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    WARNING!!!!
     


    Acid Peels Can Harm Your Skin, cause severe burns, and further scaring. Do not think the highest percentages will help if you are not experienced. Please Study fully and read as much as you can. Always spot treat when trying anything. 
    If you have any doubts have a dermatologist do it. They are experienced handling the acid. 
    Watch as many Youtube Videos as you can on your peel, start with a spot test somewhere out of the way, then try a diluted (use water) treatment 8-12% and move up to higher percentages IF YOU CAN HANDEL IT! Never go above 35% and even this can lead to burns! Start Low & work up!!!!!!!!! A test spot trial is your friend, you only have one face. 
    This goes for most acid peels, order the highest percentage, DILUTE (w/ Water) them down to 12-15%, and build up what you can handle.

     


    Case Study: AVOID Major Burns From Acid
     



    Please Learn a lesson from the below poster who used 80% TCA . Never use that much! Acid is serious stuff.
    1) Always dilute down to 8 to 12% with water any acid (ie. half of TCA 35% is 17.5% and add a little more water to get it down). Do a test spot to see how your skin reacts.
    2) Never do full strength till you know how you react.
    3) Acids are gradual, start low, and work up a little at a time (each treatment). 35% should be your max for full face peels, many never get there as it's to strong. For TCA Cross, you can buy stronger acid but the same applies, start low, and then gradually work up higher. TCA can be treated by doctors at 100%. We never do this!!!! If your skin can handle it 50% is high and never ever drip any excess acid (wring it out with gloves, or get all of it off with your toothpick).
    4) Drops / excess = burn scars (even the tiniest amount of TCA or other acid works). Toothpicks /wood pick up acid even if you wipe them dry.
    5) Use vaseline around the eyes, eyebrows around the nose, lips, and smile lines by the mouth. Acid will not work with vaseline. Vaseline can also be put around a scar that is being treated to protect the surrounding skin. 
    6) Always wear rubber gloves
    7) Do not use those fan brushes, you have no control and will cause burns, use gauze and wring it outwith no excess, or a toothpick that fits in your ice pick scar (test before acid) dip it into the acid and dab any excess on a paper towel. No drips.
    8) In case of emergency immediately put your dissolved baking soda water over the area to stop the Acid
    9) IF you have any darkness in your skin, you can tan you may cause hyperpigmentation and excess redness. Some ethnicity's cannot use TCA (light skin types don't have this issue unless the percentage is too high), either use very diluted (water) acid and do a test spot. Or darker skin types have done well with Glycolic and Salycilic acids.
    10) Never TCA Cross (high acid amount) in the middle of a scar that is wide. TCA cross is for very narrow ice picks, the narrower the better. You would be better with a dilute spot peel (full facial peel) than to widen already wide spots. 
    TCA Cross at high percentages of acid must have defined borders to touch all the walls of the scar.
    11) Acid widens the scar, while this may soften it be aware it may make it look worse, do a test spot first. Microneedle, then the next month do a peel, repeat, this can help even things out.  
    12) We suggest makeup artists choice for TCA and other peels. They have excellent customer service, and do not sell acids that are industrial grade (not medical) like Amazon and ebay (you don't want this on your skin). Acne.org's store above has a great glycolic peel.
    13) Always remember after care: A wet wound is a happy wound, some great ones to apply a few times a day are vaseline, aquaphor, triple antibiotic cream, or biafine (European for burns, doesn't react like some to vaseline). Use diluted (Water) white vinegar on a gauze daily to pat the area (kills bacteria and makes things peel), never rub! Normal soap unless it's gentle can make your face react after a peel.
    14) If you have major burns goto the hospital ASAP!
    15) An doubt have your med spa or doctor do the peels, acid peels are the number one way people get burns or make their scars worse, less is more, and spot treat to see what you can take.
    16) Darker skin types and Asian skin may not be able to use TCA, please do a test spot, at a very dilute amount (water), see how you react. Ethnic skin types do well with Glycolic and, Salycilic Acids. TCA may result in permanent darkening of the skin in the area where the peel was used. However, this problem can be overcome if TCA 20% is used after a Jessner’s solution for darker skin types. Hydroquinone aka skin bleach should be used 2 weeks before and 3 weeks after, retin a or tretinorin, AHAs, Kojic Acid, Alpha Arbutin, etc. to prepare your skin’s surface, and even out the skin tone itself. * Vitamin C Serum is also recommended to use with this treatment as preparation to avoid any hyperpigmentation. 
    17) Frosting for 15-20 minutes is a good indicator, as Deeper peeling will have frosts that can last up to an hour. Any frosting lasting over an hour is a serious problem and damaging the skin.If you are frosting for 3 days go seek a doctor, major 911 emergency (The deeper the burn the less you feel because your nerves are fried)!
    18) Men have as a general rule thicker skin and tolerate deeper peeling with higher percent acids. 
    19) After acetone (without fragrance nail polish remover) a Jessners or Salicylic peel can be applied to further remove the top layers so the TCA can reach the papillary dermis. The hope is just to reach the top or lower papillary(depending on what depth of peel you are going for) and not the reticular dermis where scarring Will occur if damaged. Most doctors will not do over 35% TCA these days for full face / spot peels. 
    20) Proline/ lysine and L' ascorbic (aka vitamin c serum) acid prior and post treatments, collagen supplement, and high protein diet, may help you produce extra collagen
    21) You should not have a chemical peel if you will continue to have excessive sun exposure. Active Herpes Simplex (have a doctor prescribe Zovirax for you), Warts, history of Keloidal scarring, any type of recent facial surgical procedures. You should not have a chemical peel if you've used Accutane in the last year (it will increase your chances of scarring), or if you are pregnant or lactating. If you have any auto immune diseases, have had any recent radioactive or Chemotherapy treatments - have sunburn, windburn or broken skin or have recently waxed or have recently used a depilatory such as Nair or use Vaniqua
    22) Make sure you have a supply of SPF (100% uva & uvb) to protect your skin before and after the peel. A minimum of 30 is required.
    23) Do not scrub your skin, let the shower take off the scabs,  or pick!!!
    >> The gentleman at the bottom of this page would be best to goto the derm or med spa and have V-beam for the redness or IPL, BBL, Photofacials, 1064nm laser. He should be using aloe Vera and honey or Emu oil for his burns or triple antibiotic, silicone liquid is also good for scars. Burn gels are sold at the store often called hydro gels.


    ___________________________________________________________________________________________

     

    Different Kinds of Acid Peels
     


    ** We recommend Makeup Artists Choice for their excellent customer service and support of their acid peels. TCA is the best all around peel for the acne scar suffer, it allows similar benefits of laser treatments at home without the fat loss and thermal damage. You can slowly step your way up to TCA peels through other peels, and the alternative peels have other advantages like hyper pigmentation, acne, and skin tone when you don't want the down time of TCA resurfacing. TCA is normally done in the Winter or early Spring as it requires one to hibernate during recovery and avoid the sun, it is part of many yearly beauty routines. 


     


    Glycolic Acid (Alpha Hydroxy) 
    A good all-around acid for normal-oily skin types to exfoliate the skin. More harsh than lactic acids. An alpha hydroxy, this peel penetrates the epidermis-only.


     


    Jessner
    Based in alcohol, this is a drying peel best suited for oily, acneic skin types. Containing both alpha and beta hydroxies along with resorcinol, this peel penetrates more deeply than an alpha or beta peel, but less deeply than a TCA. Not recommended for sensitive skin. Not recommended for dry skin. 


     


    Lactic Acids (Alpha Hydroxy) 
    Milder than glycolic acid, and typically better for working on hyperpigmentation problems. Our formulation contains licorice extract, an effective skin lightening additive. Appropriate for normal, dry, or oily skin. An alpha hydroxy, this peel penetrates the epidermis-only.  A good all around peel for the beginner. 


    Contraindication:  Do no use if you have milk allergies.


     


    Mandelic Acid (Alphy Hydroxy) 
    An alpha hydroxy acid, Mandelic Acid is derived from bitter almonds.  The molecular structure of mandelic acid is larger than better known alpha hydroxy acids such as glycolic acid and lactic acid.  This means it takes longer to penetrate the skin's surface and is much less irritating.  Excellent for acne, large pores, blackheads, wrinkles, lines, sun damaged skin, extremely sensitive skin and darker skin tones. 


    Contraindications:  Do not use if you have nut allergies.

     


    Phytic Acid (neither an alpha nor a beta)


    A superficial peel with exfoliating properties.  Desirable for skin types that cannot tolerate AHA's.  Derived from rice, this product is excellent for anti aging, skin smoothing, brightening, Melasma and general discolorations. Acne clients will see skin clearing.  Those with PIH (post inflammatory hyper pigmentation) will see excellent results.  


     


    Pumpkin Exfoliating Masque w/5% Glycolic Acid
    A wonderful combination of enzymatic properties, along with an alpha hydroxy acid to exfoliate the skin, refine texture and brighten skin tones.
     Salicylic Acid (Beta Hydroxy) 
    Oil soluble, thus making these acids perfect for oily/acne skin that needs deep pore cleansing and loosening of blackheads. Use the 3% or 8% strengths as a "first-step" when using alpha hydroxy acid peels to remove all oils from the skin, or use alone 3/4 times per week for oil/blackhead control. Use the 15% or 10% once a week only. A beta-hydroxy, this acid penetrates the upper layers of the epidermis only.  Contraindications:  Do not use if you are allergic to aspirin products. Trichloreacetic Acid (TCA) 
    Deeper peeling class of acids used for acne, lines, wrinkles, hyperpigmentation, scarring. Longer lasting results, more intensive. This peel penetrates the epidermis, into the upper layers of the dermis, thus producing a more effective peeling experience. Always begin with a low strength with this particular acid. 


     


    TCX 


    We formulated this peel with a proprietary blend of acids to work on a number of skin care issues by including the following acids:  Mandelic Acid, Salicylic Acid, TCA, Glycolic Acid, Lactic Acid, Citric Acid, Phytic Acid.  Total acid content is 30%.  Great for acne, softening of acne scars, anti aging benefits, fading of skin discolorations.  Consider this your all-in-one peel.


    Non Acid Enzyme Peel 
    All natural enzymes from papaya (papain) and pineapple (bromelain), safely dissolve surface skin debris and leave skin feeling soft, cleansed and refreshed. Our enzyme peel is professional strength, exactly what you would get in a very high-end salon. Use this product if you have sensitive skin that is non-tolerant of acid usage. Professional Enzyme Peel (non acid)
     


    Source: http://www.makeupartistschoice.com/At-Home-Chemical-Peels_c_53.html
     





    Source: Acne.org


    Peel Depth
    (Higher percentage can lead to more risk of side effects)



    Superficial: Salicylic Acid (Beta Hydroxy), & Glycolic Acid (Alpha Hydroxy), Trichloreacetic Acid (TCA) 0-20%
        - Slicylic Acid is my favorite, it unclogs the pores (great for acne) and gives a light peel, can be done more often than TCA peels, Used for skin upkeep, takes off the epidermis for fresh cell turnover and purging
    Medium: Trichloreacetic Acid (TCA) 20-35% or 20% to 50% TCA Cross
    - Used for scars and ageing rejuvenation, goes down to the upper to mid dermis
    Deep: Phenol Peel, 35-100% TCA
    - This is serious stuff, normally your put under and doctors apply peel in surgery can take off various layers of dermis, similar to dermabration with thinning the skin, used for ageing rejuvenation and deep scarring


    ___________________________________________________________________________________________



     

    Picking the Best Peel By Dr. Rullan
    *   I love microneedling and 30% salicylic plus mandelic (< gentle and unclog pores) acid peels and
    TCA of course they are like having lasers at home. Remember peeps dilute w/ water and see your       skins reaction (spot test) don't go crazy on your skin without knowing.
     

    Peels successfully treat a variety of cases of melasma, acne scars and sun-damaged skin, dermatologist Dr. Peter Rullan told colleagues, but he says it's crucial to select the right peel for the right patient. And in some cases, he says, lasers can offer better results, either in conjunction with peels or alone.


    Rullan, M.D., has a private practice in Chula Vista, Calif., and is a volunteer clinical professor of dermatology at the University of California at San Diego. He described his recommendations at the 2016 CalDerm Symposium, a continuing education seminar offered by the California Society of Dermatology & Dermatologic Surgery.
    Some of the new fractionated and minimally ablative laser devices can achieve comparable results to the peel, but it’s more expensive to use the devices compared to the low-cost alternative of peeling. Consider a pretreatment skin preparation with bleaching agents and topical tretinoin, and use antivirals, especially if treating near the lips.


    Active Acne


    For active acne Dr. Rullan recommends 30% salicylic, Jessner’s and VI peels.


    "I routinely do 30% salicylic on patients on low-to-medium doses of isotretinoin," he says. "For isotretinoin, I like 20 mg/day initially, and based on tolerance and need, I slowly titrate upward."


    Dr. Rullan adds monthly Vbeam Perfecta pulsed dye laser for red acne scars, even while the patient is on low-dose isotretinoin.


    "I use 10-msec and 8 joules, 7 mm spot size, followed immediately by a 30% salicylic peel or wash if the patient has active acne lesions," he says. "The red marks from recent acne lesions respond very well to the laser, and acne lesions such as comedones and papules dry out or exfoliate with the salicylic peel."


    Dr. Rullan offers several cautions: "Buffered glycolic works well for comedonal acne but cannot be done while using topical or systemic retinoids because it can cause blisters," he says. "And although they're effective, Jessner’s peels can cause post-inflammatory hyperpigmentation (PIH) in skin types 4-6."


    Boxcar Acne Scars


    For small boxcar or ice pick acne scars Dr. Rullan likes to mix a TCA peel with laser.


    "I do CROSS – Chemical Reconstruction of Skin Scars – with 30% TCA for thin skin, 60% for medium, and 100% for thick-skinned patients. It must be applied with a toothpick to avoid spillage onto the shoulders of the scars," he says. "It can be done in all skin types with minimal risk of PIH, but if done incorrectly it can widen the scars temporarily."


    "If I see rolling scars, then I do Nokor 18-gauge needle subcision before I do the CROSS with TCA," he adds.


    If appropriate, Dr. Rullan follows CROSS immediately with either fractional Erbium or CO2laser based on available downtime or severity of scars. He cautions that "Combining CROSS with ablative lasers is better than just lasers alone, since lasers cannot ablate the lateral walls of box or ice pick scars. Many of the patients that come to me have been very disappointed with the results and the cost of their CO2 laser peels for scars."


    Other treatment approaches, he says, can include dermabrasion, 2-day phenol chemabrasion for spot or full-face scarring, excision, punch elevation and punch grafting.


    Melasma


    "Melasma cannot be cured with any peel," Dr. Rullan states, but a 30% salicylic peel can be appropriate. He describes it as the "safest peel," one that provides a "very superficial" level of penetration.


    Dr. Rullan also recommends 70% glycolic acid peels – another kind of peel considered very superficial – and 20% salicylic plus mandelic acid peels. He points to a recent study of 90 patients in India with melasma [Dermatol Surg. 2016 Mar;42(3):384-91]. Patients were randomly assigned to peels with glycolic acid 35%, 20% salicylic plus mandelic acid and phytic combination. Patient skin was most tolerant of salicylic plus mandelic acid, the researchers reported.


    The also found that 35% glycolic acid and salicylic plus mandelic acid peels were more efficacious than the phytic combination. After 12 weeks, the melasma area and severity index scores in the patients decreased by 62%, 61% and 45%, respectively.


    In addition, a variety of other treatments can be appropriate for melasma, Dr. Rullan says, including, but not limited to, protection from heat and sun, hydroquinone 2%-6%, retinoids, glutathione 500 mg BID, and anti-inflammatory medications.


    Photoaging


    Dr. Rullan prefers pre-packaged peel kits for treatment of photo aging.


    "Commercial kits provide a well-defined procedure and post-op care that helps the physician and the staff gain confidence in chemical peels," he says.


    For mild photoaging, Dr. Rullan prefers a “superficial” level of penetration. He points to ZO 3-step stimulation peel (10% TCA, 17% salicylic acid, 5% lactic acid and 6% retinol cream), VI Peel Precision (30% phenol, 7% TCA plus salicylic and tretinoin acid, but no croton oil) and Jessner's 15-20% TCA.


    For moderate photoaging, he prefers "medium depth" peels via Jessner's 25% TCA and TCA peels assisted by blue dye.


    "These peels actually improve fine wrinkles and lentigos but do not provide the amount of skin tightness and lifting that a croton oil/phenol peel can do, especially for deep wrinkles in the mouth region."


    "They help the patients get a fresher, more even complexion that appears more glowing and with only a five-day turnaround,” Dr. Rullan says. “For example, you do the peel on Wednesday, they look pink and dry for two days, and then exfoliate for two or three days max during the weekend."


    Things to Watch Out For


    Dr. Rullan cautions about post-inflammatory hyperpigmentation from ablative lasers, intense pulse light and strong chemical peels.


    "If the patient has oily skin and acne scars and is skin type 4 or darker, you will get PIH when doing medium and deep chemical or CO2 laser peels," he says. "No pre-op regimen with hydroquinone or tretinoin will prevent it. I find it more effective to start them on very low-dose isotretinoin – when qualified – if you start seeing PIH after the peel has healed. I use doses like 10-20 mg daily for 30 days."


    Getting an Education in Peels


    "Learning peels is difficult because the residency and fellowship programs do not teach them in workshops," Dr. Rullan says. "I teach them in residency programs, and for some third-year residents this is the first time they have ever been taught peels."


    To gain experience and feel more comfortable Dr. Rullan suggests they join the International Peeling Society and attend workshops or courses.


    "Commercial kits provide a well-defined procedure and post-op care that helps the physician and the staff gain confidence in chemical peels," he says. “They should feel safe doing the 30% salicylic on acne and melasma patients. And I suggest applying 35% TCA on individual AKs – actinic keratosis -- to learn the wounding and healing process."

     
    ___________________________________________
    Guide to LA/GA Peels
     

    Lactic Acids (Alpha Hydroxy) 
    Milder than glycolic acid, and typically better for working on hyperpigmentation problems. Our formulation contains licorice extract, an effective skin lightening additive. Appropriate for normal, dry, or oily skin. An alpha hydroxy, this peel penetrates the epidermis-only.  A good all around peel for the beginner. 


    Contraindication:  Do no use if you have milk allergies


    I was never much into Lactic, but of course I am allergic to milk ;-P Buy as high as possible and water it down. Saves you money. They are just making sure you start low and go higher in case there is any issues. I always advise buying the max percentage to save $$, otherwise they will be selling you watered down peels at various strengths. I think they sell to Europe, you can always email them and ask, they have great customer service. Looks like 40% is a beginner Lactic. 
    Things You'll Need
    Mild Cleanser
    Acetone without fragrance aka Nail Polish Remover 
    LA/GA Peel Kit
    Neutralizer(baking soda)
    Moisturizer/Spf
    Gauze or Cotton Balls
    These are the stuff i used:
    A mild Cleanser- Neutregena Deep cleanse
    Acetone without fragrance aka Nail Polish Remover 
    LA/GA Peel Kit: MUAC GA kit
    Neutrilizer: ph prep solution from MUAC or Baking Soda and water
    Moisturizer: Neosporin (Triple antibiotic cream)
    Now that we have gathered all the materials we need, its time to start our very 1st peel.....
    We will be following these simple procedures during this tutorial
    Cleanse
    Prep
    Apply LA/GA Peel
    Rinse
    Neutralize
    Moisturize/Protect/Soothe
    1. Cleanse:
    Always cleanse prior to a peel, you want a clean canvas, oil and dirt free...Use a mild cleanser one thats not too harsh and wont make your skin sensitive....Avoid cleanser that are suited for acne skin because they cointain salyclinic acid.......
    DO NOT USE KOJIE SAN...big no no
    To cleanse.......
    Choose cleanser of choice
    Apply Cleanser to face:
    Rinse Face
    You have just successfully cleansed your face, it should be clean, smooth and oil-free, go ahead and dry off your face...Proceed to next step
    2. Prep:
    Prepping your face is vital prior to a peel, a well preped skin wil allow your peel to penetrate deeper, which may be more effective
    You can either Prep your skin by using Acetone without fragrance aka Nail Polish Remover, rubbing alcohol or using the pH Prep solution that came with your kit.
    Use Acetone AKA Nail Polish Remover without fragrance. 
    Apply gauze or with cotton ball 
    there might be a slight tingling sensation, after you have finished applying your acetone, allow face to completely dry for 5min.....You have now successfully preped your face.....Proceed to Next step
    3. Applying your peel:
    This where the fun begins, now that you have cleansed and preped your face you are now ready to apply your peel, Beginners i strongly urge you to begin at a low percentage....40% LA/GA are very mild for 1st timers...i also recommend getting peels from make up artist choice(MUAC)
    the best method to apply your peel is by gauze or cotton ball
    To Begin.... Wear Gloves! You can use vaseline around eyes, sides of nose the crease when you smile aka nasolabial folds, lips especially the sides, eyebrows
    Pour a small amount of peel solution in a cup
    Dip gauze or cotton ball into the LA/GA solution....wring out with hand any excess 
    Apply to face...starting with forehead and working around the perimeter of your face
    Continue to work around the edge of your face and applying
    Make your way inward towards your nose
    By this time you should be feeling the acid on your face, to some it might be mild tingling but to others it might be a little harsh, IF YOUR FEEL DISCOMFORT>>>STOP< RINSE AND CALL IT A DAY
    Allow the peel to stay on for no longer than 1-5min, 8min being the maxium...it depends on your skin's sensitivity on how the peel will react on your skin, my 1st peel had me skipping around the bathroom floor, i washed off in a matter of 3min
    4.Rinse:
    Once you have reached the 5min mark, it is now time to rinse of the solution..
    Simply rinse with water (you can use soap)
    5. Neutralize:
    After you have rinsed your face with water, you want to rebalance the ph of your face...[/B]
    You can use the ph Prep solution that came with your kit to neutralize
    Also you can Neutralize with baking soda and water
    Baking Soda receipe:
    2 cups of water 
    2 teaspoons of baking soda
    Stir together....
    Rinse face with the baking soda solution to netralize, then rinse with cold water to finish
    You have know successfully applied your LA/GA peel and neutralized it...at this point you can examine your face...it more than likely will appear red and irritated but this is normal....your face is just reacting to the acid
    6. Moisturize/Protect/Soothe
    After you have rinsed and neutralized your face, go ahead and dry off your face, the next step is probably gonna be the most important step post peel
    You need to soothe your skin and keep it well moisturized and also protected, it is gonna be sensitve for the next 48hrs
    Choose Moisturizer, you can use anything from Aloe ver gel to Zinc oxide creams or Eucerin...i used neosporin triple antibiotic cream
    Once you have applied your moisturizer, I am proud to say that you have successfully completed your 1st LA/GA peel 
    Important:
    For the next 48hrs your skin will become sensitive and therefore you must protect it from the sun, so wearing a sunblock is important 30spf+ also you might or might not notice any peeling, LA peels in general dont peel, they tend to have mild flakings
    Also dont scratch, pick, or rub your face, just allow your face to heal on its own and remember to MOISTURIZE!!!!
    http://www.skincaretalk.com/showthread.php/28893-The-Beginners-Guide-to-LA-GA-Peels-The-Illustrated-Edition
    ____________________________________________________________________________________________________________________
     
    Glycolic and lactic acids are both AHAs, 
    i.e. Alpha Hydroxy Acids





    tikvica


    Veteran Member


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    618 posts


    Gender: Female




     


    Posted June 20, 2006 · Report post





    INTRODUCTION:


    (to make things a bit clearer)


    Glycolic and lactic acids are both AHAs, i.e. Alpha Hydroxy Acids. Lactic acid is slightly milder, so it is recommended to people whose skin is more sensitive, to first time users, people constantly exposed to sun (although this does not mean you should not wear a sunscreen at all times), and people with darker skin tone.


    AHA's are skin exfoliants, which work on the skin, unlike BHAs which work inside the pore. AHAs are beneficial for skin in many ways, among them: reducing light scars and red marks and signs of photoageing, and getting back that beautiful even skin color and natural glow.


    SPF is a must everyday if you want to use the peel!


    The procedure and risks are the same for both acids.


     


    BEFORE DOING THE PEELS:


    Make sure your skin is more or less clear - a bunch of inflamed pimples will probably only get worse, since your skin, together with them, will be overly irritated after the peel. A few pimples in not so serious condition is ok.


    Do not use if you were on accutane in the last 6 months, or perscription topical retinoids in the last month. If you use non-prescription topical retinoids, i suggest you stop them one week before starting the peels, and wait one week after finishing the peels to start them again.


    The reason for these precautions is that accutane and topical retinoids lead to thinning of the skin, thus to extreme skin sensitivity. not following the instruction above may lead to skin injuries and scars.



    ** Pre Peal:  Use Acetone AKA Nail Polish Remover (without fragrance, 100%, to avoid irritation)      this removes grease / sweat/ sebrum so the peel work.
     


    WHEN BUYING ACID:


    i suggest 30% to start with. please do not try anything stronger at home, by yourself. some salons and derms go up to 50%, but after all they are proffessionals and know how to deal with it. 30% will bring you great results, especially b/c most of you have young and gentle skin that reacts much better and faster to lower percentages. high percentages of GA are usually meant for older/ageing skin.


    Be sure to check the percentage, the PH (it has to be lower than 4 in order to be effective) and i suggest buying brand names or from reliable sellers.


    Ph under 6.5 means that the substance is acidic, 6.5-7.5 being neutral, above 7.5 being alkaline. But, in order for the peel to be successful, ph above 4 won't do much, it will be a mild exfoliant. Most of the 30% ga peel are ph 2.2-2.8, which is probably what you should look for when buying an acid.


     


    IMPORTANT:


    I am not a doctor or a trained aesthetician. I am writing this with knowledge i have from my own experience with glycolic acid, with lots of instructions from my aesthetician and with what i read in various articles.


     


    INSTRUCTIONS:


     


    1.


    whatever you do, please follow these steps. Glycolic acid is an ACID and if you're not careful, even low percentage can cause burns and/or hyperpigmentation and/or various other side effects


    if used properly, GA can bring lots of benefits to your skin


     


    2.


    You will have much better results if you first prepare your skin with glycolic acid 5% (more sensitive skin) or 10% (not so sensitive skin) toner (alternatively lotions with same percentage). Apply the toner 2-3 times a day, start 7 days before the first peel. Use the lotion all the time, between and after the peels. apply generously. this is an important step, since lots of people, myself included, had much better results with involving a ga or la product into their daily regimen, prior to and during the peel.


     


    3.


    Your face should be completely clean and dry beofre the peel. it is best to wait at least 15min after washing your face, to make sure the skin is completely dry, since water can neutralize the acid.


     


    4.


