Peeling resorcinol

Glycolic acid Jessner s solution Pyruvic acid Resorcinol Salicylic acid Trichloracetic acid Deep chemical peels... 

Jessner s Solution has been used for over 100 years as a therapeutic agent to treat hyperkera-totic epidermal lesions [1]. This superficial peeling agent constitutes a mixture of salicylic acid, resorcinol, and lactic acid in 95% ethanol. Jessner s solution causes loss of corneocyte cohesion and induces intercellular and intracellular edema. Jessner s typically induces wounding to the level of the papillary dermis. Historically, resorcinol (a key component of Jessner s peels) was used in concentrations of 10-50% in the early twentieth century. High concentrations of resorcinol were associated with side effects such as allergic contact dermatitis, irritant contact... 

Fig. 3.ia-c. Chemical structures of Jessner s Peel components (a Salicylic acid, b Resorcinol, and c Lactic acid)... 

At the end of the peel some patients feel dizzy for a few minutes, probably due to the flushing that occurs secondary to resorcinol application... 

Jessner s solution contains 14% resorcinol, 14% salicylic acid and 14% lactic acid. Jessner s solution has been used alone for superficial peeling, or in combination with TCA 35% to achieve a medium-depth peel. Increasing the number of coats applied to the treated area increases the depth and reaction induced by the Jessner s peel. These peels are well tolerated with minimal side effects in the author s practice. As with glycolic acid and salicylic acid peels, Jessner s peels are most commonly used as adjimctive therapy for moderate to severe facial dyschromias, acne, oily skin, texturally rough skin, fine wrinkles, and pseudofolliculitis barbae. 

Resorcinol, which was formerly used to treat leg ulcers, is nowadays mainly used in the treatment of acne vulgaris as a peeling agent. In the older literature (1), several cases of systemic toxicity from percutaneous absorption were reported and there were deaths (2). The use of resorcinol in the treatment of acne is considered safe (SEDA-9, 142). 

Tretinoin is usually applied as a 0.05% polyethylene glycol (PEG)-400/ethanol liquid or a 0.05% hydrophilic cream. Daily application results in inflammation, erythema, and peeling of the skin. After 3 to 4 weeks. pu.stular eruptions may be seen, causing the expulsion of microcomedones. Treatment may then be changed to applications every 2 or 3 day.s. Because the homy layer is thinned, the skin is mote susceptible to irritation by chemical or physical abuse. Thus, it is recommended that other kerolytic agents (.salicylic, sulfur, resorcinol, benxoyl peroxide) be discontinued before beginning treatment with tretinoin. 

With TCA-SAS, resorcinol, salicylic acid, azelaic acid or phenol peels, the skin needs to be thoroughly cleansed of make-up, degreased and disinfected. Easy TCA solution, on the other hand, contains saponins that make pre-peel make-up removal and degreasing unnecessary the skin s natural defenses are only very slightly diminished by this peel, and therefore there is no need for any particular prepeel preparation against infections. 

Prevention of the herpes simplex virus is essential for patients who have a history of the infection (a single incidence of herpes is enough). Herpes prevention is necessary with a peel to the papillary dermis. It is also worthwhile when a more superficial peel is usually accompanied by a severe inflammatory reaction, as is the case with resorcinol, classic AHAs and TCA-SAS. It is not necessary when using Easy TCA imder its basic protocol or Easy Phytic . General infection prevention measures should be taken, depending on the depth of the peel. For more information, see the discussion of infections in Chapter 37. 

Resorcinol in paste form is used in a very specific manner the paste is usually applied three times, once a day for 3 days in a row. Post-peel care is very important diuing the following week the skin should not be hydrated at all, as it has to dry out completely for the peel to be effective and, above all, the patient must not pull off or pick at the flaking skin. Only the doctor can safely cut off any strips of flaking skin with sterile scissors. Cosmeceutical creams for age spots, acne, aging or sagging skin, etc. should only be applied after the skin has flaked. Effective sun protection (UVA + UVB + HSP inducers) is absolutely essential for approximately 6 weeks after the peel. 

AHAs are the only peels where neutralization is important - TCA, resorcinol, salicylic acid and phenol do not need neutralizing. 

After a resorcinol peel, the superficial stratum corneum comes away from the germinative layer in the stratum granulosum. The basal layer shows increased mitosis and accelerated turnover. The total thickness of the epidermis therefore increases, to the detriment of the stratum corneum, and the skin appears more hydrated. 

No analgesia or anesthesia is necessary. A resorcinol peel is neither painful nor stressful - besides which, resorcinol has a mild local anesthetic effect. 

