In recent years there has been a massive world-wide indulgence for both men and women in anti-ageing procedures. Cosmetic surgery numbers have soared, new beauty products and treatments abound, anti-ageing has become the favourite advertising slogan of the new century and we have it thrust upon us in the plethora of new lifestyle, beauty and woman’s magazines, television shows, newspaper features and even documentaries.
By far the most preferred procedures are the minimally invasive use of peels and dermabrasion treatments. Their popularity is primarily due to their efficacy, short recovery times, cost effectiveness and minimal risk.
For many years debate has been conducted by dermatologists, aestheticians and clinical technicians of these procedures, as to which is the most effective in the treatment of superficial photo-aging. The argument to date is without any clear outcomes being verified in recent research. Clearly the efficacy of both modalities have been proven to varying degrees with a number of arguments available to choose one procedure in favour of the other. Perhaps the answer is not to try to choose between the two modalities but to look into the effectiveness of utilizing both treatment modalities in tandem.
Whilst the benefits and efficacy of microdermabrasion remains an intensely debated topic amongst dermatologists and aestheticians, it has become one of the most popular forms of superficial resurfacing. It is a technique where micro-crystals are deposited on the skin through a hand piece under pressure. The machine simultaneously aspirates the crystals and debris through vacuum pressure. Control of the crystal flow, vacuum, speed of movement of the hand piece and type of crystal can all impact the depth of the dermabrasion on the skin. In the study by (Tan, Spencer, Pires, Ajmeri and Skover. 2001), it was recognized that whilst there was a void of objective clinical studies demonstrating the effectiveness of microdermabrasion, there appeared to be an overwhelming perceived benefit in the skin’s appearance and texture from patients who have undergone a course of treatments. The Tan & Colleagues study utilised a number of histological reports pre and post treatment over a six week period to detail that whilst there was a slight thinning of the stratum corneum consistent with abrasion there was not any detection of new collagen and glycosaminoglycan deposition as was postulated by other studies.
In fact, the most significant changes present were in the reticular dermis and were vascular. Tan, et al., postulates that the colour changes and improved appearance noted by patients and physicians may actually be as a result of the vacuum aspiration system of the microdermabrasion machine as it is well below the level of direct abrasion. It was felt that this negative pressure may have a greater effect on the look and changes of the skin than the abrasion of the stratum corneum. Freedman, Rueda-Pedraza and Waddell (2001), investigated epidermal and dermal changes associated with a series of microdermabrasion treatments.
They performed a series of punch biopsies after each treatment and noted an increase in epidermal thickness, papillary dermal thickening, flattening of rete pegs, liquification of basal cells, hyalinization of papillary dermis and newly deposited collagen and elastin fibres. They reported that their findings resembled a reparative process throughout the dermis and epidermis. Similarly, Rubin and Greenbaum (2000) also took biopsies after a series of microdermabraion treatments reporting a normalization of the stratum corneum, epidermal thickening and increased collagen deposition in the papillary dermis.
Despite the differing methodologies, machines and protocols of each of these studies each has indicated that there was an improvement in the epidermal and dermal architecture following microdermabrasion and substantial patient satisfaction. The advantages of microdermabrasion over chemical peels is the minimal discomfort of patients, the immediate resumption of normal lifestyle with no “downtime” and the immediate perception of improvement in tone, skin texture and pigmentation. In addition home care use of retinoids, exfoliants and other beauty treatments can be continued up to the time of treatment without any significant irritation.
However, although the treatment is considered safe on all skin types with very few reported side effects there are some complications that can arise. Over pressure of the hand piece can result in streaking and in some cases hyperpigmentation and the crystals although inert can cause eye irritation if they enter the eye area. There is also a risk of flares in patients that have a recurrent herpes simplex infection.
Superficial Chemical Peels (SCP) are described by Zakopoulou and Kontochristopoloulos (2005) as an application of a peeling agent to the skin resulting in the destruction of part or all of the epidermis. Superficial chemical peels are recommended for facial rejuvenation, photoaging, pigmentary dyschromia and acne. SCP can be used on all Fitzpatrick skin types, requires no sedation or numbing with the patient’s discomfort usually well tolerated.
There are a number of different peeling agents that can be used in SCP including Alpha Hydroxy acids, trichloroacetic acid, Jessner solution, salicylic acid, pyruvic acid, resorcinol preparations and retinoids. Because of this care must be taken in the application of each agent with knowledge of contraindications, priming and peel application techniques. Because each peel is different and will have a differing “peeling” effect on the skin dependant on type, strength, pH, combinations with other agents, pre-peel routines, application techniques and pre-existing conditions, technicians need to be aware of the appropriate procedure in order to obtain a superficial and not medium depth peel.
