Make your own free website on


Alpha hydroxy acids | Antihistamines | Beta hydroxy acids | Botulinum toxin | Chemical peels | Compresses | Corticosteroids or steroids | Finasteride | Hair replacement surgery | Immunosuppressive drugs | Implants | Intralesional steroids | Lasers | Laser resurfacing | Minoxidil | Phototherapy | Retinoids | Sunscreens


Alpha-hydroxy acids became popular during the nineties because of their beneficial effects on wrinkles.
There are several varieties of AHAs:-
  • Lactic acid derived from sour milk,
  • Citric acid derived from citrus fruits,
  • Tartaric acid from grapes,
  • Glycolic acid from sugar cane,
  • Pyruvic acid from papaya,
  • Malic acid from apples,
  • Mandelic acid from bitter almonds.
In other words, quite a few come from fruits, hence, its other name fruit acids. AHAs work by dissolving the cement that keeps our dead skin cells (the stratum corneum cells) together. In doing so, AHAs exfoliate the dead skin cells revealing the new cells underneath. This results in a smoother and more evenly toned skin. There are also studies to suggest that AHAs can increase collagen production in the dermis (deep supporting layer of the skin) and stimulate the production of hyaluronic acid, a mucopolysaccharide with superb water binding ability.

The advantage of AHAs is that, unlike tretinoin (vitamin A acid), they do not cause photosensitivity, are relatively non-irritating and can be used by pregnant women and women who are breast feeding. In terms of effectiveness, however, they nowhere near tretinoin. The activity of AHAs is very dependent on the pH. Most AHAs are only effective at a low pH of between 2.8 - 3.5. However, low pH formulations can irritate the skin so many AHA products overcome this problem by buffering. Unfortunately, doctors believe that buffering reduces their effectiveness. A 15% concentration with a pH of 5 may therefore, be less effective than a 8% one of pH 3. Unfortunately, the pH is often not indicated on the label. Generally speaking, over-the-counter AHA creams meant for the mass market are not as strong as those prescribed by doctors. AHAs are also used by doctors as a superficial chemical peel agent (see chemical peels).



Antihistamines are drugs which block the action of histamine, the chemical that is released during an allergic reaction and which causes inflammation and itching. Examples of antihistamines include:

  • Chlorpheniramine maleate,
  • Brohpheniramine maleate,
  • Homochlorcyclizine hydrochloride,
  • Buclizine hydrochloride,
  • Dexchlorpheniramine maleate,
  • Pheniramine,
  • Promethazine hydrochloride,
  • Mequitazine,
  • Trimeprazine tartrate,
  • Azatadine maleate,
  • Cyproheptadine hydrochloride,
  • Promethazine hydrochloride,
  • Mebhydrolin,
  • Hydroxyzine,
  • Loratidine,
  • Ebastine,
  • Cetrizine.

The last four antihistamines are newer and do not enter the brain and do not usually cause drowsiness. Other possible side effects include dizziness, appetite loss, nausea, dry mouth, blurry vision and problems with urination. You should not drive or operate heavy machinery if you are affected by drowsiness.



Beta-hydroxy acids or BHAs are not widely known even though one of them, salicylic acid has been used in wart and acne medicines much longer than AHAs. They work like AHAs in dissolving the cement between the dead skin cells and exfoliating them. However, unlike AHAs, salicylic acid is lipid (fat) soluble and penetrates the skin better. It is therefore, effective in lower concentrations that are even less irritating than AHAs.



Botulinum toxin (Botox ) is a bacterial nerve toxin capable of causing fatal food poisoning. In minute quantities, however, botulinum toxin has been used by doctors for treating blepharospasm, a condition causing twitching of the eyelid muscles and other types of muscular spasms. It was during treatment of blepharospasm that doctors noticed the loss of wrinkle lines. Since, then the botulinum toxin has been used successfully and safely to treat dynamic wrinkles such as forehead frown lines and crow's feet. The botulinum toxin paralyses or weakens the muscles that pull on the skin, hence reducing the lines and furrows.

The toxin comes in a freeze-dried form and has to be reconstituted and diluted. Minute quantities of the botulinum toxin is injected directly into the muscle and the procedure is not very painful. However, beneficial effect lasts only about 3 - 6 months after which treatment needs to be repeated. One possible complication is a droopy eyelid or eyebrow which is temporary, lasting 2 - 3 months.



