Management of Acne with Black Peels

Dr. Fariya Rasheed MD, DVL

Consultant Dermatologist

Dr. Fariya Rasheed’s Skin Laser Hair Clinic

Hyderabad, India

Introduction

Acne is a common dermatological condition that occurs when the skin pores become blocked with oil, dead skin cells, and bacteria. It is an inflammatory skin disorder of the pilosebaceous unit with multifactorial pathogenesis, sometimes it has a chronic course and it is self – limiting.1,2 There are multiple factors have been attributed to acne predisposition and individual variations in the severity of skin symptoms have been observed.3 The major pathogenic factors include hyperkeratinization, obstruction of sebaceous follicles resulting from abnormal keratinization of the infundibular epithelium, stimulation of sebaceous gland secretion by androgens, and microbial colonization of pilosebaceous units by propionibacterium acnes, which develop perifollicular inflammation.4

It is a chronic inflammatory disorder of the pilosebaceous unit that can present in a wide range of severity, from mild comedonal acne to severe inflammatory cystic acne. The clinical presentation of acne can vary, and can be found on the face, chest, and back.4 The characteristic lesions of acne vulgaris include open (blackheads) and closed (whiteheads) comedones, inflammatory papules, pustules, nodules, and cysts. These lesions can lead to scarring and pigmentary changes, which can have a significant impact on a person's self-esteem and quality of life.5

When assessing the severity of acne, it is important to consider the distribution of the lesions (e.g. on the face, chest, upper arms), the type and number of lesions (e.g. comedones, papules, pustules, nodules), and the presence or absence of scarring.6

Grading system for acne can be helpful to determine the type and severity of the acne (Table 1), the Global Acne Grading System (GAGS) and Acne Severity Index (ASI) are among the most commonly used grading systems. In this system, comedonal acne refers to non-inflammatory acne, such as blackheads and whiteheads, inflammatory acne includes papules and pustules, and is characterized by redness and swelling, cystic acne, also known as nodulocystic acne, is a severe form of inflammatory acne that involves large, painful cysts and nodules.5, 7

Acne scars are a common concern for many people who have had acne. They occur when the skin does not heal properly after inflamed acne lesion has resolved. The scars are caused by inflammation in the skin, which can damage the collagen and elastin fibers in the skin. There are several types of acne scars, including atrophic scars (depressed scars), hypertrophic scars (raised scars), and keloid scars (raised scars that extend beyond the boundary of the original wound). The type and severity acne scars will determine the best treatment options.8

There are several types of acne scars, including atrophic scars (depressed scars), hypertrophic scars (raised scars), and keloid scars (raised scars that extend beyond the boundary of the original wound). It's important to note that acne vulgaris is a chronic condition that tends to have fluctuating periods of improvement and exacerbation, and therefore requires long-term management. The management of acne vulgaris is tailored to the individual patient and can include topical and oral medications, as well as lifestyle changes. The type and severity of acne scars will determine the best treatment options. Effective treatment of acne vulgaris typically involves a combination of topical and oral medications, as well as lifestyle changes such as maintaining a healthy diet, avoiding harsh skin care products, and practicing good hygiene. Some common treatment options include topical treatments such as retinoids and hydroquinone, chemical peels, laser resurfacing, and microneedling, subcision and punch excision, scar revision surgery etc.7

It is recommended to visit a dermatologist for an accurate diagnosis and treatment plan, as treatment options depend on the type and severity of the acne, as well as the individual's needs and preferences.

It's important to note that the best treatment for acne scars is individualized and depends on the type and severity of the scars, as well as the patient's goals and preferences. The presented are some cases with acne (grade 2-3).

