SUMMARY
Photoaging is the accumulated result of skin aging due to endogenous effects and exposure to UV and infrared rays. Clinically, dryness, irregular pigmentation, freckling, lentigines, actinic keratosis, guttate hypomelanosis, persistent hyperpigmentation, wrinkles, telangiectasia, loss of elasticity, large comedones, sebaceous hyperplasia are observed. Glogau 4 phase; Type I is the early stage and has no wrinkles, type 2 is classified as wrinkles observed with facial expressions, type 3 is advanced, wrinkles observed at rest, and type 4 is severe, wrinkles only. Chemical skin peeling is used in the treatment of photoaging by stimulating epidermal regeneration and dermal neocollagenesis by causing controlled damage to a chemical applied to the epidermis. While alpha and beta hydroxy acids are used alone in the early stages, trichloroacetic acid and combination treatments are preferred in moderate and advanced aging.
The "Baby boomer" movement, which started under the leadership of the United States after the Second World War, spread all over the world towards the end of the 20th century and was influenced by the rapidly increasing world population, advancing technology, advertising and marketing strategies. and social communication networks such as Facebook and Instagram, which exploded after the Internet, resulted in the return to the consumer society. The focus of the consumption frenzy of "baby boomers" is "living well, staying young, looking beautiful, being thin". In the 21st century, the world's people, who have suffered from the disease of consumption, have focused on fighting against physical and mental diseases that have increased as a result of deteriorating nutrition and environmental pollution, and on protecting their youth and health. Women and men of modern society have begun to take care of their skin, which is the mirror of youth, health and beauty, and to increasingly resort to cosmetics, dermato-cosmetological and aesthetic applications that will stop skin aging. One of the most popular dermato-cosmetological procedures, which can be applied even during lunch hours and is highly satisfied, is chemical skin peeling.
In order to understand chemical peel treatments in photoaging, it is necessary to first briefly remember skin aging.
Skin aging, There are two types: internal and external. Photoaging is the accumulated result of skin aging through endogenous effects and exposure to chronic sun/solarium-induced UV+ infrared rays. Clinically, dryness, irregular pigmentation, freckling, lentigines, actinic keratosis, guttate hypomelanosis, persistent hyperpigmentation, wrinkles, telangiectasia, loss of elasticity, large comedones, and sebaceous hyperplasia may be observed(1). Compared to sun-free skin, histologically, photodamaged epidermis shows a compact and gelatinous stratum corneum, dysplasic and atypical keratinocytes, vacuolization and occasionally necrosis in epidermal cells, and a decrease in the number of Langerhans cells. Loss of vertical polarity and irregular alignment of epidermal cells are quite common in chronic sun-damaged skin. In the dermis, elastosis, homogenization in the upper papillary dermal structures, amorphous accumulation, and decrease in collagen fibers are observed. An increase in macrophages, histiocytes and mast cells containing large granules is observed. Over time, it is seen that the decreasing collagen fibers in the upper dermis are replaced by an amorphous substance accumulation surrounded by weakly stained increased reticular fibers (2).
In 1994, Glogau classified photoaging into 4 types(3).
Type 1: premature photoaging, “no wrinkles” ages 20-30, slight pigmentation changes, slight wrinkles, keratosis are not observed. Light/no make-up.
Type 2: Moderate photoaging, "wrinkles traced by facial expressions", late 30s-40s, senile lentigines, tactile keratoses, parallel laugh lines are seen. He usually uses light concealers.
Type 3: Advanced photoaging, "wrinkles at rest." Ages 50 and above, significant dyschromia, telangiectasia, visible keratoses, visible wrinkles at rest. He always uses heavy concealer.
Type 4: Severe photoaging, “only wrinkles”, age 60 and above, yellow-gray color, skin cancers are seen. Normal skin structure is not observed, there are widespread wrinkles. She doesn't wear make-up.
Chemical skin peeling is a resurfacing process that initiates epidermal renewal and restructuring of dermal collagen by creating controlled partial/full layer damage of a chemical applied to the epidermis. method(4, 5, 6). Since the 1980s, with the development of TCA and the discovery of AHAs, it has become one of the most popular office applications in the treatment of photoaging.
They are divided into 3 according to the effects they create on tissues. AHA and Tretinoin act via the metabolic pathway, TCA via the caustic pathway, and Phenol, Salicylic acid and Resorcin act via the toxic pathway(7). Chemical peelers are classified according to the depth of the effect they create, as superficial (very light / light), medium depth and deep (table 1). While very mild superficial peelers reach the stratum spinosum layer, mild ones affect the entire epidermis. While medium-depth effective peelers reach the upper reticular dermis, phenol, which is a deep chemical peeler, can reach the middle reticular dermis (4,5,6,8).
Treatment of photoaging with chemical peeling is planned according to the Glogau classification (Table 1). According to this;
In Glogau Type 1 photoaging, superficial peels,
In Glagou Type 2 and Type 3 photoaging, medium depth peels alone or in combination protocols,
In Glogau Type 4 photoaging, deep effective Baker-Gordon Phenol is used alone (9).
