MEDICAL AESTHETIC CERTIFICATION 2022

A CASE REPORT:
EFFECTS OF TOPICAL RETINOIDS PRIOR TO CHEMICAL
PEELS ON ACNE SCAR TREATMENT

Prepared by GROUP 15, B23:

Lim Xin Ying
Lim Siew Puay
Murtaza bin Mohamad Mustaffa
Norliyana binti Abdul Satar
Tan Zi Wei

30th NOVERMBER 2022

Effects of Topical Retinoids Prior to Chemical Peels on Acne Scar
Treatment: A Case Report
[1]Lim Xin Ying, [2]Lim Siew Puay, [3]Murtaza bin Mohamad Mustaffa.
[4]Norliyana binti Abdul Satar, [5] Tan Zi Wei

[1]
MD UNIMAS, [2] MD UMS, [3] MD UNAND, [4] MBBCh Alexandria University, [5] Taylor’s
University

ABSTRACT

Chemical peels is a method of targeted cutaneous ablation induced by specific caustic agents
that allows for a rapid, predictable, and uniform thickness of chemoablation to a given desired
cutaneous depth which is widely used for the treatment of acne scars and other skin conditions
as it is cost-effective and non-invasive. While chemical peels play a role in the treatment of
dyspigmentation, inappropriate use of chemical peels can also result in post-inflammatory
hyperpigmentation and other complications, which affects more on darker skin types
(Fitzpatrick skin types III to VI). Topical retinoids is a widely used skin care product which is
easily available over the counter. Topical retinoids not only help to reduce signs of aging,
including pigmentary disorders, fine lines and wrinkles as well as treatment of acne in
adolescents and young adults. In this case report, we presented a case of post-inflammatory
hyperpigmentation in a 23-year-old lady with Fitzpatrick skin type 2, secondary to chemical
peel for her acne scars treatment. After the chemical peels were completed, the history of the
topical retinoids utilised became known. This demonstrates the significance of obtaining an
accurate history from every patient prior to aesthetic procedures. Complications can be best
avoided by proper patient selection, proper patient counselling, adequate priming and good
intra-peel and post-peel care.

Keywords: chemical peels, topical retinoids, post-inflammatory hyperpigmentation

INTRODUCTION
Chemical peels are the third most commonly performed noninvasive cosmetic procedure in the
United States, with over 1,300,000 procedures performed in 2016 alone (Soleymani et al.,
2018). Chemical peeling, also known as chemexfoliation or chemical exfoliation, is a
procedure where a chemical substance applied to the skin causes controlled destruction of the
epidermis with or without part of the dermis, leading to skin regeneration and remodelling. The
induced exfoliation is followed by dermal and epidermal regeneration from the adjacent
epithelium and skin adnexa, which results in improved surface texture and appearance of the
skin. This is a simple, cost-effective procedure with several dermatological applications
(Singh-Behl & Tung, 2009). Indications for treatment can be classified into four categories:
chronic chrono- and photoaging, acne and acneiform eruptions, dyspigmentation, and pre-
malignant epidermal neoplasms.
Chemicals peels are classified based on the depth of penetration into superficial (epidermis–
papillary dermis), medium (papillary to the upper reticular dermis), and deep peels (mid-
reticular dermis) (Singh-Behl & Tung, 2009). Superficial peels are most commonly used for
mild skin disorders such as dyschromia, acne, post-inflammatory hyperpigmentation, melasma,
and actinic keratosis (Rendon et al., 2010). Medium-depth peels are used for solar keratoses or
lentigines, pigmentary disorders, and superficial scars. Deep chemical peels are used for
photoaging deep scars or wrinkles and precancerous skin lesions.
The factors affecting the depth of peeling, and thus the degree of its therapeutic effects, include
the properties of the chemical agent (e.g., concentration and pH), the physician's application
technique, and the patient's skin condition and sensitivity. When choosing the appropriate
peeling agent, physicians must individualize treatment and conduct a complete medical history
and skin examination to prevent suboptimal results or complications. The past medical history
can reveal factors that could contraindicate the peeling procedure or alter the wound healing
process.