Table 1- Grading severity of acne5

Grade Severity

Clinical findings

I Mild Open and closed comedones with few inflammatory papules and pustules

II Moderate Papules and pustules, mainly on face

III Moderately severe Numerous papules and pustules, and occasional inflamed nodules, also on chest and back

IV Severe Many large, painful nodules and pustules

Management of Acne

There are many treatment options are available to manage the acne. The treatment for acne aims to reduce its severity and recurrences of skin lesions as well as to improve patient’s skin appearance. The treatment approach is always depends on the severity of the acne, the treatment preferences, age of the patient, adherence and response to previous therapy.5 The current effective strategies of management recommended by the global alliance are directed toward one or more pathogenic factors and include topical and systemic antibiotics and retinoids, benzoyl peroxide, azelaic acid, salicylic acid and oral antiandrogens, depending on the severity of the disease.2

Topical therapies which are considered as the first-line treatments include retinoids (eg: tretinoin, adapalene), benzoyl peroxide, azelaic acid and combination with systemic agents such as oral antibiotics like doxycycline and minocycline. Hormonal therapies such as combination oral contraception [COC] or spirolactone, isotretinoin are prescribed for severe acne conditions.9

A wide range of other therapeutic options are also available to manage the acne and chemical peels are considered to be an effective treatment option for acne management. Chemical peel is a skin resurfacing procedure which helps to regenerate normal skin through the application of exfoliative agents. It is a well known technique which is being used for acne vulgaris as well as for other skin disorders such as photodamage, pigmentary disorders and

Management of Acne with Black Peels

scars.7, 10 It is a procedure where a chemical substance is applied to the skin causing controlled destruction of the epidermis with or without part of the dermis which leads to skin regeneration and remodelling. Chemical peels are generally classified on the basis of their depth of skin penetration into superficial, medium and deep peels.7

Chemical peeling, also known as chemexfoliation or chemical exfoliation, is a skin resurfacing procedure that uses chemicals to cause controlled destruction of the epidermis with or without part of the dermis, leading to skin regeneration and remodeling. It has been used for the treatment of acne vulgaris and other skin disorders for decades.

Chemical peels can be used to treat various skin conditions, such as acne vulgaris, photodamage, pigmentary disorders, and scars. Different types of chemical peels are available and vary in strength and depth of penetration, which determines the degree of skin injury and the recovery time. For acne vulgaris, chemical peels are helpful to improve the texture and color of the skin, reduce the appearance of acne scars, and improve the overall appearance of the skin.

Management of acne with Black Peels

Black peels are a type of chemical peel that uses a combination of chemicals to remove the top layers of skin, causing it to peel off. It is a new chemical composition based on black acetic acid mixed with jasmonic acid, salicylic acid, potassium iodide and biosulfur. It is often used to improve the appearance of acne scars, as well as to treat other skin conditions such as sun damage, age spots, and uneven skin tone. Black acetic acid have been numerous pharmacological effects like anti-tumor, antioxidant, antihypertensive. The specific type of black peel and the strength of the peel used will depend on the severity of the acne scars and the individual's skin type and goals for treatment. They work by removing the top layers of skin, which can help to smooth out the texture and tone of the skin.7, 10,11 Potassium iodide (KI) is also important composition of black peel which was empirically used for deep fungal infection and severe vacuities-induced wound. It can be used as a topical treatment for some skin conditions as it works against infection and as an anti-bacterial and anti-fungal agent. Jasmonic acid and salicylic acid are plant secreting acid that are released to defend themselves when they are attacked or damaged. Jasmonic acid activates the expression of protease inhibitors which can stop the attack of the harmful insects. Both jasmonic acid and salicylic acid play an important role in the pathogen defence response and also have the anti-inflammatory effect as well as the exfoliating property which can induce a beneficial response of the living layers of skin by correcting a number of signs associated with skin impairment. Biosulfur is useful in acne as it helps to kill bacteria on the skin, which results in an improvement in acne, pimples, seborrhoea and psoriasis conditions. It acts as a keratolytic and also has germicidal action.12

They may cause side effects such as redness, swelling, and peeling of the skin, and there is a risk of complications such as scarring, hyperpigmentation, or infection.