Chemical peels involve the application of chemicals to wound the skin to a desired depth so that with healing, wrinkles, irregularities of contour and pigmentation become less prominent. In other words, old imperfect skin is removed, unveiling a fresher, clearer, smoother looking complexion. Chemical peels are usually performed on the face where the good blood supply aids healing. Many doctors prescribe tretinoin (vitamin A acid) creams for 2 - 6 weeks prior to peeling as this seems to improve healing, especially after medium-depth and deep-depth peeling. If there is a risk of pigmentation, hydroquinone (a skin lightening) cream is sometimes also included.

    Conditions that may benefit from chemical peels

  • Wrinkles (rhytides).
  • Hyperpigmentation or uneven pigmentation.
  • Sun-damaged skin.
  • Actinic lentigines (age spots).
  • Solar keratoses (precancers).
  • Seborrhoeic keratoses (age warts).
  • Scars - for example, acne scars (but not the ice-pick variety which should be excised first), chickenpox scars, surgical and traumatic scars.
  • Acne vulgaris..

The recovery after medium and deep-depth chemical peeling is hastened and the risk of developing postinflammatory hyperpigmentation (increased pigmentation) can be reduced by using tretinoin and hydroquinone lightening creams, respectively, 2 - 6 weeks before the procedure. Different chemicals penetrate the skin to different degrees. Generally, the higher the concentration the greater the penetration with the sole exception of phenol which is stronger when diluted. Chemical peels are classified into three types:

  • Superficial chemical peels.
  • Medium-depth chemical peels and.
  • Deep-depth chemical peels..

Superficial peels
Superficial peels penetrate the epidermis predominantly or may extend slightly into the papillary dermis. Multiple peels (3 - 6 peels) are necessary to induce the production of collagen. The discomfort is mild so no anaesthesia or sedation is necessary. Recovery is also very fast, hence they are sometimes also called "office-peels" and serious complications are rare. Superficial peels are suitable for all skin types.

    Agents used

  • 10 - 20% trichloroacetic acid (TCA).
  • Alpha-hydroxy acids (AHAs) - glycolic acid, lactic acid.
  • Jessner's solution (contains salicylic acid, lactic acid and resorcinol).


  • Improve the texture of sun-damaged skin.
  • Improve fine lines and mild wrinkles.
  • Improve uneven pigmentation.
  • Reduce pore size.
  • Improve acne vulgaris (pimples) and oily skin.

Medium-depth peels
Medium-depth peels penetrate into the papillary dermis and upper reticular dermis. The benefits are more pronounced than multiple superficial peels and one or two peels are usually sufficient. Medium-depth peels are very suitable for skin phototypes I and II. They can also be used in darker skin types but patients have to be warned about the possibility of temporary hyperpigmentation (especially in skin phototypes III and IV skins) which may require treatment with hydroquinone-containing lightening creams. Although, medium-depth peels are more painful than superficial peels, anaesthesia is usually not necessary. Oral or occasionally, intramuscular sedation may be used in patients who are very anxious or have a low pain-threshold. The only exception is the medium-depth phenol peel which requires the same sedation or anaesthesia as the deep-depth phenol peel (see the next section).

    Agents used

  • Full-strength phenol (88%).
  • Trichloroacetic acid (TCA) 35 - 45%.
  • Combination peels

    • Jessner's solution and TCA 35%.
    • Glycolic acid and TCA 35%.
    • Solid carbon dioxide and TCA 35%.

  • Improve mild to moderate wrinkles.
  • Improve mild to moderate sun-damage.
  • Improve uneven pigmentation.
  • Remove solar keratoses (precancers).
  • Improve mild scars.

Deep-depth peels
Deep-depth peels penetrate to the mid-reticular dermis. Only one peel is sufficient and microscopic studies suggest that the benefits of deep-depth phenol peels may last as long as two decades. However, phenol is a toxic chemical so full blood counts, liver and kidney function tests, urine tests and an electrocardiogram (ECG) of the heart must be done before the procedure. Pain is severe so general anaesthesia or nerve blocks alone or with intravenous (IV) sedation is necessary. The electrocardiogram (ECG), blood pressure and blood oxygen must be monitored throughout the procedure. Hypopigmentation (lightened skin) is common after deep-depth peeling so this treatment is not very suitable for people with skin phototypes IV - VI. Deep chemical peels are being replaced by laser resurfacing which does not have toxicity problem of phenol.