Appropriate patient and peel selection, counselling, priming and aftercare minimises the risk
of complications. Despite such measures, adverse effects can occur following chemical peeling
and vary according to peel depth. Minor complications include the development of acneiform
eruptions, infection (bacterial, fungal and viral), persistent erythema, demarcation lines and
milia,pigmentary changes (hyperpigmentation and hypopigmentation), scarring (atrophic,
hypertrophic and keloid) and the increased pigmentation of naevi may also occur (O'Connor et
al., 2018).Although major complications are rare, major local and systemic complications of
chemical peeling such as allergic reactions, laryngeal oedema, toxic shock syndrome,
cardiotoxicity, salicylism, acute kidney injury, lower lid ectropion, corneal damage, significant
scarring and dyspigmentation (O'Connor et al., 2018).

The physical exam will determine skin type, degree of photodamage, and presence of other
skin disorders. The Fitzpatrick scale is a useful tool to classify skin based on pigmentation and
ability to tan . It can also be used to stratify risk of hyperpigmentation following a peel. Patients
with darker skin types (IV–VI) are at greater risk of developing post-peel or post inflammatory
hyperpigmentation, whereas those with type I and II skin do not usually develop this
complication(Castillo & Keri, 2018).Following worldwide trends, acne is one of the most
common skin problems among Asians, as shown by many studies. Asians are Fitzpatrick skin
type III–V. As mentioned before, their skin type puts them at risk of post-peel complications.
The appropriate peeling agent should address acne lesions and prevent and treat post-
inflammatory hyperpigmentation(Castillo & Keri, 2018).

A detailed consent form should be taken prior to the procedure. Pre-peel photography under
proper lighting is advised in all cases. The patient should be counselled about the nature of the
treatment, the risks involved, the expected results, the early warning signs like erythema,
hyperpigmentation, crusting, etc., the need for applying proper topical treatment after peels for
maintenance and preventing complications and the need for avoidance of sun and irritant
chemicals(Anitha, 2010).

The pre-peel precautions to be taken to prevent complications include identifying the patients
at risk by a detailed history and examination. Other precautions include the following a)
Adequate priming of the skin for at least 2–4 weeks prior to peel and discontinuing 3–5 days
before the procedure is of vital importance. The application of depigmenting agents such as
hydroquinone or retinoic acid and the use of sunscreens does priming. b) Patient should be
instructed not to bleach, wax, scrub, massage or use depilatories or scrubs, or schedule any
vital event 1 week before the peel and to stop retinoid 3 days before the peel (Khunger ,2010).c)
In patients with active lesion or a history of herpes simplex, a prophylactic antiviral such as
acyclovir or valaciclovir should be given, beginning two days before the peel and continued
for 10–14 days after peeling, till reepithelialisation occurs(Anitha, 2010).
Chemical peeling is a simple, safe and cost-effective procedure. Thorough knowledge about
chemical peeling and the risks involved, adequate patient counselling and education, and
performing peels with all basic precautions minimise the complications of chemical peels.

CASE PRESENTATION
A 23-year-old lady presented to our clinic complaining of acne scars over the cheeks. She
complaints are of low self-confidence and self-aware of the scars on her face. She has never
done any aesthetic procedures before . During the active acne vulgaris , she visited the
dermatologist who had just given her antibiotics.
She has no previous history of any medical conditions. She clamied she only use her regular
skin care products such as moisturiser and cleanser.
All the options were offered and explained to the patient. The patient was not keen on any
injectable procedure. However, she was keen on chemical peesl. Written consent was taken
from the patient.
On examination, the patient is Fitzpatrick skin type 2. She has multiple acne scars over bilateral
cheek and chin area. She also had minimal active acne.
The patient’s face was cleaned and subsequently sterilised with alcohol swab. Vaseline was
applied around the corner of the eyes, mouth, and nasal alar region to prevent the solution
pooling into the eyes and mouth.
Jessner’s solution was used in this case. The solution was applied evenly with a brush. Since it
was the patient’s first-time treatment, only a single layer was applied. After 30 seconds, the
patient started complaining of a burning sensation over the bilateral cheek and chin region.
Upon examination, noted that the area had started to turn erythema. The solution was
immediately washed off. Patient had some erythema. However, no burns were visible. SPF was
applied and the patient was counselled for constant sun protection factor use.
Post-treatment day 1, the patient complained that the area around the cheek and chin turned
dark. On inspection, there were hyperpigmented spots over the cheek and chin. The patient was
started on topical steroids.
Post-treatment day 5, noted that the burns were improving and reducing. Upon further
questioning, the patient admitted to using retinol four days prior to the procedure. The patient
was advised to inform prior to any procedure as a complication may occur.
MANAGEMENT
1. Topical steroids Started for patient to reduce the inflammation of the area.