It is important to carefully follow the post-treatment instructions provided by healthcare provider to ensure proper healing and to minimize the risk of complications. It is also important to protect the treated skin from the sun, as it will be more sensitive to UV rays after the peel.13

Result

We got the good result in the age group of the patients are 21 -27 years who presented acne (grade 2 – 3) in our clinic. Diagnosis was done on the basis of typical clinical presentation and then used the black peels option to manage the acne and acne scars.

The pictures are taken before treatment and after the treatment effects on patients using black peel. The pictures are taken between the two consecutive sessions of the therapy.

The face of the patient was thoroughly prepared for the peeling session. Chemical peeling is the widely used procedure in the management of acne vulgaris and in this study patients were subjected to the black peel which contains black acetic acid, jasmonic acid, salicyclic acid and potassium iodide which was used topically for the course of 2 treatment sittings.

Following some cases showed good result after treatment.

Management of Acne with Black Peels

Patient 1

Before treatment After treatment

Before treatment After treatment

Patient 2

Before treatment After treatment

Before treatment After treatment

Before treatment

After treatment

Discussion

Acne is the common skin condition with the prevalence of 35% - 90% in the adolescent age. It peaks between the age of 14 and at the beginning of the third decade also it persists in 20% men and 35% women.2

Multidisciplinary investigations into the pathogenesis of acne vulgaris have significantly progressed over last few years. Studies of the etiology of acne from the perspectives of sebaceous gland biology, sebum, genetics, keratinization, differentiation, hair cycles, immunology, bacteriology, and wound healing have elucidated its pathogenesis. This has led to the development of new therapies and paved the way for advanced technologies that enable the further evolution of acne vulgaris treatment. 14

Chemical peeling is a widely used procedure in the treatment of acne and acne scars. Black peel can be used as promising and hopeful alternative treatment for acne vulgaris.15

To analyze efficacy and safety of Azelaic peel (20% Azelaic acid peel), black peel (Acetic acid 8% peel), Kojic acid peel (12% kojic acid peel), Lactic acid peel (90% lactic acid peel), Mandelic acid peel (35% mandelic acid peel) in treating patients of acne vulgaris between grade I to III. The study was conducted which included a total 120 patients. Patients in each arm were subjected to respective chemical peels at an interval of 15 days for a total of 6 sessions. Last visit was finished at 12th week. Evaluation was done by dermatological assessment for acne including counting the number of comedones, papules and pustules. Patients with progress report at the end of 12 weeks the overall reduction rate observed was 60.4%, 72.4%, 24.1%, 35.2% and 50.1% with Azelaic peel, Black peel, Kojic acid peel, Lactic acid peel and Mandelic acid peel respectively. The study thus concluded that the efficacy of black peel is highest in the treatment of acne vulgaris between grade I to III in Indian patients.11

Peels cause controlled destruction of a part or the entire epidermis, with or without the dermis, leading to exfoliation and removal of superficial lesions which is followed by regeneration of new epidermal and dermal tissues. A series of chemical peels can lead to significant improvement over a brief period, leading to patient satisfaction and maintenance of clinical results.15

Conclusion

Acne can be mild or severe, and while it is not a serious health risk, it can cause physical discomfort and have a negative impact on a person's self-esteem and quality of life. To help prevent acne, it is important to keep the skin clean and moisturized, and to avoid picking at or squeezing pimples, which can cause them to become infected. Understanding the multiple diverse, interdependent and complicated etiological factors of acne and the biology of sebaceous glands is an extremely important part.

Superficial to medium depth chemical peels are more useful adjuvant therapies in acne. It effectively targets the different factors involved in the development of this skin condition and enhance the effects of other topical formulations. The benefits and its complications varies among racial groups, and special attention should be given when dealing with dark-skinned patients. However, it is important to note that the benefits and complications of chemical peels may vary among racial groups, and special attention must be paid when dealing with darkskinned patients. Darker skin types are more susceptible to hyperpigmentation, so it's important to use the appropriate strength of peel and to follow post-treatment instructions to avoid complications. It is important to consult with a qualified professional, such as a dermatologist, to determine if chemical peels are appropriate for you and to ensure proper technique and aftercare is followed.