    THE PEEL:


    gently apply over your whole face, even the areas that are not affected by scars, leave it for up to 6 minutes (depending on the sensitivity of the skin). when you feel burning (unpleasant tingling) and notice redness, take it off. it is very important that you follow the process all the time in the mirror and have everything prepared for rinsing the acid, as a second longer can cause burns. i suggest that you do part by part of your face, in that way, you'll be more able to control what's going on. for example, first do the forehead, that after it reacts, remove and than do one cheek, then the other one, then nose and chin. apply extremely gently. no rubbing in.


    from my experience there are times when it becomes unbearable after only 2-3 times, but there are times, when i almost don't feel a thing. it probably depends on various reasons and skin condition of that day


    you can apply the acid with your fingers, or you can alternatively use a brush or a cotton swab.


    FIRST TIME USERS: Please start with 2-3min time, then you can gradually increase by a minute.


     


    5.


    TAKING THE ACID OFF


    it is very important to remove it AS SOON as your skin starts to get red and/or you experience unbearable tingling and/or the temperature of your skin raises.


    you can either remove the acid with a neutralizer (sodium bicarbonate eg.) or you can just rinse it with lots of water. water has a much higher ph than a peel does, so it will neutralize it, no worries.i suggest taking it off with only lots of water (cold or lukewarm, never hot), but i suggest always having some baking soda on your side just in case, b/c with it you can react faster.


     


    6.


    IMPORTANT NOTICE


    be careful not to let the acid into your eyes. it's acid. you must not put the acid on the eye area and be very careful not to touch any of that thin sensitive skin around the eyes with it.


    if you're a first time user, do the peel every 7 days for the first series of peels, then gradually you can shorten the time between the peels, but never do them more often than every 4 days. you should do six peels in a series, make a break for at least one month and then continue the same.


    it's best do the peels in the evening


    never expose yourself to direct sunlight at least 1 hour after applying the toner (if you're using one), don't do the treatments in the summer, or if you know you'll travel somewhere where you'll be exposed to direct sunlight most of the time, always use SPF cream when you're going out and never use sunbeds or other artificial tanning stuff during and at least three weeks after the treatment.


    also avoid other sensitive areas like the line under your lower lip and around the nose.


     


    7.


    after rinsing, tap dry, very gently and apply a moisturizer (if you're using moisturizers with active ingredients, like AHA eg. don't use that one after the peel, but find sth that is very neutral and nourishing - like jojoba oil, emu oil, aloe vera or panthenol, eg.)


     


    8. COMMON SIDE EFFECTS:


    excessive dryness


    excessive oiliness


    breakouts


    increased skin sensitivity


    flaking


     


    9. DO NOT:


    exfoliate your skin during the treatment, because glycolic acid is an exfoliator itself, and, due to increased skin sensitivity, you can cause dmage to the skin by excessive exfoliation.


    Also, do not use products containing BP, SA, retinoids, or any other active ingredient 24hrs prior to the peel and 24hrs after the peel.


     


    If your concern is mainly redmarks, i suggest you also try the following:


    1. sleep - rest is important for the cells to function properly and cell healing comes in sleep.


    2. eat healthy, drink lots of water and never forget your vitamin c - skin healing also comes from the inside


    3. never use products on your face that can be drying, irritating or harsh in any other way to your skin - dry and/or orritated skin cannot heal itself as easily as healthy skin can. you can find a list of common skin irritants here:http://www.acne.org/messageboard/index.php?showtopic=102347


    4. don't ever ever touch your face! touching a pimple irritates your skin even more and can result in even bigger and stronger redmarks


    5. always wear a sunscreen. you can find a list of recommended sunscreens here:


    http://www.acne.org/messageboard/index.php?showtopic=102347


     


    some AHA products you might want to consider:


    Paula's Choice 8% Alpha Hydroxy Acid Gel


    Neutrogena Healthy Skin Face Lotion


    anything from Alpha Hydrox


    ProActiv Revitalizing Toner


     


    There are also quite a few studies done on the effect of glycolic, lactic and salicylic acid peels on asian and black skin, for treating various skin conditions, from hyperpigmentation to melasma. if you are of color, i suggest reading those studies before doing the peel (there are quite a few of them, so i won't link them here, also since lots of them are in pdf. i suggest you google "acid peel asian" or "acid peel black")
    _________________________________________________________________________________________________________________
    Salicylic and Mandelic, Good Basic Peels
     



    On 3/9/2017 at 1:08 PM, QuanHenry said:




    Salicylic peels are great. Stridex is so cheap it's basically free.





    This was my favorite before I jumped on the TCA bandwagon. It's a good stepping stone before you go TCA. Great for acne and hyperpigmentation, cleans out the pores, Salicylic is made of similar components of Asprin hence it's effect on redness. You don't have to neutralize Salicylic or Mandelic peels with baking Soda or wash. Some people pre peel with this before their TCA peels to help give a more even peel and break up the oil layer of the epidermis. I also like Mandelic which is quite similar to this and has anti acne properties as well.
    From Amazon : " Salicylic Acid is a great kertolytic which means it helps loosen the bonds between skin cells to promote exfoliating. It is the only hydroxy acid which is oil soluble which allows it to penetrate into clogged pores. It can be used more frequently than the other peels without must risk for irritation. The 30% solution For use only after you have acclimated your skin to the 20% peel. LIGHT SCARS AGING SKIN WARTS ACNE VULGARIS LESIONS UNDER THE SKIN (TRAPPED OIL) LIP CREASES LIGHT SCARS HYPERPIGMENTATION WHITE SPOTS BLACK SPOTS LIVER SPOTS SUN DAMAGED SKIN CONTROLS ALL TYPES OF ACNE DULL AND WORN SKIN."
    https://www.amazon.com/SALICYLIC-Acid-Skin-Chemical-Peel/dp/B004YOXJTM/ref=sr_1_2_a_it?ie=UTF8&qid=1489131031&sr=8-2&keywords=Salicylic+peel+60
    http://www.makeupartistschoice.com/25-Salicylic-Acid-Peel_p_254.html
     


    alicylic acid is oil soluble, thus making this acid perfect for oily/acne skin that needs deep pore cleansing and loosening of blackheads. 


    Benefits:


     


    Cleans pores


    Removes oily residue from skin


    Helps to clear acne


    Helps to loosen blackheads



     


    Other important cautions:


     


    --Because salicylic acid is in the aspirin-family, it's important for clients who are allergic to aspirin products to avoid using this product.


     


    --If you are pregnant or lactating, consult with your OB/GYN before using chemically based products.


     


    --Always patch-test the skin before using acid-based products.  If you experience irritation, rinse immediately with cool water.


    --Wait 24-48 hours to see if irritation develops. 


     


    --Do not apply to red, irritated skin.


     


    --Do not use manual exfoliants, nor scrubbing brushes within 24 hours of use.


    --Do not use drying acne products, other acids, nor retinoids for 48 hours before using this, and do not resume for 48 hours after the peel.


    --Chemical peels cause the skin to be photo-sensitive, so be sure to use sun protection after your peel.


    Here is the Mandelic Peel from Makeup Artists Choice 
    http://www.makeupartistschoice.com/40-Mandelic-Acid-Peel-from-Makeup-Artists-Choice_p_276.html
    https://www.amazon.com/Cellbone-Technology-cbman201-Mandelic-Acid/dp/B01FGC58H6/ref=sr_1_10_s_it?s=beauty&ie=UTF8&qid=1489134064&sr=1-10&keywords=mandelic+acid+peel
    "Mandelic acid is an alpha hydoxy acid derived from bitter almonds.The molecular structure of mandelic acid is larger than better known alpha hydroxy acids such as glycolic acid and lactic acid. This means it takes longer to penetrate the skin's surface and is much less irritating. Do not use if you have nut allergies. It also works on darker skin types unlike some acids."
     

    What is Mandelic Acid?
    Mandelic Acid is an alpha hydroxy acid.  Derived from bitter almonds, it has a number of benefits for the skin.
    The molecular structure of mandelic acid is larger than better known alpha hydroxy acids such as glycolic acid and lactic acid.  This means it takes longer to penetrate the skin's surface and is much less irritating.  Benefits
    --Rapidly exfoliates dead skin cells and surface debris from the skin.
    --Mandelic acid has antimicrobial/antibacterial properties, making it an excellent choice for all types of acne, including cystic acne.


    --Loosens blackheads for easy extraction.


    --Cleans and refines pores.
    --Refines the tone and texture of the skin, brightens.


    --Mandelic acid is excellent for clients with darker skin tones.  It does not cause the unwanted, lighter skin tone changes that you might experience with other AHA's.


    --Mandelic acid inhibits the growth of melanin, the cause of brown patches, freckles, uneven skin tone and other sun-related skin care issues.


    --Mandelic acid, with continued use, can help repair sun damaged skin.


    --Mandelic acid reduces lines and wrinkles without the irritation of other AHA's.
    --Mandelic is typically an excellent exfoliator for clients suffering from Rosacea.


     


    What can I expect when using this peel?Upon application, within the first minute-or-so, you will feel very little topical sensation... it will be a warm tingling sensation. This acid penetrates more slowly than others, due to its larger molecular size, but don't be fooled.  It *is* processing your skin, so please follow directions as written and use a non-acid moisture post peel.  


    Post peel you'll see some light flaking, perhaps more apparent around the mouth and nasal areas.  

     


    General Cautions:


     



    Never use manual exfoliators nor scrubbing brushes within 24 hours of using a peel.


    Stop Retin A, benzoyl peroxides, acne products and any other drying agents 24 hours before and after using an alpha hydroxy or beta hydroxy peel.


    If you are allergic to aspirin products, never use a salicylic acid nor beta hydroxy peel.


    Never apply a peel without doing a patch-test first and waiting 48 hours for results.


    Never apply a chemical peel to inflamed skin.


    Always read product directions in their entirety and don't take shortcuts.


    Use our BellEvolve Advanced Repair Cream for skin that has been chemically over processed.  It contains advanced healing agents that will quickly get your skin back to normal.


    When in doubt about a caution, please write or call us for more information.






    ______________________________________________________________





    TCA, Microneedling, Subcision w/ Filler give the best results for Acne Scars!
    ** Look at Those Below Pics...
     






     






    Combination Therapy in the Management of Atrophic Acne Scars



    Shilpa Garg and Sukriti Baveja





    J Cutan Aesthet Surg. 2014 Jan-Mar; 7(1): 18–23.


    doi:  10.4103/0974-2077.129964




    Go to:


    Abstract




    Background:


    Atrophic acne scars are difficult to treat. The demand for less invasive but highly effective treatment for scars is growing.




    Objective:


    To assess the efficacy of combination therapy using subcision, microneedling and 15% trichloroacetic acid (TCA) peel in the management of atrophic scars.




    Materials and Methods:


    Fifty patients with atrophic acne scars were graded using Goodman and Baron Qualitative grading. After subcision, dermaroller and 15% TCA peel were performed alternatively at 2-weeks interval for a total of 6 sessions of each. Grading of acne scar photographs was done pretreatment and 1 month after last procedure. Patients own evaluation of improvement was assessed.




    Results:


    Out of 16 patients with Grade 4 scars, 10 (62.5%) patients improved to Grade 2 and 6 (37.5%) patients improved to Grade 3 scars. Out of 22 patients with Grade 3 scars, 5 (22.7%) patients were left with no scars, 2 (9.1%) patients improved to Grade 1and 15 (68.2%) patients improved to Grade 2. All 11 (100%) patients with Grade 2 scars were left with no scars. There was high level of patient satisfaction.




    Conclusion:


    This combination has shown good results in treating not only Grade 2 but also severe Grade 4 and 3 scars.




    KEYWORDS: Ablative laser for scars, dermaroller for scars, subcision


    INTRODUCTION


    Acne is prevalent in over 90% adolescents and it persists into adulthood in approximately 12%-14% of cases with psychological and social implications.[1,2,3] In some patients with acne, the inflammatory response results in permanent, disfiguring scars from either increased tissue formation or due to loss or damage of tissue. Hypertrophic scars and keloids are examples of scars that result from increased tissue formation. Scars with loss or damage of tissue can be classified into icepick, rolling and boxcar scars.[4] There is no standard treatment option for the treatment of acne scars. Medical management of atrophic scars can be done by using topical retinoids. Surgical management can be done using punch excision, elliptical excision, punch elevation, skin grafting and subcision depending on the type of scar. Procedural management includes microdermabrasion, chemical peels, percutaneous collagen induction by microneedling and dermabrasion. Tissue augmentation can be done using xenografts, autografts and homografts. Various ablative and non-ablative lasers and light energies are also available for treatment of atrophic acne scars.[5] Out of these multiple treatment options, treatment has to be tailored to patient's needs, tolerance, and goals along with the physician's assessment, skills and expectation. Patient should be counselled that the ultimate goal of any intervention is to improve the scars and no currently available treatment will attain total cure or perfection.


    In 1995, Orentreich and Orentreich described subcision as a method of subcuticular undermining of scars using a tri-beveled hypodermic needle. This results in lifting the scar by releasing the papillary dermis from the binding connections of the deeper tissues and by the formation of connective tissue that results from the course of normal wound healing.[6] It is mainly used for the treatment of rolling type of atrophic scars.[4]


    The mechanism hypothesised for action of percutaneous collagen induction using dermaroller is that it creates thousands of microclefts through the epidermis into the papillary dermis. These wounds create a confluent zone of superficial injury which initiates the normal process of wound healing[7] with release of several growth factors. This stimulates the migration and proliferation of fibroblasts resulting in collagen deposition[8] which continues for months after the injury.[9] Another hypotheses states that on penetration of skin with the microneedles, the cells react with a demarcation current which in addition to the needles own electrical potential results in release of various growth factors. This cuts short the healing process and stimulates the healing phase.[10] Dermaroller also opens pores in upper layers of epidermis and allows creams to be absorbed more effectively by the skin.


    Fifteen percent tricholoroacetic acid (TCA) peel is superficial peeling agent. It causes exfoliation, improves the skin texture and induces collagen synthesis.[11]


    The aim of our study was assessment of combination therapy using subcision, dermaroller and 15% TCA peel for the management of atrophic acne scars. The rationale for combining these three minimally invasive procedures was their additive action on acne scars. Subcision releases the scars from the underlying adhesions which should be the first step for any treatment for acne scars. Microneedling with dermaroller causes collagen induction along with enhancing absorption of tretinoin cream. Fifteen percent TCA peel causes improvement in skin texture as well as collagen induction. Hence by combining these three minimally invasive modalities one can release the scars, enhance collagen induction, increased penetration of topical agents and resurface the skin.

     

    MATERIALS AND METHODS


    Fifty patients with atrophic acne scars were enrolled in this study. Exclusion criteria were patients with active acne, active herpes labialis, patients on systemic retinoids, evidence or history of keloid scars, pregnancy or lactation, history of any facial surgery or procedure for scars and patients with unrealistic expectations. All the patients were counselled for surgical intervention and written informed consent was taken. The atrophic acne scars were graded by a single non-treating physician using Goodman and Baron Qualitative scar grading system [Table 1].[12]





    Table 1


    Goodman and Baron Qualitative scar grading system




    Patient's skin was primed using topical tretinoin cream 0.05% at night along with sunscreen with a minimum SPF of 30 during the day for 2 weeks prior to starting the treatment. At the start of treatment, subcision was performed only once using a 24G needle. One day after the subcision, patient was called for the first sitting of microneedling with dermaroller containing 192 needles of needle size 1.5 mm. Eutectic mixture of lignocaine 2% and prilocaine 2% cream was applied under occlusion for 1 hour to the affected areas which was removed using gauze. Thereafter topical tretinoin cream 0.05% was applied to the affected area. Treatment was performed by rolling the dermaroller in vertical, horizontal and diagonal directions in the affected area until appearance of uniform fine pinpoint bleeding. Then the area was wiped with saline soaked gauze and tretinoin cream 0.05% was applied and washed off after 30 minutes. Two weeks after dermaroller, patient was called for 15% TCA peel. Whole face was cleansed using spirit and degreased using acetone. Fifteen percent TCA peel was applied with cotton tipped applicator on full face. Appearance of speckled white frosting was the end point of treatment with peel. After using dermaroller and 15% TCA peel, patient was instructed to apply sunscreen in the morning and mometasone furoate cream 0.1% twice daily for 5 days after which sunscreen was continued in the morning with tretinoin cream 0.05% applied at night time. Patient was asked to discontinue topical tretinoin cream application 2 days prior to TCA peel. Thereafter, dermaroller and 15% TCA peel were repeated alternately after every 2 weeks for six sessions of each and this was taken as the end point of our study. In some patients who developed inflammatory lesions of acne during treatment, capsule doxycycline or topical clindamycin cream 1% was given as and when required. Any adverse effects and interference in daily activities post-treatment were noted. Patients were evaluated for results 1 month after the last procedure was performed. Post-treatment scars were graded again by the same physician using Goodman and Baron Scale. Patient graded their response to treatment as poor, good, very good or excellent with 0-24%, 25-49%, 50-74% and 75-100% improvement, respectively, in their acne scars. The patients were followed up for 1 year at two monthly intervals to observe the sustenance of improvement in scars. Digital colour facial photographs were taken before treatment, during each visit of treatment, at 1 month after the last procedure and at 2 monthly intervals for 1 year after the last procedure. Patients were instructed to continue application of topical tretinoin cream 0.05% for 1 year after the last procedure.



    Statistical analysis


    Descriptive statistics such as mean and standard deviation are calculated. Data is presented in frequencies and their respective percentages. Data was entered and analysed using SPSS version 18.


     

    RESULTS


    Out of 50 patients, 49 patients completed the treatment. Out of 49 patients 2 patients were treated with capsule doxycycline during the treatment protocol due to active acne eruptions. Out of 49 patients there were 30 females and 19 males with age group between 18-39 years with mean age of 25.6 ± 5.2 yrs. 9 patients (18.4%) had Type III Fitzpatrick skin type, 32 (65.3%) type IV and 8 (16.3%) patients had type V Fitzpatrick skin type. Pre treatment melasma was present in 3 (6%) patients.


    Out of 49 patients who completed the treatment, 16 patients had Grade 4, 22 patients had Grade 3 and 11 patients had Grade 2 scars before treatment. The physician's assessment of response to treatment based on Goodman and Baron Qualitative scar grading system is summarised in Table 2. In patients with Grade 4 scars, 10 patients (62.5%) showed improvement by 2 grades i.e., their scars improved from Grade 4 to Grade 2 of Goodman Baron Scale [Figure [Figure1a1a and andb].b]. Six patients (37.5%) with Grade 4 scars showed improvement by 1 grade [Figure [Figure2a2a and andb]b] with scars being obvious at social distances of 50 cm or greater. In 22 patients with Grade 3 scars, 5 patients (22.7%) showed improvement by 3 grades i.e., they were left with no scars at all [Figure [Figure3a3a and andb],b], Two patients (9.1%) improved by 2 grades and as per Grade 1 they were left with only hyper-pigmented flat marks [Figure [Figure4a4a and andb]b] and 15 patients (68.2%) showed improvement by 1 grade by moving to Grade 2 [Figure [Figure5a5a and andb]b] as per Grade 2 their scars were not obvious at social distances of 50cm or greater. All 11 patients (100%) who had Grade 2 scars before treatment showed improvement by 2 grades in their scars and were left with no scars [Figures [Figures6a6a–b and and7a7a–b]. Hence all 49 patients (100%) had improvement in their scars by some grade with no failure rate. In patients with Grade 4 scars [Table 3], 12 patients (75%) graded their response to treatment as very good with 50-74% improvement in their acne scars after treatment and 4 patients (25%) had good improvement in their scars with 25-29% improvement. In patients with Grade 3 scars, 8 patients (36.4%) graded their response to treatment as excellent with 75-100% improvement in their scars and 14 patients (63.6%) reported the response as very good with improvement between 50 and 74%. All 11 patients (100%) with Grade 2 scars graded their response after treatment as excellent with improvement between 75 and 100%. Poor response with 0-24% improvement in scars was reported by none of the patients. Improvement in scars was first noted in majority of the patients after completing two sitting of dermaroller and peel. At the end of 1-year of follow-up, it was observed that all the 49 patients sustained the level of improvement in their grade of scars which was attained at the end of the last procedure [Figure [Figure8a8a–c]. Although improvement in the scars as noticed by the patient and the physician continued in the follow up period of 1 year, there was no further shift in the grade of scars.





    Table 2


    Physician's assessment of response to treatment based on Goodman and Baron Qualitative scar grading system







    Figure 1


    (a) Grade 4 acne scars; (b) Improvement in acne scars from Grade 4 to Grade 2 after treatment







    Figure 2


    (a) Grade 4 acne scars; (b): Improvement in acne scars from Grade 4 to Grade 3 after treatment







    Figure 3


    (a) Grade 3 acne scars; (b) Post-treatment patient had no scars







    Figure 4


    (a) Grade 3 acne scars; (b) Improvement in acne scars from Grade 3 to Grade 1 after treatment







    Figure 5


    (a) Grade 3 acne scars; (b) Improvement in acne scars from Grade 3 to Grade 2 after treatment







    Figure 6


    (a) Grade 2 acne scars; (b) Post-treatment patient had no scars







    Figure 7


    (a) Grade 2 acne scars; (b) Post-treatment patient had no scars







    Table 3


    Patient's assessment of response to treatment







    Figure 8


    (a) Grade 4 acne scars; (b) Improvement in acne scars from Grade 4 to Grade 2 after treatment; (c): Sustenance of improvement in acne scars from Grade 4 to Grade 2 at 1 year of follow-up




    There was improvement in rolling, boxcar and linear tunnel type of scars with little or no improvement in ice pick scars. All patients tolerated the procedure well. Side effects were mild and transient. Post-dermaroller transient erythema and oedema lasted for 1-4 days with a mean of 2.4 ± 0.7 days. Post-peel exfoliation of skin was present from 2 to 7 days with a mean of 4.4 ± 1 day. Only three patients (6%) developed post-inflammatory hyper-pigmentation (PIH) which was treated with sunscreen in the morning and triple combination of tretinoin, hydroquinone and mometasone at night time. The PIH subsided after 5 months of topical treatment. One patient (2%) developed mildly tender cervical lymphadenopathy each time after dermaroller which lasted for around 3 weeks and subsided on its own. There was no interference in daily activity with no loss of days at work.

     

    DISCUSSION


    This study has shown good results in patients with severe Grade 4 and 3 acne scars with 10 (62.5%) patients with Grade 4 scars moving to Grade 2 and 5 (22.7%) patients with Grade 3 scars improving to have no scars at the end of treatment. In Grade 2 scars all the 11 patients (100%) showed improvement by 2 grades and were left with no scars. Hence, all 49 (100%) patients showed improvement in their scars by some grade with no failure rate. The physician's analysis also correlated with the patient's assessment of improvement in scars with 12 (75%) patients with Grade 4 scars reporting improvement as very good, 8 (36.4%) patients with Grade 3 scars as excellent and 11 (100%) patients with Grade 2 scars as excellent with poor response reported by none of the patients. The procedure was well tolerated by all the patients. Post-procedure there was no loss of work days and side effects were mild and transient. In spite of patients being of Type III, IV and V Fitzpatrick skin type, only three patients (6%) developed PIH during the treatment, which subsided within 5 months of topical therapy. It has the advantage of being an office procedure and in being cost-effective. Topical tretinoin 0.05% favours the development of a regenerative lattice-patterned collagen network rather than the parallel deposition of scar collagen found with cicatrisation. Since dermaroller opens pores in the upper layer of epidermis and allows creams to be absorbed more effectively, it is for this reason that topical tretinoin was applied during dermaroller and kept for 30 minutes post-procedure to maximise its absorption in skin. Also the improvement in the grade of scars was sustained in the follow-up period of 1 year.


    Although ablative laser resurfacing is generally considered to be the most effective option for scar resurfacing, it is associated with significant damage to the epidermis and basal membrane with associated inflammation which causes erythema, scarring and pigmentation problems.[13,14,15] It also has a long downtime. In comparison, percutaneous collagen induction does not induce post-operative dyspigmentation as the epidermis and basal membrane are left intact.[16]

     

    CONCLUSIONS


    As the demand for less invasive, highly effective cosmetic procedures is growing, this combination of treatment for acne scars has shown good results not only in Grade 2 but also in severe Grade 4 and 3 acne scars. The treatment is well tolerated in Fitzpatrick skin types III, IV and V with no failure rates or loss of days at work. There is a high level of patient satisfaction, minimal downtime and the treatment is cost-effective to the patient. To our knowledge, this is the first study using this combination of therapy in the management of atrophic acne scars and the first in which topical tretinoin cream was applied both during and immediately after doing dermaroller.

    __________________________________________________________________________________________________________________





    Indian Dermatol Online J. 2014 Jan-Mar; 5(1): 95–97.


    doi:  10.4103/2229-5178.126053






    PMCID: PMC3937506






    Subcision plus 50% trichloroacetic acid chemical reconstruction of skin scars in the management of atrophic acne scars: A cost-effective therapy



    Jasleen Kaur and Jyotika Kalsy1




     



    Treatment of acne scars is a dilemma both for the treating physician and the patient as no oral or topical medicine works and it is associated with emotional and psychological stress. Acne scars are classified into three different types: Atrophic, hypertrophic, or keloidal. Atrophic scars are the most common type of acne scars. They have been further classified into three types as described by Jacob et al.[1] into ice-pick scars, rolling scars, and boxcar scars. Most of the patients with atrophic acne scars have more than one type of scars.


    Various treatment modalities like punch excision and elevation, subcision, chemical peeling using various strengths of TCA, micro-needling, ablative, non-ablative lasers and fillers either singly or in combinations have been described in literature with varying results. Most of these procedures require costly equipment and materials and not affordable by many people.


    Subcision or subcutaneous incision-less surgery is a term coined by Orentreich and Orentreich[2] in 1995 as the treatment option for atrophic acne scars. Here hypodermic 18 no. needle is used to break the fibrotic strands that tethered the scars to the underlying tissues leading to uplifting of scars. Combining subcision with other scar revision techniques or repeated subcisions may be beneficial to the patients.[3] TCA chemical reconstruction of skin scars (CROSS)[4] is another useful method for treatment of atrophic acne scars. It involves focal application of 50-100% of TCA with a wooden applicator on the base of an atrophic scar, which causes precipitation of proteins and coagulative necrosis of cells in the epidermis. There is necrosis of collagen in the papillary and upper reticular dermis. Healing is rapid because of sparing of adjacent normal tissues and adnexal structures. So there is reorganization of dermal structural elements and increase in collagen content that leads to filling of the atrophic scar.


    While going through the literature, we found that different studies have used subcision and CROSS TCA alone or in combination with other techniques as well as their comparative studies but we did not find any study combining these two techniques together to the best of our knowledge. Encouraged by that, we combined subcision and TCA cross in all types of scars as subsicion breaks the dermal tethering of the scar tissue and TCA will remodel the collagen underneath the scar which treats the basic pathology of the scar to some extent.


