Ana Paula Gomes Meski, MD1, Luiz Carlos Cucé, MD PhD1
Keywords: SKIN AGING, CHEMABRASION, METHODS, DERMABRASION, TRICHLOROACETIC ACID, THERAPEUTIC USE, IMMUNOHISTOCHEMISTRY, LANGERHANS CELLS
Several techniques used to improve the skin photoaging promote ablation of the epidermis and/or the dermis, among them the chemical peels, dermabrasion and ablative lasers. The mechanical abrasion, described in the literature by the term dermabrasion, is one of the oldest techniques.1,2 Realized with steel diamond sandpaper coupled with high-speed engines, it presents several risks such as: accidental trauma in the eyes and lips, spreading particles of contaminants to the medical team,3 hypochromia,4 and scars.
The same procedure performed manually with water sandpapers presents itself as a safer technique, because the physician has absolute control of the intensity of abrasion and the level of depth, without reaching unwanted areas or disseminating contaminant particles. It was considered by some authors as the treatment of choice for perioral5 wrinkles by allowing gradual abrasion, deeper on wrinkles and superficial on the periphery of the treated area, avoiding lines of demarcation. In 1996, Chiarello reported good results in the treatment of perioral wrinkles using initially more rough water sandpapers followed by finer ones.6
Ablative techniques can be combined to obtain better results with less risk. In 2006, the laser abrasion was described, which consists in the combination of CO2 laser and dermabrasion for the treatment of deep perioral wrinkles with improvement of 95%.17
The association of dermabrasion with chemical exfoliation was proposed by Dupont and colleagues in 1972,8 and it was named chemabrasion in 1977 by Stagnone.9 Both authors used 88% phenol before dermabrasion with diamond sandpaper. In 1994, the technique of manual dermabrasion with water sandpaper was described followed by the application of trichloroacetic acid (TCA) 25% for treatment of facial photoaging.10 The implementation of TCA 35% before manual dermabrasion was reported for treating nondistensible acne scars,11 and this is the first study that demonstrates this technique for the treatment of perioral wrinkles.
Perioral wrinkles are dynamic wrinkles resulting from mastication and speech, and in more advanced age they are transformed into static wrinkles12. In 1998, Baker classified them into three types, based on their number, location and depth. Type I perioral wrinkles are superficial and affect 1/3 to 1/2 of the upper lip in number less than or equal to 8, type II are moderate and present in more than 2/3 of the upper lip, varying in number from 9-15, while type III lines are profound and affect the upper and lower lips in more than 16.13 The treatments that give the best results for these wrinkles are ablative procedures.
Herpes simplex virus reactivation is common after these procedures. The infection usually occurs in the first week of the postoperative period, according to the report of the first case in 1940.14 Recent studies report a reduced number and altered function of the Langerhans cells in the epidermis, with the occurrence of a symptomatic disease after the reactivation of the virus.15,16 The ablative methods completely remove the epidermis and, consequently, they also remove the Langerhans cells.
The objectives of this study were to evaluate the clinical results of chemabrasion performed with TCA 35% followed by mechanical abrasion with water sandpaper in perioral photoaged skin and to quantify Langerhans cells in the postoperative period.
A prospective, open, uncontrolled study was approved by the ethics committee of the Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo. After information and consent, chemabrasion was performed in 12 female patients, aged between 45 and 80 years, phototypes I and III according to Fitzpatrick classification, presenting with perioral wrinkles types II and III, according to the classification proposed by Baker.13 Patients with a history of herpes simplex infection, altered healing process, use of keratolytic substances in the treatment area or systemic isotretinoin in the previous 12 months, and those who were unable to realize adequate photoprotection for at least 60 days after surgery were excluded.
A series of standardized photographs were performed with the same camera used for all the patients, the same lighting and focal distance, before chemabrasion and after 30 days and 12 months.
