Chemical Peels, PRP, and Microneedling Best Practices

At the 2024 Pigmentary Disorders Exchange Symposium in Chicago, Dr. Pearl Grimes, a leading international authority on vitiligo and pigmentation disorders, delivered an insightful lecture on the best practice for using chemical peels, microneedling and PRP  in dermatology. Dr. Grimes’ presentation delved into the nuances of various peeling agents, their indications, and key considerations for their use across different skin types. She emphasized the importance of selecting the appropriate peel based on the patient’s skin type, photoaging severity, and individual history to achieve optimal outcomes while minimizing complications. In case you missed it, you here are the key takeaways from her lecture!

Overview of Chemical Peels and Their Use in Diverse Skin Types

Dr. Grimes referenced a landmark study by Dr. Stegman from 1982, which compared the histologic effects of three peeling agents and dermabrasion on both normal and sun-damaged skin (Stegman, 1982). She highlighted the critical role of understanding the histologic impact of peeling depth and its correlation with injury depth, which in turn dictates the appropriate peel for different skin types. Additionally, a study on hairless mice demonstrated that as the depth of the peel increases, collagen density also rises, particularly during the healing phase (Han, 2011). While this may seem beneficial for rejuvenation, deeper peels carry a higher risk of post-inflammatory hyperpigmentation in skin of color (Roberts, 2004). Therefore, the use of chemical peels requires thorough knowledge to ensure optimal patient outcomes. Clinicians must carefully consider the peel depth, the condition being treated, its place on the clinical disease spectrum, the Fitzpatrick skin type, and the associated risks versus benefits.

Chemical peels are a widely used dermatological treatment, with varying depths of penetration and effects on the skin. They are classified into superficial (very light or light), medium, and deep depth peels. Glycolic acid, a superficial peel, is a staple in chemical peels, known for its effectiveness and safety profile. Trichloroacetic Acid (TCA) induces epidermal necrosis and is considered a gold standard. Depth of injury is dependent on concentration of TCA. However, it requires caution with use, especially in darker skin types, due to a higher risk of post-inflammatory hyperpigmentation. Finally, phenol is a deep peeling agent that causes significant keratolysis and protein coagulation.

Peel Selection Based on Skin Type and Aging

• • Lighter Skin (skin types 1-3): More prone to fine and coarse lines. Peeling is primarily for photodamage, textural changes, actinic keratoses, and dyschromia.
    • For mild to moderate photoaging (Glogau Classification 1-2), superficial to medium-depth peels are recommended.
    • Advanced photoaging (Glogau Classification 3-4) may require more aggressive peels such  as medium to deep-depth peels.

• • Darker Skin (skin types 4-6): Ages ~10 years slower compared to lighter skin but is more prone to dyschromia (Vashi, 2016). Peeling is primarily for hyperpigmentation, acne, fine lines, and textural changes in Dr. Grimes’ experiences.
    • Superficial to medium-depth peels are preferred to control side effects and ensure efficacy.
    • While TCA is effective for photoaging and photodamage in lighter skin types, TCA requires caution in darker-skinned individuals due to a higher risk of post-inflammatory hyperpigmentation compared to glycolic, salicylic, and ferulic acids.

Patient Assessment and History

A thorough patient assessment, including detailed history, patient expectations, and baseline photographs, is crucial. This helps set realistic expectations and track treatment progress, mitigating potential disputes about outcomes.

Contraindications and Precautions

• • Active infections or inflammation
  • Allergies to peeling agents
  • Recent isotretinoin use (guidelines have relaxed, but caution is advised)
  • To decrease risk of post-inflammatory complications, priming the skin for at least 4 weeks and ensuring photoprotection are essential.

• • In patients with skin of color, ask them to stop using tretinoin at least one week before the peel to avoid inadvertently increasing the intended depth of the peel.
  • Photoprotection always!

Best Practices in Chemical Peeling

• • Combination is key: Chemical peels should complement daily regimens for hyperpigmentation and acne, not replace them.
    • Dr. Grimes notes that peels are her second line for treating acne and PIH. They cannot replace a patient’s daily regimen!

• • Pre-Peel Care: Priming with exfoliants and antioxidants; use antivirals for patients with a history of herpes. Never forget photoprotection!

• • Post-Peel Care: Includes the use of lighteners, standard skincare regimens, and topical corticosteroids. High-potency corticosteroids are particularly important to manage excessive frosting or aggressive peeling. Again, never forget photoprotection.