    In our study, 10 female patients between the age group of 20-35 years of skin type 4 and 5 with atrophic acne scars on the face were randomly selected. Most of the patients had more than one type of atrophic scars of grade 4 severity as described by Goodman.[5] In all the patients, there were no active acne lesions and none of them were on oral isotretinoin 3 months prior to inclusion in our study. Patients with keloidal tendencies, bleeding diathesis, and history of recurrent herpes simplex were excluded. Complete hemogram, random blood sugar levels, and viral markers were done in all the patients. Written consent after explaining the risks and benefits of treatment was taken from all the patients along with pre-/post-procedure photographs. Subcision followed by 50% TCA CROSS was done at 4 weeks interval for three sessions. Patients were followed-up monthly for improvement in scars up to 6 months.


    Priming was done 2 weeks prior to the treatment with 2% hydroquinone and tretinoin 0.025% cream at night and sunscreen more than 30 sun protection factor (SPF) was given in the morning. Procedure was carried out after application of topical anesthetic cream for 45 min followed by infiltration of 2% Xylocaine with normal saline under aseptic conditions. A no. 18 hypodermic needle attached to a syringe was introduced horizontally underneath each scar and was moved back and forth till the snapping sound was heard. We used no. 18 hypodermic needle because it is cheap and easily available. Homeostasis was maintained by pressure. We cleaned the entire area with normal saline which was followed immediately by 50% TCA with the tip of a toothpick by pressing hard on the entire area of depressed atrophic acne scars irrespective of the type of scar and frosting was taken as the end point, antibiotic cream was applied, and patient was sent home. Patient was advised to apply antibiotic cream twice daily followed by sunscreen in the morning. Erythema, edema, and crusting lasted for 7-10 days in all the patients to varying severity. After 10 days, the patient was advised to apply azelaic acid 20% cream at night.


    Results were evaluated on the basis of global scar grading system, visual improvement by photographs and patient satisfaction. The global acne scarring classification is a four-category qualitative system by Goodman[5] based on scar morphology and ease of masking by makeup or normal hair patterns. Grade 1 means macular scarring only, Grade 2 is mild atrophy, which is not visible beyond 50 cm and can be easily masked by makeup, Grade 3 is moderate atrophy obvious at social distance not easily masked by makeup while Grade 4 is severe atrophy.


    Percentages in improvement were calculated as a combination of the three parameters, i.e. global scar grading system by Goodman, visual improvement by photographs showing the change in the grade and patient satisfaction, which was assessed by giving a questionnaire to the patient where they had to rate their improvement on 0-10 point scale.


    Excellent >70%


    Good 50-70%


    Fair 30-50%


    Poor <30%


     



    We labeled results as excellent when there was a two-grade change in the scars observed by the dermatologist both by grading system, photographs, and patient rated his improvement as more than 7 [Figures [Figures11 and and33].





    Figure 1


    Sites involved right cheek. (a) Post-acne scars mostly ice pick, boxcars and few roller scars. (b) Decrease in number and depth of scars







    Figure 3


    Site involved is left cheek and left temple. (a) Many ice pick scars and a few boxcars and very few rolling scars. (b) Decrease in depth and size of scars






    Results were taken as good when there was one-grade improvement in acne scars observed by the dermatologist both by grading system, photographs, and patient rated his improvement as 5, 6, or 7 [Figure 2].





    Figure 2


    Sited involved right cheek. (a) Multiple post-acne ice pick and roller scars. (b) Decrease in size and depth of all the scars






    Results were taken as fair when there was improvement in acne scars observed by the dermatologist by photographs only and patient rated his improvement as 3, 4, or 5.




    Results were taken as poor when there was no improvement in acne scars observed by the dermatologist either by photographs or by grading system but it was only subjective improvement as told by the patient when they rated it between 1 and 3.



     


    In all the patients, scar grading improved from grade 4 to grade 2 and results were graded excellent, good, and fair in 6, 3, and 1 patients respectively [Table 1]. Although in various studies best results with CROSS TCA are seen in ice-pick scars but since in our study we combined it with subcision, results were equally good even in rolling scars and boxcars scars. Post-inflammatory hyperpigmentation was transient in three patients, which persisted for 15-20 days post-procedure, which further decreased over the time period with 20% azelaic acid and in one case, the mild hyperpigmentation persisted even at the end of 6 months in spite of the best efforts for reasons not known. The patients were also happy with the results except for the one where hyperpigmentation persisted. Although the procedure has a downtime in the form of erythema, edema, and crusting, it is comparable to all other resurfacing procedures and the problem of post-inflammatory hyperpigmentation can be judiciously tackled with the proper and repeated use of sunscreens and lightening agents. Each procedure when done individually has downtime of few days. So, we tried to reduce it by combining the two procedures. Hence, it can be concluded that subcision combined with TCA CROSS is a simple, safe, and cost-effective procedure, which does not require any specialized or costly equipments or materials or any special training and can be performed as an out-patient-department procedure by any budding dermatologist.


    __________________________________________________________________________________________________________________
    How to Do TCA CROSS for Icepicks and Small Boxcars
    - Note: Spot TCA Peels are done in a similar way without toothpicks (guaze instead) and no more than 35% strength




     
     




    Items you will need: Toothpick or wood part of swab broken off to fit inside scar (sandpaper), TCA Acid 35-50%, Paper Towel, Baking Soda dissolved water, Vaseline / triple antibiotic / or biafine / hydrogel burn section first aid, Acetone aka nail polish remover (without fragrance, 100%) , rubber gloves, small container for acid (glass or ceramic), mirror
    1) Wash face with a gentle soap, nothing to harsh or acidic. Let it dry fully
    2) Use the Acetone aka nail polish remover (without fragrance, 100%) to pre treat the area (de grease it).
    3) Sand down your toothpick (Sandpaper) to fit into scar (you want to touch the bottom of the scar not the side walls as much as possible) or break a wooden swab stick and make it fit into the scar, TCA Cross does better on scars with defined walls all around, the closer the walls the scar the better it will heal. Icepicks and "small" boxcars can be treated. Bigger scars should be treated with weaker acid dilution over the effected area (soften the transition to the surrounding skin), not just inside the spot.  -- Never do icepicks very close to each other, they can connect, do some one treatments, and some the next time.
    4) Put on those gloves
    5) put vaseline anywhere you think is important to protect. The acid will not react there. Nose, lips, around eyes, eyebrows, smile lines. You can also surround the area with vaseline if you wish for extra protection but it's not necessary.
    6) Pour a little acid or drop it into the glass or ceramic. Add equal amount to half it. You should always do test spots before you treat all your scars. This can be done at a dilute amount 20% if doing TCA Cross, and less for a full face or spot peel 8-12%. You are seeing how you heal, how it looks, and how you react to the acid.
    7) Use your toothpick or wooden q-tip swab. Dip it in the TCA. You will take your paper towel and get any excess off. Drips make burns, wood holds acid, even if you cannot see it. The smallest amount works, not excess. You are pressing firmly into the icepick or box car but not spreading it outside of that scar, reach the bottom of the scar but never break the skin by pressing to hard. 
    8) It should start to turn white, if it does not, you may in 5 mins do it again (if your at a lower dilution for that test spot, it will not turn white and that's ok, white is only at higher amounts). Turning White assumes you have reached the appropriate strength for your skin and it's not too much.  
    9) Some people in case of emergency or to stop it because it hurts too much, take their dissolved baking soda water and stop the acid. TCA is self neutralizing, hence the white it is reaching the keratin in the skin. Never wash it off with soap (ouch!).
    10) Put your vaseline, triple antibiotic cream, hydrogel from the first aid section for burn stuff, or biafine my favorite on the spot. You can take some antihistamine and or Tylenol if you need for pain and swelling. 
    11) Daily put more of the above to keep it moist, and once or twice a day used diluted (Water) vinegar to pat with gauze the area, never rub. This clean and kills bacteria, also it makes it peel naturally. 
    12) If you need to use acne stuff, only put it on the spots, never the scab or wound
    13) If your in the shower, it can make the scab fall off, this is bad, splash your face, don't let it fall off.
    14) Do not pick, it will make it worse.
    15) Only do these peels once a month, more and you will make it deeper.
    16) After the scab has fallen off you can use honey and aloe vera to heal the red spot or triple antibiotic cream. 
    17) Wet Green tea bags help with redness and soothing
    18) The scar will not be flat, that takes multiple treatments, it will lessen a percentage as it raises the bed or bottom of the scar, ... I suggest microneedling, and alternating months doing peels for collagen production.
    19) Ethnic skin (darker) types may not be able to use TCA, please do a test spot, at a very dilute amount (water), see how you react. Ethnic skin types do well with Glycolic and, Salycilic Acids. TCA may result in permanent darkening of the skin in the area where the peel was used. However, this problem can be overcome if TCA 20% is used after a Jessner’s solution for darker skin types.
    20) Avoid any sun exposure whatsoever in the days following the peel (Use Sunscreen After).

    Further Reading on TCA Cross: 
    http://cosmeticskin.com/chemical-reconstruction-of-skin-scars-cross-case-study/
    http://www.sunnyvalederm.com/Dr._Bernard_Recht_-_Sunnyvale_Dermatology/Dr._Recht_-_CROSS_files/CROSS_paper.pdf
    https://www.researchgate.net/publication/47754426_Complication_of_Cross-Technique_on_Boxcar_Acne_Scars_Atrophy
    ___________________________________________________________________________________________
    How to Do TCA Spot Peels or Full Face TCA Peels


    Full Face peels are great upkeep and many do them yearly to have fresh skin. For acne scar suffers, or those with smaller issues use  spot peels (large pores, rolling, or boxcars). You alternate your peels with http://derminator.com every other month (everything should be completely healed). This continues on for a year(s). If you spot peel make sure you feather the edges by using a more diluted weaker acid around the edge to feather out the treatment area.
    1) Pre Peal:  Use Acetone AKA Nail Polish Remover (without fragrance, 100%, to avoid irritation) this removes grease / sweat / sebrum so the peel work. You may now use a Salicylic, Glycolic, or Jessner peel but this is not required.
    2) Do not apply Retin A / tretinorin or a leave-on acid product the day before your peel – Let it rest for 1 day. Never use abrasive products (scrubs) immediately prior to a peel.
    3) Those with darker skin (or Asian) prone to hyperpigmentation please prepare your skin by using hydroquinone (skin bleach) a few weeks before and after treatment, also vitamin c serum, and spot test at lower levels to see how you handle the acid / healing.
    4) Items you will need: medical gauze or paper towel, TCA Acid 35%, Baking Soda dissolved water, Vaseline / triple antibiotic / or biafine / hydrogel burn section first aid, Acetone aka nail polish remover (without fragrance, 100%) , rubber gloves, small container for acid (glass or ceramic), mirror
    1) Wash face with a gentle soap, nothing to harsh or acidic. Let it dry fully
    2) Use the Acetone aka nail polish remover (without fragrance, 100%) to pre treat the area (de grease it).
    3) In a bowel or container combine your water and TCA acid (to a low enough percentage, hopefully you have already done a small test spot to see how you heal and can handle that percentage, starting percentage is 12-15%, your slowly working your way over many peels to as much as you can handle of 35%, some never reach that and that's ok). 
    4) Put on those gloves
    5) put Vaseline anywhere you think is important to protect. The acid will not react there. Nose, lips, around eyes, eyebrows, smile lines. You can also surround the area of treatment  with Vaseline if you wish for extra protection but it's not necessary.
    7) Use your gauze. Dip it in the TCA. You will take your paper towel and get any excess of (wring it out). Drips make burns, gauze holds acid, even if you cannot see it. The smallest amount works, not excess. 
    8) It will only turn white at higher percentages, otherwise you won't see anything, if you feel nothing you may in 5 mins do it again (if your at a lower dilution for that test spot). 
    9) Some people in case of emergency or to stop it because it hurts too much, take their dissolved baking soda water and stop the acid early. Never wash it off with soap (ouch!).
    10) Put your Vaseline, triple antibiotic cream, hydrogel from the first aid section for burn stuff, or biafine my favorite on the spot. You can take some antihistamine and or Tylenol if you need for pain and swelling. 
    11) Daily put more of the above to keep it moist, and once or twice a day used diluted (Water) vinegar to pat with gauze the area, never rub. This clean and kills bacteria, also it makes it peel naturally. 
    12) If you need to use acne stuff, only put it on the spots, never the scab or wound
    13) If your in the shower, it can make the scab fall off, this is bad, splash your face, don't let it fall off.
    14) Do not pick, it will make it worse.
    15) Only do these peels once a month, more and you will make it deeper.
    16) After the scab has fallen off you can use honey and aloe vera to heal the red spot or triple antibiotic cream. 
    17) Wet Green tea bags help with redness and soothing
    18) The scar will not be flat, that takes multiple treatments, it will lessen a percentage as it raises the bed or bottom of the scar, ... I suggest microneedling, and alternating months doing peels for collagen production.
    19) Ethnic skin (darker) types may not be able to use TCA, please do a test spot, at a very dilute amount (water), see how you react. Ethnic skin types do well with Glycolic and, Salycilic Acids. TCA may result in permanent darkening of the skin in the area where the peel was used. However, this problem can be overcome if TCA 20% is used after a Jessner’s solution for darker skin types.
    20) Avoid any sun exposure whatsoever in the days following the peel (Use Sunscreen After).
    The collagen production will continue for the next several months.
    21)  If anything does not “look or feel” right to you, see a doctor for an evaluation!







     





     










     






    https://www.youtube.com/watch?v=5qz1FOUwF0Q
     




    Medium Depth Chemical Peels


    Gary D. Monheit, M.D.
    Associate Professor
    Department of Dermatology
    University of Alabama at Birmingham
    Birmingham, Alabama


    Synopsis
    Medium Depth Chemical Peeling
    Gary D. Monheit, M.D.


    The combination medium depth chemical peel – Jessner’s solution + 35% TCA, has been accepted as a safe, reliable and effective method for the treatment of moderate photoaging skin.


    ** Pre Peal:  Use Acetone AKA Nail Polish Remover (without fragrance, 100%, to avoid irritation)      this removes grease / sweat/ sebrum so the peel work.
    Chemical peeling involves the application of a chemical exfoliant to wound the epidermis and dermis for the removal of superficial lesions and improve the texture of skin. Various acidic and- basic chemical agents are used to produce the varying effects of light to medium to deep chemical peels through differences in their ability to destroy skin. The level of penetration, the nature of destruction and the inflammatory response determines the level of the peel. The stimulation of epidermal growth through the removal of the stratum corneum without necrosis consists of light superficial peel. Through exfoliation, it thickens the epidermis with qualitative regenerative changes. Destruction of the epidermis defines a full superficial chemical peel inducing the regeneration of the epidermis. Further destruction of the epidermis and induction of inflammation within the papillary dermis constitutes a medium-depth peel. Then, further inflammatory response in the deeper reticular dermis induces new collagen production and ground substances which constitutes a deep chemical peel.1 These have now been well classified and usage has been categorized for various degenerative conditions associated with photoaging skin based on levels of penetration. The physician, thus, has tools capable of solving photoaging skin problems that may be mild, moderate or severe with agents that are very superficial, superficial, medium-depth, and deep peeling chemicals. The physician must choose the right agent for each patient and condition.


    Medium depth peeling is thus defined as the use of a chemical agent to wound skin through papillary dermis. It is most useful for the removal of epidermal or superficial lesions and to improve skin texture in moderate photodamaged skin (grade II Glogau photoaging skin)2. Medium depth peeling agents create changes through necrosis of the epidermis and part or all of the papillary dermis with an inflammatory reaction in the upper reticular dermis. The procedure is performed to remove actinic keratoses, mild photoaging of the skin including rhytides, treat pigmentary dyschromias, and improve depressed scars.3 (Table I)


    Trichloracetic acid has been the gold standard in quantitating chemical peel strength and depth. Ten to 30% has been quantitated as superficial wounding while above 50% is deep chemical peeling. The level, 35-50% trichloracetic acid is the spectrum of medium depth peeling. It is standard to think of 45 or 50% trichloracetic acid corresponding to a wounding level of mid to deep reticular dermis. This concentration of trichloracetic acid, though, has been found unreliable and associated with a higher incidence of pigmentary dyschromia, textural change, and even scarring.4 In an attempt to reduce the morbidity of higher concentration trichloracetic acid, a combination of products have been devised that improve the absorption of the lower concentration of trichloracetic acid without the associated complications.5 The combination peels include:


    Solid carbon dioxide freezing with trichloracetic acid 35%.


    Jessner's solution + 35% trichloracetic acid.


    Glycolic acid 70% plus 35% trichloracetic acid.


    The combinations produce a more even peel with deeper penetration of the wounding agent without the associated complications of higher concentration trichloracetic acid. This chapter will review the scope of medium depth peeling, the patients and conditions most commonly treated, the techniques of application, wound healing, and complications.


    Trichloracetic Acid


    Trichloracetic acid has become the gold standard of chemical peeling agents for its long history of usage, its versatility in peeling, and its chemical stability. It has been useful in many concentrations because it has no systemic toxicity and can be used to create superficial, medium or even deep wounds in the skin. Trichloracetic acid is naturally found in crystalline form and is mixed weight-by-volume with distilled water. It is not light sensitive, does not need refrigeration and is stable on the shelf for over six months. The standard concentrations of trichloracetic acid should be mixed weight-by-volume to accurately assess the concentration. That is, 30 gm. trichloracetic acid crystals mixed with 100 cc. distilled water will give an accurate 30% concentration, weight by volume. Any other dilutional system - volume dilutions and weight by weight, are inaccurate in that they do not reflect the accepted weight by volume measurements.


    Since TCA itself is an agent more likely to be fraught with complications, especially scarring, in strengths of 50% or higher, the higher concentration has fallen out of favor.6 It is for this reason that the combination products along with a 35% TCA formula have been found equally effective in producing this level of control damage without the risk of side effects.


    Brody first developed the use of solid CO2 applied with acetone to the skin as a freezing technique prior to the application of 35% trichloroacetic acid. The preliminary freezing appears to break the epidermal barrier for a more even and complete penetration of the 35% trichloroacetic acid.7


    Monheit then demonstrated the use of Jessner’s solution prior to the application of 35% trichloroacetic acid. The Jessner’s solution was found effective in destroying the epidermal barrier by breaking up individual epidermal cells. This also allows a deeper penetration of the 35% TCA and a more even application of the peeling solution.8 Similarly, Coleman has demonstrated the use of 70% glycolic acid prior to the application of 35 % trichloroacetic acid. Its effect has been very similar to that of Jessner’s solution.9 (Table II)


    All three combinations have proven to be as effective as the use of 50% trichloroacetic acid with a greater safety margin. The application of acid and resultant frosting are better controlled with the combination so that the “hot spots” with higher concentrations of TCA can be controlled, creating an even peel with less incidence of dyschromias and scarring. The combination peel produces an even, uniform peel. The Monheit version of the Jessner’s solution – 35% TCA peel is a relatively simple and safe combination. The technique is used for mild-to-moderate photoaging including pigmentary changes, lentigines, epidermal growths, dyschromias, and rhytids. It is a single procedure with a healing time of seven to ten days. It is useful also to remove diffuse actinic keratoses as an alternative to chemical exfoliation with topical 5-fluorouracil chemotherapy. Topical chemotherapy is applied for three weeks creating erythema, scabs and crusts for up to six weeks.10 The combination peel will produce similar therapeutic benefits within ten days of healing. It thus reduces the morbidity significantly and gives the cosmetic benefits of improved photoaging skin.


    Skin preparation is of vital importance to encourage correct healing and avoid complications. Agents used prior to the peel to prepare the skin correctly include:11 (Table III)


    Sunscreen


    Exfoliations - abrasive cleansers, 5-10% glycolic acid lotion


    Tretinoin .05% used six weeks to three months prior to the peel


    Bleaching products - hydroquinone 4-8% used in patients with pigmentary dyschromias and those with type III-VI Fitzpatrick skin pigmentation.


    Anti-viral agents in selected patients with history of facial HSV I infections.


    The procedure is usually performed with mild preoperative sedation and nonsteroidal antiiflammatory agents. The patient is told that the peeling agent will sting and burn temporarily and aspirin is given before the peel and continued through the first twenty-four hours if the patient can tolerate the medication. Its inflammatory effect is especially helpful in reducing swelling and relieving pain. If given before surgery, it may be all the patient requires during the postoperative phase. For full-face peels, though, it is useful to give preoperative sedation (diazepam 5 to 10 mg orally) and mild analgesia, meperidine 25 to 50 mg (Demerol – Winthrop, New York), and hydroxyzine hydrochloride 25 mg intramuscularly (Vistaril – Lorec, New York). The discomfort from this peel is not long lasting, so short acting sedatives and analgesics are all that are necessary.12


    Vigorous cleaning and degreasing is necessary for even penetration of the solution. The face is scrubbed gently with Ingasam (Septisol - Vestal Laboratories, St. Louis, Missouri) four-inch by four-inch gauze pads and water, then rinsed and dried. Next, an acetone preparation is applied to remove residual oils and debris. The skin is essentially debrided of stratum corneum and excessive scale. A thorough degreasing is necessary for an even penetrant peel. The physician should feel the dry, clean skin to check the thoroughness of degreasing. If oil is felt, degreasing should be repeated. A splotchy peel is usually the result of uneven penetration of peel solution due to residual oil or stratum corneum, and a result of inadequate degreasing.


    After thorough cleaning, the Jessner’s solution is applied with either cotton-tip applicators or 2” x 2” gauze. (Table V) The Jessner’s solution is applied evenly with usually one or two coats to achieve a light but even frosting. The frosting achieved with Jessner’s solution is much lighter than that produced by TCA and the patient is usually comfortable, feeling only heat. A mild erythema appears with a faint tinge of splotchy frosting over the face. Even strokes are used to apply the solution to the unit area covering the forehead to the cheeks to the nose and chin. The eyelids are treated last creating the same erythema with blotchy frosting. (Fig 1). The application of Jessner’s solution alone is equal to a superficial or light chemical peel.13


    After the Jessner’s solution has dried, the TCA is applied. The TCA is painted evenly with one to four cotton-tipped applicators that can be applied over different areas with light or heavier doses of the acid. Four cotton-tipped applicators are applied in broad strokes over the forehead and also on the medial cheeks. Two mildly soaked cotton-tipped applicators can be used across the lips and chin, and one damp cotton-tipped applicator on the eyelids. Thus, the dosage of application is technique dependent on the amount used and the number of cotton-tipped applicators applied. The cotton-tipped applicator is useful in quantitating the amount of peel solution to be applied. Care must be taken to ensure the acid is not dripped inadvertently over unwanted areas such as neck or eyes.


    The white frost from the TCA application appears complete on the treated area within 30 seconds to 2 minutes. Even application should eliminate the need to go over areas a second or a third time, but if frosting is incomplete or uneven, the solution should be reapplied. Thirty-five percent TCA takes longer to frost than Baker’s formula or straight phenol, but a shorter period of time than the superficial peeling agents do. The surgeon should wait at least 3 to 4 minutes after the application of TCA to ensure the frosting has reached its peak. He then can document the completeness of a frosted cosmetic unit and touch up the area as needed. Areas of poor frosting should be retreated carefully with a thin application of TCA. The physician should achieve a level II to level III frosting. Level I frosting is erythema with a stringy or blotchy frosting, seen with light chemical peels. Level II frosting is defined as white-coated frosting with erythema showing through. A level III frosting, which is associated with penetration through the papillary dermis, is a solid white enamel frosting with little or no background of erythema.14 A deeper level III frosting should be restricted only to areas of heavy actinic damage and thicker skin. Most medium-depth chemical peels use a level II frosting and this is especially true over eyelids and areas of sensitive skin. Those areas with a greater tendency to scar formation, such as the zygomatic arch, the bony prominences of the jawline, and chin, should only receive up to a level II frosting. Overcoating trichloroacetic acid will increase its penetration so that a second or third application will drive the acid further into the dermis, creating a deeper peel. One must be careful in overcoating only areas in which the take up was not adequate or the skin is much thicker. (Fig 2)


    Anatomic areas of the face are peeled sequentially from forehead to temple to cheeks and finally to the lips and eyelids. The white frosting indicates keratocoagulation or protein denaturation of keratin and at that point the reaction is complete. Careful feathering of the solution into the hairline and around the rim of the jaw and brow conceals the line demarcation between peeled and non-peeled skin. The perioral area has rhytids that require a complete and even application of solution over the lip skin to the vermilion. This is accomplished best with the help of an assistant who stretches and fixates the upper and lower lips while the peel solution is applied.


    Certain areas and skin lesions require special attention. Thicker keratoses do not frost evenly and thus do not pick up peel solution. Additional applications rubbed vigorously into the lesion may be needed for peel solution penetration. Wrinkled skin should be stretched to allow an even coating of solution into the folds and troughs. Oral rhytides require peel solution to be applied with the wood portion of a cotton-tipped applicator and extended into the vermilion of the lip. Deeper furrows such as expression lines will not be eradicated by peel solution and thus should be treated like the remaining skin.


    Eyelid skin must be treated delicately and carefully. A semidry applicator should be used to carry the solution within 2 to 3 mm of the lid margin. The patient should be positioned with the head elevated at 30 degrees and the eyelids closed. Excess peel solution on the cotton tip should be drained gently on the bottom before application. The applicator is then rolled gently on the lids and periorbital skin. Never leave excess peel solution on the lids because the solution can roll into the eyes. Dry the tears with a cotton-tipped applicator during peeling because they may pull peel solution to the puncta and eye by capillary attraction. (Fig 3) The solution should be diluted immediately with cool saline compresses at the conclusion of the peel. The Jessner’s-TCA peel procedure is as follows:


    The skin should be cleaned thoroughly with Septisol to remove oils.


    Acetone or acetone alcohol is used to further debride oil and scale from the surface of the skin.


    Jessner’s solution is applied.


    Thirty-five percent TCA is applied until a light frost appears.


    Cool saline compresses are applied to dilute the solution.


    The peel will heal with 0.25% acetic acid soaks and a mild emollient cream.


    There is an immediate burning sensation as the peel solution is applied, but this subsides as frosting is completed. Cool saline compresses offer symptomatic relief for a peeled area as the solution is applied to other areas. The peel reaction is not neutralized by saline solution as the reaction is completed when frosting occurs.15 The compresses are placed over the face for 5 to 6 minutes after the peel until the patient is comfortable. The burning subsides fully by the time the patient is ready to be discharged. At that time, most of the frosting has faded and a brawny desquamation is beginning.


    Postoperatively, edema, erythema, and desquamation are expected. With periorbital peels and even forehead peels, eyelid edema can occur and may be enough to close the lids. For the first 24 hours, the patient is instructed to soak four times a day with a 0.25% acetic acid compress made of 1 tablespoon white vinegar in 1 pint of warm water. A bland emollient is applied to the desquamating areas after soaks. After 24 hours, the patient can shower and clean gently with a mild nondetergent cleanser. The erythema intensifies as desquamation becomes complete within 4 to 5 days. Thus, healing is completed within 1 week to 10 days. At the end of 1 week, the bright red color has faded to pink and has the appearance of a sunburn. This can be covered by cosmetics and will fade fully within 2 to 3 weeks.