2. Sunscreen Patient was adviced to constantly use sunscree especially when

going out in the sun
3. Topical retinoids Patient was advised to stop retinoid cream, as well to inform the
doctor prior to any procedure

4. Peeling Agent Patient was also advised to avoid any products with peeling agent
until skin has recovered

OUTCOME
Post procedure, skin started becoming erythema. Patient complained of mild pain. The steroid
cream was started.

Figure 1: Post day 1, there were burn marks on the cheek and chin region.

Figure 2: Post day 3, burn mark showing slight improvement

 Figure 3: Post day 7, burn marks improved. Mild pigmentation visualised

Figure 4

DISCUSSION
The main complaint of the patient in this case is multiple acne scars over bilateral cheek and
chin area. Acne scars can be classified into three different types: atrophic, hypertrophic, or
keloidal. Atrophic acne scars are the most common and divided into three main types: ice pick,
rolling, and boxcar scars.1,2,3 A number of treatments are available to reduce the appearance of
scars, including chemical peeling, dermabrasion, laser treatment, punch techniques, fat
transplantation, other tissue augmenting agents, needling, subcision, and combined therapy. In
this case, the patient opted for a chemical peeling which is a non-invasive procedure.

Chemical Peeling
In order to resurface, rejuvenate and induce regeneration processes in the skin, chemical peels
have been used for destruction of upper parts of the skin since many years. Besides age-
related skin changes, peeling have been demonstrated over decades to play an important role
in improving acne, dyspigmentations and scars. Various substances, including all sorts of
chemical compounds (e.g. alpha hydroxy-, beta- or lipohydroxy-, glycolic-, lactic-, bi- or
tricarboxylic-, salicylic-, trichloroacetic-, retinoic- or alphaketo-acids, as well as phenol,
resorcinol, Jessner's solution, their combinations and many others) are available on the
market.4-7
The above mentioned peeling agents may be divided according to their depth of penetration
into very superficial, superficial, medium and deep peels reaching stratum corneum, stratum
basale, upper or mid reticular dermis, respectively. The classification of peeling agents are
listed in Table 1.8,9 Depending on the potency level of the respective peels, practitioners should
strictly follow the recommended indications and respect known contraindications (e. g. Baker-
Gordon phenol deep peel in Fitzpatrick skin types V and VI), as well as communicate all
possible adverse events and complications beforehand with the patient.5

Classification of Peeling Agents

Depth of Penetration
Very superficial
Histologic Level
Destruction of the stratum
corneum without creating a
wound below the stratum
granulosum
Peeling Agents
Glycolic acid, 30% to 50%,
applied briefly (1 to 2
minutes)
Jessner solution, applied in 1
to 3 coats

TCA 10%, applied in 1 coat

Superficial Destruction of part or all of
the epidermis, anywhere
from the stratum
granulosum to the basal cell
layer
Glycolic acid, 50% to 70%,
applied for a variable time
(2 to 20 minutes)
Jessner solution, applied in 4
to 10 coats

TCA, 10% to 30%

Medium Destruction of the epidermis Glycolic acid 70%, applied
and part or all of the for a variable time (3 to 30
papillary dermis minutes)

TCA, 35% to 50%

Augmented TCA (CO2 plus

Deep Destruction of the epidermis
and papillary dermis,
extending into the reticular
dermis
TCA 35%; Jessner solution
plus TCA 35%; glycolic
acid 70% plus TCA 35%)
Phenol 88%
Baker-Gordon phenol
formula