Case Studies and Efficacy

Dr. Grimes presented several case studies demonstrating the effectiveness of different peels (e.g., TCA, glycolic acid, salicylic acid) in treating various conditions like post-inflammatory hyperpigmentation and photoaging. Comparative studies highlighted the efficacy of glycolic acid over TCA in some cases and the promising results of ferulic acid in treating periorbital hyperpigmentation (Kumari, 2010; Dayal, 2020). She also referenced a study that showed Jessner’s peel is equally as effective as the Nd:YAG Q-switch laser in reducing pigment and erythema (Ertam, 2022).  These studies underscore the importance of tailoring peel selection to individual patient needs, leveraging the specific strengths of each agent to achieve optimal therapeutic outcomes.

Adjunctive Treatments: Microneedling and PRP

• • Microneedling: Effective for enhancing transcutaneous delivery of topical agents and transcutaneous elimination of melanin (e.g., for melasma). Despite its benefits, it’s not entirely colorblind and requires careful patient selection. Dr. Grimes’ standard depth is 1.5mm for microneedling.
  • PRP (Platelet-Rich Plasma): Used alone or in combination with microneedling for conditions like melasma and vitiligo. It provides growth factors that may upregulate TGF-beta, inhibiting (Deng, 2022; Mercuri, 2020).

To wrap it up, chemical peels remain a cost-effective, versatile treatment option in dermatology. Emerging treatments like microneedling and PRP offer additional tools for managing complex skin conditions. Ensuring patient safety and satisfaction through meticulous assessment, appropriate pre-peel regimens and peel selection, and comprehensive post-peel care is crucial. A couple things that Dr. Grimes made sure to emphasize throughout her talk were the importance of photoprotection and obtaining baseline photographs. I hope this review has equipped you with valuable best practices from Dr. Grimes for maximizing therapeutic outcomes while minimizing risks!

REFERENCES

1. 1. Stegman S. J. (1982). A comparative histologic study of the effects of three peeling agents and dermabrasion on normal and sundamaged skin. Aesthetic plastic surgery, 6(3), 123–135. https://doi.org/10.1007/BF01570631
   2. Han, S. H., Kim, H. J., Kim, S. Y., Kim, Y. C., Choi, G. S., & Shin, J. H. (2011). Skin rejuvenating effects of chemical peeling: a study in photoaged hairless mice. International journal of dermatology, 50(9), 1075–1082. https://doi.org/10.1111/j.1365-4632.2010.04712.x
   3. Roberts W. E. (2004). Chemical peeling in ethnic/dark skin. Dermatologic therapy, 17(2), 196–205. https://doi.org/10.1111/j.1396-0296.2004.04020.x
   4. Vashi, N. A., de Castro Maymone, M. B., & Kundu, R. V. (2016). Aging Differences in Ethnic Skin. The Journal of clinical and aesthetic dermatology, 9(1), 31–38.
   5. Dayal, S., Sangal, B., & Sahu, P. (2020). Ferulic acid 12% peel: An innovative peel for constitutional type of periorbital melanosis-Comparing clinical efficacy and safety with 20% glycolic peel and 15% lactic peel. Journal of cosmetic dermatology, 19(9), 2342–2348. https://doi.org/10.1111/jocd.13292
   6. Kumari, R., & Thappa, D. M. (2010). Comparative study of trichloroacetic acid versus glycolic acid chemical peels in the treatment of melasma. Indian journal of dermatology, venereology and leprology, 76(4), 447. https://doi.org/10.4103/0378-6323.66602
   7. Ertam Sagduyu, I., Marakli, O., Oraloglu, G., Bulut Okut, E., & Unal, I. (2022). Comparison of 1064 nm Q-switched Nd:YAG laser and Jessner peeling in melasma treatment. Dermatologic therapy, 35(12), e15970. https://doi.org/10.1111/dth.15970
   8. Deng, T., Cheng, F., Guo, S., Cheng, H., & Wu, J. (2022). Application of PRP in Chloasma: A Meta-Analysis and Systematic Review. Computational intelligence and neuroscience, 2022, 7487452. https://doi.org/10.1155/2022/7487452
   9. Mercuri, S. R., Vollono, L., & Paolino, G. (2020). The Usefulness of Platelet-Rich Plasma (PRP) for the Treatment of Vitiligo: State of the Art and Review. Drug design, development and therapy, 14, 1749–1755. https://doi.org/10.2147/DDDT.S239912

This information was presented by Dr. Pearl Grimes during the 2024 Pigmentary Disorders Exchange Symposium. The above session highlights were written and compiled by Dr. Sarah Millan. 

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