    Agents used

  • Baker's formula phenol peel (50%).
  • Trichloroacetic acid (TCA) 50% is rarely used.


  • Improve moderate to severe wrinkles, especially those around the mouth.
  • Improve blotchy and sun-damaged skin.
  • Remove solar keratoses (precancers).
  • Improve scars.

How long do the benefits of a chemical peel last?
It is important to understand that the effects of a chemical peel will not last forever because the ageing process will continue. Dr Albert Kligman who did the pioneering work on tretinoin studied women who underwent deep phenol peels and then facelifts 1 1/2 to 20 years later. He examined the excess skin removed during the facelift and noticed striking differences between the peeled and unpeeled skin. The epidermis was more normal in appearance, melanin was more evenly distributed and there was no microscopic evidence of actinic lentigines (age spots) and solar keratoses (precancers) in the peeled skin. The dermis also showed evidence of new collagen and elastin tissue on top of a disorganised mass of deeper, presumably unpeeled dermis. These findings suggest that the benefits of a deep phenol peel may last as long as 2 decades (average of 5 - 7 years). There are no data on the duration of benefit from medium-depth peels but most doctors estimate that they last 1 - 2 years. The benefits of multiple superficial peels, last only about 6 months so superficial peels have to be repeated.

What to do before a chemical peel
You must fully understand what the peel involves, what reaction to expect after the peel and how to look after the peeled skin. Much of this should have been provided by the doctor or his assistant but do not be afraid to ask until you are clear about this.

Chemical peels are usually performed as outpatient procedures. Clean your face with soap and water and do not apply any cosmetics for 24 hours prior to a peel. Arrange for transport and someone to accompany you home after medium- or deep- depth peels because the swelling may close your eyes and if sedation is used. This is not necessary after a superficial peel. You should also not eat or drink for at least 6 hours before the procedure if you are having a general anaesthesia or IV sedation.

Anaesthesia and sedation
  • Superficial peels - Anaesthesia and sedation is usually not required.
  • Medium-depth trichloroacetic acid peels are more painful - Oral or intramuscular sedation may, occasionally, be used if the patient is very anxious or has a low pain threshold.
  • Deep-depth phenol peels - Phenol peels are much more painful and require general anaesthesia, local anaesthesia or nerve blocks alone or with intravenous (IV) sedation. An anaesthetist will be present when general anaesthesia is used and a qualified nurse or an anaesthetist when IV sedation is used. The ECG (heart tracing), blood pressure and blood oxygen need to be monitored during phenol peels.
Peel application
In the clinic, you will be asked to lay down on a couch with the head slightly raised so that the peel solution will not get into the eyes. You will probably be asked to put on a protective gown or sheet and a hair-band may be used to keep the hair away from the face. The doctor or his assistant begins by cleaning the skin with a pre-peel cleanser or a degreasing agent such as alcohol or acetone to remove surface oil and ensure uniform penetration of the peel agent. The chemicals most commonly used for superficial, medium- and deep-depth peels are glycolic acid (an alpha-hydroxy acid), trichloroacetic acid (TCA) 35 - 45% and Baker's formula phenol, respectively. The method of application, post-peel course and after-care are described in greater detail below.

Superficial peel with glycolic acid 20 - 70%

  • The peel solution is applied with a brush, cotton-tip applicator or gauze.
  • It is left on for 3 - 6 minutes before neutralising with water or a solution containing 1% sodium bicarbonate.
  • You will then be asked to rinse your face with cool water until any stinging sensation subsides.
  • Your skin is cleansed once again with the neutraliser to remove residual acid.
  • A small amount of soothing cream is then applied to your face.
  • A small hand-held fan or dry ice pack may be used to reduce the mild burning discomfort.
  • The entire procedures takes only about 10 minutes to perform.
  • Peeling has to be repeated for 4 - 6 times at 2 - 4 weekly intervals until the desired result is obtained.
  • The depth of peeling depends on the concentration and the time the solution is left on the skin before neutralising. With subsequent applications, either the concentration of the peel solution or the time it is left on the skin is increased.
  • The main advantage of glycolic acid peels is the short recovery time. Reactions are mild, ranging from a sunburn appearance to slight weeping and crusting and short-lived. Glycolic acid peels are often called "lunch-time peels" or "office peels" because the patient may even return to work immediately after the peel.
  • The after-care is very simple.