Reference

1.Sutaria AH, Masood S, Schlessinger J. Acne Vulgaris. [Updated 2022 Aug 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm. nih.gov/books/NBK459173/

2. Bhat YJ, Latief I, Hassan I. Update on etiopathogenesis and treatment of Acne. Indian J Dermatol Venereol Leprol. 2017 May-Jun;83(3):298-306. doi: 10.4103/0378-6323.199581. PMID: 28195079.

3.Heng, A.H.S., Say, YH., Sio, Y.Y. et al. Gene variants associated with acne vulgaris presentation and severity: a systematic review and meta-analysis. BMC Med Genomics 14, 103 (2021). https://doi.org/10.1186/s12920-02100953-8

4. Toyoda M, Morohashi M. Pathogenesis of acne. Med Electron Microsc. 2001 Mar;34(1):29-40. doi:

10.1007/s007950100002. PMID: 11479771.

5. Kraft J, Freiman A. Management of acne. CMAJ. 2011 Apr 19;183(7):E4305. doi: 10.1503/cmaj.090374. Epub 2011 Feb 28. PMID: 21398228; PMCID: PMC3080563.

6. Alsulaimani H, Kokandi A, Khawandanh S, Hamad R. Severity of Acne Vulgaris: Comparison of Two Assessment Methods. Clin Cosmet Investig Dermatol. 2020 Sep 28;13:711-716. doi: 10.2147/CCID. S266320. PMID: 33061511; PMCID: PMC7532287.

7. Samargandy S, Raggio BS. Skin Resurfacing Chemical Peels. 2022 May 1. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 31613532.

8. Fabbrocini G, Annunziata MC, D'Arco V, De Vita V, Lodi G, Mauriello MC, Pastore F, Monfrecola G. Acne scars: pathogenesis, classification and treatment. Dermatol Res Pract. 2010;2010:893080. doi: 10.1155/2010/893080. Epub 2010 Oct 14. PMID: 20981308; PMCID: PMC2958495.

9. Eichenfield DZ, Sprague J, Eichenfield LF. Management of Acne Vulgaris: A Review. JAMA. 2021 Nov 23;326(20):2055-2067. doi: 10.1001/ jama.2021.17633. PMID: 34812859.

10. Castillo DE, Keri JE. Chemical peels in the treatment of acne: patient selection and perspectives. Clin Cosmet Investig Dermatol. 2018 Jul 16;11:365-372. doi: 10.2147/CCID. S137788. PMID: 30038512; PMCID: PMC6053170.

11. Karia U, Parghi M, Padhiar B, Shah B. A study of efficacy and safety of newer chemical peels for acne vulgaris grade 1 to grade 3. IP Indian J Clin Exp Dermatol 2022;8(3):180-185.

12. Kumar R, Sachan P, Singh SK, Gupta AK, Mohan L.A prospective observational study on efficacy of black acetic acid combination peel in patients of facial nodulocystic acne.Int J Res Dermatol2019;5:673-7.

13. Nikalji N, Godse K, Sakhiya J, Patil S, Nadkarni N. Complications of medium depth and deep chemical peels. J Cutan Aesthet Surg. 2012 Oct;5(4):254-60. doi: 10.4103/09742077.104913. PMID: 23378707; PMCID: PMC3560165.

14. Kurokawa I, Nakase K. Recent advances in understanding and managing acne. F1000Res. 2020 Jul 29;9:F1000 Faculty Rev-792. doi: 10.12688/f1000research.25588.1.

PMID: 32765835; PMCID: PMC7391011.

