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Skin Care Dictionary from DM|MD

Alpha Hydroxy Acids (AHA)

AHA is a chemical made of carboxylic acid with a hydroxy group.  AHA are made of aliphatic glycolic (sugar cane), lactic (sour milk) Tartaric (grapes) malic (apples), citric (citrus), and aromatic (mandelic antibacterial).

Most AHA are made of concentrations of 50-70 %.

At lower concentrations, they help decrease the cohesions between the corneocytes allowing these cells to “unglue” and go through an exfoliation.

At higher concentration, they  are more  destructive and need to be neutralized with a weak buffer.  AHA have an Epidermal effect (renewal  of  stratum  corneum) and a dermal effect (increase skin  thickness  by  increasing  the  collagen and mucopolysacharides with  minimal inflammation). The severity of the agent however becomes more noticeable with increase in its concentration.

Mandelic Acid

In looking for a reliable  treatment of sun damage, acne and fine wrinkling, this Aromatic AHA has a PK of 3.37.

It has a molecular formula, C8H803. It appears as a white  crystalline  that is soluble in organic solvents (creams) and water.

For many years this agent has been used to treat urinary tract infections. It’s use is well established as an oral antibiotic.

We have found this agent to treat acne and reduce its re-occurrence.

Since this molecule is rather large and antibacterial, it has great advantage over regular glycolic acid.  Dr. James Fulton has popularized the use of mandelic acid  as early as 1969. Mandelic  acid is helpful  in  prepping the skin surface prior to laser resurfacing; as well as immediate post laser resurfacing in order to shorten the recovery period.

Azeleic Acid (AA)

Azeleic acid, also known as Bi Carboxylic Acid with PK 4.550 to 5.598 is 1.7- heptanedicarboxylic acid, usually present in rye , barley,and wheat.

Its best performance is in a concentration of 15-25%. It is a useful agent in treating various stages of Acne.

It is decreasing the population of the bacteria Propion and Staph epidermis.

It is a Keratolytic  and comedolytic agent, as it helps the re-growth of new cells and helps with the lining of the hair follicles.

The Azelaic acid reduces inflammation by acting as a free radical scavenger.

It helps control hyper pigmentation and it is well tolerated by most skin types.

The AA has two different PK’s. Its second PK (5.5) is similar to the PH of a normal skin. AA does not  need to  be neutralized  or buffered.  It is an excellent  antiviral  agent. In certain  cases of treating hyperpigmentation and darker skin types, the longer the duration  of preconditioning prior to the peel the greater benefit to the patient.

The use of AHA, 4% Hydroquinone, Azelaic Acid, and Kojic Acid, prior  to a superficial and/or medium  peel the  better  the  results. Its use immediately after  such a peel is important in preventing post inflammatory hyper pigmentation.

The use of Retin-A even in a low concentration helps that process even more.

One should be aware that retinoids can increase the penetration and depth of these peels. While in Fitzpatrick skin type 1-3, including retinoids, is helpful in darker skin, it may increase the inflammation, cell turnover and PIH.

Bleaching Agents

Various bleaching agents can decrease the condition of Post Inflammatory Hyperpigmentation. Hydroquinone’s: Their concentration can run between  2-14%, but there is a remote  possibility of developing Ochronism.  Other alternatives  that also help with bleaching are Retinoids, Alpha and Beta hydroxy  acids, Mulberry, Niacinamide, Azelaic acid, Vitamin  C, Melatonin, licorice, Aloesin Alpha and Arbutin. I recommend alternating these agents in 6 months cycles.

Phenol

Phenol  is  considered  an  Aromatic   alcohol   with   properties   of   weak  acid  (according  to Tenenbaum classification). It has a PK 9.95, which by itself will behave in a toxic rather than metabolic. Its other  name is hydroxybenzene. It comes ready as 88% solution  of colourless, soluble in alcohol and ether, and does not mix well with  water. Phenol is sometimes called carbolic acid when it is in a mixture  with  water. Having high PK 9.95, it served in the past as antiseptic, antifungal, and has anesthetic features. Phenol, by itself having a PH of 5.5, has very little caustic action on the skin. Using 88% pure phenol solution on the skin will give only a medium peel; as it will cause coagulation of the top Epidermal reticular  layer of the skin and it will block itself from   further   penetration dreaming  itself  ineffective.  However, using  different   agents  as outlined above, we  allow  combined  caustic  metabolic  and  toxic  effects  of  several agents without the downtime that would have occurred if they were used separately. Some acids with a PKa>3 (mandelic, salicylic, and phenol) may seem too complicated to use for some physicians with  little experience in peeling. However, by combining  a relative small amount  of a phenol base with lactic, phytic, alpha Arbutin base, Retinol, Mulberry Mandelic acid, Hydroquinone  4% and steroid in low dosage, one can get a long-term solution in a form of superficial and medium depth peel.

We are able to combine superficial, medium, and deep chemical peel agents and improve the Papillary layer of the Epidermis and some of the Reticular layer of the dermis. We are able to improve  both  layers of the  skin with minimal  down  time  and still effects the deep Reticular layer.