Medium-depth peel with trichloroacetic acid 35 - 45%

  • Trichloroacetic acid (TCA) is usually applied with a piece of folded gauze or sponge and a cotton-tipped applicator near the eyes. Some doctors use cotton-tip applicators as in a phenol peel for the entire face.
  • A frost appears within a few minutes of application and this is accompanied by immediate tightness, warmth and stinging. The discomfort is usually severe for about 10 minutes and then subsides. It can be relieved by applying a cool compress or a dry ice pack.
  • The doctor may apply a dressing to reduce post-peel discomfort or he may use an open dressing method which involves soaking the face with cool water several times a day followed by application of vaseline or an antibiotic ointment.
  • The TCA peel takes about 15 minutes to perform.
  • A touch-up peel may be performed after 6 months, if necessary.
  • Unlike glycolic acid, TCA peels do not need to be neutralised. The depth of wounding is related to the strength of the TCA and not the time it is left on the skin.
  • The recovery period is longer and patients may have to remain homebound for about 1 week.
  • The after-care is extremely important in order to avoid complications.
    Deep-depth peel with Baker's formula phenol
  • The peel solution is applied with one to three regular cotton-tip applicators. To avoid toxicity, the doctor divides the face into 6 - 8 segments, applying phenol slowly over 15 - 20 minutes to one segment at a time. Phenol is not used on the eyelids. Dilution of phenol by tears increases its potency so an assistant is at hand to soak up any tears with a dry cotton applicator.
  • The skin develops a frost very rapidly, within seconds of the application.
  • The doctor may tape the skin for the first 24 - 48 hours to increase penetration or apply an antibiotic ointment or vaseline.
  • As with TCA peels, the after-care is extremely important.
  • You may be hospitalised for 1 - 2 days after a full-face phenol peel.
Generally, the peel application is applied a little over the hairline, borders of the lips, under the jaw and upper edge of the neck to avoid creating transition lines between peeled and unpeeled skin. Tears rolling down the cheeks can dilute the peel solution causing a streaked appearance. In the case of phenol, dilution increases the strength of the peel causing a deeper wound than is intended. An assistant is therefore, at hand to soak up tears with a cotton-tip applicator.

Post-peel course and after-care
It is very important that you understand the changes that occur after a peel so that you are not too alarmed. The after-care is especially important after medium- and deep-depth peels and will be reiterated to you or the person looking after you. Handouts may be given and you should consult the doctor or his nurse whenever you are unsure.

    Care of the skin after glycolic acid superficial peel
  • There is immediate redness after application of glycolic acid peel solutions which lasts less than an hour.
  • Slight redness, dryness and peeling of the skin may occur, generally lasting less than 4 days.
  • The irritation is mild and can be reduced with the application of a cold compress or a dry ice pack.
  • Healing occurs after 2 - 4 days.
  • A soothing cream is usually prescribed until the skin has healed.
  • You can return to work almost immediately and wear cosmetics after 24 hours.
  • Avoidance of the sun is the main requirement and sunscreens should be used during daylight hours and preferably, for life in order to delay ageing.
  • You can start to use the prescribed medicines such as glycolic acid creams or tretinoin cream once the skin has healed which is usually between 3 - 7 days.
  • The peel can be repeated after 2 weeks for a total of 4 - 6 times in order to achieve a smoother, brighter complexion.
  • The benefits last less than 6 months.
    Care of the skin after a medium-depth TCA peel
  • Immediately after the TCA peel, the skin is red and may be slightly swollen.
  • Most of the pain is felt during the application itself but if it continues, use cold compresses and dry ice packs. Over the first 2 days the skin becomes deeply tanned and the tanned skin will peel of as a membrane afterwards. It is usually possible to return to work after 7 days.
  • As in superficial peels, it is very important to use sunscreens and avoid unnecessary exposure to the sun.
  • The benefits lasts about 1 - 2 years.
    Care of the skin after a deep-depth phenol peel
  • The reaction after a phenol peel is more severe.
  • The skin begins to swell within a few hours and the swelling usually shuts the eyes. Sleeping with the head slightly elevated helps to reduce the swelling.
  • Ice packs can be applied (over the dressing, if necessary) and a simple painkiller such as paracetemol may be taken to reduce the discomfort. The dressing, if used, is usually removed after 1 - 2 days.The skin usually looks raw and weepy like a second degree burn.
  • Rinse the face with cool water or apply wet compresses several times a day followed by application of the antibiotic ointment or vaseline provided.
  • The aim is to keep the area moist and to soften and gently remove crusts that would otherwise serve as a medium for bacterial growth.
  • Healing occurs 10 - 12 days after a phenol peel.
  • The benefits last 5 - 7 years.