15. Kontochristopoulos G, Platsidaki

E. Chemical peels in active acne and acne scars. Clin Dermatol. 2017 MarApr;35(2):179-182. doi: 10.1016/j. clindermatol.2016.10.011. Epub 2016 Oct 27. PMID: 28274356.

Picosecond lasers for tattoo removal could benefit from enhancements, expert says

Picosecond lasers are a type of laser technology used in various medical and aesthetic procedures, including tattoo removal, skin rejuvenation, and treatment of pigmented lesions. They deliver energy in extremely short pulses, measured in picoseconds (trillionths of a second), which can break down pigments or other targeted tissues with high precision and minimal damage to surrounding tissues. When picosecond lasers hit the market about 10 years ago, they became a game-changer for tattoo removal, boasting the delivery of energy that is about three fold faster than with nanosecond lasers. However, picosecond lasers are far from perfect even in the hands of the most experienced clinicians, according to researchers. It took a long time for these lasers to come to the market, and they are still fairly expensive and require a lot of maintenance, they noted.

Today, most clinicians use Q-switched nanosecond and picosecond lasers for tattoo removal, though appropriate wavelengths need to be selected based on the tattoo ink color. Tattoo ink particles average about 0.1 mcm in size, and the thermal relaxation size works out to be less than 10 nanoseconds, with shorter pulses better at capturing the ink particles that are smaller than average. Black is the most common tattoo color dermatologists treat. “For that, we can typically use a 1064, which has the highest absorption, but we can also use many of the other wavelengths,” they said. “Other colors are less common, followed by red, for which we would use a 532-nm wavelength.”

Researcher underscored the importance of setting realistic expectations during consults with patients seeking options for tattoo removal. Even with picosecond laser technology, many treatments are typically required and “a good patient consultation is key to setting proper expectations,” they said. The clinical endpoint to strive for during tattoo removal is whitening of the ink, which typically fades about 20 minutes after treatment. That whitening corresponds to cavitation, or the production of gas vacuoles in the cells that were holding the ink. This discovery led to a technique intended to enhance tattoo removal. In 2012, researcher and colleagues published results of a study that compared a single Q-switched laser treatment pass with four treatment passes separated by 20 minutes. After treating 18 tattoos in 12 adults, they found that the technique, known as the “R20” method, was more effective than a single-pass treatment (P < .01).

Researcher suggests that consuming collagen-dense foods can directly benefit skin or joint health

Collagen is a protein that is naturally produced by the body and is a key component of the skin, hair, nails, and connective tissues. As we age, our natural production of collagen decreases, which can lead to wrinkles, sagging skin, and joint pain.

Researcher suggests that consuming collagen-dense foods can directly benefit skin or joint health. We produce less collagen as we age. External factors can slow down our collagen production, including smoking, sun exposure, lack of sleep/exercise, and alcohol consumption. Though human studies are lacking, some trials have found that collagen supplements may improve skin hydration and elasticity. “Maybe there’s some benefit, but the digestive process breaks collagen down into amino acids.

Some over-the-counter supplement that aims to relieve moderate hair thinning or strengthen hair to prevent breakage, and is physician-formulated with medical-grade ingredients that target root causes of thinning such as stress, lifestyle, hormones, and nutrition. As for biotin, we now know that high levels of biotin can actually cause hair loss. If you have advanced hair loss, supplements may not work for you. There is no hair regrowth supplement that can bring back a dead hair follicle. Platelet-rich plasma injections have been shown to stimulate hair growth, but only if the follicle is miniaturized, not if it’s totally gone.

In a review of healthy adults, the composition of microbial communities was found to be primarily dependent on the physiology of the skin site, with changes in the relative abundance of bacterial taxa associated with moist, dry, and sebaceous environments, the researcher reported. “The microbiome is the genetic material of all the microbes that live inside the body, including bacteria, fungi, protozoa, and viruses. The more diverse the microbiota is, the healthier it’s considered. That diversity is enriched through a diet full of various vegetables and fruits.

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