    The medium-depth peel is dependent on three components for therapeutic effect: (1) degreasing, (2) Jessner’s solution, and (3) 35% TCA. The amount of each agent applied creates the intensity and thus the effectiveness of this peel. The variables can be adjusted according to the patient’s skin type and the areas of the face being treated. It is thus the workhorse of peeling and resurfacing in my practice as it can be individuated for most patients we see.


    The medium-depth chemical peel thus has five major indications:


    destruction of epidermal lesions – actinic keratoses


    resurfacing the level II or III moderate photoaging skin


    pigmentary dyschromias


    mild acne scars


    blending photoaging skin with laser resurfacing and deep chemical peeling


    Actinic keratoses


    This procedure is well suited for the patient with epidermal lesions such as actinic keratoses which has required repeated removal with either cryosurgery or chemoexfoliation (5-fluoruracil). The entire face can be treated as a unit or subfacial cosmetic unit such as forehead, temples, and cheeks, and can be treated independently. Active lesions can be removed, as well as incipient growths as yet undetected, will be removed as the epidermis is sloughed. Advantages for the patient with photodamaged skin include a limited recovery period – 7 to 10 days, with little post operative erythema after healing.16 There is little risk of pigmentary changes either hypopigmentation or hyperpigmentation, thus, the patient can return to work after the skin has healed.(Fig 4)


    Moderate photoaging skin


    Glogau level II or III damage responds well to this peeling combination with removal of the epidermal lesions and dermal changes that will freshen photoaging characterized as sallow, atrophic skin with fine rhytides. This peel is favored over deeper resurfacing procedures such as CO2 laser and deep peel in that it will heal in ten days with minimal risk of textural or color complications. It, though, is only designed for medium-depth damage. (Fig 5)


    Pigmentary dyschromias


    Though color change can be treated with repetitive chemical peeling, the medium-depth peel will be a single treatment preceded and followed by the use of bleaching agents and retinoic acid.17 In most cases, the pigmentary problems are resolved with this single peel as an adjunct to the skin care program.


    Blending other resurfacing procedures


    In a patient in which there is advanced photoaging changes such as crow’s feet and rhytides in the periorbital and/or perioral area with medium-depth changes on the remaining face, a medium-depth peel can be used to integrate these procedures together. That is, laser resurfacing or deep chemical peeling can be performed over the periorbital and perioral areas that has more advanced photoaging changes, while the medium-depth chemical peel is used for the rest of the face. This will blend the facial skin as a unit so that the textural and color changes will not be restricted to one area. The patients requiring laser resurfacing in a localized cosmetic unit will have the remaining areas of their face blended with this medium-depth chemical peel. Patients having laser resurfacing or deep peeling to the perioral or periorbital areas alone develop a pseudo hypopigmentation that is a noticeable deformity. The patient requiring laser resurfacing at a localized cosmetic unit will have the remaining areas of their face blended with this medium-depth peel. The alternative – a full-face deep peel or laser resurfacing has an increased morbidity, longer healing and risk of scarring over areas such as the lateral jaw line, malar eminences, and forehead. If deep resurfacing is needed only over localized areas such as perioral or periorbital face, a blending medium-depth peel does reduce morbidity and healing time.18 (Fig 6)


    Results


    This medium depth peel will produce superior results for the conditions listed.(Table III) Removal of actinic keratoses, both present and incipient, affords the patient a single procedure with healing time within one week to ten days, as a preventive therapeutic modality for the removal of precancerous growths over the face.(Fig 4) A comparison study of the efficacy of Jessner's solution plus 35% trichloracetic acid with 5-Fluorouracil documented superior effectiveness of this single procedure with a significant reduction in morbidity.19 It is, thus, an effective, safe and simple single procedure that can be used to remove actinic keratoses and epidermal growths as both a therapeutic and cosmetic procedure.


    Glogau grade II photoaging skin can be effectively treated for improvement in both texture, color change, and epidermal growths with a medium depth Jessner's - TCA peel. Of equal importance to the procedure is choosing the correct patient for the procedure. Patients with superficial textural changes and those with epidermal growths seem to respond best to this peel. Fine wrinkles, cross-hatched lines, sallow color changes of photoaging along with the crinkly appearance are the textural changes that will respond to this peel. Additionally, epidermal growths such as freckles, lentigenes, actinic keratoses, and seborrheic keratoses will also respond well.(Fig 5) The more advanced changes seen with deeper grooves and wrinkles, pebbly appearance of the skin and more pronounced gravitational changes of Glogau III and IV photoaging skin require either deep chemical peeling or laser resurfacing. Using trichloracetic acid or any of its combinations as a deep chemical peel for these more advanced indications will only risk potential side effects and complications.


    Pigmentary dyschromias such as melasma, blotchy hyperpigmentation, and pigmentary growths do respond well to medium depth chemical peeling. This is especially suited for those problems which have not resolved well with medical treatment or repeated light chemical peeling. Epidermal pigment seems to respond the best and this can be identified with Wood's light examination. Dermal pigment will show some response but not as effective as epidermal pigment. This combination peel is effective in that it will fully remove the epidermis as well as have an effect on melanocytes in the pilar apparatus during reepithelialization. It is important that these patients be prepared correctly with 4-8% hydroquinone, tretinoin and sunscreen begun at least six weeks prior to the peeling procedure. The bleaching agent is reinstituted after reepithelialization and tretinoin six weeks later. It should be continued for up to three months after the chemical peel and sunscreen used for longer period of time to insure the dyschromia does not return. There are many bleaching agents on the market today which have some lightening effect, but hydroquinone is the most effective.


    When localized areas of the face have advanced or severe photoaging such as deeper wrinkles around the eyelids and rhagades on the lips, the combination Jessner's trichloracetic acid peel can be used to blend the remaining areas of the face if they have only moderate photoaging of the skin. Thus, eyelids and lips can be resurfaced with a pulsed carbon dioxide laser and the remainder of the face treated with the Jessner's - trichloracetic acid peel. In this instance, the peel should be performed first in the manner described above and then appropriate anesthesia, eye protection and preparation be used to laser the designated areas. Healing will occur in the usual manner for either laser or peel with soaks and occlusive ointments. This is an effective method of reducing morbidity with deeper agents to areas that don't need them. It will also blend the photoaging skin, texture, color and appearance to that of the laser treated skin.(Fig 6)


    Post-Operative Care and Complications


    The four stages of wound healing are apparent after a medium depth chemical peel.20 They include:


    Inflammation


    Coagulation


    Reepithelialization


    Fibroplasia


    At the conclusion of the chemical peel, the inflammatory phase has already begun with a brawny, dusky erythema that will progress over the first twelve hours. With the medium depth peels, the epidermis will begin to separate, creating a leathery, dry, cracking appearance to the epidermis. This is an accentuation of pigmented lesions on the skin as the coagulation phase separates the epidermis, producing serum exudation, crusting and pyoderma. It is during this phase that it is important to use debrident soaks and compresses as well as occlusive salves. These will remove the sloughed necrotic epidermis and prevent the serum exudate from hardening as crust and scab. I prefer the use of 1/4% acetic acid soaks found in the vinegar water preparation (one teaspoon white vinegar, one pint warm water), as it is antibacterial, especially against pseudomonas and gram negatives. In addition, the mildly acidic nature of the solution is physiologic for the healing granulation tissue, mildly debrident, as it will dissolve and cleanse the necrotic material and serum. Occlusive dressings including bland emollients and salves and biosynthetic membranes. For medium depth peeling, I prefer the occlusive salves as these can be monitored carefully day by day for potential complications.


    Reepithelialization begins on day three and continues until day seven to ten. Occlusive salves promote faster reepithelialization and less tendency of delayed healing.21 The final stage of fibroplasia continues well beyond the initial closure of the peeled wound and continues with neoangiogenesis and new collagen formation for three or four months. Prolonged erythema may last two to four months in unusual cases of sensitive skin or with contact dermatitis. New collagen formation can continue to improve texture and rhytides for a period up to four months during this last phase of fibroplasia.


    Many of the complications seen in peeling can be recognized early on during healing stages. The cosmetic surgeon should be well acquainted with the normal appearance of a healing wound in its time frame for medium depth peeling. Prolongation of the granulation tissue phase beyond one week may indicate delayed wound healing. This could be the result of viral, bacterial or fungal infection, contact irritants interfering with wound healing, or other systemic factors. A red flag should alert the physician that careful investigation and prompt treatment should be instituted to forestall potential irreparable damage that may result in scarring. Thus, it is vitally important to understand the stages of wound healing in reference to medium depth peeling. The physician then can avoid, recognize and treat any and all complications early on. Specific complications will be discussed in the appropriate chapter.


    Longterm care of peeled skin would include sunscreen protection for up to six months along with reinstitution of medical treatment such as low strength hydroxy acid lotions and tretinoin. Re-peeling areas should not be performed for six months from the previous peel. If any erythema or edema persists, the peel should not be performed as the re-injury may create complications. This peel should not be performed on undermined skin such as facelift or flap surgery performed up to six months prior to the peel.22


    The evolution of medium depth chemical peeling has changed the face of cosmetic surgery. It has introduced new techniques into the armamateria of the cosmetic surgeon to treat problems that previous have been approached with tools inadequate to obtain the results for moderate photoaging skin or with overly-aggressive treatment using deep peeling agents. The combination peels have provided some of the more popular tools needed to approach a burgeoning population with photoaging skin.
     



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    Dilute and Have Emergency Baking Soda Water to Neutralize!
    Don't go buy TCA Acid at high percentages which is car part cleaner on various places on the internet and think my scars are bad so I will put the strongest possible.
    This is your face not concrete!!!! 
    Always Dilute Full Face or Spot Peels: 12-15% and test on a small area
    TCA Cross Dilute your acid to 20% and spot treat one tiny spot and see (how you heal, how long it takes, etc). 




    -- The person below has ethnic darker pigmented skin (This also can happen to lighter Asian skin, ...Caucasians have less pigmentation reaction),  dilute more depending on your skin type and test . Anyone with darker skin must also skin bleach cream (hydroquinone) before & after acid or laser procedures. 

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    Complications of Medium Depth and Deep Chemical Peels



    Nanma Nikalji, Kiran Godse, Jagdish Sakhiya,1 Sharmila Patil, and Nitin Nadkarni




    INTRODUCTION


    Chemical peel is the most popular and common non-invasive cosmetic procedure done since the 18thcentury. The earliest use of caustic preparations for peeling procedures was described in the Egyptian medicine in the Ebers papyrus as early as 1550 BC.[1,2] Dermatologists began to show interest in peeling in the 19th century. In 1874 in Vienna, the dermatologist Ferdinand von Hebra used the technique to treat melasma, Addison's disease, and freckles. In 1882 in Hamburg, Paul G. Unna described the actions of salicylic acid, resorcinol, trichloroacetic acid (TCA), and phenol on the skin.


    During the first half of the 20th century, phenol and TCA were used in several centers. Alpha-hydroxy acids (AHAs) became available as superficial peeling agents in late 1980s and the 1990s. AHAs are used in treating aging skin, melasma, photoaging and acne.


    They are classified as superficial, medium, and deep peels. The superficial chemical peels are very safe when used properly but can cause itching, erythema, increased skin sensitivity, epidermolysis, allergic and irritant contact dermatitis, and post-inflammatory hyperpigmentation (PIH). All peels can cause activation of herpes viral infection, whereas medium and deep peels can cause scarring. Deep peels are no longer popular in Indian skin. They can cause milia, secondary infection, and scarring.




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    COMPLICATIONS OF CHEMICAL PEELS


    Chemical peeling involves the application of a chemical agent of a defined strength that results in exfoliation of the skin followed by regrowth of new skin leading to skin rejuvenation. It is a technique-dependent procedure. Although rare, complications may occur including persistent erythema, milia, scarring, etc.[3]




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    CLASSIFICATION


     



    Intraoperative[4]




    Incorrect peel pharmacology




    Accidental solution misplacement






    Post-operative




    Local infection




    Contact dermatitis




    Improper care during healing





     


    Based on the time of onset, complications can be immediate or delayed.


     



    Immediate (within minutes to hours after peeling):[5]




    Irritation, burning, pruritus, and pain




    Persistent erythema




    Edema




    Blistering






    Delayed (within a few days to weeks):




    Infections (bacterial, herpetic, and candidal)




    Scarring, delayed healing, milia, and textural changes




    Hyperpigmentation, hypopigmentation, and lines of demarcation




    Loss of cutaneous barrier and tissue injury




    Acneiform eruptions




    Allergic reactions, toxicity, and ectropion






    Accidental




    Ocular complications.





     


    Usually, complications are minor and are more common in dark-skinned individuals. They are seen more in medium and deep depth peels.




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    PAIN AND BURNING


    Prolonged sun exposure, inadequate application of sunscreen, using topical retinoid or glycolic acid immediately after peels can lead to this complication. Paradoxically, in some patients, sunscreens can themselves cause contact sensitization or irritant dermatitis.[6]


    Pain and burning is commonly encountered during a peel procedure in sensitive skin. It can persist up to 2-5 days after the peel till re-epithelialization is completed.



    Treatment


     



    Immediate ice application reduces the pain and burning sensation




    Topical calamine lotion soothes the skin




    Topical steroids such as hydrocortisone or fluticasone reduce the inflammation




    Emollients to moisturize the skin




    Sunscreens to prevent PIH.



     




    Persistent erythema


    It is characterized by the skin remaining erythematous beyond what is normal for an individual peel. Erythema disappears normally in 3-5 days in superficial peel, 15-30 days in medium peel,[4] and 60-90 days in deep peel. Erythema persisting beyond the above-mentioned time is abnormal and is an alarming sign. It is a predictor of potential scarring.




    Causes


     



    Usage of topical tretinoin just before and after peel




    Isotretinoin administration (<0.5 mg/kg body weight) prior to peel




    Minimal amount of alcoholic beverages[7]




    Contact dermatitis




    Contact sensitization




    Exacerbation of pre-existing skin disease




    Genetic susceptibility.



     


    It is due to angiogenic factors stimulating vasodilation which indicates that the phase of fibroplasia is being stimulated for a prolonged period of time. Hence, it can be accompanied by skin thickening and scarring.




    Treatment


     



    Topical, systemic, or intralesional steroids if thickening is occurring




    Pulsed dye laser to treat the vascular factors.



     




    Pruritus


    It is more common after superficial and deep peels, although may occur following re-epithelialization.[8]


     



    It may be due to contact dermatitis to a topical agent (retinoid)




    If papules, pustules, and erythema occur along with pruritus, it is suspected to be contact dermatitis and treatment should start as early as possible to prevent PIH




    Care should be taken not to start any new topical agent during maintenance period after peel




    If erythema with pruritus or burning or stinging, rule out active infection or flaring of an underlying skin condition.



     




    Edema


    It is more common with medium and deep peels occurring within 24-72 h of chemical peeling. In case of superficial peels, care should be taken while peeling patients with thin, atrophic, dry skin and in the periocular area since edema can occur in these settings because of deeper penetration.[8]




    Treatment


     



    Usually subsides spontaneously




    Application of ice




    Systemic steroids (short courses).



     




    Blistering


    It is more common in younger patients with loose periorbital skin and around eyes. Deeper peels, especially AHAs, can cause epidermolysis, vesiculation, and blistering especially in the sensitive areas such as nasolabial fold and perioral area. TCA 50% and glycolic acid 70% can cause blistering [Figure 1].





    Figure 1


    Blistering seen post-chemical peel on cheeks





     


    Prevention


    The nasolabial folds, inner canthus of the eye, and corners of the mouth should be protected with petroleum jelly.





    Ocular complications


    Accidental spillage of any chemical peel agents in the eyes can cause eye injuries in the form of corneal damage.



     


    Treatment


    In cases of accidental spillage, the eyes should be flushed copiously with normal saline to prevent corneal damage. If phenol peels have been used, flushing should be done with mineral oil instead of saline. Referral to an ophthalmologist should be done.




     


    Prevention


     



    Extreme care should be taken while peeling the periorbital area




    Dry swab stick should be kept ready to absorb any tears




    Peeling agents should not be passed over the eyes.



     





    Ectropion of the lower eyelid


    It is usually seen after a Baker Gordon phenol peel.[8]



     


    Predisposing factors


     



    Older patients with senile lid laxity




    Patients who have undergone previous transcutaneous blepharoplasty




    Patients with thin skin.



     





    Treatment


    Most of the time the process is self-limiting and corrects spontaneously or with conservative care.





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    CONSERVATIVE CARE


     



    Massaging of lower lid skin




    Adequate taping of the eyelid, especially at night




    Protection of the globe with artificial tears.[9]



     




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    INTRALESIONAL STEROIDS



    Surgical repair



     


    Prevention


    Be cautious when using phenol in the periorbital area to avoid burning in the eye.


    An assistant should always have a clean dry cotton-tipped applicator in his hand which should be used to absorb any tears that may drip down the face or into the temporal area.[9]




     


    Inherent errors


     



    Incorrect peel pharmacology




    With resorcinol combinations, TCA, or phenol formulas, evaporation of the alcohol or water vehicle base can occur, inadvertently producing a stronger solution.






    Accidental solution misplacement




    Avoid accidental spillage of the solution




    Never move the cotton-tipped applicators directly over the eye area





     






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    INFECTIONS


    They are rare in TCA and phenol peels since these peels are bactericidal.


     



    Impetigo and folliculitis (streptococcal and staphylococcal)




    Pseudomonas or Escherichia coli infections.[10]



     




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    PRE-DISPOSING FACTORS


    Prolonged application of biosynthetic membranes or thick occlusive ointments and poor wound care.



    Clinical features


     



    Delayed wound healing




    Folliculitis




    Ulceration, superficial erosions, crusting, and discharge.



     




    Treatment of bacterial infections


     



    Swab for culture and sensitivity




    Appropriate antibiotics: Topical and oral




    Wound cleaning with potassium permanganate soaks or acetic acid soaks three to four times a day




    Topical mupirocin for gram-positive infections




    Light debridement.



     




    Candidal infections


     



    Recent intake of oral antibiotics is often a pre-disposing factor




    Superficial pustules can occur in candidal infections




    Immunocompromised patients Diabetics




    Oral thrush




    Prolonged topical steroid use.



     




    Treatment


     



    Topical clotrimazole, 1%




    Systemic anti-fungals (fluconozole, 50 mg/day).



     




    Herpes simplex infection


    It is characterized by reactivation of herpes simplex on face and perioral area presenting as sudden appearance of grouped erosions associated with pain.




    Treatment


    Active herpetic infections can easily be treated with anti-viral agents. A course of Valaciclovir, 1 g twice daily for 10 days may be given. If detected early and treatment is given on time, they do not scar.[11]




    Prevention


    Patients with a positive history of herpes simplex should be given 400 mg of acyclovir three times a day beginning on the day of the peel and continuing for 7-14 days, depending on whether it is a medium depth or deep chemical peel. Few recommend acyclovir 200 mg five times a day or valaciclovir, 1 g times a day starting 2 days before a peel and continued for 14 days. It is preferred to treat all patients with anti-viral agents regardless of a positive history as many patients do not remember prior herpes simplex infection that may have occurred years ago. A negative history of cold sores cannot predict development of post-operative herpes simplex virus infection after a procedure.[10,11] Since all anti-viral agents inhibit viral replication in the intact epidermal cell, the drug would not have an inhibitory effect until the skin is re-epithelialized, which is 7-10 days in medium and deep peels. In the past, these agents were discontinued at 5 days and in these patients, clinical infection became apparent in 7-10 days.




    Prevention of infections


     



    Frequent post-operative visits should be done so that it can be ensured that appropriate home wound care is being performed and to minimize the risk of infection.




    Avoid occlusive dressing in the immediate post-operative period because of its propensity to promote folliculitis and streptococcal and staphylococcal infections.



     




    Delayed healing


    Prolongation of granulation tissue beyond 1 week to 10 days signifies delayed healing. Presence of persistent erythema is a sign of the wound not healing normally. It could be due to the following:


     



    Infections




    Contact dermatitis




    Systemic factors




    Diminished or absent skin appendages may impair epidermal regeneration with delayed wound healing.[12] Presence of vellus hairs may indicate that epidermis is capable of regenerating after a chemical peel in spite of previous radiation for cancer.[3]



     




    Treatment


     



    Treatment of infections already discussed




    Debridement if necessary




    Treatment of contact allergic or irritant dermatitis with steroids




    Change of contact agents or protection with a biosynthetic membrane. Daily dressing along with a close watch on healing skin is a must.



     




    Prevention


     



    Strict sun avoidance and use of broad spectrum sunscreens before and after the peels indefinitely




    Hypopigmenting agents (hydroquinone, kojic acid, and arbutin) should be strictly enforced in the post-peel period too.



     




    Treatment


    Triple combinations of hydroquinone, tretinoin, and steroids should be started once re-epithelialization is completed.


     



    Hypopigmentation [Figure 2] superficial peels





    Figure 2


    Hypopigmentation seen post-peel






    Transient lighter complexion is seen due to sloughing off of the epidermis and removal of excess melanin.



     




    Medium peels


     



    More prolonged hypopigmentation because of removal of basal layer




    Especially with 50% TCA and phenol peels.



     




    Hyperpigmentation


    It can occur any time after a peel and can be persistent, if treated inadequately. It is the most common complication of TCA peeling.


    Complications from superficial peels are limited to transient hyperpigmentation or dyschromia especially in dark-skinned patients. With medium depth peels, irregular pigmentation can occur. Temporary accentuation of lentigines and nevi may also occur because the existing sun damage has been cleared. Patients should be warned that lesions like solar lentigines may initially disappear and then return after chemical peel. This occurs because the melanocytes that are responsible for pigmentation reside below the level of chemical peel [Figure 3].





    Figure 3


    Hyperpigmentation post-peel






    High-risk groups


     



    Types III-VI skin




    Types I and II skin following intense sun exposure and tanning or use of photo-sensitizing agents




    Use of photosensitizing agents such as Non steroidal anti-inflammatory drugs, oral contraceptives, etc.




    Early exposure to sunlight without adequate broad spectrum sunscreens




    Estrogen containing medication, e.g., oral contraceptives and hormone replacement therapy



     




    Treatment


     



    Retinoic acid, 0.05% cream in combination with 4% hydroquinone once or twice daily for 3 weeks or longer if necessary




    Hydrocortisone cream can be used for several weeks as needed if erythema due to retinoic acid poses a concern




    Use of sunscreen with Sun protection factor 30.



     


    In some cases, a superficial peel (glycolic acid, 30-40%) is used to hasten resolution.




    Prevention


    Good skin care regimens can sustain more long-lasting results though studies have shown that peeled skin returns to its baseline status within 2-6 months without maintenance therapy.


     



    Strict sun avoidance and use of broad spectrum (ultraviolet A and sunscreens before and after the peels indefinitely




    Pre-treatment with a depigmenting agent and tretinoin




    In case of superficial peels, start at low strengths and titrate up very slowly




    Cessation of use of birth pills during peripeel period because it may invoke pigmentary changes.



     


    Incorporate broad spectrum sunscreens/bleaching agents (hydroquinone, kojic acid, arbutin)/retinoids/AHAs and beta-hydroxy acids/other anti-oxidant cosmeceuticals and bleaching creams singly or in combination as post-peel skin care regime.




    Skin depigmentation


    Bleaching effect can be seen after phenol peels. It is often noticed in the jaw neck region where untreated skin in the neck appears more obvious as it abuts the newly rejuvenated cheek or periorbital skin. This appearance may be desired in some but in patients undergoing regional facial peeling, this bleaching may become noticeable and troublesome. It is due to melanocytes losing their function to produce melanin.




    Lines of demarcation


    These are seen in medium and deep depth peels in darker skin types. They can be prevented by feathering edges using peeling agents of lower concentrations to merge with surrounding normal skin.




    Milia


    These are inclusion cysts which appear as a part of the healing process and are more common with dermabrasion than chemical peels. It is usually seen during the first few weeks of the recovery period. The post-peel care of deeper peeling may cause milia by occluding the upper pilosebaceous units with ointments. Thicker-skinned patients have been said to be in greater risk.




    Treatment


    Milia often resolve spontaneously with normal cleansing of the face. Sometimes, extraction or gentle electrodessication is effective.




    Prevention


    Returning to gentle epidermabrasion after re-epithelialization or the use of tretinoin both before and after peeling may retard their appearance.




    Texture changes


    Temporary appearance of enlarged pores post-peel can occur due to removal of stratum corneum. If the wounding agent is not capable of peeling below the defect, lacks the surfactant to provide an even depth of wounding, or has a very high surface tension, then uneven results will be produced from the selection of this inadequate wounding agent to peel below defect depth. Patients with telangiectasias may notice a worsening after phenol peeling which can be treated with vascular lasers.




    Atrophy


    It is characterized by the loss of normal skin markings in the absence of scarring. It may occur with phenol peels but has not been usually seen with superficial or medium depth TCA peels. Periorbital skin is very prone since it is physiologically thinner than most facial areas.[1]





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    INTRALESIONAL STEROIDS



    Surgical repair



     


    Scarring


    Patchy erythema which may be indurated or persistent erythema can predict early scarring. The risk of hypertrophic scarring from medium depth peels is rare. If it occurs, it is most commonly seen along the mandibular region and in the perioral regions. TCA is more caustic than phenol and may be more likely to produce scarring [Figure 4].[13]





    Figure 4


    Scarring seen on left cheek after peel






     


    Predisposing factors


     



    History of smoking




    History of recent intake of 0.5 mg/kg isotretinoin (during the previous 12 months). Clinically, it is safe to perform a peel on patients after their skin begins to produce normal oil. Before performing any resurfacing procedure, most practitioners recommend to wait for 18-24 months after high-dose isotretinoin has been stopped, except in case of superficial peels. Low-dose isotretinoin in the dose of 10-20 mg three times a week is found to be safe and effective during the peel period.[14]




    Recent facial surgery that required significant undermining




    Recent ablative resurfacing procedures including dermabrasion or laser within 6 months of procedure. Since re-epithelialization occurs from adnexal structures, some authors have theorized that patients recently treated for hair removal with lasers may have trouble healing after medium or deep depth peels.[15]




    Past history of keloids/hypertrophic scars.




    Overzealous application of TCA




    Medium depth peels on the areas like mandible, neck, and chest because these areas are more likely to scar




    Thin-skinned patients are more prone for scarring because the TCA is more likely to penetrate deep into the reticular dermis.



     





    Treatment


     



    Scar massage




    Topical/oral/intralesional steroids




    Surgical revision after scar maturation




    Pulsed dye laser therapy




    Silicon gel sheet.



     




    Systemic side-effects


    Phenol peels can cause cardiac, renal, and pulmonary toxicities. The best management of these complications is to avoid them.