General measures
Despite counselling by the doctor and/or his assistant, it is not uncommon for patients to experience variable degrees of anxiety after chemical peels. This is quite natural and you should not hesitate to contact your doctor or his assistant if you are in any way worried. The following are some general measures you can take to help your face recover quickly:

    General post-peel measures
  • Do not pick or peel off the skin. Loose skin can be trimmed with a sharp pair of scissors.
  • Pat dry, do not rub the skin.
  • Avoid scrubs and abrasive sponges such as Buf-puf as the skin is very sensitive at this stage.
  • Avoid astringents and toners until advised otherwise by your doctor.
  • Do not scratch. Ask the doctor for some antihistamine tablets if itching is a problem.
  • Take a simple painkiller such as paracetemol for pain relieve and inform the doctor if the pain is not relieved.
  • Avoid excessive exertion and alcohol which would increase blood flow to the skin and encourage the development of telangiectasias (broken capillaries) for at least 2 weeks after surgery.
  • Avoid excessive talking, laughing and chewing after deep-depth peels.
  • Take a liquid diet if the mouth is very swollen.
  • Avoid excessive exposure to sunlight and use a broad-spectrum sunscreen until the redness has cleared and the skin has regained its normal colour. Sunscreens should be used indefinitely thereafter, to prevent further sun-damage.
  • Moisturise the skin regularly with the cream provided. You can resume application of your prescribed creams after the skin has resurfaced but remember that the skin will be more sensitive than usual.
  • Make-up can be applied to areas of skin that has resurfaced but remember that the skin is more sensitive after chemical peels. If irritation occurs, discontinue it.
  • Avoid contact sports where there is a risk of bumps or injury to the skin for at least 6 weeks.
  • Contact your doctor if there is redness, tenderness and a pus-like discharge from the skin. It may indicate bacterial infection which may require antibiotic treatment.
  • Contact your doctor if the skin becomes red, raised and itchy after it has apparently healed as this may indicate the development of lumpy scars (keloids).
  • Contact the doctor immediately if blisters appear because it may indicate a recurrence of herpes labialis or "cold sores".
Complications are generally rare and can usually be treated and reversed.
  • Pigmentary changes
    People with skin phototypes I - II skins are ideal for chemical peels. Darker skinned individuals are more at risk of developing pigmentary problems like hypopigmentation (lightened skin) or postinflammatory hyperpigmentation (darkened skin). Hypopigmentation is common after deep-depth or phenol peels which is why they are generally avoided in people with skin phototypes IV - VI, especially men because they cannot wear make up. It may occur temporarily with more superficial other peels. Hyperpigmentation may occur after superficial and medium-depth chemical peels in darker skinned individuals, especially type III and IV skin phototypes. Hyperpigmentation can be treated with lightening creams and may be averted by putting susceptible individuals on hydroquinone lightening creams before peeling and after the new skin has resurfaced.
  • Scarring
    Superficial peels are generally safe. Medium- and deep- depth peels may occasionally produce scarring and should be avoided in people with a tendency to develop abnormal or lumpy scars (keloids). Scarring has been reported after isotretinoin treatment which is why medium and deep -depth peeling should only be done 12 - 18 months after completion of isotretinoin treatment.
  • Infection
    Bacterial, yeast and viral infections may occasionally occur. Bacterial infections occur but are generally uncommon. Presumably, this is because the peel agents themselves sterilise the surface of the skin and there is a good supply of blood to the face. The risk of infection can be reduced by soaking off crusts that may otherwise provide a rich media for bacterial growth and by following the doctors after-care instructions carefully. Bacterial infections can be treated with oral antibiotics. Deep chemical peels may reactivate herpes labialis (cold sores) and cause scarring. Patients with a past history of herpes labialis are usually prescribed an anti-herpes drug such as acyclovir or famcyclovir 24 hours before and continued for a total of 7 - 10 days to prevent a recurrence.
  • Milia
    These are tiny "whiteheads" formed when the new skin grows over. They usually occur 2 - 3 weeks after the skin has resurfaced and can be extracted by the doctor with a number 11 scalpel blade.
  • Systemic side effects
    This complication applies only to phenol peels. Unlike other chemicals, diluted phenol actually penetrates deeper than full-strength phenol and may enter the blood circulation to produce toxic effects. The main effect is on the heart which may result in heartbeat irregularities. This is why phenol must be applied slowly over one segment at a time to allow the body to clear the phenol and prevent the accumulation of toxic levels of phenol. The electrocardiogram (ECG), blood pressure and blood oxygen must be monitored during application of phenol. Blood test and urine tests have to be done before a phenol peel to assess the function of the liver and kidneys, both of which participate in the metabolism and excretion of phenol.
  • Poor patient physician relationship
    Patient dissatisfaction is a common complication and may be caused by the doctor's failure to understand the patients desires or unrealistic expectations on the part of the patient.



