Dermal peels

Skin Preparation for Photodynamic Therapy, Chemexfoliation, and Ablative Laser Resurfacing: a Systematic Literature Review

BACKGROUND

Photodynamic therapy, chemexfoliation, and ablative laser resurfacing are common practices for dermatologists, yet no formal protocols exist regarding preprocedural skin preparation.

OBJECTIVE

To review and summarize the skin preparation protocols for photodynamic therapy, chemexfoliation, and ablative laser resurfacing available in the literature.

METHODS

Data Sources A systematic review of English and non-English articles using the PubMed database was performed. A manual search of bibliographies from relevant articles was also performed to collect additional studies. Study Selection Only articles in the English language with full texts available that pertained to skin preparation for photodynamic therapy, chemexfoliation, and ablative laser resurfacing were included. Data Extraction Article selection was performed by one author, and relevant sources were verified by other authors using predefined inclusion and exclusion criteria.

RESULTS

There is a paucity of scientific research regarding efficacy and safety of dermatologic preprocedural skin preparation agents. Only 2 studies have compared various cleansing agents for these measures. Yet, strong statements regarding the importance of degreasing are published without supportive data.

CONCLUSION

Consensus guidelines for preprocedural protocols are lacking for photodynamic therapy, chemexfoliation, and ablative laser resurfacing. Further studies are warranted to explore the efficacy and safety of various preprocedural cleansing agents.

The Efficacy of Carbone Dioxide Laser Debridement Along With Low-Level Laser Therapy in Treatment of a Grade 3 Necrotic Burn Ulcer in a Paraplegic Patient (A Case Report)

Introduction: A deep burn ulcer, especially in areas with sensory-motor dysfunction, is hard to cure. Case Report: The patient was a 20-year-old paraplegic girl with a grade 3 necrotic burn ulcer for 3 weeks. We used a fractional Co₂ laser along with chemical debridement with trichloroacetic acid (TCA 80%) and low-level laser therapy (LLLT) with a 808 nm infrared laser, 6 J/cm² for the necrotic area, and a 650 nm red laser, 2 J/cm² for the open wound area. Complete healing occurred after 25 sessions without surgery. Conclusion: Laser debridement along with LLLT and TCA administration may be useful to treat necrotic ulcers without surgery.

Is There an Association Between Hyperbaric Oxygen Therapy and Improved Outcome of Deep Chemical Peeling? A Randomized Pilot Clinical Study

Background

Phenol chemical peeling (PCP) treatment is associated with prolonged recovery and sustained adverse events. Hyperbaric oxygen therapy (HBOT) is known to accelerate wound healing. The purpose of the current study was to evaluate the effect of HBOT on PCP recovery period and adverse events.

Methods

This is a pilot randomized controlled clinical study. Women following PCP underwent 5 consecutive daily HBOT sessions, compared with PCP alone. Pain, pruritus, erythema, crusting, scaling, and edema were daily evaluated up to 28 days following PCP. Photographs taken on days 14 and 35 following PCP were assessed. Confidence to appear in public was assessed 14 days following PCP.

Results

Eight participants equally assigned to HBOT and control groups. Lower severity scores for erythema, scaling, and pruritus were documented in the HBOT group (mean difference 1.19, P = .006; .84, P = .04; and 2.19, P = .001, respectively). Photographic assessment severity score was higher for skin tightness, edema, erythema, crusting, and scaling in the control group on day 14 post PCP (P < .05) and for erythema on day 35 post PCP (P < .05). Epithelialization percentage was higher in the HBOT group on day 14 post PCP compared with controls (98.5% ± 1% vs 94.2% ± 1%; P = .021). The HBOT group scored higher in confidence to appear in public (20.8 ± 1.7 vs 14.5 ± 1.3; P = .029).

Conclusion

Hyperbaric oxygen therapy following PCP is associated with faster recovery as assessed by both patients and caregivers. So far, HBOT was mainly used in the treatment of problematic or chronic wounds. Our study suggests expanding the indications in which hyperbaric oxygen treatment is applicable and recommended.

A double-blind randomized controlled trial to assess the efficacy of daylight photodynamic therapy with methyl-aminolevulinate vs. Placebo and daylight in patients with facial photodamage

BACKGROUND

Daylight PDT (dPDT) is easy to use and does not require light equipment. Such therapy has been exhaustively proved to be successful in the treatment of actinic keratosis, but its use in skin photodamage remains unclear.