    Cardiac arrhythmias


    In patients deliberately face peeled with phenol in 30-min time, tachycardia was usually noted first followed by premature ventricular contractions, bigeminy, paroxysmal atrial tachycardia, and ventricular tachycardia. Some progressed to atrial fibrillation,[16,17] Resorcinol resembles phenol in its systemic actions. Theoretically, similar complications might be induced if painted over one-third of body surface. A 40% peeling resorcinol paste applied daily for 3 weeks produced dizziness, pallor, cold sweat, tremors, and collapse on final application.[3,18] Resorcinol has an anti-thyroid activity. Hence, continuous application can cause myxedema. Repeated applications should be applied with caution in low body weight patients.




    Laryngeal edema


    Stridor, hoarseness, and tachypnea have been reported developing within 24 h of phenol peeling. It may be due to hypersensitivity reaction in a larynx already chronically irritated by cigarette smoke and may resolve with warm mist therapy. Anti-histamines prior to peel may prevent this.




    Toxic shock syndrome


    Physician should be alerted if patients develop fever, syncopal hypotension, vomiting, or diarrhea 2-3 days after a peel followed by scarlatiniform rash and desquamation. Other symptoms include myalgias, mucosal hyperemia, and hepatorenal, hematological or central nervous system involvement. Beta-lactamase-resistant antibiotics with large volumes of parenteral fluid should be given to prevent vascular collapse.[19,20]




    Prevention of complications


     



    Select only skin types I and II for deep peel




    Limit systemic levels of phenol due to absorption from skin




    Intravenous hydration with 0.5-1 of fluid (lactated ringers) before and during procedure to enhance phenol excretion and avoid renal toxicity.[15]




    Cardiac monitoring to detect any electrocardiography abnormality (premature ventricular contraction/premature atrial contractions).[21] In such cases, the procedure should be halted.




    In a series of full face phenol peels, the incidence of cardiac arrhythmias was 6.6%.




    Full face peels should be performed over a 60-90 min period of time. Each cosmetic unit (forehead, cheeks, nose, perioral, and periorbital areas) should be peeled in 15 min increments.[9] Peeling segments of the face in intervals with diuresis will allow metabolism and excretion of phenol and reduce arrhythmias.[3]



     


    Intraoperative oxygen to prevent arrhythmias.




    Allergic reactions


    Allergic contact dermatitis is more common with resorcinol, salicylic acid, kojic acid, lactic acid, hydroquinone, etc.


    Irritant contact dermatitis can be caused by glycolic acid. Any peel can cause irritant dermatitis when used with excessive frequency, inappropriate high concentration, and vigorous skin preparation using acetone or another degreasing solution.




    Deeper penetration of peel



     


    Predisposing factors


    Beginning a regimen with tretinoin


    Facial shaving


    Use of exfoliating scrubs.




     


    Prevention


     



    Closely examine condition of skin




    Elicit a good history from the patient prior to peel




    Correct patient and peel selection




    Priming of skin




    Post-peel care and sun protection




    Beware of habitual skin pickers




    Beware of those who have a tendency for PIH



     


    The complications of superficial and medium deep peels are summarized below Table 1





    Table 1


    Complications for peeling procedures[22]








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    SUMMARY


    Chemical peels represent a flexible and useful tool for improving skin texture and the effects of ageing. The level of expertise of a dermatologist is crucial for the rate of side-effects and for the final peel results. Superficial peels are easy to perform and their complications are rare if appropriate pre-peel and post-peel care is taken.
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    Chemical burn following 50% trichloroacetic acid for acne: Presentation of a case and a focused review


    Hannah Liua, , 


    Amor Khachemouneb, , , 


    Rashid M. Rashidc, 


    1. Introduction



     


    The use of chemical peels to improve the appearance and quality of skin has been described as early as 1550 BC in the Egyptian Papyrus Ebers (Bryan, 1974). Ancient Egyptian women, most famously Cleopatra, were known to bathe in sour milk to soften the skin. Since the 19th century, dermatologists have made use of various chemical agents to perform peels as a treatment for acne, pigmentary changes, actinic keratoses, and photoaging. In 2000, the chemical peel was the most popular minimally invasive cosmetic procedure with over 1 million treatments performed. Although this number has remained stable, in recent years peels have been surpassed by the rapid growth of botulinum toxin and soft tissue filler procedures (American Society of Plastic Surgeons, 2013). Trichloroacetic acid (TCA) holds an important place in the assemblage of chemical peeling agents, and is widely known for its safety and reliability. However, its use is highly technique-dependent and results rely heavily on the operator. TCA is frequently used dependably by the experienced practitioner, and there is a relative dearth of reports of complications related to TCA peels. Here we present a case of improper home usage of 50% TCA by a patient resulting in chemical burn. There are no similar reports in the peer-reviewed literature involving this strength of TCA, nor are there previously published histopathological data to support this unique complication. We also review adverse events related to chemical peels in the English literature.


    2. Case synopsis


    A 38-year-old Asian male with Fitzpatrick Phototype IV skin was using 10% TCA at home for treatment of acne. Seeing that his acne was improving with this regimen, he sought to achieve faster and more dramatic results. The patient then purchased 50% TCA online and applied it to his face. Upon application he felt severe stinging and noted white frosting of the skin. He tried to wash off the TCA with cold water; however, over the next few days, noticed that his skin began to change color. He presented to clinic for a consultation and evaluation 4 days after using 50% TCA. On examination of his face (Fig. 1) there was intense hyperpigmentation of the skin with an almost ecchymotic color, and sharp lines of demarcation. The skin was non-tender and no hyperkeratosis or peeling was noted. A biopsy was performed of skin from an involved area on the forehead near the hairline.








    Fig. 1. 

    Erythema and hyperpigmentation four days following 50% TCA application to the face (a) and temple (b).





    Figure options

     






    The microscopic specimen showed necrosis of the superficial spinous layer as well as focal full-thickness epidermal keratinocyte necrosis (Fig. 2). There was a mild superficial perivascular lymphocytic infiltrate with few neutrophils and eosinophils. Also, there was pigment found within many of the necrotic and remaining viable keratinocytes, likely contributing to the clinical findings. There was focal dermal pigment incontinence with few melanophages found in the papillary dermis. In addition, much of the epidermal pigment within the necrotic and remaining keratinocytes was retained. The histopathological findings correlated well with a chemical burn following TCA exposure.








    Fig. 2. 

    Histopathological specimen from affected skin of the right forehead near the hairline showing epidermal necrosis and pigment incontinence.





    Figure options

     






    3. Clinical course


    This patient was started on a regimen of fluocinolone 0.01% cream, hydroquinone 4% cream, and tretinoin 0.05% cream, as well as aggressive moisturization. He was also instructed to use sun protection by wearing a hat and applying sunscreen every few hours. Unfortunately, this patient was subsequently lost to follow-up.


    4. Discussion


    TCA is one of the most widely used peeling agents, along with alpha-hydroxy acids (AHAs) and phenol. Unna first described the action of this inorganic acid on the skin in 1882 (Brody et al., 2000), and several authors soon followed. There are a multitude of indications for TCA peels including photoaging, rhytides, lentigines, actinic keratoses, acne, acne scars, melasma, and dyschromia. TCA works by precipitating proteins and inducing coagulative necrosis of the epidermis and/or papillary dermis. This is followed by sloughing off of the necrotic layers and reepithelialization via germinative centers of neighboring hair follicles over the next several days. TCA peeling also promotes dermal collagen remodeling, which can continue for months (Nguyen and Rooney, 2000). TCA has a protein dissociation constant (pKa) of 0.52, making it an inherently stronger acid than AHAs (pKa of glycolic acid – 3.83). TCA is self-neutralizing within minutes after application, and appearance of a white frost indicates the endpoint of the peel.


    TCA in strengths of 35% or less is used for superficial peeling whereas in strengths of 35–50% it is used for medium-depth peeling. When used alone at the higher concentrations, TCA is less predictable and is associated with an increased risk of adverse events, including hypertrophic scarring (Nguyen and Rooney, 2000). For this reason, TCA at lower concentrations is often combined with other peeling agents to achieve the desired depth while minimizing the side-effect profile. One common approach is to use 35% TCA after Jessner’s solution for treatment of actinic keratoses. Currently, there is a relative scarcity of reports in the literature on adverse events following TCA peels. It is likely that such events have been underreported, but are nevertheless quite rare.


     




    The risk of an adverse event following a peel is directly related to the depth of the peel, which in turn is determined based on the level of injury produced (Table 1). Complications associated with chemical peels can be divided into immediate onset effects, which occur within minutes to hours, and late onset effects, which occur in days to weeks (Nikalji et al., 2012) (Table 2). Our patient’s striking presentation following 50% TCA reflects hyperpigmentation in combination with persistent erythema. Hyperpigmentation is the most common complication occurring after a TCA peel (Nikalji et al., 2012). The mechanism underlying TCA induced hyperpigmentation may be related to the skin stress response system. A recent study suggests that TCA activates the skin stress response system by directly inducing pro-opiomelanocortin and melanocortin-1 receptor production by keratinocytes (Kimura et al., 2012). Persistent erythema is erythema lasting longer than expected for an individual peel (Monheit, 2004). It is often a predictor of scarring, and some authors assert that areas of erythema three weeks after a peel should be viewed as definite precursors to scars that must be treated aggressively (Rubin, 1995).





    Table 1.

    Level of peel, peeling agent, and depth of injury. DEJ – Dermal–epidermal junction.





    Level of peel


    Peeling agent


    Depth of injury


    Superficial


    10–35% TCA, 30–70% AHA


    Epidermis +/− DEJ


    Medium


    35–50% TCA, combination peels


    Papillary/upper reticular dermis


    Deep


    >50% TCA, phenol


    Reticular dermis




    Table options

     









    Table 2.

    Side effects and complications of TCA peels.





    Immediate onset (minutes to hours)


    Late onset (days to weeks)


    Erythema


    Herpes reactivation


    Irritation


    Secondary infection


    Burning


    Persistent erythema


    Pruritus


    Scarring and milia


    Pain


    Delayed healing


    Edema


    Acneiform eruptions


    Blistering


    Textural changes


    Photosensitivity


    Dyschromia (hyper or hypopigmentation)


    Contact dermatitis


    Lines of demarcation


     


    Atrophy and telangiectasias


     


    Ectropion and ocular complications




     


    Adapted from Nikalji et al. (2012).


     




    Table options

     






    Several factors predispose patients to hyperpigmentation following chemical peels. Ethnic or Fitzpatrick Phototype III–VI skin is particularly vulnerable to both hyperpigmentation and hypopigmentation. In addition, skin of color responds less predictably to chemical peels, and is more prone to hypertrophic scarring (Roberts, 2004 ;  Salam et al., 2013). These factors preclude such patients from receiving deep peels, and warrant the use of great caution for superficial or medium peels, even by the experienced practitioner (Roberts, 2004 ;  Salam et al., 2013). In addition, use of estrogen containing medications, photosensitizing drugs, and early exposure to sunlight all increase the risk for hyperpigmentation (Nikalji et al., 2012). In the case of our patient, skin type and improper self-administration of high strength TCA were the leading instigating factors.


    Preventative measures are the most ideal methods for avoiding complications related to chemical peels. Although there is no universally accepted protocol, several authors recommend pre-treating the skin with a combination of a topical retinoid, hydroquinone, and topical steroid applied daily for 2–4 weeks prior to the peel (Roberts, 2004; Salam et al., 2013 ;  Fischer et al., 2010). Nanda et al. (2004) found that pre-peel priming with 2 % hydroquinone was effective in reducing the risk for hyperpigmentation, with similar improvements as those seen with 0.025% tretinoin at 12 weeks post-peel. However, the hydroquinone group had a statistically superior reduction in hyperpigmentation at 6 months. These agents, in addition to rigorous sun protection, are thought to suppress melanocytes (Bulengo-Ransby et al., 1993) prior to the peel and hence prevent hyperpigmentation. Some recommend continuing this regimen post-peel as well for maximal efficacy, and a similar approach is used to treat hyperpigmentation resulting from a peel. For refractory hyperpigmentation, laser treatment may be of benefit.


    In summary, chemical burn is a very rare complication following TCA peels. Here, we report the first case to our knowledge of a chemical burn from 50% TCA presenting with striking dyschromia. This clinical scenario emphasizes the importance of understanding the adverse effects of peeling agents, as well as the differential responses of ethnic skin to these treatments. Finally, physicians must be aware of the accessibility of these chemicals outside of the medical setting, and the potential for misuse.



     



     
  3. Forums Scar treatments 11  replies 3,406  views






    I posted this 2- years ago when I was asked for proof of successful treatments "pics", or has anyone had success. This is now included in my DIY Guide to Acid peels (Linked off the FAQ - top of the acne scar sub - first post - Under Peels).
    This post was made so you can see the treatments we offer do successfully work even if people do not post "pics". Acid peels are very successful as a alternative to laser at resurfacing the skin (without the side effects). If your doing DIY it takes many treatments over time ) 3 months it takes collagen to develop, or your Dr can do a "deep" sedated TCA or Penol peel to get under the scars. Microneedling without TCA is not effective they work synergistically together over time. This may be subsituated with RF Microneedling (Infini) if you have the proper scars and $$$$.  Also be aware the above study exact method might not work for you or your individual case, this is why the FAQ was made (many studies like this hide secrets Dr's do for treatment or do things unsafe for home DIY. Do not attempt this without reading the FAQ and Acid Peel Guide. AS always a doctor can treat with much better results and quicker outcomes for your personalized scar types. https://www.acne.org/messageboard/topic/361029-official-acne-scar-solutions-qa-faq-read-before-posting/
    Point anyone who wants proof to this post ("Pics" below).
    ______________________________
    TCA, Microneedling, Subcision w/ Filler give the best results for Acne Scars!
     



     



     






    Combination Therapy in the Management of Atrophic Acne Scars



    Shilpa Garg and Sukriti Baveja





    J Cutan Aesthet Surg. 2014 Jan-Mar; 7(1): 18–23.


    doi:  10.4103/0974-2077.129964




    INTRODUCTION


    Acne is prevalent in over 90% adolescents and it persists into adulthood in approximately 12%-14% of cases with psychological and social implications.[1,2,3] In some patients with acne, the inflammatory response results in permanent, disfiguring scars from either increased tissue formation or due to loss or damage of tissue. Hypertrophic scars and keloids are examples of scars that result from increased tissue formation. Scars with loss or damage of tissue can be classified into icepick, rolling and boxcar scars.[4] There is no standard treatment option for the treatment of acne scars. Medical management of atrophic scars can be done by using topical retinoids. Surgical management can be done using punch excision, elliptical excision, punch elevation, skin grafting and subcision depending on the type of scar. Procedural management includes microdermabrasion, chemical peels, percutaneous collagen induction by microneedling and dermabrasion. Tissue augmentation can be done using xenografts, autografts and homografts. Various ablative and non-ablative lasers and light energies are also available for treatment of atrophic acne scars.[5] Out of these multiple treatment options, treatment has to be tailored to patient's needs, tolerance, and goals along with the physician's assessment, skills and expectation. Patient should be counselled that the ultimate goal of any intervention is to improve the scars and no currently available treatment will attain total cure or perfection.


    In 1995, Orentreich and Orentreich described subcision as a method of subcuticular undermining of scars using a tri-beveled hypodermic needle. This results in lifting the scar by releasing the papillary dermis from the binding connections of the deeper tissues and by the formation of connective tissue that results from the course of normal wound healing.[6] It is mainly used for the treatment of rolling type of atrophic scars.[4]


    The mechanism hypothesised for action of percutaneous collagen induction using dermaroller is that it creates thousands of microclefts through the epidermis into the papillary dermis. These wounds create a confluent zone of superficial injury which initiates the normal process of wound healing[7] with release of several growth factors. This stimulates the migration and proliferation of fibroblasts resulting in collagen deposition[8] which continues for months after the injury.[9] Another hypotheses states that on penetration of skin with the microneedles, the cells react with a demarcation current which in addition to the needles own electrical potential results in release of various growth factors. This cuts short the healing process and stimulates the healing phase.[10] Dermaroller also opens pores in upper layers of epidermis and allows creams to be absorbed more effectively by the skin.


    Fifteen percent tricholoroacetic acid (TCA) peel is superficial peeling agent. It causes exfoliation, improves the skin texture and induces collagen synthesis.[11]


    The aim of our study was assessment of combination therapy using subcision, dermaroller and 15% TCA peel for the management of atrophic acne scars. The rationale for combining these three minimally invasive procedures was their additive action on acne scars. Subcision releases the scars from the underlying adhesions which should be the first step for any treatment for acne scars. Microneedling with dermaroller causes collagen induction along with enhancing absorption of tretinoin cream. Fifteen percent TCA peel causes improvement in skin texture as well as collagen induction. Hence by combining these three minimally invasive modalities one can release the scars, enhance collagen induction, increased penetration of topical agents and resurface the skin.

     

    MATERIALS AND METHODS


    Fifty patients with atrophic acne scars were enrolled in this study. Exclusion criteria were patients with active acne, active herpes labialis, patients on systemic retinoids, evidence or history of keloid scars, pregnancy or lactation, history of any facial surgery or procedure for scars and patients with unrealistic expectations. All the patients were counselled for surgical intervention and written informed consent was taken. The atrophic acne scars were graded by a single non-treating physician using Goodman and Baron Qualitative scar grading system [Table 1].[12]





    Table 1


    Goodman and Baron Qualitative scar grading system




    Patient's skin was primed using topical tretinoin cream 0.05% at night along with sunscreen with a minimum SPF of 30 during the day for 2 weeks prior to starting the treatment. At the start of treatment, subcision was performed only once using a 24G needle. One day after the subcision, patient was called for the first sitting of microneedling with dermaroller containing 192 needles of needle size 1.5 mm. Eutectic mixture of lignocaine 2% and prilocaine 2% cream was applied under occlusion for 1 hour to the affected areas which was removed using gauze. Thereafter topical tretinoin cream 0.05% was applied to the affected area. Treatment was performed by rolling the dermaroller in vertical, horizontal and diagonal directions in the affected area until appearance of uniform fine pinpoint bleeding. Then the area was wiped with saline soaked gauze and tretinoin cream 0.05% was applied and washed off after 30 minutes. Two weeks after dermaroller, patient was called for 15% TCA peel. Whole face was cleansed using spirit and degreased using acetone. Fifteen percent TCA peel was applied with cotton tipped applicator on full face. Appearance of speckled white frosting was the end point of treatment with peel. After using dermaroller and 15% TCA peel, patient was instructed to apply sunscreen in the morning and mometasone furoate cream 0.1% twice daily for 5 days after which sunscreen was continued in the morning with tretinoin cream 0.05% applied at night time. Patient was asked to discontinue topical tretinoin cream application 2 days prior to TCA peel. Thereafter, dermaroller and 15% TCA peel were repeated alternately after every 2 weeks for six sessions of each and this was taken as the end point of our study. In some patients who developed inflammatory lesions of acne during treatment, capsule doxycycline or topical clindamycin cream 1% was given as and when required. Any adverse effects and interference in daily activities post-treatment were noted. Patients were evaluated for results 1 month after the last procedure was performed. Post-treatment scars were graded again by the same physician using Goodman and Baron Scale. Patient graded their response to treatment as poor, good, very good or excellent with 0-24%, 25-49%, 50-74% and 75-100% improvement, respectively, in their acne scars. The patients were followed up for 1 year at two monthly intervals to observe the sustenance of improvement in scars. Digital colour facial photographs were taken before treatment, during each visit of treatment, at 1 month after the last procedure and at 2 monthly intervals for 1 year after the last procedure. Patients were instructed to continue application of topical tretinoin cream 0.05% for 1 year after the last procedure.



    Statistical analysis


    Descriptive statistics such as mean and standard deviation are calculated. Data is presented in frequencies and their respective percentages. Data was entered and analysed using SPSS version 18.


     

    RESULTS


    Out of 50 patients, 49 patients completed the treatment. Out of 49 patients 2 patients were treated with capsule doxycycline during the treatment protocol due to active acne eruptions. Out of 49 patients there were 30 females and 19 males with age group between 18-39 years with mean age of 25.6 ± 5.2 yrs. 9 patients (18.4%) had Type III Fitzpatrick skin type, 32 (65.3%) type IV and 8 (16.3%) patients had type V Fitzpatrick skin type. Pre treatment melasma was present in 3 (6%) patients.


    Out of 49 patients who completed the treatment, 16 patients had Grade 4, 22 patients had Grade 3 and 11 patients had Grade 2 scars before treatment. The physician's assessment of response to treatment based on Goodman and Baron Qualitative scar grading system is summarised in Table 2. In patients with Grade 4 scars, 10 patients (62.5%) showed improvement by 2 grades i.e., their scars improved from Grade 4 to Grade 2 of Goodman Baron Scale [Figure [Figure1a1a and andb].b]. Six patients (37.5%) with Grade 4 scars showed improvement by 1 grade [Figure [Figure2a2a and andb]b] with scars being obvious at social distances of 50 cm or greater. In 22 patients with Grade 3 scars, 5 patients (22.7%) showed improvement by 3 grades i.e., they were left with no scars at all [Figure [Figure3a3a and andb],b], Two patients (9.1%) improved by 2 grades and as per Grade 1 they were left with only hyper-pigmented flat marks [Figure [Figure4a4a and andb]b] and 15 patients (68.2%) showed improvement by 1 grade by moving to Grade 2 [Figure [Figure5a5a and andb]b] as per Grade 2 their scars were not obvious at social distances of 50cm or greater. All 11 patients (100%) who had Grade 2 scars before treatment showed improvement by 2 grades in their scars and were left with no scars [Figures [Figures6a6a–b and and7a7a–b]. Hence all 49 patients (100%) had improvement in their scars by some grade with no failure rate. In patients with Grade 4 scars [Table 3], 12 patients (75%) graded their response to treatment as very good with 50-74% improvement in their acne scars after treatment and 4 patients (25%) had good improvement in their scars with 25-29% improvement. In patients with Grade 3 scars, 8 patients (36.4%) graded their response to treatment as excellent with 75-100% improvement in their scars and 14 patients (63.6%) reported the response as very good with improvement between 50 and 74%. All 11 patients (100%) with Grade 2 scars graded their response after treatment as excellent with improvement between 75 and 100%. Poor response with 0-24% improvement in scars was reported by none of the patients. Improvement in scars was first noted in majority of the patients after completing two sitting of dermaroller and peel. At the end of 1-year of follow-up, it was observed that all the 49 patients sustained the level of improvement in their grade of scars which was attained at the end of the last procedure [Figure [Figure8a8a–c]. Although improvement in the scars as noticed by the patient and the physician continued in the follow up period of 1 year, there was no further shift in the grade of scars.





    Table 2


    Physician's assessment of response to treatment based on Goodman and Baron Qualitative scar grading system







    Figure 1


    (a) Grade 4 acne scars; (b) Improvement in acne scars from Grade 4 to Grade 2 after treatment







    Figure 2


    (a) Grade 4 acne scars; (b): Improvement in acne scars from Grade 4 to Grade 3 after treatment







    Figure 3


    (a) Grade 3 acne scars; (b) Post-treatment patient had no scars







    Figure 4


    (a) Grade 3 acne scars; (b) Improvement in acne scars from Grade 3 to Grade 1 after treatment







    Figure 5


    (a) Grade 3 acne scars; (b) Improvement in acne scars from Grade 3 to Grade 2 after treatment







    Figure 6


    (a) Grade 2 acne scars; (b) Post-treatment patient had no scars







    Figure 7


    (a) Grade 2 acne scars; (b) Post-treatment patient had no scars







    Table 3


    Patient's assessment of response to treatment







    Figure 8


    (a) Grade 4 acne scars; (b) Improvement in acne scars from Grade 4 to Grade 2 after treatment; (c): Sustenance of improvement in acne scars from Grade 4 to Grade 2 at 1 year of follow-up




    There was improvement in rolling, boxcar and linear tunnel type of scars with little or no improvement in ice pick scars. All patients tolerated the procedure well. Side effects were mild and transient. Post-dermaroller transient erythema and oedema lasted for 1-4 days with a mean of 2.4 ± 0.7 days. Post-peel exfoliation of skin was present from 2 to 7 days with a mean of 4.4 ± 1 day. Only three patients (6%) developed post-inflammatory hyper-pigmentation (PIH) which was treated with sunscreen in the morning and triple combination of tretinoin, hydroquinone and mometasone at night time. The PIH subsided after 5 months of topical treatment. One patient (2%) developed mildly tender cervical lymphadenopathy each time after dermaroller which lasted for around 3 weeks and subsided on its own. There was no interference in daily activity with no loss of days at work.

     

    DISCUSSION


    This study has shown good results in patients with severe Grade 4 and 3 acne scars with 10 (62.5%) patients with Grade 4 scars moving to Grade 2 and 5 (22.7%) patients with Grade 3 scars improving to have no scars at the end of treatment. In Grade 2 scars all the 11 patients (100%) showed improvement by 2 grades and were left with no scars. Hence, all 49 (100%) patients showed improvement in their scars by some grade with no failure rate. The physician's analysis also correlated with the patient's assessment of improvement in scars with 12 (75%) patients with Grade 4 scars reporting improvement as very good, 8 (36.4%) patients with Grade 3 scars as excellent and 11 (100%) patients with Grade 2 scars as excellent with poor response reported by none of the patients. The procedure was well tolerated by all the patients. Post-procedure there was no loss of work days and side effects were mild and transient. In spite of patients being of Type III, IV and V Fitzpatrick skin type, only three patients (6%) developed PIH during the treatment, which subsided within 5 months of topical therapy. It has the advantage of being an office procedure and in being cost-effective. Topical tretinoin 0.05% favours the development of a regenerative lattice-patterned collagen network rather than the parallel deposition of scar collagen found with cicatrisation. Since dermaroller opens pores in the upper layer of epidermis and allows creams to be absorbed more effectively, it is for this reason that topical tretinoin was applied during dermaroller and kept for 30 minutes post-procedure to maximise its absorption in skin. Also the improvement in the grade of scars was sustained in the follow-up period of 1 year.


    Although ablative laser resurfacing is generally considered to be the most effective option for scar resurfacing, it is associated with significant damage to the epidermis and basal membrane with associated inflammation which causes erythema, scarring and pigmentation problems.[13,14,15] It also has a long downtime. In comparison, percutaneous collagen induction does not induce post-operative dyspigmentation as the epidermis and basal membrane are left intact.[16]

     

    CONCLUSIONS


    As the demand for less invasive, highly effective cosmetic procedures is growing, this combination of treatment for acne scars has shown good results not only in Grade 2 but also in severe Grade 4 and 3 acne scars. The treatment is well tolerated in Fitzpatrick skin types III, IV and V with no failure rates or loss of days at work. There is a high level of patient satisfaction, minimal downtime and the treatment is cost-effective to the patient. To our knowledge, this is the first study using this combination of therapy in the management of atrophic acne scars and the first in which topical tretinoin cream was applied both during and immediately after doing dermaroller.