Compresses may be of two types - dry compresses and wet compresses. Dry compress may use cold (cold compresses) to relieve a very swollen area or heat (warm compresses) to bring an abscess such as a furuncle to a point and aid drainage. Wet compressed or wet dressings use gauze or some other absorbent material soaked in water, saline, Burrow's solution or diluted potassium permanganate solution. They are useful for weeping and crusted areas or . Wet compresses are applied on the area for 20 - 30 minutes two to four times a day. Evaporation soothes and dries the area.



Corticosteroids or steroids for short are a group of synthetic hormones similar to those produced by the adrenal glands sitting on top of the kidneys. They have strong anti-inflammatory properties and are useful in the treatment of inflammatory disorders such as eczema and psoriasis. Steroids are divided into the following groups depending on how they are used:

  • Topical steroids which are externally administered, eg., creams, lotions, ointments and sprays. To increase penetration occlusion is sometimes used. Occlusive therapy, as this method is called, uses an occlusive dressing or household polythene wrap.
  • Systemic steroids which go into the general circulation and reach all parts of the body, eg., oral steroids (taken by mouth), intramuscular steroids (injected into muscles) and intravenous steroids (injected into veins).
  • Intralesional steroids which are injected into a chronic or resistant skin abnormality such as prurigo nodularis, lichen simplex chronicus or keloids or into acne cysts.

    Side effects
    Steroids are extremely useful and their benefits far outweigh the risks when used properly. Side effects may be divided into local and systemic side effects:

  • Local side effects
    This may occur with topical and intralesional steroids.


  • Systemic side effects
    These may occur with systemic steroids and very occasionally may be caused by increased absorption through the skin when strong topical steroids are used under occlusion or over large areas of skin.
    • Immune suppression.
    • Diabetes.
    • Stomach ulcers.
    • Hirsutism (facial hair).
    • High blood pressure and heart failure due to salt retention.
    • Osteoporosis (thinning of the bones).
    • Muscle weakness, especially of the shoulder and hip muscles.
    • Stunting of growth in children.
    • Eye problems such as cataracts and glaucoma.
    • Redistribution of fat - accumulation of fat on the face (moon face), below the back of the neck (buffalo hump), truncal obesity and reduction of fat in the limbs.
    • Cushing's syndrome.
    • Psychological problems such as insomnia (inability to sleep), mood changes and even psychosis.
    • Adrenal suppression - prolonged use of systemic steroids may suppress the body's own production of steroids. These steroids are needed for the body's response to stress. Shock and coma may develop when systemic corticosteroids are stopped suddenly. This is why doctors taper off the dose slowly.
    Guidelines on the proper use of topical steroids on the skin
  • Apply only on the affected areas.
  • Different strengths of steroids are used on different sites (milder steroids are used on the face), for different severities (milder steroids are used for milder problems) and for different ages (milder steroids are generally used in infants and young children). Understand and follow the doctors instructions, do not mix them up.
  • Do not use steroids on areas other than they are intended as they can make the problem (especially infections) worse.
  • Do not oversuse steroids.