First application (first day) contact time 10-25 minutes. A few minutes after the first application, the patient feels some heat and then a tolerable burning sensation. This sensation starts where the resorcinol has penetrated most rapidly. The cheeks are usually more permeable than the forehead. The areas where the patient first feels burning are the first to be cleaned of the resorcinol paste at the end of the peel. The sensation of acid burning can sometimes become intense, and a yellow serous fluid may be seen to weep through the partially lysed epidermis. In this case, the patient should be given an analgesic for the first night paracetamol (acetaminophen) plus codeine. 

Third application (third day) contact time 30-35 minutes. The third application must be carried out with extreme caution if the resorcinol membrane that is forming has modified the permeability of the skin, epidermolysis is present and the skin has been badly injured rough handling (or paste that is too compact) could pull away the skin and sharply increase the risk of post-peel complications in the form of erythema and pigmentary changes. 

At the end of contact time, the paste is removed with a tongue depressor and a dry gauze pad. A small amount of paste can be left on the skin at the end of the peel so that a thin layer of resorcinol remains to give full results. It is not strictly necessary to take the paste olf in the same order it was applied. It can be left to work longer in certain places to increase the strength of the peel locally - for example on the more resistant skin on the forehead. 

The patient must not pull off the strips of peeling skin. At the most, they can be cut off with scissors, without pulling the skin at all. The skin is pink and sensitive underneath the resorcinol membrane. As soon as flaking starts. 

According to Unna, the resorcinol paste can be applied again as soon as flaking has finished. We are rarely called upon to repeat an application of resorcinol paste nowadays. The results of an Unna s paste peel remain modest in relation to the complexity of the treatment and the downtime involved, and patients are not prepared to accept these conditions. 

Resorcinol is toxic by ingestion of an average dose of 6 g. Serious accidents have been described after ingestion of 3.5 g, however. ft irritates the mucous membranes and the skin, and ingestion can cause methemoglobinemia, cyanosis, convulsions or even death. Cases of methemoglobinemia have been described after application on leg ulcers, but not after a peel on normal skin. 

Allergies to resorcinol have been widely described. It is therefore wise to do a skin sensitivity test behind the ear 8 days before a resorcinol peel. Any contact with resorcinol can sensitize the patient (or the physician) to it, so the test... 

It is important not to confuse an allergy with the skin s natural response to the chemical peel applied behind the ear. A highly localized and normal skin reaction to the peel will occur erythema followed by flaking. The appearance of any blistering or pruritus contraindicates any further contact with resorcinol completely and definitively. If a patient is allergic, Unna s paste causes reversible facial eczema, with no cosmetic benefit. 

Pigmentation disorders are relatively common after a resorcinol peel. Effective sun protection (see Chapter 3) must be used for 1-3 months after the peel. 

Potential problems with pigmentary changes are treated in the usual manner, as described in Chapter 37. Pigmentation problems such as ochronosis after a resorcinol peel, also described in the literature, are more complicated to treat. 

A few areas of mild erythema, which changes color with the cold, alcohol or emotion, can very occasionally last for several weeks. Erythema after a resorcinol peel is usually reversible without treatment, but requires preventive treatment against pigmentary changes, especially in high-risk patients (see the preceding paragraph and Chapter 37). 

If the results are considered inadequate, the patient might benefit from further peels. A maintenance resorcinol peel can be done every year, if indicated. According to Unna (quoted by Arouette ), under some circumstances, it is necessary to do several successive exfoliations that can be performed without interruption . 

Used alone, a resorcinol peel at 5% triggers light exfoliation. The real peeling effect starts at 25% and becomes more obvi-ons at 40%. 

See Chapter 24 for more details. Although resorcinol is known to have allergenic properties, there have been no allergies reported when it has been used in small quantities with phenol. However, the combined use of these two substances in the same peel solution does not appear to have any clinical value, as the phenol will have finished working before the resorcinol has started. Resorcinol cannot therefore modify the effect of phenol. No data are available on the potential clinical effect of resorcinol on skin that has just been coagulated by phenol. 

Erythema is inevitable after a phenol peel (Figure 37.18). ft can sometimes be less severe and of a shorter duration if a corticosteroid is injected intravenously at the beginning of the peel. Its intensity varies from patient to patient, from light and imperceptible to severe and deep. Resorcinol is a potentially allergenic phenol derivative persistent, pruritic erythema after a resorcinol peel might be a sign of contact dermatitis. 

Edema comes from dermal inflammation, and peels that do not cause inflammation in the papillary dermis do not cause much edema. If the patient has an allergic reaction to one of the components used (e.g. resorcinol), then severe edema can set in rapidly, however. Any severe edema after a peel that does not go beyond the basal layer is most likely associated with an allergy or infection. 

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