Table 1. Classification of Chemical Peeling Agents

Jessner’s solution
The amount and type of chemical peeling agent used for this patient is a single coat of Jessner’s
solution (very superficial peel). The Jessner’s solution was first formulated over a hundred
years ago, and has the ability to reduce age spots, the appearance of scars, smooth fine lines
and wrinkles, even out skin tone, and treat melasma, hyperpigmentation, and acne scars.
Jessner’s solution is used for light peels alone or in preparation for a TCA peel to enhance the
penetration of TCA (medium depth peel). The preparation is made from salicylic acid (14g),
resorcinol (14g), lactic acid 85% (14g), and ethanol (100mL q.s).10 It is a clear, amber-coloured
solution that needs to be kept in a brown bottle to prevent photo-oxidation.11,12 The depth of
the peel depends on the number of coats of solution applied. Different patients may require
different number of coats to achieve the same level of peel. This is because penetration of the
solution depends on a number of factors, including the preparation of the skin, the thickness of
the corneum, and the sensitivity of the skin. Jessner’s solution is generally applied in two to
three coats before mild erythema and delicate, patchy frosting develops.11,13 It does not require
neutralisation. Patients may experience a burning sensation with this peeling agent.11 During
the first treatment, it is recommended to apply one layer of solution and gradually increase the
number of layers with each treatment.14

Retinoids
Retinoids are a group of compounds containing Vitamin A, its derivatives and other
compounds activating retinoid receptors. Mostly known example of retinoids are retinol, retinal,
retinyl palmitate, retinyl acetate, and retinoic acid (Tretinoin). The local actions of retinoids is
based on accelerating the turn-over-time process and exfoliating the stratum corneum, in order
to which the process of epidermal cell renewal is regulated. Topical tretinoin is used for the
treatment of various dermatoses such as acne, melasma, scars, and skin aging. Tretinoin’s
mechanism of action is based on thinning the stratum corneum, which results in a smoother
skin. Moreover, tretinoin induces the dispersion of melanin granules into the epidermis, which
reduces skin hyperpigmentation. Retinol is the alcohol formulation of vitamin A. This
compound is very stable, being the most used vitamin A analog in cosmeceuticals. Compared
to tretinoin, retinol is better tolerated by the skin, but the effect of tretinoin is stronger. The
effect of retinol is to improve the skin structure, lighten discoloration and smooth fine lines.
The effects of retinyl palmitate and retinyl acetate are the weakest of all vitamin A analogs. It
is caused by the fact that they first need to be converted to retinol and then to retinoic acid.
Retinal is the aldehyde analog of vitamin A. The effect caused by this compound is also weak.
Retinal is characterized by gentle improvement of the fine lines and it is less irritating than
tretinoin.15
Retinoids enables the peeling agent to penetrate the skin more rapidly and deeply, hence it must
be halted prior to chemical peel to avoid exaggerated effects or complications of peeling. It
may be restarted after the procedure once healing is complete, usually after about a week.

Relative Contraindications of Chemical Peel

1. The patient’s philosophy of sun exposure.
2. Pregnancy/breast-feeding women.
3. An immunocompromised status and/or being under medical treatment.
4. A history of keloid scars.
5. A history of viral, bacterial and/or fungal infections.
6. A history of surgery and/or radiation therapy.
7.A history of treatment using topical and oral retinoids (tretinoin, adapalene and
isotretinoin).16

Referring to the above-mentioned relative contraindications, note that this patient has been
using an unknown amount and frequency of topical retinoids 4 days prior to procedure. The
immediate erythema and intense burning sensation that occurred even before frosting appear,
with development of post-inflammatory hyperpigmentation later on are most probably the
consequences of not stopping topical retinoids prior to the procedure which caused the
exaggerated peeling effects and increased skin sensitivity of skin topped with retinoids.

Complications of chemical peels

Chemical peels are a relatively safe procedure provided they are performed under the
supervision of an experienced clinician. Appropriate patient and peel selection, counselling,
priming and aftercare minimizes the risk of complications.17 Despite such measures,
complications can occur following chemical peeling and generally related to peel depth, with
deeper peels providing more marked results and higher incidence of complications.
Complications are also more likely with darker skin types (Fitzpatrick skin types III to VI),
certain peeling agents, and sun exposure. They are divided into minor and major subgroups.