Technique: After antisepsis of the face, anesthesia of infraorbital and mentonian bilateral nerves with 2% lidocaine and epinephrine 1:100,000 was performed. The application of TCA 35% was realized with cotton until Rubin17 white solid level 3 was achieved across the perioral region, covering nasogenian grooves, 3 mm from the outer edge of the vermilion of the lips, and the lower edge. Water sandpaper numbers 180, 220 and 400 were used in this order, i.e. from the more rough to the most delicate. The sheets of paper were cut into pieces of 4 x 5 cm and autoclaved. To increase the flexibility and the abrasive power, the sandpapers were soaked in 0.9% sterile saline and, for ease of handling, they were firmly attached around the body of a 3-mL sterile syringe.
The skin was stretched during the sanding process, and the procedure was realized with uniform pressure, in horizontal and circular movements. Sandpaper number 180 was the first one used in order to remove surface skin bleached by TCA until the bleeding began, indicating the plane of the papillary dermis. Sanding was deeper on the wrinkles. Sandpaper number 220 was used until the appearance of confluent points of bleeding, indicating that the upper reticular dermis was reached. Sandpaper number 400 was used to the final phase of dermabrasion. The dressing was made with gentamicin sulphate 1 mg/g ointment and sterile gauze, and it was removed the next day. Application of the ointment was kept for 10 days, three times daily (Figure 1).
The evaluation was done by clinical examination, picture comparison and change in the type of wrinkles, according to the Baker classification, 30 days and 12 months after the procedure. The quantification of Langerhans cells by immunohistochemical test was realized, and 2 biopsies in the upper lip and in the inferior-lateral portion of the right nostril were collected with 4 mm punches, ten days before chemabrasion, and 30 days after at the contralateral symmetrical region, both in photoexposed areas.
The material was frozen, submitted to cryomicrotomy, fixed in acetone, incubated with primary antibody and processed by the avidin-biotin modified method.18 The mouse monoclonal antibody used in the study was the anti-CD1a for Langerhans cells (Dako M721, 1:100). The reaction was developed with diaminobenzidine (Sigma Chemical) and counterstained hematoxylin.
The readings of the immunohistochemical examinations were performed in optical microscopes, with a 40X objective and graticule coupled to a 10X ocular, with an increase in microscopic fields of 400X. The graticule area in this increase corresponds to 0.0625 mm2. For each fragment the areas of five fields were analyzed, and the average number of immunomarked cells per unit area (mm2) was obtained. The epidermal Langerhans cells are characterized by the epidermal fraction area with positivity for CD1a.
The statistical analysis was performed by the Wilcoxon nonparametric test in order to compare the number of cells. A significance level of 0.05 (a = 5%) was used. Descriptive levels (P) lower than this value were considered significant and represented by *.
Clinical outcome: In the day following the surgery, there was intense yellowish exudate which gradually disappeared between the 7th and 10th days, when reepithelialization was complete in all patients. They reported mild pain without the use of analgesics. The skin showed erythema and edema for two to three weeks after the procedure, and transient hypochromia was observed in the region treated, lasting up to 30 days in all cases.
There was erythema, exudate, crusting, pustules and painful erosions in 3 (25%) patients on the fifth day postoperatively, as well as herpes simplex infection, which was treated with oral acyclovir (2 g/day) for 10 days. The improvement was noticeable from the second day of treatment with resolution on the tenth day. It did not result in healing sequelae. The treatment of maintenance was based on the continuous and exclusive use of sunscreen.
Thirty days after treatment, all patients showed improvement of the aged perioral region at clinical examination, and in four of them a better definition of the lip contour was noticed. The deeper wrinkles and furrows caused by the flaccidity of the skin did not improve.
After 12 months the results were maintained in all patients and the improvement of the general appearance of the skin was more evident, especially a larger rejuvenation of the perioral region when compared to the rest of the face (Figure 2). According to the classification proposed by Baker, the analysis of perioral wrinkles made 30 days after the procedure showed that among the four patients initially with wrinkle type II two improved, changing their classification to type I, and two remained as type II, despite the improvement in skin texture and clinical appearance.
