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Complications after Chemical Peels and Dermabrasion: Prevention and Remedies

In cosmetic dermatology, considerable amount of treatments leads to some damage to dermis and epidermis. Most complications caused by iatrogenic manipulations are non-specific. They develop due to loss of skin integrity or as a result of an inflammatory response. Expert skin preparation and management of patients during the recuperative period immensely minimize the risk of complications.

All expected reactions and complications that occur in the post-peel period can be divided into the following groups:

- immediate complications that arise within 1-14 days after the treatment
- complications that occur in the recuperative period, i.e. 2-6 weeks after the treatment
- persistent changes that are present when the recuperative period is over, i.e. on the 3rd -10th week of recovery

Immediate Complications

a) expected complications

Chemical peels and microcrystal dermabrasion always cause damage to the integrity of epidermis, which leads to inflammations, erythema and swollen skin:

• Epidermal Dehydration

The stratum corneum, which is the major component of the epidermal barrier, is damaged and partly removed. This normally causes skin dehydration.

• Erythema

The extent and duration of erythema may vary depending on the depth of a chemical peel treatment or resurfacing, chemical agents that are used and their specific damaging properties. Chemical peels using alpha hydroxy acids, mandelic or phytic acids may cause uneven moderate erythema, which lasts for 1-3 hours. Resorcinol peels lead to bright even erythema, which is present up to 1-2 days, while retinoic and medium-depth peels produce bright persistent erythema lasting from 3 to 5 days.

• Skin flaking

Skin flaking is the most characteristic side effect following any chemical peel. As a result of such treatment, skin peels; this actually explains the name of the procedure. Superficial peels with alpha hydroxy acids make skin peel in small scales on the 2nd-3rd day after the treatment (usually, lasts no longer that 1-3 days). Other chemical peel solutions (e.g. those containing retinoids, resorcin, salicylic or trichloracetic acids) cause desquamation of large skin scales during 2-7 days.

• Swollen and puffy skin

Swollen and puffy skin is the result of the bodily inflammatory response to skin damage. Huge amounts of pro-inflammatory mediators (interleukins, histamine, bradykinin) are released. They make vessel walls porous and cause tissue swelling. Puffy skin is usually seen on eyelids and neck where skin is thinner.

In order to reduce the load of the expected complications, post-peel care should consist of the following skin care routines:

- moisturization,
- restoration of epidermal barrier,
- preventive measures against outbreak of infections.

These measures are crucial for normal regeneration and epithelization of skin. In the first few days after the treatment, it is recommended to use such skin care products as liquids, gels, or foams. They are easy to apply, fast absorbing, and do not need to be ‘rubbed’ into skin. Later, when skin flaking occurs (i.e. on the 3rd-5th day of the recuperative period), one should use creams instead.

Moisturization. Intensive moisturization of epidermis reduces subjective unpleasant sensations (skin tightness) after chemical peels and allows for normal epithelization, minimizing the risk of scarring. Hyaluronic acid is known for its outstanding moisturizing properties. Hyaluronic acid creates a polymer film on the skin surface, which ‘captures’ water molecules and facilitates cell migration leading to faster regeneration.

Restoration of the epidermal barrier helps to reduce transepidermal water loss and heightened skin sensitivity. For these reasons, skin care products that are used in the post-peel period should contain shea butter, phospholipids, ceramides, omega-6 fatty acids, and waxes.

Regenerating agents (placenta-based products, panthenol, retinol, bisabolol, zinc etc.) allow for faster wound healing. Their use is recommended after superficial-to-medium depth, medium depth and deep chemical peels.

Antioxidants (selenium, zinc, tocopherol, ubiquinone, pycnogenol, and other bioflavonoids) are compulsory components of skin care products that should be used during the post-peel period. Antioxidizing agents considerably reduce the extent of inflammations, prevent lipid peroxidation, and – most crucially – minimize the risk of post inflammatory hyperpigmentation.


b) non-expected complications

Herpes Infection

The exacerbation of pre-existing herpes infection is more common in case of chemical peels with retinoids or trichloroacetic acid (25-30%). Herpes lesions may lead to formation of atrophic scars or hypertrophic scars (less common). In order to prevent undesirable skin changes, administration of antiherpetic medications (Aciclovir, Valtrex) is compulsory in patients who suffer from herpes outbreaks twice a year or more often. If preventive measures have not been taken and lesions have occurred after a chemical peel, a patient should receive pulse therapy consisting in administration of 1g of Aciclovir or Valtrex once a day for 1-5 days (depending on how fast the lesions regress).