    __________________________________________________________________________________________________________________





    Indian Dermatol Online J. 2014 Jan-Mar; 5(1): 95–97.


    doi:  10.4103/2229-5178.126053



     



    PMCID: PMC3937506






    Subcision plus 50% trichloroacetic acid chemical reconstruction of skin scars in the management of atrophic acne scars: A cost-effective therapy



    Jasleen Kaur and Jyotika Kalsy1




     



    Treatment of acne scars is a dilemma both for the treating physician and the patient as no oral or topical medicine works and it is associated with emotional and psychological stress. Acne scars are classified into three different types: Atrophic, hypertrophic, or keloidal. Atrophic scars are the most common type of acne scars. They have been further classified into three types as described by Jacob et al.[1] into ice-pick scars, rolling scars, and boxcar scars. Most of the patients with atrophic acne scars have more than one type of scars.


    Various treatment modalities like punch excision and elevation, subcision, chemical peeling using various strengths of TCA, micro-needling, ablative, non-ablative lasers and fillers either singly or in combinations have been described in literature with varying results. Most of these procedures require costly equipment and materials and not affordable by many people.


    Subcision or subcutaneous incision-less surgery is a term coined by Orentreich and Orentreich[2] in 1995 as the treatment option for atrophic acne scars. Here hypodermic 18 no. needle is used to break the fibrotic strands that tethered the scars to the underlying tissues leading to uplifting of scars. Combining subcision with other scar revision techniques or repeated subcisions may be beneficial to the patients.[3] TCA chemical reconstruction of skin scars (CROSS)[4] is another useful method for treatment of atrophic acne scars. It involves focal application of 50-100% of TCA with a wooden applicator on the base of an atrophic scar, which causes precipitation of proteins and coagulative necrosis of cells in the epidermis. There is necrosis of collagen in the papillary and upper reticular dermis. Healing is rapid because of sparing of adjacent normal tissues and adnexal structures. So there is reorganization of dermal structural elements and increase in collagen content that leads to filling of the atrophic scar.


    While going through the literature, we found that different studies have used subcision and CROSS TCA alone or in combination with other techniques as well as their comparative studies but we did not find any study combining these two techniques together to the best of our knowledge. Encouraged by that, we combined subcision and TCA cross in all types of scars as subsicion breaks the dermal tethering of the scar tissue and TCA will remodel the collagen underneath the scar which treats the basic pathology of the scar to some extent.


    In our study, 10 female patients between the age group of 20-35 years of skin type 4 and 5 with atrophic acne scars on the face were randomly selected. Most of the patients had more than one type of atrophic scars of grade 4 severity as described by Goodman.[5] In all the patients, there were no active acne lesions and none of them were on oral isotretinoin 3 months prior to inclusion in our study. Patients with keloidal tendencies, bleeding diathesis, and history of recurrent herpes simplex were excluded. Complete hemogram, random blood sugar levels, and viral markers were done in all the patients. Written consent after explaining the risks and benefits of treatment was taken from all the patients along with pre-/post-procedure photographs. Subcision followed by 50% TCA CROSS was done at 4 weeks interval for three sessions. Patients were followed-up monthly for improvement in scars up to 6 months.


    Priming was done 2 weeks prior to the treatment with 2% hydroquinone and tretinoin 0.025% cream at night and sunscreen more than 30 sun protection factor (SPF) was given in the morning. Procedure was carried out after application of topical anesthetic cream for 45 min followed by infiltration of 2% Xylocaine with normal saline under aseptic conditions. A no. 18 hypodermic needle attached to a syringe was introduced horizontally underneath each scar and was moved back and forth till the snapping sound was heard. We used no. 18 hypodermic needle because it is cheap and easily available. Homeostasis was maintained by pressure. We cleaned the entire area with normal saline which was followed immediately by 50% TCA with the tip of a toothpick by pressing hard on the entire area of depressed atrophic acne scars irrespective of the type of scar and frosting was taken as the end point, antibiotic cream was applied, and patient was sent home. Patient was advised to apply antibiotic cream twice daily followed by sunscreen in the morning. Erythema, edema, and crusting lasted for 7-10 days in all the patients to varying severity. After 10 days, the patient was advised to apply azelaic acid 20% cream at night.


    Results were evaluated on the basis of global scar grading system, visual improvement by photographs and patient satisfaction. The global acne scarring classification is a four-category qualitative system by Goodman[5] based on scar morphology and ease of masking by makeup or normal hair patterns. Grade 1 means macular scarring only, Grade 2 is mild atrophy, which is not visible beyond 50 cm and can be easily masked by makeup, Grade 3 is moderate atrophy obvious at social distance not easily masked by makeup while Grade 4 is severe atrophy.


    Percentages in improvement were calculated as a combination of the three parameters, i.e. global scar grading system by Goodman, visual improvement by photographs showing the change in the grade and patient satisfaction, which was assessed by giving a questionnaire to the patient where they had to rate their improvement on 0-10 point scale.


    Excellent >70%


    Good 50-70%


    Fair 30-50%


    Poor <30%


     



    We labeled results as excellent when there was a two-grade change in the scars observed by the dermatologist both by grading system, photographs, and patient rated his improvement as more than 7 [Figures [Figures11 and and33].





    Figure 1


    Sites involved right cheek. (a) Post-acne scars mostly ice pick, boxcars and few roller scars. (b) Decrease in number and depth of scars







    Figure 3


    Site involved is left cheek and left temple. (a) Many ice pick scars and a few boxcars and very few rolling scars. (b) Decrease in depth and size of scars






    Results were taken as good when there was one-grade improvement in acne scars observed by the dermatologist both by grading system, photographs, and patient rated his improvement as 5, 6, or 7 [Figure 2].





    Figure 2


    Sited involved right cheek. (a) Multiple post-acne ice pick and roller scars. (b) Decrease in size and depth of all the scars






    Results were taken as fair when there was improvement in acne scars observed by the dermatologist by photographs only and patient rated his improvement as 3, 4, or 5.




    Results were taken as poor when there was no improvement in acne scars observed by the dermatologist either by photographs or by grading system but it was only subjective improvement as told by the patient when they rated it between 1 and 3.



     


    In all the patients, scar grading improved from grade 4 to grade 2 and results were graded excellent, good, and fair in 6, 3, and 1 patients respectively [Table 1]. Although in various studies best results with CROSS TCA are seen in ice-pick scars but since in our study we combined it with subcision, results were equally good even in rolling scars and boxcars scars. Post-inflammatory hyperpigmentation was transient in three patients, which persisted for 15-20 days post-procedure, which further decreased over the time period with 20% azelaic acid and in one case, the mild hyperpigmentation persisted even at the end of 6 months in spite of the best efforts for reasons not known. The patients were also happy with the results except for the one where hyperpigmentation persisted. Although the procedure has a downtime in the form of erythema, edema, and crusting, it is comparable to all other resurfacing procedures and the problem of post-inflammatory hyperpigmentation can be judiciously tackled with the proper and repeated use of sunscreens and lightening agents. Each procedure when done individually has downtime of few days. So, we tried to reduce it by combining the two procedures. Hence, it can be concluded that subcision combined with TCA CROSS is a simple, safe, and cost-effective procedure, which does not require any specialized or costly equipments or materials or any special training and can be performed as an out-patient-department procedure by any budding dermatologist.

     
  4. Forums Hypertrophic (raised) scars 0  replies 416  views

    Keloid and Hypertrophic Scars Are the Result of Chronic Inflammation in the Reticular Dermis.
    Ogawa R1.

     


    Abstract



    Keloids and hypertrophic scars are caused by cutaneous injury and irritation, including trauma, insect bite, burn, surgery, vaccination, skin piercing, acne, folliculitis, chicken pox, and herpes zoster infection. Notably, superficial injuries that do not reach the reticular dermis never cause keloidal and hypertrophic scarring. This suggests that these pathological scars are due to injury to this skin layer and the subsequent aberrant wound healing therein. The latter is characterized by continuous and histologically localized inflammation. As a result, the reticular layer of keloids and hypertrophic scars contains inflammatory cells, increased numbers of fibroblasts, newly formed blood vessels, and collagen deposits. Moreover, proinflammatory factors, such as interleukin (IL)-1α, IL-1β, IL-6, and tumor necrosis factor-α are upregulated in keloid tissues, which suggests that, in patients with keloids, proinflammatory genes in the skin are sensitive to trauma. This may promote chronic inflammation, which in turn may cause the invasive growth of keloids. In addition, the upregulation of proinflammatory factors in pathological scars suggests that, rather than being skin tumors, keloids and hypertrophic scars are inflammatory disorders of skin, specifically inflammatory disorders of the reticular dermis. Various external and internal post-wounding stimuli may promote reticular inflammation. The nature of these stimuli most likely shapes the characteristics, quantity, and course of keloids and hypertrophic scars. Specifically, it is likely that the intensity, frequency, and duration of these stimuli determine how quickly the scars appear, the direction and speed of growth, and the intensity of symptoms. These proinflammatory stimuli include a variety of local, systemic, and genetic factors. These observations together suggest that the clinical differences between keloids and hypertrophic scars merely reflect differences in the intensity, frequency, and duration of the inflammation of the reticular dermis. At present, physicians cannot (or at least find it very difficult to) control systemic and genetic risk factors of keloids and hypertrophic scars. However, they can use a number of treatment modalities that all, interestingly, act by reducing inflammation. They include corticosteroid injection/tape/ointment, radiotherapy, cryotherapy, compression therapy, stabilization therapy, 5-fluorouracil (5-FU) therapy, and surgical methods that reduce skin tension.


    KEYWORDS:


    hypertrophic scar; keloid; radiation; steroid tape; surgery


     



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  5. Forums Announcements and feedback 6  replies 1,791  views
    My images in the FAQ and my personal Signature seem to be missing the image and just have placeholders with the name. Has something changed?
    BA
  6. Forums Scar treatments 28  replies 6,690  views

    July 2016 Davin Lim on Energy Devices and Scar Treatment
    Interesting Infini (goes 3.5mm, laser only 1.5mm) is his favorite when he is the Fraxel Spokesman, he gets the machines for free and is paid to talk at conferences. 
    Fraxel he said "is the most overrated treatments out there", good for minor scars but not many things. CO2RE is more powerful than the Fraxel device, even Re:pair.
    His number one recommendation seems to be Subcision & Filler depressed scars, & TCA Cross Icepics.
    As I have been saying in the FAQ for out Sub Forum... lasers are for surface texture and filler, subcision, microneedling, tca cross / spot tca peels, are great for scars before you go the laser route. Start with non energy treatments first and move to energy devices if you are ready ;-P
    He said to only do a derminator not a dermaroller they are not effective microneedles and often tear
     



    Syneron Candela Core / Co2re laser (good for acne scars "laser of choice acne scars" as it is customizable up to 80mj setting and can do hybrid mode like Total FX or shallow settings like Re:Store ETC All-in-one)


    Fraxel re:pair (tightens, refreshes skin, acne scars)


    Cynosure Picosure focus laser (great for large pores, no down time, ethnic skin, hyperpigmentation)


    Lutronic Infini Radio Frequency Microneedling (tightens & plumps, fractionated skin refreshing, goes deeper than laser, low down time)


    Ematrix (active acne pustules ablates top surface of skin)


    Scition erbium laser (great for ethnic skin or stacking with CO2 laser)


    Video Overview / Fractional laser resurfacing- dermatologist Review of All New Laser Technologies and Radio Frequency and Pluses of Each: 



     



    Syneron Candela Core / Co2re laser with deep acne scars:



     



    Results of Laser Acne Scar Procedures:



     



    Subscision is Still the Best Cheap Non Laser Treatment for Rolling Acne Scars: Tethered / Anchored / Puckered:



    TCA Cross for icepicks Procedure:  



     



     
  7. Forums Scar treatments 3  replies 6,293  views


     

    INTRODUCTION

    Hyaluronic acid (HA) is a glycosaminoglycan composed of alternating D-glucuronic acid and N-acetyl- D-glucosamine monosaccharide residue. These are cross-linked to form long unbranched chains, which form an anionic biopolymer. The 3-dimensional structure forms a space-occupying molecule, and the chemical makeup draws a large volume of water to the compound. Due to its combination of properties, endogenous HA contributes turgor and elasticity to the dermis.
    Hyaluronic acid has become the leading dermal filler due its combination of low allergenicity, high biocompatibility as demonstrated in ocular and intra-articular uses, and longevity. It is suitable for injection into facial skin, where, in addition to providing immediate and short-term augmentation, it appears to induce longer-term effects by stimulating collagenesis by native fibroblasts.1,2 Improvements in its in vivo longevity by cross-linking have further boosted its popularity. To maximize its utility and range of applications, HA has been prepared in a variety of forms, which vary in viscosity and formulation. Hyaluronic acid's viscoelastic properties are a function of the length of the molecular chains of the polymer, cross-linking, concentration, and particle size.3 Medium viscosity HA is best for moderate lines and wrinkles, such as glabellar lines and nasolabial folds. It is injected into the mid-to-deep dermis. Finer HA formulations are available for correction of fine facial lines, such as perioral and periorbital rhytids, and are injected in the superficial dermis. Specialized formulations are designed to be injected into the lip, while others indicated for restoring volume lost due to natural aging or HIV-related lipoatrophy are injected into the subcutaneous or supraosteal regions.
    Restylane® Vital is a low-viscosity HA gel, available in 12 mg/mL or 20 mg/mL. It is injected with a metered dose injector that deposits 10 μL per injection site (Figure 1).
    Given the properties, superficial injection, and microdosing delivery technique, Restylane Vital is an excellent candidate product for the treatment of ice pick acne scars. Twelve patients, whose moderate to severe ice pick acne scars had responded well overall to fractional laser resurfacing but who exhibited residual deep focal ice pick scars, were treated with Restylane Vital. The improvement was immediate, as expected, and the treatment was well tolerated by all patients. Restylane Vital therefore appears to offer an improved treatment modality for the treatment of acne scarring.
    Skin Boosters for Face

    Author: Dr Naomi / 28 Oct 2015


     


     





    Skinboosters injection into cheeks



     


    Skin boosters are related to dermal fillers in terms of what they are made of, the difference with skin boosters compared with dermal fillers is that they are not structural, ie they only improve the skin, rather than improve the supporting structures of the face.


    Aging of the skin


    Over time, levels of the naturally occurring substance responsible for maintaining skin hydration, HA, reduce.


    Hyularantic acid is a moisture binding substance in the skin, giving the skin firmness, plumpness and elasticity. It helps prevent lines wrinkles and fold forming. Moisturizing the surface of the skin with creams cannot replace the Hyaluronic acid loss which is occurring over time.


    The solution is to restore the skins natural hydration where the loss is occurring.


    What are skin boosters?


    Skin boosters replace the body’s Hyaluronic acid and rejuvenate the skin from the inside, it restores the skins hydrobalance, improves the elasticity and skin structure. Creating a youthful luster and glow


    What is the procedure for skin booster injection?


    The patient has consultation and photos and signs a consent form.


    For skinbooster injection into the face, a cannula is most often used. A small injection of local anaesthetic is given in 4 areas on the face (2 at each hairline and 2 at the jawline) a fine needle then creates a hole through which the cannula can enter. The skin booster is injected through the cannula


    Pain relief during treatment


    A numbing cream (eg EMLA or LMX ) may be applied to the area prior to the treatment (45 minutes prior is ideal) Glad wrap may be used over the numbing cream to increase its effect.


    If a cannula is used, local anaesthetic is used prior to the cannula being introduced into the skin


    There is local anaesthetic in the dermal filler


    Ice is always used to decrease pain and to reduce the risk of bruising.


    Very rarely patients will use Penthrox for skin boosters


    Nitrous oxide (happy gas) is available for patients to use


    How will I look immediately after the skin booster injections?


    There will be redness and swelling


    The skin around the 4 entry points for the cannula may be white due to local anaesthetic.


    Who is suitable for skin booster treatment?


    Everyone is suitable (not pregnant or breastfeeding patients)


    in particular;


    * Those with tired and dry thin skin, lack of skin tension


    * Those patients with signs of skin aging


    * Those who want the most natural looking results


    * Those who are frightened of dermal fillers because or are already happy with their structure, but still want to improve their skin. These patient will be very suitable for skin boosters


    * Those with thin skin


    * Those with acne scarring


    Results for skin boosters:


    Improved skin elasticity tone and thickness.


    Smoother and firmer skin


    Prevention of wrinkles, lines and folds


    Protocol for skin boosters


    one treatment, once per year suggested, but many patients have it 6 monthly because they love the results


    Side effects risks of skin boosters


    Bruising occurs in a significant number of cases.


    Swelling in the injection area will occur. This may last for 5 days


    Infection is a very rare complication, but always a possibility when the needle goes into the skin.


    Necrosis (blood vessel being blocked, interfering with blood supply to the skin) is very rare. This could lead to scarring


    Need for further treatment: 


    How long until the patient will see results


    The results will be seen immediately.


    Results will improve over the next 3-6 months as collagen stimulation effects start to show


    Cost of skin boosters


    From $420 per ml. Full face requires 3-4mls. So typical cost for treatment is $1260





    Before and after skinboosters, dermal filler, lightening cream and tretinoin







    Before and after 1 treatment of 3mls of skinboosters in cheeks.








    Before and after skinbooster


     




  8. Forums Prescription acne medications 0  replies 461  views
    This is a cross post from the Acne Scar sub discussing new data 2017 changing the thinking of (one must wait 6 months for treatment after tane),... Accutane / Isotretinoin and the possibility of acne / scar treatment during and shortly after prescription usage. 
    https://www.acne.org/messageboard/topic/371909-acne-scar-revision-will-this-change-things-acne-scar-treatment-usage-during-after-accutane-isotretinoin/
  9. Forums Hyperpigmentation - red/dark marks 0  replies 319  views


    Updated FAQ for Hyperpigmentation and PIE (post acne wounding), new video update with solutions.
    Naturally PIE / Hyperpigmentation takes time to heal (over a year for some. Checkout the FAQ (Very First Post of This Sub)!
    https://www.acne.org/messageboard/topic/365640-qa-faq-post-inflammatory-erythema-pie-post-inflammatory-hyperpigmentation-pih- hypopigmentation-read-before-posting/
     
  10. Forums Scar treatments 21  replies 7,377  views





    beautifulambition





    Veteran Member


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    Gender: Male


    Location: San Francisco, CA


    Interests: Improving my acne scars, ^Adam Levine is a inspiration of perfect skin. Done:Subcision,Retin-A,Microneedling,Dermal Graft,TCA,Ematrix,CO2RE,Infini,Fillers,etc





     


    Posted May 3 (edited) · Report post
     





    Silicone (permanent - complications) or artefill / bellafill (permanent micro beads in the skin). Our faces change as we age, so the permanent solutions will not age with you. Also no plastic surgeon (in the future) will touch a face injected with permanent materials as it ab lead to complications. Silicone and Bellafill can also shift in the face and create grandulomas, biofilm formation. Reactions appear months and years after, not right away when it looks best.
    I mean, people shoot botox like junkies with a wallet full of cash, get their hair done every month, and their teeth whitened and cleaned, but rather than get the temp fillers which can be customized to the ageing face that changes, they risk serious side effects with permanent ones. Where is that permanent filler lump going to be in 10 years.
    I suggest everyone who is looking at this at least does one HA filler session to make sure you like the results, otherwise your stuck with it for life 
    Filler is the best bet for fat loss, I will paste my filler recommendation here from another post I just made. 
    I have skin just like yours but with bigger rolling scars.
    you need Subcision done followed by filler to lift up the car areas.
    Perlane LYFT / Juvederm Ultra which is for cheek augmentation is good and its a Hyluranic Acid Filler that can be reversed, lasts 1 year to see if you like the filler route. I am not a big proponent but arteflle / bellafill is a semi permanent filler with micro beads, it cannot be corrected once done, as we age they can migrate a bit and chance of grandulomas, some people on this site do micro silicone injections but this must be done by someone with thousands of procedures experience and a little micro injections at a time (Same side effects as Bella....). 
    Filler is your best option at this point (it's all we have if we are fat deficient and atrophic), subcision to untether the scars, and some tightening of the areas possibly with Infini RF . Secret RF / Intracel 



    On 7/5/2016 at 5:24 PM, Paula B. said:



    If you have fat loss, wouldn't fat transfer be a good possible solution? I haven't read too much about it, but it seems ok in theory.




    Yes that is a future option if I do liposuction or something. Acne Scar suffers heal terribly so if injected poorly and not in micro injection one would look lumpy. Also fat is not 100% in and 100% saved, you retain 10% or 20% and must possibly have a revision. I had dermal grafting (dermis /fat from behind ear)  in the past and my body just ate up that fat and tethered down again. Some laddies on Real Self spend 3000 USD per surgery and need 3 of them. The fat does not last forever or your face sags and so it can be expensive.  Fat underneath fibrotic scar tissue will not take blood supply as well so that could be bad if it dies and is absorbed. 
    ________________________________________________________________________________________________________________________________


    Harrokitty





    Member


    1


    14 posts





     


    Posted April 22 (edited) 






    I have been suffering from acne scarring since I was 13. I'm almost 22 now so it's almost been a decade with these little bastards. My acne scarring is pretty moderate maybe even severe and I have skin texture problems. yes it probably looks as bad it sounds lol. Anywho I tried TCA cross around 7-8 rounds but my last round of TCA cross with Howard Bargman in Toronto left me with 4 hummmmoooungousss craters .. You know ones that acne scars can't cause. They were HUGE right on my forehead and one on my right cheek and this asshole excuse of a doc even tried blaming it on me. Still have harsh feelings over it. ANYWHO other than the 4 scars I got from TCA cross, I had decent results (but only when I went to another derm in Montreal and NOT douchebag bargman.) 
    The ONLY mentionable results from my procedures was cross and energet. I had cross, laser, saline injections at home, micro needling and energet. I stopped for a while trying to improve my scars because after energet I think I got like a 30-40% reduction and learned how to apply make up that would cover acne scarring better. BUTTT last month I got silicone injections done by dr. Jay Barnett.
    My scars that improved the most were deep boxcars. Ice pick scars had no to little luck improving or the doc even skipped them ( I have a bunch of those too) The scars from douchebag Bragman actually improved too ! And these scars were so deep I can feel the ditches on my forehead like I'm missing part of my skull. Honestly now I'm more concerned about my uneven texture and hyper pigmentation issues instead of the actual scars.  Cost was 1200 USD and I'm Canadian so fml but it's worth it, for now! 
    Btw I have ice pick and boxcar scars only. And scattered around my whooooole face except my chin ( I never scar there for some reason)
    just got got a second treatment today 5 weeks after my first and the pic under is immediately after. 

    Edited April 28 by Harrokitty 
    Add more pictures



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    Tadamasa



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    Interests: Dancing and sleeping and eating and acne




     


    Posted April 23 · Report post





    By silicone injections you mean silicone micro droplet right. I've been doing silicone micro droplet treatment for a while now and yeah this treatment is pretty good. Honestly it's the only scar treatment I got that gave my any noticeable improvement. By noticeable I mean really noticeable. Definitely works best on rolling and boxcar. Dang I remember I used to get soo depressed whenever I saw myself in the mirror, but now I kinda feel like a normal human being. Anyways I'm glad you got good results. I usually wait 4 weeks between treatments, since it takes atleast 2-3 weeks for the swelling to fully die down. Oh yeah I don't know if your doctor will mind but what I do is I stare at a mirror in terrible lighting and circle all the scars on my face beforehand with a pen. Like I would draw around 10 circles or more. This not only saves the doctor time but it guarantees that every scar that bothers you is treated. I used to get really dissapointed whenever my doctor will completely miss some of the scars that really bothered me, but now he doesn't miss a single one.




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    blahblah82



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    Posted April 26 · Report post





    Silicone does fill up scars, but always be sure that the scars are not tethered, because if the silicone "donuts" around a tethered scar, it will be very difficult to correct.  Permanent fillers are pretty tricky and do have some inherent risk.  I think the most likely risk from permanent fillers is overcorrection, where you end up with visible bumps and ridging.  It is best to go slow and give it some time for the collagen to build up.  Remember the volume created is  from both the silicone and your body's reaction to it and the collagen that encapsulates the material.   




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    beautifulambition



    Veteran Member


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    168 posts


    Gender: Male


    Location: San Francisco, CA


    Interests: Improving my acne scars, ^Adam Levine is a inspiration of perfect skin. Done:Subcision,Retin-A,Microneedling,Dermal Graft,TCA,Ematrix,CO2RE,Infini,Fillers,etc




     


    Posted April 26 (edited) · Report post





    With all respect to the OP, i'm glad they found something that worked for them.
    Silicone is BAD! All Permanent Fillers are. Why is it not FDA approved? Do you know what they do when you have any issue with silicone, cut the chunk out of your face. There is no way to dissolve it like HA products, no safety methods. What are you going to do when you get old and your face starts sagging because of fat loss the silicone will move. Biofilms are a real thing, our body does not like nasty substances in them and starts to have a reaction around the filler building pus and infection... that is worse than any acne you could get. Silicone has been known to migrate to other places and "move" around. I read all the horror stories all the time on Real Self. Why are some rating so good... it't not a common procedure, doctors pay off bad reviewers, doctors make you sign papers you will not leave negative reviews after the procedure.  Sometimes years latter you might have issues. Few doctors will do a face lift on those with Silicone. Have you seen the shows like "botched" where they have to remove silicone breasts from women, enough said. It's a nightmare.
    Same with Bellefill / Artefill (outlawed in Europe ) who's genius idea was it to put fiberglass balls in the skin, that then move around (migrates) and can cause issues (again they must be cut out). They can remove micro balls from our soaps because it harms the environment, but not our face.  
    Dr. Raffy in LA specializes in removal and he calls it cutting out chunks blindly, these people can sped thousands to fix it and never look good after. 
    Fat is the only permanent filler I would suggest as it's natural and even then you can get someone who is bad at it and it will be lumpy or overfilled ( you can lipo it). HA is the way to go, get a lump dissolve it, other issue same thing.  
    Tranny performers are known to use silicone to plump up areas in their body, do a Google image search for silicone injection problems, and you will see people have lost legs, etc... 
    If you must do silicone have them do a test injection by your ear or something, come back months later if things look ok, with micro injections on various planes of skin... you must get many of them $$$$ to not over correct or create large areas (bolluses) that biofilms can cling to.
    You do not want permanent results (permanent problems), our face moves, it ages, it changes.  You will not look the same forever. Get something that is correctable.
    https://www.youtube.com/watch?v=2VJTKfm0ebk

    Edited April 26 by beautifulambition



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    somethingsomethingagain



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    Posted April 27 · Report post





    Sadly I have to agree with beautifulambition. If silicone was a safe option then there would be no one with acne scars!
    By now it would have become the mainstream treatment and everyone would be doing it. It's not whether it's FDA approved that matters to me, just think about how it works and how your skin is an ever changing organ, renewing its cells all the time. Having a foreign body put in there is scary as shit if you've seen these complications!
    I'd love for it to work as I'd be the first to fill all my scars with it, unfortunatelly I'm not willing to risk further damage for now... I'm sticking with less invasive treatments first and then we'll see what comes.
    p.s. Beautifulambition, remember that bellafill is FDA approved so what does that tell us? Sure, its rate of complications is lower but artefill's wasn't and they're the same thing...