Among the eight patients with deeper perioral wrinkles (type III), four had their classification altered to type II, and four remained as type III (Table 1).
Immuno-Histochemical Analysis
Comparing the findings before and after chemabrasion,
there was statistically significant decrease in the number of
Langerhans cells in the epidermis (p = 0.002) (Figure 3).
(Tables 2 and 3)
In this study, the TCA 35% was applied before manual dermabrasion with water sandpaper, since queratocoagulation caused by the acid makes the skin friable and defines the depth to be achieved, facilitating the dermasanding. The procedure also becomes more predictable with its use, eliminating variables that are interfering with the depth of dermabrasion, such as the skin thickness.19
The chemabrasion technique most often described in the literature associates phenol 88% with motor dermabrasion.20 The advantage of using phenol is immediate anesthetic effect after its application to the skin but its use increases the risk of permanent hypochromia, due to the destruction that this drug can cause in melanocytes.21 Some authors use the freezing of the skin to facilitate dermasanding, which can damage melanocytes, causing hypopigmentation.22
Hypochromia occurred in all patients in our study, with average duration of 15 days after chemabrasion for removal of melanocytes by sanding. The clinical analysis of patients showed no subsequent change of skin pigmentation, showing that this technique is safe.
The photoaging signs improvement of the perioral region was observed in all patients. Among those with no change in the number of wrinkles and in the Baker classification, 13 patients showed improvement of skin texture and color. After one year monitoring, the improvement of photoaging was more evident, even if topical treatments other than sunscreens were not used, suggesting a delayed response of the skin to the ablative process.
The most important complication was the high rate of infection with herpes simplex (25%), which may have been influenced by the absence of prophylaxis with oral acyclovir, not used in this study due to the inclusion of only patients with no previous history of disease.
There is controversy in the literature about the prophylaxis recommendation. In 2001 Harmon suggested that prophylaxis for herpetic infection after dermabrasion lasted 10-14 days.23
In 1996 Perkins and Sklarew published a study with 181 patients undergoing dermabrasion or chemical exfoliation of the perioral region, and they found that patients with no history of herpetic infection who did not receive acyclovir orally showed a 50% rate of infection after the procedure.24,25
In such cases, treatment of infection should be promptly initiated to prevent local spread, secondary bacterial infection, delayed healing, scarring, and pigmentary changes.
The herpes simplex virus activation is a common complication of cutaneous ablative techniques, showing that during these procedures the skin undergoes immunological changes. It is believed that the reduction in the number of Langerhans cells is one of the major factors that contribute to the installation of these infections, due to their role in immune surveillance.26
Even mild trauma to the skin with adhesive tape leads to migration of Langerhans cells from the epidermis to the lymphatic vessels in four days and their return to normal counting after 15 days.27 There is no provision of an exact time for the reappearance of these cells in the epidermis, but it is believed that it is lower when the trauma does not result in its total elimination, because the remaining cells undergo division and produce new ones.28 The chemabrasion remove all skin, so a slower occurrence of Langerhans cells is expected, depending solely on the migration of cells from the bone marrow. This study showed that its occurrence is independent from the skin complete healing and it does not occur after 30 days. Further research is necessary to know the period in which the normalization of the number of Langerhans cells occurs after the use of techniques that result in total ablation of the epidermis.
The recommendation that patients do not expose themselves to the sun and use sunscreens after ablative treatments is essential to avoid further reduction in the number of Langerhans cells, as the ultraviolet radiation is another cause of their reduction in the epidermis with the apoptosis stimulus.29 Topical tretinoin should be recommended during this period. It speeds up the healing process,30 reduces the risk of post-inflammatory hyperpigmentation31 and increases the number of Langerhans cells in the epidermis if used at 0.025%.32
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