By combining Phenol with  these agents, we can weaken its’ toxic effects and we lessen the denaturation  of  the proteins.  The  potential cardiac, renal, and  hepatic  side  effects  are eliminated and one gets the benefits of a younger looking skin without the erythema, swelling, ­and downtime.

The goal of the OM IMD is to replace part of the epidermis  and start a process of collagen remodeling; thereby improving sun damage, fine rhytides, pigmentation abnormalities, and mild scarring.

The OM IMD  as a medium  depth  peel has replaced  a 50% TCA as an agent  with  a safer approach. By using Jessner’s solution, 70% glycolic acid or small amount  of 35% TCA peel and the other  agents as outlined, one gets the benefits  without the risks  of the 50% TCA or the phenol.

This peel  allows  good  control  of  some  actinic  keratosis, fine  lines, melasma, Seborrheic keratosis and solar lentigines.

There is significant improvement of the skin texture and dark circles to the lower eye lids. By using various bleaching agents like Hydroquinone, mandelic mulberry, and kojic acid, there is decrease in chances of developing PIH in darker skins. Patients with acne and rosacea usually will  experience prolonged  recovery with a medium  depth peel, but  a very short one with  the OM IMD. With the DM IMD, we don’t  allow heavy emollients  used in other medium depth peels that cause swelling, inflammation, and erythema. Unlike a deep peel where phenol is used, cardiac arrhythmias  are not even an issue. There is no change in heart rate and there  is no pain involved. The pigmentation in a dark  skin patient  is very sensitive and this formula has put these agents together  with great planning. Through years of practice I came up with a very meticulous and consistent technique that has number of buffers built into it.

The OM IMD can be safely kept in a refrigerator in a dark container.

It contains also Azelaic acid, lactic acid, and phytic acid and 8% HQ, and the phenol formula. This mixture is a weak acid. It doesn’t irritate the skin, the patients experience  minimum inflammation with no protein  precipitation.

This peel can be done easily done twice a year and each application is made in two stages, so that a patient actually receives 4 peels rather than two.

Separately, the  patient  receives the  sliver  jar that  contains  same components  with  weaker bleaching agent, Retinol  and no phenol. This cream is applied once a day for period  up to 3 months, at which point  the Hydroquinone is changed to mulberry cream or mandelic acid.

 

OM IMD: The Procedure

In  order  to  minimize  the  side  effects  (sensitizing, inflaming), the  skin of  all  Fitzpatrick  1-6 including  dark skin, we suggest performing the peel as a 2-stage process two weeks apart. The initial peel is delivered  at the lowest  concentration in order  to gauge the patient  sensitivity. That’s done using the principle: No Rush, do it twice!

Good digital photos in specific angles (front, sides, 45 degrees, smile and fully animated) should

be taken. Informed consent should be signed (see form A).

The face is cleaned with  soap and water after  wiping off excess of oil with  alcohol swabs. The hair is pulled  back with  a band or a cap. The patient  sits with  closed eyes to avoid accidental spillage of the cream into the eyes.

The skin is degreased again with alcohol and acetone. Check the label of each of the ingredient that are about to be used.

A Jessner peel is used in moist 2×2’s all over the face in several coats while the patient is asked for 1-10 level of discomfort (where 5 is the ideal endpoint). No neutralization is required. If a glycolic acid peel is performed, it should be neutralized in 3 minutes with 10 % of bicarbonate solution. In both cases we are looking for mild erythema and/or frost as an endpoint.  At this point, the OM IMD cream is applied with gloved finger, spatula or a brush to a thickness level of 1/2 mm coat.

The patient can drive. The patient  removes the cream layer that dried.

At the end of the 6-8 hours, the patient  showers, shampoos the hair and may go to sleep.

Post Peel Care

The patient  is reassured that this treatment requires a temporary mild to a moderate care. The treated skin should not be neglected.

We are interested in a very rapid recovery with minimal complications.

Most of our patients come to us because of sun damage and hyperpigmentations.

In order  to  obtain  maximum  results after  the initial 8 hours, the patient  is required  to use a gentle cleanser. Calming cream, 0-silver and silicone water are used to sooth the skin. OM IMD part 2 home maintenance is applied twice a day for the first two weeks post treatment. Patient is instructed to  use SPF  29 or higher  at all times.  The patient  may witness  some swelling, erythema, and flaking.

Patients are warned to avoid picking on their new skin. Avoid lifting and separating their flaking skin, as it may cause irritation leading to scarring and hyperpigmentation. The goal of  this unique method  is to have an uneventful rapid recovery free from potential complications, such as infection that my delay their new epithelization. A severe infections may turn  a superficial medium peel to  a deep one that  may leave the  patients  with  irregularities  and scars. If a patient develops excessive crusting and drainage, a culture should be taken. Topical and/or oral antibiotics, as well as Domboro solution soaks, should be applied until full healing takes place.