Minor
Minor complications may occur within minutes to hours of the procedure. These include
irritation, burning, erythema, pruritus, oedema and blistering.18,19,20 Minor complications also
occur in a delayed fashion appearing over days to weeks. These include the development of
acneiform eruptions, infection (bacterial, fungal and viral), persistent erythema, demarcation
lines and milia. Pigmentary changes (hyperpigmentation and hypopigmentation), textural
changes, scarring (atrophic, hypertrophic and keloid) and the increased pigmentation of naevi
may also occur.17,21

Major
Although they are rare, major local and systemic complications of chemical peeling include
allergic reactions, laryngeal oedema, toxic shock syndrome, cardiotoxicity, salicylism, acute
kidney injury, lower lid ectropion, corneal damage, significant scarring and dyspigmentation.

Post-inflammatory Hyperpigmentation
Post-inflammatory hyperpigmentation (PIH) is a common sequelae of inflammatory
dermatoses that tends to affect darker skinned patients with greater frequency and severity.
Medication-induced PIH is caused by hypersensitivity reactions or cutaneous injury from
irritants, burns, or cosmetic procedures.22
PIH results from the overproduction of melanin or an irregular dispersion of pigment after
cutaneous inflammation.23 When PIH is confined to the epidermis, there is an increase in the
production and transfer of melanin to surrounding keratinocytes. Although the exact
mechanism is unknown, this rise in melanocyte activity has been shown to be stimulated by
prostanoids, cytokines, chemokines, and other inflammatory mediators as well as reactive
oxygen species that are released during the inflammatory process. PIH within the dermis results
from inflammation-induced damage to basal keratinocytes, which release large amounts of
melanin. The free pigment is then phagocytosed by macrophages, now called melanophages,
in the upper dermis and produces a blue-gray appearance to the skin at the site of injury.24,25
PIH typically appears as irregular hyperpigmented macules or patches in the same distribution
as the initial inflammatory process. The colour of the pigment depends on the location of the
excess pigment within the skin layers. Epidermal hyperpigmentation is tan, brown, or dark
brown while dermal hyperpigmentation appears as blue-gray appearance. The diagnosis of PIH
is clinical however wood’s lamp examination may be helpful to distinguish between epidermal
and dermal PIH as wood’s lamp examination of epidermal PIH may appears fluorescence. Skin
biopsy may be helpful if diagnosis is uncertain as histopathology may reveals patchy epidermal
or dermal melanosis.23
It is important to initiate treatment early for PIH to prevent worsening of the hyperpigmentation.
The first line of treatment is topical hydroquinone along with UV protection with a sun
protection factor (SPF) of 30. Hydroquinolone often combines with other agents such as
retinoids, corticosteroids, antioxidants, glycolic acid to increase efficacy.26 We used SPF
immediately for this patient to prevent further darkening of the skin as well as topical steroid
as it can lessen the irritant effects, however steroid can only be used for up to 8 weeks to
minimize the side effects of steroid. Chemical peeling or laser therapy can be used for severe
or refractory cases.27 Salicylic , glycolic, and trichloroacetic acid peels are common chemical
peeling. Laser therapy including Q-switched ruby lasers, Q-switched Nd:YAG lasers, and
picosecond (short, intense pulse) lasers have been used to treat PIH as they have fractional
photothermolysis.22,28
Some important preventive measures to reduce the risk of getting PIH includes UV protection,
treat injuries or inflammation promptly, follow an established skin care regimen. Hence in this
case, we can prevent the risk of getting PIH by looking into patient’s skin care regime carefully
and give clear instruction to patient to stop using abrasive exfoliants such as retinol for a
minimum of 2 weeks prior to chemical peeling.

CONCLUSION
Abrasive exfoliants such as topical retinol should be avoided at least two weeks prior to any
chemical peeling. In this case, the percentage, amount, frequency and types of application of
topical retinoids was not known prior to the chemical peels. Therefore, a good and thorough
history taking on the patient’s cosmetic and skin care products or any recent aesthetic
procedures are done before planning for an aesthetic procedure is crucial. The ultimate goal of
aesthetic procedures is to get a result that is as optimal and predictable as possible, so lowering
the likelihood of undesired complications and gaining the patients' trust and confidence.
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