septisol (increases surface tension and slows the penetration of phenol)
2ml distilled reaction

16. Phenol
The reaction following application of phenol is characterized by:
Keratocoagulative necrosis of the epidermis extending into the papillary dermis
A marked inflammatory reaction
Epidermal regeneration begins within 48h and is completed within 1 week
Dermal regeneration takes longer than the epidermal and is characterized by rigid, compact collagen in the upper dermis replacing the disorganized collagen seen in elastosis.

17. Deep phenol peeling may lead to irreversible hypopigmentation and therefore is advised not to be used on skin types V and VI.
Cardiac arrythmias sometimes severe

18. Complications Of Chemical Peels
Adverse sequelae following superficial and medium depth peels are usually minor and reversible including prolonged erythema and post inflammatory hyperpigmentation.
Hypertrophic scarring can occur, rarely and can be managed by the use of anyone or a combination of therapies including topical or intracesional steroid, silicone gel sheeting and pulsed dye laser irradiation.
 3t is a common practice to pretreat patients with tretinoin or/and hydroquinone for 4 to 6 weeks prior to a chemical peel. This regimen decreases the stratum corneum thickness ensuring a more uniform response following the application of the peeling solution.