OBJECTIVE

To evaluate dPDT's efficacy in skin facial photodamage.

PATIENTS AND METHODS

This was a parallel-group double-blind, randomized placebo-controlled trial. Sixty participants with symmetric facial photodamage were allocated to topical methyl aminolevulinate (MAL) and daylight vs. matching placebo and daylight. Primary outcome was global photodamage improvement/failure 1 month after the third session. Secondary outcomes included: pain evaluation; specific photodamage severity scores; sun irradiance quantification and Skindex-29 scores. Adverse events were also investigated.

RESULTS

Primary analysis included all randomized patients. All patients sun-exposed for 120min in 3 sessions. The risk of failure was lower in the MAL-dPDT group than in the placebo plus daylight group (RR: 0.18; 95% CI: 0.08-0.41). Mean solar irradiance (W/m(2)) during the first, second and third sessions was 480.82, 430.07 and 435.84, respectively. Items 5 and 14 of Skindex-29 in the MAL-dPDT group showed statistical significant differences. Two patients in the MAL-dPDT group had serious and non-serious events not directly related to the product.

CONCLUSION

dPDT with MAL was un-painful, effective and safe for the treatment of facial photodamage. Herpes simplex prophylaxis should be considered before sessions.

Pharmacotherapy of actinic keratosis: an update

INTRODUCTION

Actinic keratosis (AK) represents the initial intraepidermal manifestation of abnormal keratinocyte proliferation, with the potential of progression to squamous cell carcinoma (SCC). Few visible AKs lead to the use of lesion-directed treatments, including ablative and/or surgical procedures. Multiple and/or the suspicion of subclinical (non-visible) AKs lead to the use of field-directed therapies, including topical and ablative treatments. Predicting which AK will progress to SCC is difficult, and so all are treated. The goals of treatment are to eliminate visible AKs and to treat subclinical (non-visible) AKs, minimizing their risk of progression to invasive SCC, while pursuing good cosmesis.

AREAS COVERED

This review discusses the prevention of AKs (such as ultraviolet light avoidance, sunscreen use, protective clothing, and frequent self-examinations, in addition to chemoprevention with retinoids, eflornithine, silymarin, and others). It also covers lesion-directed treatments (e.g., cryotherapy, electrodessication and curettage, and surgery). Field-directed treatments are also mentioned (including laser resurfacing, dermabrasion, chemical peels, topical immunomodulators (imiquimod and diclofenac), topical chemotherapeutic agents (5-fluorouracil and retinoids), and photodynamic therapy). Finally, newer and investigational treatments are discussed (including ingenol mebutate).

EXPERT OPINION

There is no panacea in the treatment of AKs. The current best approach is the sequential treatment with a lesion-directed and a field-directed therapy. Several combinations seem to work well; they just need to be selected based on the evidence and adjusted to patient needs, preferences and dermatologist expertise.

The efficacy of 5% trichloroacetic acid cream in the treatment of cutaneous leishmaniasis lesions

INTRODUCTION

Cutaneous Leishmaniasis (CL) is an endemic disease in Iran. Based on the results of our previous study, this study was designed as a pilot trial to evaluate the effect of 5% trichloroacetic acid (TCA) cream in the treatment of leishmaniasis lesions.

METHODS

16 patients with positive smear for leishmaniasis were randomly selected for treatment with 5% TCA cream, twice a day for 8 weeks or up to complete healing of the lesions. Scar size was measured 6 months after complete epithelization of the lesions.

RESULTS

Mean area of the lesions was 38.81+ 81.9 mm(2) before treatment and 3.6 + 9.1 mm(2) at 6 month follow up period. Complete cure was achieved in 1 patient (6.3%) at week 2, 13 patients (86.7%) at week 7, and in all patients at week 8. There was no serious adverse reaction in none of the patients.

CONCLUSION

Decreasing the scar size and the low cost are two promising aspects in introducing 5% TCA cream as a potential alternative for intralesional glucantime in the treatment of CL. Considering the self limiting nature of the disease, this effect should be assessed further through a double blind randomized controlled trial.

[Chemical peels]

Chemical peels have become established over the past 40 years as an effective outpatient method for skin rejuvenation as well as the treatment of a variety of skin conditions. Although laser skin rejuvenation has claimed much attention in recent years, phenol peels, despite problems with scarring and hypopigmentation, remains the gold standard for skin resurfacing [11], against which other methods should be evaluated [21]. We present both a theoretical overview of chemical peels and practical step-for-step instructions.