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    beautifulambition



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    Gender: Male


    Location: San Francisco, CA


    Interests: Improving my acne scars, ^Adam Levine is a inspiration of perfect skin. Done:Subcision,Retin-A,Microneedling,Dermal Graft,TCA,Ematrix,CO2RE,Infini,Fillers,etc




     


    Posted April 27 (edited) · Report post






    On 4/27/2016 at 0:40 AM, somethingsomethingagain said:



    Sadly I have to agree with beautifulambition. If silicone was a safe option then there would be no one with acne scars!
    By now it would have become the mainstream treatment and everyone would be doing it. It's not whether it's FDA approved that matters to me, just think about how it works and how your skin is an ever changing organ, renewing its cells all the time. Having a foreign body put in there is scary as shit if you've seen these complications!
    I'd love for it to work as I'd be the first to fill all my scars with it, unfortunatelly I'm not willing to risk further damage for now... I'm sticking with less invasive treatments first and then we'll see what comes.
    p.s. Beautifulambition, remember that bellafill is FDA approved so what does that tell us? Sure, its rate of complications is lower but artefill's wasn't and they're the same thing...




    Oh I know, FDA approves drugs that can kill and harm us. But I take notice when Europe also bans it because it's unsafe. Also it's not a naturally occurring substance and it's not reversible (HA and Fat are). Type in Artefill in real self its horrifying and yet they rebooted and re-marketed as bellafill and its magically the shit all doctors use. I know several who will not because of the liability (they were sued) and past issues with Artefill. The ones who do make their patients sign special agreements not to take action or say anything bad. Do you know the Ambassador of Artefille is against the product now saying its unsafe, that says something. Edited April 27 by beautifulambition


     


     


     


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    Tadamasa



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    Posted April 29 · Report post





    Yeah even though I've done many sessions of silicone micro droplets, I do not tell anybody but my family about it. It's really not something to tell the whole world about since you don't want people blindly getting silicone injected to solve their problems. My doctor told me how silicone injections got bad rep from careless doctors injecting cheap industrial grade silicone on their patients, which led to a lot of problems in the future. A lot of people on this forum will only recommend permanent fillers as last resort and that's exactly what I did. I've done multiple treatments of laser, subcision, and microneedling with very little improvement, so this was the last thing on the list for me. But I have to honest though, silicone microdroplets really did change my life drastically. I'm finally moving on with my life since the past 3 years of being completely obsessed with my acne scars. I wouldn't say I look completely normal but more to the point where I'm not bothered by them anymore.




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    beautifulambition



    Veteran Member


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    Gender: Male


    Location: San Francisco, CA


    Interests: Improving my acne scars, ^Adam Levine is a inspiration of perfect skin. Done:Subcision,Retin-A,Microneedling,Dermal Graft,TCA,Ematrix,CO2RE,Infini,Fillers,etc




     


    Posted May 3 (edited) · Report post






    On 5/3/2016 at 0:26 AM, templeofdoom said:



    This is a very interesting post from both sides of the argument. I bet silicone would sort my problem right out! But obviously as stated it isn't a safe option.
    @beautifulambition. - You stated FAT was the best solution for permanent fillers? But Fat transfer only lasts 2 years does it not? I looked into it getting it last year in the UK. It was £3000. A lot of coin for just 2 years.
    Is that correct?



    No offense but I am trying to protect people from making a terrible decision "silicone", thats the only reason I responded. Your body, your choice and all that... I once thought silicone was a miracle but quick fixes never last forever. But hey if it works for you and you are the percentage with no side effects great. The research I did was terrible and the results bad for even micro injections. Foreign body in your body and nothing they can do but cut. Tell me where silicone is in the body naturally. Second silicone is made from oil / Patroleum the same shit they have to clean when there is massive spills. It's not like we don't have acne issues and aren't immune comprised for foreign body / topicals. Do you know Silicone was used in the 60s / 70s in Hollywood's famous faces with tons of issues, some had to cake on that makeup.  I seemed to hit  a nerve with the OP who wants her decision to be right and I am very happy it worked for her, but it is a gamble like going to Vegas. Hell they have a face transfer from a cadaver if someone wants perfect skin. When someone can give me a official medical aesthetics white paper stating Silicone is the golden ticket, then I will listen. I have seen the complications , who here has studied all of them??? OP Silicone travels, it migrates, you inject micro and it can move anywhere, we age and our skin moves and changes. Someone who is knowledgeable and not just giving their personal opinion tell me about biofilms / surface area / and the body / and Silicone. But it's micro like those beads in Artefill / now Bellafill that has a 10% approval rating from all the botched faces. It is sad I have to say this but Bellafill would be less risky than Silicone.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3396457/
     

    Marvin Rapaport is liquid silicone's most outspoken critic. He is adamant that the substance has the potential for great harm. Rapaport is not alone in his concerns; many cases have been reported in medical journals, documenting complications such as chronic cellulitis (inflammation of connective tissue), nodules or ulcers, and infections, occurring anywhere from 2 to 35 years after the injection. In the past, "whenever a patient showed side effects from silicone injections," wrote Rapaport in an editorial for Dermatological Surgery, "it was argued it was the wrong amount, the wrong material, or the wrong practitioner."


    A New York patient named Tricia believes that the silicone fluid, the technique, and the amount used were all correct in her case. In late 1991, when she was 33 years old, Tricia consulted a doctor about a small pockmark on the side of her nose. The Park Avenue dermatologist injected the blemish with a drop of medical-grade, liquid silicone. Then he offered her silicone for her laugh lines. She still recalls his words. "You'll stay looking young for a long time."


    A month later, she went back for more, and would have returned for a third round, had the FDA not banned liquid injectable silicone. Two years afterward, the injected side of Tricia's nose began growing, and raised bumps appeared in her laugh lines. Tricia went to a plastic surgeon, who told her this was a reaction to the silicone, and that Tricia had little recourse, since silicone is almost impossible to remove. Instead, he built up the uninjected side of her nose with cartilage from her ear to balance the nostrils. "Can you imagine making your nose larger, on purpose?" Tricia says, stupefied. After continued inflammation in the silicon-treated nostril, another doctor tried inserting it to smooth out the bumps. That nostril started shrinking, which looked even stranger. As for the lumps in her laugh lines, a fourth doctor told her nothing could he done for them. "So, where others have a crease, I have a raised line," Tricia says. "How do you camouflage bumps with makeup? I just want to hide my face."


    Too many women are rushing into injections without exploring the possible risks, says Diane Madfes, a New York dermatologist. Nothing illustrates this more vividly than the rise in silicone parties hosted by itinerant injectors. "There are women who would stuff a Vuitton bag in their face if someone said it was permanent," says dermatologist Arnold Klein, who predicts the widespread availability and use of permanent fillers "will be a disaster."
     


    Doctor Answers 2



     




    Migration of silicone injections



    July 25th, 2012



     +1 






    Silicone and other permanent fillers may migrate after years of subcutaneous presence. I would recommend evaluation by an experience plastic surgeon who can help control the inflammatory cycle associated with silicone injections.



    Web reference: http://karemd.com/cosmetic-dermatology/34/lip-silicone-removal.aspx
    DR Raffy Karamanoukian (Filler Removal Expert)









     







    @templeofdoom Fat can last a lifetime, people like most procedures want quick fixes. When you loose fat it can go away, gain fat it can goto other areas. Fat is incremental, meaning only a portion will survive , the body will absorb and get rid of the rest. You need multiple treatments, not a one off. That puffyness will be gone otherwise. If you put too much you can have a chunky face, some doctors do this as they know some will be gone. You need a specialist in this, look at his past pictures and ask "how many procedures do I need to achieve that. Why don't more doctors do fat... You have to lipo it from elsewhere. It takes a expert injection or it will look lumpy and uneven. Fillers make them so much more money Cha Ching $$$$ time for a top up.  People do not want to do multiple procedures over years time and instead inject and be done. As we age we loose fat permanent or not. Drs do not want to guarantee something that has different results, in one it may last longer than another. Nothing permanent or not lasts over 10 years with how the face changes as we age. Watch Dr. Lams Youtube on Fat Transfer. Personally I only use HA fillers because they are reversible but PMMA suture based materials which last longer are also a option. 
    https://www.youtube.com/watch?v=rvz--nkj1Yk
    https://www.youtube.com/watch?v=4oZndjMJmdQ
    https://www.youtube.com/watch?v=S22Rqw97Smw
    https://www.youtube.com/watch?v=veyJWYAYri8
    https://www.youtube.com/watch?v=mcPuht5aNJ8
     Edited May 3 by beautifulambition



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    Posted May 3 · Report post





    Great post!!
    From what I understand these doctors are saying that even though Bellafill is not the best option, it's still safer than liquid silicone, right?
    I don't really believe that doctors make you sign something because if that was the case, at least on the internet people could use different names to post complaints. And maybe if quantities are minimal then the risks are less than significant, still I wonder if all this silicone-rage and bad publicity isn't funded by those that would have interest in throwing the business down like HA producers or even plastic surgeons/derms that get more money from multiple visits instead of just one and done...
    It's a shame there's so little objective published content about this for us to read and learn...




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    beautifulambition



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    Posted May 3 (edited) · Report post






    On 5/3/2016 at 6:37 AM, somethingsomethingagain said:



    Great post!!
    From what I understand these doctors are saying that even though Bellafill is not the best option, it's still safer than liquid silicone, right?
    I don't really believe that doctors make you sign something because if that was the case, at least on the internet people could use different names to post complaints. And maybe if quantities are minimal then the risks are less than significant, still I wonder if all this silicone-rage and bad publicity isn't funded by those that would have interest in throwing the business down like HA producers or even plastic surgeons/derms that get more money from multiple visits instead of just one and done...
    It's a shame there's so little objective published content about this for us to read and learn...



    Well Bella / Arte is approved by the FDA while Silicone isn't and has been around since the dinosaurs. Old Hollywood all had it in their faces off label, that's how they learned about the side effects. Michael Jackson's old doctor used to inject this in several patients. You'd think if it was that great they would approve it. After all the cost of the purified and lab made Silikon 1000 ain't cheap. 
    Regarding the sign something, there are very few reviews. Look on real self. The ones that are positive are suspect. How do I learn about this. Read Yelp reviews and people will say the doctor made me take down my negative review or the doctor paid me to change my review. They also can pay some of these sites to remove them, and of course their is lawyers to threaten for their reputations. Of course then there is the doctors who shame them and the people want nothing more than to be left alone. They are quite damaged. Regardless all that does not matter, there is not the volume to give proper reviews on Silicon because hardly no one does it. In the US Anyways. In Europe it's banned.
    Direct Quote: "Dr. SXXXX MXXXX, at that time, was making his patients sign a legal paper where you agree that you will never write a negative review about his work on the internet (pursuant to legal action). You can verify this with his other patients. He was (probably still is) essentially fooling the review system. He made me sign this paper at the last minute, minutes before surgery. I went along thinking what the heck, and I paid the price. At that time yelp was the source of my knowledge about doctors, and he had couple of good reviews on yelp. He also had a fancy office in downtown SF. "
    From a liability standpoint do you want to inject something you cannot fix? There is no dissolving it like HA. Even some longer lasting injections (of suture material) eventually dissolve. What if someone sues you. Do you as a Doctor want to cut up someones face. 
    http://www.yourfaceinourhands.com/plastic-surgery/artefill.cfm
     

    Reversibility


    One of the greatest benefits of aesthetic injections is that the procedure is reversible in most cases. If a patient is unsatisfied for any reason, a special enzyme known as "Hyaluronidase" can be injected into the treatment area within the first 24 hours. This enzyme immediately dissolves hyaluronic acid fillers such as Restylane®, JUVÉDERM®, and Perlane®. RADIESSE® is typically more difficult to dissolve, but can be reduced by about 30%. Ultimately, the effects of dermal fillers are temporary as they are naturally reabsorbed by the body over the course of a few months.


    The Truth About Artefill


    For several years Mabrie Facial Cosmetic has offered Artefill, the only FDA-approved permanent filler on the market. As of 2014, our practice has discontinued the use of Artefill, and will no longer offer this product to our dermafiller patients.


    Artefill is currently the only FDA-approved permanent filler for use in the face. It is approved exclusively for treatment of the nasolabial folds.


    Although we achieved some very good results while using Artefill to treat the nasolabial folds, we have decided to stop using this product for the following reasons:


    We seldom focus treatment primarily on the nasolabial folds. In our practice, we typically concentrate on cheekbone augmentation, treating the nasolabial folds as a secondary adjunctive procedure.


    Artefill is too soft for structural augmentation. The soft consistency of Artefill is beneficial for treating the nasolabial folds, but makes it less effective for non-surgical chin augmentation and non-surgical rhinoplasty procedures.


    The effects of Artefill are irreversible. With results lasting up to 18 months, reversible fillers like Restylane are a safer, long lasting option for treating delicate areas like the tear troughs.


    There is tons of data on this, one must search medical white papers and read reviews good and bad, I cannot do the work for everyone.
    Here is a posting from one of the Ambassador Doctors of Bellafill
    Bellafill is basically Artefill renamed, PMMA fiberglass beads with cow bovine which many are allergic too (needs 2 skin tests). Known to cause granulomas, cysts, hematoma, shift, biofilms, and allergic reaction. Fat Grafts (expensive) and HA seem so much safer!Raffy Karamanoukian, MD, FACS in LA specializes in removing it, apparently it's a nasty surgery they have to remove all those fiberglass beadsHere are the reviews, many are displeasled with product. Also read DR. Klein's info below very interesting what the FDA did to approve it and how it is not allowed in Europe. http://www.realself.com/Artefill/reviewshttp://www.realself.com/bellafill- Arnold W. Klein, MDThe number of Injectables seem to increasing at a astronomic rate. Agents such as Bioalcamid, Aquamid, and Injectable Silicone are a few of the new names we are beginning to hear. The supposed experts are now trying to blame bacteria which supposedly grows on the surface of injectables ( Biofilms )for all the reactions we are seeing. How are you the patient going to decide what to use. First you talk to an expert like Scott Binder The Chief of Pathology at UCLA. He is truly the king of the microscope and says that these filler reactions are not due to biofilms but agrees that they are immune reactions of the body to agents that should never be used in humans. We both agree that TEMPORARY agents like the pure Hyaluronic acids are the best available products. Permanent fillers have permanent problems !Furthermore don’t take your face to Costco but go to someone you know is experienced in the use of injectables. Finally stay far away from consultants to drug companies because these are the ones responsible for the making the field of soft tissue augmentation into a filler fantasy where profit comes before safety. Biofilms have been found on solid breast implants but not on liquid injectables. I will find the best doc for you in Toronto.Since 2006 I have warned people about Artecoll,Artefill and Artesense. In 2007 in the Wall Street Journal (http://online.wsj.com/article_email/SB118834446251311594-lMyQ...) I did an article about the disastrous nature of agent and since then am no longer invited to speak at medical meetings. The true sadness of the control of medicine by the greed of doctors and Big Pharma is the patients end up scarred. Industry has accomplished the approval of synthetic agents which should have never reached the market. Once injected under skin the body cannot digest these agents and the immune system walls them off with resultant formation of nodules, which at times require surgical removal. One such product that was approved was Artefill® or Artecoll. This product is polymethylmethacrylate or which is injectable Plexiglas beads. This product has long been associated in the worldwide dermatologic literature with scarring, and disfigurement only amenable to correction by surgery. At present, Artecoll, the predecessor of Artefill, is no longer available in Europe or Canada. In 2003, the American Society of Dermatologic Surgery newsletter 'Currents" promoted the use of Artefill to fellow dermatologists. Physicians in this Newsletter encouraged and promoted the use of this agent. It was later revealed that at least one of these physicians had been given a large amount of stock (35,000 shares) by the manufacturer, which was not publicly revealed.We knew from the experience of Artecoll in Canada that pharmaceutical companies cannot be relied upon to report adverse events to authorities, yet the FDA claims that it can evaluate adverse reactions by relying on doctors and "Big Pharma" to report these directly to the FDA. Furthermore, merely changing the name of the product (e.g. Artecoll to Artefill) doesn't change the history or adverse experiences of the past. In the literature, consultants have used the names interchangeably. Furthermore, if Artefill is new and improved, how can one gain FDA approval of Artefill and Artesense by studying Artecoll. The only good news is that I have begun to treat adverse reactions to these products with injectable 5FU combined with Kenalog with very promising results. I will keep you posted.!In 2003 The "Currents" newsletter of the American Society of Dermatologic Surgery established an expert panel on fillers from which I was excluded. This was odd as I was the filler editor of the Journal of Dermatologic Surgery as well as the recognized world authority on fillers. Could the reason be that I had lectured prior to this newsletter on the problems with Plexiglas fillers? It was well known to me that Artefill®/Artecoll® (Artes-Medical, San Diego, CA) caused severe adverse reactions which frequently required surgical removal of the product. It was later revealed that Artes founder Dr. Gottfried Lemperle, a plastic surgeon, improperly injected 10 people in the United States with some form of the company's wrinkle-filler before it was approved for market by the FDA. Subsequently, Gottfried Lemperle resigned as the company's chief scientific officer and a director but was retained by the company briefly as a consultant.Both Gottfried and his son were cited in a lawsuit filed by Hairdresser Elizabeth Sandor, 40, who alleged in May 2006 that Dr. Lemperle used Artefill® as an injection to fill her facial wrinkles in 2002. She alleges that Lemperle falsely convinced her that Artefill® had received FDA approval, and that he never disclosed his lack of license in California. Her claims detail suffering of pain and disfigurement she attributed to a reaction to Artefill. Sandor's face was inflamed, she had scarring near the injection sites and had a fever and aches and pains. Prior to approval by the FDA there were European reports of a significant incidence of large lumps 3-4 years post implantation. Furthermore both Germany and Switzerland had already advised physicians not to use this product. I have found the best way to remove these lumps is an accurate injection of 5fu and Kenalog into them . Remember Hyaluronidase only works on Hyaluronic Acid which Artefill is not..Arnold W Klein...Things Get Ugly Over a Beauty Injection - WSJ.com 1 of this is an article I wrote in the Wall Street Journal about Artefill- Brent Moelleken, MD You may see from my several other posts how opposed I am to fillers of this nature.I wil'll tell you about my experience with this filler and the unfortunate patients who suffered long term complications requiring surgery.Artefill is not approved by the FDA for cheek implants, and should not be routinely advocated for that purpose.Cheek augmentation requires a relatively large volume to achieve an effect. Depending on the position of the augmentation, it may be above the zygomatic (cheek) bone or the midfacial muscles of expression. The poly methyl methacrylate beads contained in Artefill get into tissues. They do not stay exactly where you place them.Large volumes of synthetic substances injected into the face are particularly worrisome. The body cannot develop a blood supply in the injected material to defend itself against the bacteria that are in the region.I have personally surgically removed many such deposits of many different semipermanent fillers, some available only in Europe (Aquamid for instance) and replaced them with LiveFill (fascial fat grafts). The surgical removal is difficult and fraught with problems because the material can migrate around deep nerves and cause chronic pain syndromes; surgery to remove the material will necessarily involve dissection around the nerves and is by its nature incomplete since the material infiltrates the tissues themselves. In the cheek the infraorbital nerve is particularly vulnerable.If you develop an infection years later, or a chronic inflammatory reaction, you may have no way of removing the Artefill. Likewise if the Artifill beads migrate over time and the appearance changes or becomes deformed, there is no way to remove them completely.If however you have a silastic cheek implant, these implants can typically be removed from inside the mouth easily and completely and replaced with a different implant or LiveFill (fascial fat grafts) if they should become visible or the patient does not like their shape. Many patients in our practice have LiveFill grafts placed in well defined pockets. These completely autologous (natural to the patient) grafts maintain their shape and volume over time as studied by 3-D CT scans and clinical photographs. 
      Edited May 3 by beautifulambition


     


     


     


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    Posted May 4 · Report post





    I've done a total of 7 cc, I know it's a lot... I didn't do a full cc every treatment though, my doctor wanted to go slow so most of the times he did 0.5 cc per visit. I think I'm done for now though. I got my treatments done by Dr. Resnik.
     




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    On 5/4/2016 at 2:00 PM, Tadamasa said:



    I've done a total of 7 cc, I know it's a lot... I didn't do a full cc every treatment though, my doctor wanted to go slow so most of the times he did 0.5 cc per visit. I think I'm done for now though. I got my treatments done by Dr. Resnik.
     




    Wait, hold up.... 7ccs?????   Are you sure?  Is it possible you mean 0.7cc?  
    7ccs of any filler is a tremendous amount of volume.  I can't image you had that much volume loss on your entire face.  This would be an incredibly large amount of silicone injected.   The actual total volume you end up with would be much greater than 7 cc's because silicone causes the body to react and encapsulate it with collagen.   Does your face look significantly fuller?  
    The medical grade versions of silicone, like Silikon 1000 which is made by Alcon, is FDA approved however for retinal detachment.  Doctors have the ability to use it off-label to treat other things that are not explicitly approved by the FDA.  It is not approved for injection into the skin, which is why it is used off-label as a filler material.  Botox for example is only approved for certain medical uses and for crow's feet and yet doctors use it just about everywhere on the face.  As long as the product is FDA approved, the law allows doctors to use products in off-label ways when patients give consent.  
     



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    Posted May 5 · Report post





    Uh oh am I going to die? Yeah each treatment is 2 syringes of 0.5cc. So yes I had a total of 7cc unfortunately... But my doctor recommended 5 treatments when I came in for the first time so it's not that far off. It could've been less but in the beginning I told my doctor to inject wherever he wanted, which wasted silicone on scars that didn't bother me. 
    Yeah actually the volume loss on my face was that bad. There is a pretty noticeable difference between before and now. So yeah I guess I can say my face does look noticeably fuller. 
    You are right about the overfilling though. There are a few spots which had an overreaction to the silicone and created a larger lump than intended, which is why I understand why. you recommended to go slowly. But it looks better than having deep shadows so I don't mind. The thing is that the overreaction effect happens randomly so it's impossible to predict it, and can potentially mess up your face. For that reason I don't recommend silicone micro droplet.




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    On 5/5/2016 at 0:14 PM, Tadamasa said:



     



    First off, I think you'll do fine.    They have used Silikon 1000 in even more substantial volumes for patients with significant fat atrophy like long-term HIV patients.  From what I've read, those patients have done well.  Personally, I think if you inject deeply you will avoid the main issue with permanent fillers, which is visible lumps and bumps.  It could look unaesthetic, but you won't get sick or anything.  Significant complications like the stuff you see in the news is always from black market, industrial silicone injected by shady non-medical people in a back alley, not a doctor's office.  
    So are you happy with your final result or you feel uncertain whether to recommend it?   If it was a net positive for you then that's good.  I was just really surprised that it was that much volume.   Like I stated 7 ccs is a lot of filler, and with silicone you have to factor in the collagen production / encapsulation that happens as your body reacts to the silicone.  Anytime you put a foreign substance into the human body it will react and try to "wall-off" the substance.  That's actually what is intended with permanent fillers like silicone and Bellafill.  How much volume is generated is unpredictable, because it's just based on your own physiology.  That's why it's really important to go very slow with permanent fillers because you have to gauge your body's reaction.
    My personal advice for anyone going for permanent filler would be to
    1)  Be conservative with the volume
    2)  Go very slowly because you can't predict your body's reaction and how much volume it will generate
    3)  Do not inject ice-pick scars.   Even the Bellafill marketing material explicitly states that you should only inject untethered rolling scars.  The same would apply for silicone.
    4)  Maintain strict hygiene in the first 24 hours after injection (no makeup, touching your face) because you want to avoid potential biofilms
    5)  Be careful about injecting shallower scars because overcorrection is a distinct possibility.
     




    My Experience With Injectable Silicone


    Started by oopli , April 7, 2012


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    oopli





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    Posted April 7, 2012 (edited) · Report post





    I just want to share my experience with microdroplet silicone injections. I had a total of 3 rounds for my severe forehead scarring over 4 months and the first two session went well but the latest one has left me with a lump at the top of my forehead which you can clearly see in the picture. I also have another hard lump inbetween my eyes(near the right eye). I didnt experiece complications on every scar and most responded really well but the lumps obviously keep me from being satisfied with the procedure. I was aware about the risks invloved but every where i read and doctors i spoke to all said the complication rate was around 1-2% but i think its much higher. Its been 2 weeks since the 3rd round and i plan on waiting about a month before i go see my doc again and ask what can be done about the lumps. I know my options are very limited since silicone is permanent but I at least have to try. Anyway just want to give people out there my thoughts, i an not knocking silicone just think i was unlucky or had a bad reaction who knows. I will add updates to the thread when needed.




    Edited April 7, 2012 by oopli



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    Posted April 7, 2012 · Report post





    I've had silicone microdroplet as well, but not much filling for me. I did have an adverse reaction immediately after injection in one area, right where the needle went it. Because it was so soon after injection, they said it was not an immune response as it takes at least a few weeks to get any immune response. That is what they the office told me anyhow. The hard lump eventually resolved but left slight scarring. I won't do silicone anymore. Would you pm me your doctors name if you are not comfortable writing it here. By the way I don't see much lumps in the pic. I bet it will resolve some on it's own over time.




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    Posted April 7, 2012 (edited) · Report post






    On 4/7/2012 at 4:46 PM, tricia said:



    I've had silicone microdroplet as well, but not much filling for me. I did have an adverse reaction immediately after injection in one area, right where the needle went it. Because it was so soon after injection, they said it was not an immune response as it takes at least a few weeks to get any immune response. That is what they the office told me anyhow. The hard lump eventually resolved but left slight scarring. I won't do silicone anymore. Would you pm me your doctors name if you are not comfortable writing it here. By the way I don't see much lumps in the pic. I bet it will resolve some on it's own over time.


     




     


    I think you can see the raised lump more clearly here. The lump between my eyes is harder to see but its the size of an almond and its hard to the touch. I really hope it goes away somehow either on its own or maybe the doc can inject a steroid. Its just scary knowing that if indeed this is a complication like granuloma or nodule formation than its pretty much permanent. BTW how long did it take for your lump to resolve??