Infections

Infections usually develop due to the violation of rules of antiseptics and aseptic conditions during the treatment and in the post-peel period. Streptostaphylococcal pyoderma is the most common mixed infection. Standard antibacterial therapy consists in the use of Baneocin ointment; if there are indications, systematic antibacterial therapy should be given (Kefzol, Tavanic, Oxycort etc.)

Allergies

Allergies belong to very rare complications after chemical peels. Usually, allergies may be caused by certain additional components of peel solutions such as kojic or ascorbic acids.

Inflammation

Inflammation is the expected skin response to a chemical peel treatment. In case of persisting erythema or swelling of skin on the face, eyelids, or neck, lasting more than 2-3 days, it is recommended to use antioxidizing and anti-inflammatory agents, which contain zinc, 18-glycyrrhetinic acid, non-steroid anti-inflammatory medications (Voltaren, indomethacin), Traumeel.

Complications in the Recuperative Period (2-6 weeks)

Persistent Erythematous Patches

This complication may develop after medium-depth and deep chemical peels as well as skin resurfacing in patients with rosacea and telangiectasias.

In case of persistent erythema, one should follow the below mentioned recommendations:

- Avoid the sunlight, physical exercise, and saunas. Alcohol should be avoided (especially red wine) as well as hot, spicy food, and marinades.
- Оmega-3 polyunsaturated fatty acids – considerably increase elasticity of vessel walls and prevent new telangiectasias from forming. Their use is recommended both during pre-peel preparation and in the recuperative period.
- ‘Vasoactive agents’ are an essential part of persistent erythema treatment. Hepatrombin ointment or gel, Lioton gel, and Arnica cream are considered to be the most effective.
- Photocoagulation. Use of laser therapy is recommended no earlier than 2-3 months after the peel. The intensity of light input is determined individually; skin phototype and sensitivity are taken into consideration. No fewer than 3 procedures should be performed with an interval of 1 month.
- Stimulation current therapy, or biocybernetic therapy, improves microcirculation and lymphatic drainage, makes the condition less severe, and activates tissue regeneration after a chemical peel of skin resurfacing. The use of microcurrent therapy is possible (and recommended) even in the first few days of the post-peel period.

Postinflammatory Hyperpigmentation

The reason for development of postinflammatory hyperpigmentation is the increased production of the melanocyte-stimulating hormone by keratinocytes. This action is triggered by inflammation resulting from a chemical peel or dermabrasion. It is not linked to excessive sunlight exposure in the recuperative period. Patients with pre-existing hyperpigmentation or skin phototype IV-V most likely develop postinflammatory hyperpigmentation after medium-depth chemical peels and laser skin resurfacing.

In order to reduce the risk of postinflammatory hyperpigmentation, the following is recommended:

1. Choose patient carefully. Peel solutions containing retinoic, azelaic, lactic, citric, or glycolic acids should be used to treat hyperpigmentation, chloasma and the like.

2. Patients with skin phototype IV-V require 1-month pre-peel preparation before a medium-depth chemical peel or laser skin resurfacing. Tyrosinase inhibitors are normally used for this purpose, such as retinoic acid (0,025-0,05%), kojic acid (3-5%), azelaic acid (5-30%), arbutin, glabridin, ascorbic acid (L-Ascorbic Acid, Magnesium-Ascorbyl-2-Phosphate), N-Acetyl Cysteine, kinetin.

The use of the following is essential in the post-peel period:

• anti-inflammatory products (zinc, bisabolol, Traumeel etc.)

• antioxidants

• tyrosinase inhibitors

In case of postinflammatory hyperpigmentation, the following treatments and products are recommended for skin whitening:

• Superficial chemical peel with retinoic, azelaic, lactic or other acids

• Skin care products and medications containing hydroquinone (2-4%)

• Phonophoresis with ascorbic acid (10-20%)

Seborrhea, Miliums, Exacerbation of Acne

Patient with oily skin are most prone to these complications after medium-depth and deep chemical peels, dermabrasion and laser skin resurfacing.

Normally, no special treatment is required as in 90 per cent of cases sebum production reduces naturally within 2-3 months after the treatment. If required, the following sebum suppressors should be used: Aevit (1 capsule 2 times a day within 1-3 months), Zincteral or Zinkit (1 tablet 2 times per day within 1-2 months). If inflammatory acne is developed, no matter how severe or extensive, antibacterial (Vybramycin, Wilprafen, Zinerit), anti-inflammatory medications (Curiosin gel), and sebum suppressors are prescribed. It should be remembered that the use of products containing azelaic and retinoic acids, and Benzoyl peroxide is not recommended during the post-peel period.