Table 1. Classification of chemical peelers according to depth, effect and photoaging types
Superficial
Glogau type 1-2
Very light
str. spinosum
Medium
Glogau type 2-3
Upper reticular dermis
Deep
Glogau type 4
Middle reticular dermis
10-20% TCA*
Low potency AHA**(GA, MA)
BHA***
LHA* ***
Tretinoin 10% mask
Light
entire epidermis
TCA 20-30%
Jessner solution
70% CI
40-50% PA*****
35-50% TCA
Jessner solution + 35% TCA
70% GA + 35% TCA
Salicylic acid + 35% TCA
Salicylic acid+ 50% PA
70% PA
Baker-Gordon Phenol
*TCA; trichloroacetic acid, **AHA; alpha hydroxy acid(GA; glycolic acid, MA; mandelic acid), ***BHA; beta hydroxy acid, ****LHA; lipo hydroxy acid, *****PA; pyruvic acid
ALFA HYDROXY ACIDS (AHA)
Alpha hydroxy acids, superficial chemistry They are used quite frequently among prime peelers and are known as “lunch break peelers” due to their fast healing time (7). They perform epidermolysis and exfoliation. They must be neutralized with a basic solution such as ammonium salts, sodium bicarbonate, sodium hydroxide. Although the most commonly used and known AHA is Glycolic acid, Pyruvic acid and Mandelic acid have started to be used in the treatment of photoaging in recent years (5,10,11,12). Lactic acid is another alpha hydroxy acid used in the treatment of moderate photoaging, along with salicylic acid in Jessner's solution (13).
Studies have shown that AHAs, str. It has been shown that it causes thinning of the corneum layers, epidermal thickening by increasing the amount of epidermal mucopoisaccharides, an increase in the amount of dermal collagen, an improvement in the quality of elastic fibers, and a decrease in photocarcinogenesis (14).
Glycolic acid (GA)
It has the smallest molecular weight. GA, an AHA, is frequently used in 20-70% concentrations to regulate skin tone and eliminate fine wrinkles, especially in people with skin phototypes I-VI and stage 1.2 photoaging. It has no effect on deep wrinkles. It can be used together with 35% TCA at 70% concentrations in stage 3 photoaging. Although it is most commonly used on the face, it can also be used on the hands, neck, décolleté and back. The eye area and neck are the most sensitive areas and the treatment should be kept in low concentrations (20-35%). 4-6 sessions are recommended at 2-4 week intervals (4,15). It has also been found to be effective and safe in the treatment of photoaging on ethnic skin of Asian and African origin, at 20-70% concentrations and in repeated sessions at 10-14 day intervals (8).
Mandelic Acid (MA)
MA, obtained from bitter almonds, is a larger molecule than glycolic acid and has been used in medicine as a urinary antiseptic for many years. It has significant antibacterial activity against S. Aerius and gram-negative bacteria. It has an anti-aging effect as strong as glycolic acid, and its side effects such as redness, peeling and crusting are much less than glycolic acid. It was found to be effective on type 1-2 photoaging in concentrations of 30-50%, on all skin types, in repeated sessions at 2-4 week intervals (12). Wojcik et al. Age 49-71 with moderate to advanced photoaging In their study comparing the effects of 20% Azeleic acid and 40% Mandelic acid on sebum secretion in 28 female patients, they emphasized that both acids control sebum secretion while also reducing the signs of aging (16). Mandelic acid is actually an important peeling agent, but it has not found the value it deserves in photoaging treatment.
Pyruvic Acid (PA)
PA, an alpha keto-acid, is a strong acid with a small molecular weight that quickly descends to the upper papillary dermis and causes dermo-epidermal separation. It turns into lactic acid in the tissue. In addition to its keratolytic, antimicrobial and sebostatic effects at 50-70% concentrations, it stimulates the production of dermal glycoprotein, collagen and elastin fibers and regulates skin tone (4). In the literature, in 2 studies conducted with 50% PA in the treatment of photoaging, it was found to be effective on the regulation of skin tone, fine wrinkles, and increase in elasticity in Glogau Type 1 and 2 photoaging, when applied in 4 sessions with 2 weeks intervals (10,11). It has been emphasized that severe burning and stinging are felt during application, but no prolonged erythema is observed, and it is well tolerated by patients (10,11).
BETA HYDROXY ACIDS (BHA)
Salicylic acid (ortho-hydroxybenzoic acid) is a lipophilic, hydrophobic beta hydroxy acid. It has a keratolytic effect on intercellular lipids in the epidermis. At 30% concentrations, it stimulates corneocyte separation, proliferation in the basal layer, activation of dermal fibroblasts, and collagen production. It is quite effective on its own in the early stages of photoaging. It also has anti-inflammatory and antimicrobial effects(4,5,17,18). What makes salicylic acid superior to other chemical peelers is that it can be used safely in patients with skin phototype V-VI and accompanying dyschromia and acne, in the treatment of photoaging without the risk of post-inflammatory hyperpigmentation (8). Salicylic acid causes a severe stinging and burning sensation that passes within a few minutes after application. 3 min. In excessive applications, frosting appears on the skin surface. The process is finished with water to reduce the burning sensation and allow the salicylic acid salts to precipitate. Normally, SA does not require an absolutely basic neutralizer such as glycolic acid.(4) Kligman et al. In 50 female patients between the ages of 25-55, with Glogau 1-2 and Fitzpatrick I-III.
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