    Edited April 7, 2012 by oopli



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    Posted April 7, 2012 · Report post





    Well, my lump was smaller and was mainly caused by inflammation from the needle I believe, but I wondered if my injector did get some of the silicone a little too shallow when she was withdrawing the needle which made it bubble up. I did eventually squeeze some stuff out, but the inflammation persisted for awhile, it wasn't like a normal pimple. It did take a few weeks to resolve. Since you had two rounds fairly recently yours could be a granuloma after two weeks, there could be that immune response. I had problems with my third round as well, but my first two were at least four years prior, so I knew it wasn't an immune response a day after injection. They will probably give you oral prednisone as steroid injections do not really work on silicone and can make it worse. This is what I've read, but different doctors may believe differently. You could need antibiotics. I would start with calling the doctor and send her your pics if you can't go in. The lump close to your eyes could be a real hazard, as you don't want any infection close to your eyes and affect vision. Not trying to scare you, but definitely don't wait a month.




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    Posted May 5, 2012 · Report post





    So today i got kenalog injections on both bumps, the doc said that they were due to overcorrection and if the kenalog is going to work i will see the bumps lessen within a week. Hopefully it works.




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    Posted May 5, 2012 · Report post





    Good luck, let us know how it goes. I can't believe some people get overcorrection after three rounds, and i have two divot scars that had three rounds and it still won't fill in! I wonder if your doctor was more agressive with the last round.




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    Hey having been stuck on my cell phone while my computer is sent to repair for a few weeks, ... it would be nice to have the ability to respond via email to messages we receive instead of having to login via the phone's browser. 
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  12. Forums Hyperpigmentation - red/dark marks 3  replies 627  views

    Wanted to share...
    While this isn't hyperpigmentation related I think it's a important reminder. Many times posters compare themselves to those with "perfect skin." Society sells us the fact we must be Photoshop perfect. Watch this video and see how extra coats of makeup and a filter make you faux flawless. There is nothing wrong with males and females wearing makeup to cover imperfections and gain some self confidence and be able to live their lives. Often times as Acne scar suffers we are very hard on ourselves comparing to others with a form of BDD / acne dysmorphia we expect nothing less than perfection. This is where therapy helps weather face to face (cheaper at colleges even if you do not goto one, or talkspace a smartphone app where you can talk to a therapist even without leaving your house). No one is flawless!  
    https://www.youtube.com/watch?v=Z1lovMzixm0
    These are the ideals people hold themselves to, be inspired just as you are.
    https://www.youtube.com/watch?v=WWTRwj9t-vU

    https://www.youtube.com/watch?v=gXlIAS-rI4E

    https://youtu.be/QbxinUJcLGg

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    Wanted to share...
    While this isn't scar related I think it's a important reminder. Many times posters compare themselves to those with "perfect skin." Society sells us the fact we must be Photoshop perfect. Watch this video and see how extra coats of makeup and a filter make you faux flawless. There is nothing wrong with males and females wearing makeup to cover imperfections and gain some self confidence and be able to live their lives. Often times as Acne scar suffers we are very hard on ourselves comparing to others with a form of BDD / acne dysmorphia we expect nothing less than perfection. This is where therapy helps weather face to face (cheaper at colleges even if you do not goto one, or talkspace a smartphone app where you can talk to a therapist even without leaving your house). No one is flawless!  
    https://www.youtube.com/watch?v=Z1lovMzixm0
    These are the ideals people hold themselves to, be inspired just as you are.
    https://www.youtube.com/watch?v=WWTRwj9t-vU

    https://www.youtube.com/watch?v=gXlIAS-rI4E

    https://youtu.be/QbxinUJcLGg

  14. Forums Cosmetics & grooming 0  replies 416  views

    Wanted to share...
    While this isn't acne related I think it's a important reminder. Many times posters compare themselves to those with "perfect skin." Society sells us the fact we must be Photoshop perfect. Watch this video and see how extra coats of makeup and a filter make you faux flawless. There is nothing wrong with males and females wearing makeup to cover imperfections and gain some self confidence and be able to live their lives. Often times as Acne scar suffers we are very hard on ourselves comparing to others with a form of BDD / acne dysmorphia we expect nothing less than perfection. This is where therapy helps weather face to face (cheaper at colleges even if you do not goto one, or talkspace a smartphone app where you can talk to a therapist even without leaving your house). No one is flawless!  
    https://www.youtube.com/watch?v=Z1lovMzixm0
    These are the ideals people hold themselves to, be inspired just as you are.
    https://www.youtube.com/watch?v=WWTRwj9t-vU

    https://www.youtube.com/watch?v=gXlIAS-rI4E

    https://youtu.be/QbxinUJcLGg

  15. Forums Scar treatments 0  replies 1,217  views
    Hi All,
    Acne.org does not promote Dr. Lim, I share this for educational purposes to give you a insight to the treatments we advocate here in the Scar Treatments sub. To give you both sides, Dr. Lim is great with his videos and scar knowledge, but a few members have not been happy with their treatments with him. We all heal differently, and mistakes can happen, I have had experts do damage with lasers to my skin. The nice thing is the information shared in this video can be done locally at your nearby Dermatologist  / Plastic Surgeon. Checkout the FAQ in my signature below to learn more about these procedures. The greatest change I have seen consistently is through Nokor traditional subcision, followed by a filler session (can be at a latter date to prevent tethering). TCA Cross for large pores and Icepick scars, and tca peels and microneedling for boxcars / rolling scars. Laser has caused many damage (fat loss, etc). Please be aware I am not advocating for you to fly to AUS and get laser done. 
    Enjoy, BA!
    https://www.youtube.com/watch?v=sK00I_1BrrQ
  16. Forums Scar treatments 1  reply 721  views
    https://www.youtube.com/watch?v=MojLy-T0qKw
    emilhenningsen.dk/behandling_ar/
  17. Forums Hyperpigmentation - red/dark marks 0  replies 30,334  views

    Q&A / FAQ; POST INFLAMMATORY ERYTHEMA (PIE), POST INFLAMMATORY HYPERPIGMENTATION (PIH), & HYPOPIGMENTATION:
    <If You Have Updates / Hints / Tips for This Thread, or Questions, Please PM Me>Special Thanks  for Contributors : DeLovely, Dan Owner of Acne.org  
    Disclaimer: The information below is provided as a courtesy to address general questions. As we are not medical professionals, we cannot be held responsible for the accuracy of this information. By reading this information, you agree not to hold us liable for any damages that may result in your use of this information. This information should not replace information that your Doctor, Dermatologist,  or Plastic Surgeon provides you. Please keep in mind that this is for general information only and results will vary for each individual.TABLE OF CONTENTS:
    1. DEALING WITH SPOTS AT HOME & NATURAL HEALING
    2. DIET NEEDED FOR HEALING
    3. WHAT IS: POST INFLAMMATORY ERYTHEMA (PIE) - red spots, turn white after pressed on
    4. WHAT IS: POST INFLAMMATORY HYPERPIGMENTATION (PIH) - brown or red spots that stay brown red after being pressed on
    5. WHAT IS: HYPOPIGMENTATION - white spots
    6. SKIN: PORES & TEXTURE, DRYNESS, & COVERING UP SPOTS
     



    ___________________________________________________________



    1. DEALING WITH SPOTS AT HOME
    Q: Where do I start?A: Hyperpigmentation takes a long time to heal. You can try to simply wait it out...but it never hurts to try and heal your spots naturally:-Aloe vera gel + honey and vitamin K (gets rid of bruises and red) keeps the spots moist creating quicker healing.OR
    You can use Emu oil or triple antibiotic cream to keep your wounds moist (Note: this breaks out some people so please spot test). In the morning you use cool water to cleanse your face. Use diluted white vinegar and pat (not rub) the face to sterilize it. Moisture with a pure 100% Hyaluronic Acid Serum, this avoids skin irritation.-Topical Vitamin C serum can help some fade their reds and browns and in others it has irritated their skin. Always wear sunscreen. In the morning you use cool water to cleanse your face. Use diluted white vinegar and pat (not rub) the face to sterilize it. Moisture with a pure 100% Hyaluronic Acid Serum, this avoids skin irritation. These spots can take months to heal being irritated wounds, the remnants of acne or other skin issues.
    If this doesn't work stronger treatments are below>>
     










     







    https://www.youtube.com/watch?v=Re_NdcVGI_A




     








    hhttps://www.youtube.com/watch?v=Bsd0YbvZdaI
    ___________________________________________________________
    2. DIET NEEDED FOR HEALINGQ: What can I do diet-wise to deal with my spots (red, brown, white)?A: Eliminate: sugar, dairy, gluten, start eating fermented foods and bone broths, take your probiotics, and antioxidants such as green tea, vitamin C, and niacinamide. Smoking stops healing as does too little rest. You need animal foods in your diet, especially healthy fats, so don't be afraid to eat fatty meats! If you are a vegetarian eat nuts, hummus, coconut & olive oils, Many with these spot flare-ups mixed with red hyperpigmentation have candida (yeast) and gut health issues. This might need addressing. After antibiotics, this common yeast can cause issues in the body.___________________________________________________________


     





    3. WHAT IS: POST INFLAMMATORY ERYTHEMA (PIE)
         - red spots that turn white after being pressed on



    Q: What Is Post Inflammatory Erythema (PIE)? A: Post Inflammatory Erythema (PIE) describes pink to red discoloration after an inflammatory acne lesion. Patients with lighter skin types (I-III) the post-inflammatory dyspigmentation is often not hyperpigmentation, but instead discrete erythematous macules (PIE). Acne may not be the only cause of post inflammatory erythema, as any resolving cutaneous inflammatory process may have residual erythema.


    Treatments (ranked most effective to least): V-beam, or IPL, or Excel V, or 1064nm, or QuadroStar Pro Yellow Laser (vascular laser can help these areas quickly by making the body dissolve the trapped red blood / surface veins), **please note for anyone with Ethnic skin meaning you tan Picosure lasers are extremely effective for ethnic skin types, vascular for lighter skin types. steroid creams from the derm,  Retin-A Cream, Bactroban cream, Silicone Sheets and topicals (known as scar gels), 2.5% hydrocortisone twice per day (only for a weeks time - it thins the skin), triple antibiotic. Some find light (%) peels helpful like Salicylic Acid or Glycolic (Acne.org has an excellent one in the store)... Your skin must not be raw, overly thin, or any allergy to aspirin (Sali) . Please do not use Scrubs, Harsh Soaps or Exfoliants that prolong the wounding. Emu Oil, Honey, Aloe Vera, and Green Tea are soothing / healing. Visine aka red reducing eye drops temporarily reduces the red and concealer (makeup), while you heal.






    How to care for Erythema


    First, get your skin completely clear from active acne. This way you are preventing any future Erythema. Once you are clear, you can try a Erythema treatment above to reduce the marks you might have. Topical treatments are the first choice for treating Erythema. The treatments most commonly prescribed by dermatologists are Steroids.Erythema is common among people of Caucasian descent. Erythema can also occur in darker skin, albeit less frequently. UV light – the light from the rays of the sun – can make Erythema worse and cause it to remain longer. However, it is not clear whether UV light worsens acne itself, as research studies have reported that UV radiation can both increase6 and decrease7 acne. Regardless, for all skin types, it is important to take appropriate steps to protect your skin from excessive sun in order to avoid worsening of Erythema and allow any Erythema you currently have to heal as fast as possible.


    How to prevent Erythema



    Picking at acne lesions is the worst culprit when it comes to creating Erythema. Absolutely do not pick at acne lesions. Properly pop a pimple only when it is ready to be popped, and then leave the lesion alone. Also, while it may seem intuitive to scrub marks away, harsh scrubbing will only prolong their duration and should be avoided. Be sure to wash gently. Next, as mentioned, keeping Erythema skin out of the sun when possible is a huge help in allowing these marks to fade as quickly as possible. Wearing a sunscreen is important as well.1,5,9

    The best way to prevent hyperpigmentation is to treat the acne itself, thus preventing future acne lesions and any Erythema that they might leave behind.10 Acne is treated the same regardless of skin color and responds extremely well to proper topical treatment with benzoyl peroxide. When acne is severe, widespread, and deeply scarring, Accutane (isotretinoin) is also an option.


    ___________________________________________________________



    4. WHAT IS: POST INFLAMMATORY HYPERPIGMENTATION (PIH)
        - brown spots or red that stay after being pressed on



    Q: What Is Post Inflammatory Hyperpigmentation (PIH)? A: Post Inflammatory Hyperpigmentation (PIH) is related to brown spots, and permanent red spots. The discolorations are caused by an excess production of melanin. Vitamin C Serum, Glycolic, Hydroquinone (skin bleaching cream) are all great tools for inhibiting melanin which will fade the discoloration. PIH is more common in darker skin types (Fitzpatrick IV-VI), although it is not limited to any skin type.



    Treatments ( ranked most effective to least): V-beam, or IPL/ photofacials, or Excel V, or 1064nm, or QuadroStar Pro Yellow Laser (vascular laser can help these areas quickly by making the body dissolve the trapped red blood / surface veins), **please note for anyone with Ethnic skin meaning you tan Picosure lasers are extremely effective for ethnic skin types, vascular for lighter skin types. Alpha Hydroxy Acid peels: glycolic * good also for smaller pores, TCA, Mandelic (Acne.org has an excellent one in the store), Skin bleaching creams (aka hydroquinone or Kojic cid w/ Arbutin), Retin-A Cream for cell turnover, Vita-K cream for Blotchy Skin .



     


    How to care for hyperpigmentation


    First, get your skin completely clear from active acne. This way you are preventing any future hyperpigmentation. Once you are clear, you can try a hyperpigmentation treatment from above to reduce the marks you might have. Topical treatments are the first choice for treating hyperpigmentation. The treatments most commonly prescribed by dermatologists are hydroquinone (HQ) and retinoids.11Hyperpigmentation is common among people of African, Asian, and Latino descent, as well as other forms of non-Caucasian skin.1-5 Hyperpigmentation can also occur in Caucasian skin, albeit less frequently. UV light – the light from the rays of the sun – can make hyperpigmentation worse and cause it to remain longer. However, it is not clear whether UV light worsens acne itself, as research studies have reported that UV radiation can both increase6 and decrease7 acne. Regardless, for all skin types, it is important to take appropriate steps to protect your skin from excessive sun in order to avoid worsening of hyperpigmentation and allow any hyperpigmentation you currently have to heal as fast as possible.
     


    How to prevent hyperpigmentation



    Picking at acne lesions is the worst culprit when it comes to creating hyperpigmentation. Absolutely do not pick at acne lesions. Properly pop a pimple only when it is ready to be popped, and then leave the lesion alone. Also, while it may seem intuitive to scrub marks away, harsh scrubbing will only prolong their duration and should be avoided. Be sure to wash gently. Next, as mentioned, keeping hyperpigmented skin out of the sun when possible is a huge help in allowing these marks to fade as quickly as possible. Wearing a sunscreen is important as well.1,5,9

    The best way to prevent hyperpigmentation is to treat the acne itself, thus preventing future acne lesions and any hyperpigmentation that they might leave behind.10 Acne is treated the same regardless of skin color and responds extremely well to proper topical treatment with benzoyl peroxide. When acne is severe, widespread, and deeply scarring, Accutane (isotretinoin) is also an option.


    Hydroquinone: (Bleach Eze®)



    Hydroquinone is the first choice of treatment for hyperpigmentation.12 It is normally used at a concentration of 4%. In higher concentrations it can cause "spotted halos," which appear as lighter colored ring around marks. Hydroquinone treatment results in a marked improvement or complete clearing of PIH in 63% of the patients.4 The efficacy of hydroquinone may be increased by the addition of a retinoid and a low potency corticosteroid, such as hydrocortisone.13 Side effects of hydroquinone include burning, redness, and itching in 30% of the patients.12 The addition of ascorbic acid (Vitamin C) to a topical hydroquinone treatment may help minimize side effects.2-3 Hyperpigmentation starts to subside after 4 weeks of hydroquinone treatment, but maximum results usually require 8 to 12 weeks of treatment. Be certain to work closely with your physician or dermatologist if you decide to use hydroquinone to ensure proper dosage and reduction of side effects.


     Read Reviews   

     

       No Reviews


     


    Retinoids



    Tretinoin (Retin-A®), Adapalene (Differin®), or Tazarotene (Tazorac®). Retinoids are vitamin A analogues that are typically used together with hydroquinone. Retinoids are topical treatments that can help fade marks and treat acne at the same time. According to the Journal of the American Academy of Dermatology, “Of particular significance to skin of color patients is the ability of retinoids to treat both acne and PIH. By increasing epidermal turnover, these agents facilitate melanin dispersion and removal.”8 A study published in The New England Journal of Medicine on people with skin that was darkened by hyperpigmentation showed that daily retinoid treatment resulted in “much lighter” skin in 53% of participants and in “somewhat lighter” skin in an additional 33% of patients.14

    If retinoids are used alone and not in combination with hydroquinone, dermatologists often prescribe a topical corticosteroid in order to reduce the irritation and potential worsening of PIH that retinoids can cause when they are used alone. An expert opinion in Skin Therapy Letters sums it up: “The use of retinoids as monotherapy is not recommended as an irritant reaction may cause inflammation that induces paradoxical hyperpigmentation; a similar concern exists over the use of HQ as monotherapy at very high concentrations (i.e., 8-20%).”12

    Retinoids typically take 8 to 12 weeks to produce maximum results. The frequency and concentration of retinoid therapy depends on the severity of hyperpigmentation and should be determined by a dermatologist.



    Tretinoin

     Read Reviews   

     

       3.54/5 - 1396 reviews



    Adapalene

     Read Reviews   

     

       3.3/5 - 1305 reviews



    Tazarotene

     Read Reviews   

     

       3.51/5 - 615 reviews


     


    Niacinamide, also known as Nicotinamide.



    Niacinamide is a B vitamin that can be administered topically, and is currently being investigated as a potential therapy for hyperpigmentation. A study published in the journal Cutis in 2015 showed that a topical cream containing 4% niacinamide in combination with the other pigment-lightening and anti-inflammatory compounds arbutin, bisabolol, and retinaldehyde reduced hyperpigmentation due to melasma by 34% over a period of two months. Melasma is a common skin problem where brown marks appear on the face due to pregnancy or sun exposure.15 To date, there exists no published research that has investigated whether niacinamide is also effective in treating PIH, but studies are currently in progress.


     Read Reviews   

     

       4.5/5 - 3 reviews


     


    Azelaic acid



    Azelaic acid is another topical acne prescription that is sometimes used for PIH that works by slowing down the production of melanin. It is a gel that doctors normally prescribe in 20% concentration for PIH, applied twice a day. Azelaic acid is safe and effective for the treatment of both acne and PIH conditions in darker skin types. Common side effects include mild redness, scaling, and burning.16 Due to the mechanism of action of azelaic acid, results are not seen for the first few months of azelaic acid treatment, but results are eventually seen after six months.


     Read Reviews   

     

       3.89/5 - 218 reviews



    Gentle Chemical Exfoliation



    Over-the-counter glycolic acid products are available in strengths up to 10% and can provide gentler chemical “peeling,” which is better described as gentle chemical exfoliation. At lower percentages in over-the-counter products, glycolic acid does not cause the skin to visibly peel off in sheets like professionally administered chemical peels do, and instead provides exfoliation of only the surface cells of the skin. This is a slower and safer way to achieve the skin turnover required to reduce hyperpigmentation and can be used on a more frequent basis when compared to chemical peels. Most people find that they can tolerate over-the-counter 10% glycolic acid products every two or three nights, or every night when mixed ½ and ½ with moisturizer.



    Acne.org AHA+

     Read Reviews   

     

       4.41/5 - 332 reviews



    Alpha Hydrox Enhanced Lotion

     Read Reviews   

     

       4.11/5 - 58 reviews



    ___________________________________________________________



    5. WHAT IS: HYPOPIGMENTATION 
         - white spots 



    Q: What Is Hypopigmentation? A: Hypopigmentation is: Vitiligo, pigment loss due to burns, scars, skin discoloration.




    Treatments: XTRAC Excimer Laser at 308nm or Light Box phototherapy treatments UV-B lamp, Melgain (Decapeptide - Basic Fibroblast Growth Factor), and microneedling at home. Clinics use costly Recell which only has a small percentage of working on scars. A new spot treatment is LATISSE (bimatoprost ophthalmic solution) to darken the hypopigmentation and and cause "some" pigment to slowly return. Checkout the link below for how a member fixed his hypopigmentation. If nothing works there is medical tattooing http://basmahameed.com/paramedical/surgical-scars.php


    Read More here: http://www.acne.org/messageboard/topic/352685-recell-for-hypopigmentation-burn/?page=5









     


     







     


    https://www.youtube.com/watch?v=lW7VAUMclIk


    ___________________________________________________________
    6. TEXTURE, DRYNESS, & COVERING UP SPOTS


     




    Q: How do I improve my large pores, and orange peel texture?
    -- Please See the Filler and Subcision Section below for a detailed description for scars.


    A: At Home




    Retin-A - Increases Skin turnover production.


    BHA (Glycolic acid peels) like you find from Acne.org store above. 


    Paula's Choice 10% niamincide booster. Niamincide has been proven to thicken skin and shrink pores.


    There is a cream called Benefit Cosmetics "Pore"fessional that blurs these spots, used as a primer under makeup or by itself.


    TCA Cross using 50%, you need a very tiny way to either get into the pore and not hit the walls doing a little at a time until they heal. Some have used a broom bristle, shaved down toothpick, and tiny needle to fit inside pores or ice picks.


     


    For a larger area you can spot treat with TCA full peels (spot treatment on your scars 35% and under, start at 15% and move up, do a test spot to see how your skin reacts before going crazy). Always degrease with acetone or rubbing alcohol and a pre-peel jesner / glycolic peel  before.  You can do a few at a time, so you can cover with makeup.


    Doctors treatments:


    -PDT (Photo Dynamic Therapy) using led blue light and medication to shrink pores


    -Infini shrinks pores


    -Laser Genesis, Clear and Brilliant, Fraxel 1927 (only, not 1550), Shrinks pores and small acne scars


    -Sublative (ematrix) is good for surface texture takes many treatments, results are subtle like laser genesis


    -Microneedle .05mm followed by botox to the pores superficially shrinks them.


    Q: Can Guys Do Anything to Cover Their spots and Help with Self Esteem?A: Guys you can be as manly as you want and wear makeup (the ladies have had this tool for some time).
    Hear me out. Movie stars, news anchors, models, musicians, Youtubers, and even politicians wear makeup. Buy a concealer for just your acne scars and spots (spot treat them). You want it to match exactly your skin color and not be shiny ("matte"). My favorite is sold at Sephora (they color match you) Makeup Forever Camouflage Concealer, this looks extremely natural on the spots. Dermablend is sold at Macy's and Nordstrom. This is used for medical scars and to cover tattoos (they match your color) and it's very thickly pigmented. Ben Nye Cover All Wheel and Bill Nye Concealer Wheel sold on Amazon and Ebay (it has various shades), this is used in the theater.  



     



     



    Q: What can I do for extreme dryness, bumpy or bad texture, small wrinkles, or marks?-- Please See the Filler and Subcision Section below for a detailed description for scars.


     


    A: Moisture with a pure 100% Hyaluronic Acid Serum, this avoids skin irritation or ...
    Skin boosters (very popular in Europe and Asia) like Restylane Vital, Juvederm Hydrate or other HA products are not crosslinked like what is used in filler and much more superficial (just under the epidermis). Filler provides lift; but boosters are different making a bunch of small injections to provide intense hydration, minor skin correction, and small textural improvements.http://www.acne.org/messageboard/topic/357406-skin-boosters-restylane-vital-hyaluronic-acid/




     



     




  18. Forums Scar treatments 5  replies 4,904  views

    Hi Everyone,
    I want to update the FAQ, since a common topic seems to be PIE - Post Inflammatory Erythema (redness related to acne, popped pimples, infection, chemical burns, over-exfoliation, cuts, scrapes, scratches, sunburn, ... it goes away when you press on the area). Unlike PIH - Post Inflammatory Hiperpigmentation which is permanent changes in the skins pigment. I have seen a few posters recently come to the acne scar sub with PIE issues and they want solutions for their scars. 
     
    What's the difference between Post Inflammatory Hyperpigmentation and Erythema?

    Post Inflammatory Hyperpigmentation (PIH) is related to brown spots, not red spots. The brown discolorations are caused by an excess production of melanin. Vitamin C, AHAs, Hydroquinone are all great tools for inhibiting melanin which will fade the brown discoloration, but it will not do anything for red or purple scarring - which is something I believe is mistaken on this sub. PIH is more common in darker skin types (Fitzpatrick IV-VI), although it is not limited to any skin type.




    Post Inflammatory Erythema (PIE) is a new term that is starting to pick up awareness in dermatology terminology. PIE is in the process of becoming the new terminology used to describe pink to red discoloration after an inflammatory acne lesion. Patients with lighter skin types (I-III) the postinflammatory dyspigmentation is often not hyperpigmentation, but instead discrete erythematous macules (PIE). Acne may not be the only cause of postinflammatory erythema, as any resolving cutaneous inflammatory process may have residual erythema.


    source: https://www.reddit.com/r/SkincareAddiction/comments/1tk78i/post_inflammatory_erythema_pie/
    PIE
    PIH
    Treatments:
    PIE's: V-beam (vascular laser), Silicone Sheets, cortisone shots aka Kenalog (Can cause skin atrophy). Fresh Lemon, triple antibiotic, or Bactroban cream. Topical green tea also has a soothing effect on the skin-5 per cent concentration of room temperature has been shown to be effective. 2.5% hydrocortisone twice per day (only for a weeks time - it thins the skin). Antioxidant vitamins, Niacinamide . And topical Vitamin C serum.
    PIH: Skin bleaching cream and acid peels, laser resurfacing, photo facial, IPL.
     
  19. Forums Scar treatments 11  replies 3,199  views

    There is a new treatment for acne scars in Korea and Sweden it's called INNO Plus+Subcision + RF using a cannula, can also use filler. It's a subtle change, seems like it would be perfect for box cars, rolling, and tethered spots. If you are near Korea / Sweden there is a new treatment subcision with RF. If anyone gets it please post a update here as we cannot get this in the USA ;-P-- Korea http://blog.sina.com.cn/s/blog_b9ef0f610102vmrr.htmlhttp://rnmeskin.blogspot.com/2015/06/inno-plus-upgraded-rf-procedure-for.html-- Swedenhttps://www.bokadirekt.se/en-US/places/laserfocus-clinique-5126/inno-plus-170994https://www.youtube.com/watch?v=4DTxmayQTRE
  20. Forums Announcements and feedback 6  replies 690  views
    In regard to a recent user that was blocked by the MOD (Thank you MOD for your help) and many users who have Body Dysmorphic Disorder (and its subset acne scar dysmorphia) / Narcissism (the topics always become about them)  and are overtaking the Acne Scar area of the forum (making the experience terrible for the users). In fact they are saying they want to commit suicide often even after being told to seek therapy.
    ** Can we have a feature please MOD on this forum to block individual user names that we do not wish to see their content or have them contact us, that would be extremely helpful and allow them to still be part of the forum, just not part of a individuals experience. 
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Improving Scars. Have tried it all. ^ Adam Levine is great inspiration of beautiful skin ^