Increased skin sensitivity

Most likely to develop in patient with thin skin with reduced regenerative abilities. Increased skin sensitivity can be present for 6-12 months. In order to restore normal skin functions, microcurrent therapy is performed. One should use creams containing shea butter, borage oil, aleurites moluccana, black currant seed oil, evening primrose oil, grape seed oil, as well as omega-6 fatty acids, ceramides, phospholipids, waxes, reparatives, and skin hydrating agents (hyaluronic acid, placenta extract, panthenol etc.)

Demarcation lines

Demarcation lines are one of the possible complications following medium deep and deep chemical peels, dermabrasion, and laser resurfacing. Patient with thick, ‘spongy’ skin are most prone to it. Demarcation lines are visible boundaries between two areas. Recommended treatments include superficial-to-medium depth chemical peels and microcrystal dermabrasion.

Pore Enlargement

Common complication after laser resurfacing and dermabrasion in patients with seborrhea. No cosmetic correction is used.


Persistent Changes Formed after the Period of Regeneration (3rd -10th week of the recuperative period)

Hypo- and depigmentation

This complication is characteristic of deep phenol peels; in very rare cases, it may develop after laser skin resurfacing. The only solution is to conceal imperfections with the proper use of decorative cosmetics. Permanent make-up should be done by professionals only, using high quality coloring agents.

Hypertrophic and keloid scars

The risk of scarring is higher in case of deep chemical peels, laser skin resurfacing, and personal inclination to formation of hypertrophic and keloid scars. The possibility of scarring also increases due to secondary infection or herpes outbreak.

The following treatments and medications are recommended:

- Grenz ray therapy
- Triamcinolone injection (once in every 10-14 days)
- Cryodestruction effectively reduces the amount of scar tissue. It is recommended to combine cryodestruction and injections of triamcinolone (once in every 3-4 weeks)
- Ozone therapy
- Silicone patches, Contractubex, and other medications for topical use reduce the possibility of formation of hypertrophic and keloid scars. Their use is recommended as an additional treatment to the above mentioned

Ectropion

This is a very rare complication of deep chemical peels. Surgical correction is recommended.

Expected reactions and possible complications after various cosmetic dermatology procedures.

Expected reactions / possible complications	Chemical peels		Microdermabrasion	Phototherapy	Mesotherapy	Removal of new growths
	Superficial	Medium-depth Deep
Immediate reactions (1-14 days after the treatment)
Dehydration	+	+	+	-	-	-
Exfoliation	+	+	±	±	±	-
Erythema	+	+	+	+	+	+
Puffy skin / Swelling	±	+	-	+	-	-
Maceration / Cutaneous condition	+	±	+	-	+	+
Herpes	-	+	-	-	-	-
Infections	±	+	±	-	+	+
Allergy	±	-	-	±	+	+
Inflammation	±	+	±	±	+	+
Complications during the recuperative period (2-6 weeks after the treatment)
Persistent erythema	-	+	-	-	-	-
Postinflammatory hyperpigmentation	±	+	-	-	±	±
Seborrhea, miliums, exacerbation of acne	-	+	-	-	-	-
Skin hypersensitivity	±	+	-	-	-	-
Demarcation line	-	+	-	-	-	-
Pore enlargement	-	±	-	-	-	-
Persistent changes formed after the recuperative period (3-10 week of the recuperative period)
Keloid and hypertrophic scars	-	+	-	±	-	+
Hypo- and depigmentation	-	±	-	-	-	+
Ectropion	-	+	-	-	-	-

Thus, prognosis and proper management of patients in the recuperative period help to considerably reduce the risk of complications. We have used Curiosin in the form of solution or gel to moisturize skin, restore the epidermal barrier, and prevent infections during various skin treatments. 37 patients (aged 18-64, 31 female and 6 male) took part in clinical study of the efficacy of Curiosin. Curiosin solution was used in the recuperative period (2-4 times a day during 3-7 days) following superficial chemical peels, microcrystal dermabrasion, phototherapy, mesotherapy, and removal of benign new growths. Curiosin was well-tolerated by all participants.

The great advantage of Curiosin is that it is effective on all clinical stages of the recuperative period. Its main active ingredient – zinc hyaluronate – facilitates skin moisturization and regeneration, combines anti-inflammatory and antiseptic properties.

The clinical study has shown that Curiosin can be used in a wide range of cases. The usage of Curiosin gel is not limited to treatment of acne vulgaris, whereas Curiosin solution is effective in multiple treatments other than removal of new growths (see table).

by O. V. Zabnenkova, Candidate of Medical Science, Senior Research Assistant of the Laboratory for Research of Skin Reparatory Processes of I.M.Sechenov Moscow Medical Academy


Tags: peel