Unlike microdermabrasion it is recommended that both pre and post peel care is undertaken. Pre-peeling preparation should start up to three weeks prior to the peel procedure. In effect, this pre-conditioning will reduce the healing time, produce a more uniform penetration of the peel, reduce the risk of post peel complications such as hyperpigmentation and can help in determining the patient’s skin tolerances and allergies. Post-peeling care involves soothing and cooling compresses, healing care solutions, avoidance of inflammatory agents and sun care. Histologically, a series of regular SCP procedures have been shown to create a decrease in the corneous layer, increase in the epidermal thickness with better organisation of the malpighian strata and lengthening of the cristae cutis. Clinically, they show an improvement in the texture and appearance of the skin. (Hexel, et al. 2005).
Histological studies have shown an increase in epidermal and dermal thickness with activation of the epidermal basal cells and underlying fibroblasts observed. This suggested a reorganization of the epidermis and a rebuilding of the superficial connective tissue with new collagen type I and III deposition and increased synthesis of glycosaminoglycans. Whilst SCP is considered a safe and effective procedure for the improvement in photoaging, most dermatologists and aestheticians recommend a series of regular peels to exact a visible result. There are so many different agents available in varying combinations, strengths and application procedures that specialized training is required in order to contain the depth of the peel. In this way there is greater risk of complication to microdermabrasion. Many of the peels are capable of exacerbating pre-existing medical conditions such as warts, seborrheic or atopic dermatitis, psoriasis and recurrent herpes simplex. Therefore a thorough medical history is needed prior to undergoing peel treatments.
The Alam et al. (2002) study compared the efficacy of microdermabrasion to glycolic acid peels by having patients undergo a series of low strength peels on one side of their face and low intensity microdermabrasion treatments to the other. The interesting findings were that of the two treatments there was no significant difference in terms of efficacy. In fact, investigator ratings and photographic comparisons were of no discriminative value. Whilst the peels were seen to be associated with greater smoothness and softness of the skin post treatment and were also preferred for improvement of wrinkles and brown spots to microdermabrasion by the sample group, microdermabrasion was reported to better reduce skin redness.
However, most of the differences were not seen as statistically significant and so fails to answer adequately which of the two modalities was in fact, more effective. Perhaps the answer is to utilize both modalities together. Hexel et al. (2005) compiled a pilot study comparing microdermabrasion followed by a chemical peel to just the utilization of the chemical peel alone. Whilst the study shows that both sample groups saw an improvement in texture, pigmentation and appearance of the skin, the sample group undergoing both the microdermabrasion and chemical peel together produced better clinical and histological results in decease of the thickness of the strata corneum and increased thickness in the epidermis than the group just receiving the peel on its own. They found that microdermabrasion could be safely combined with SCP with minimal side effects and did not represent a contraindication. The results and benefits increased without significantly increasing the side effects and in fact, had the advantage of requiring a fewer number of treatments when compared to just using peels alone.
It is clear both modalities are enormously popular and minimally invasive. Whilst the variation in peels, their different application techniques and care requirements might provide greater selectivity for individual skin types, far more research needs to be done on the effect of varying grain size of the ablative material, negative vacuum pressure, increased abrasion and increased passes over the skin before a true picture of how effective microdermabrasion truly is. The best conclusion might be that when used in tandem they can be more effective than when used in isolation.
Article written by Ilse Vermeulen
Ilse Vermeulen is the Director at Youth Beauty.
For more information visit: www.youthbeauty.co.nz
Alam M, Omura N E, Dover J S, Ardnt K A. Glycolic Peels Compared to Microdermabrasion: A Right-Left Controlled Tiral of efficacy and patient Satisfaction. Dermatol Surg 2002; 28 : 475-479
Freedman BM, Rueda-Pedraza E, Waddell S P. The epidermal and dermal changes associated with microdermabrasion. Dermatol Surg 2001 ; 27 (12) : 1031 - 1034
Hexel D, Mazzuco R, Del Forno T, Zechmeister D. Microdermabrasion followed by a 5% retinoid acid chemical peel vs. a 5% retinoid acid chemical peel for the treatment of photoaging – a pilot study. Journal of Cosmetic Dermatology. 2005 Apr 12; 4: 111 – 116
Tan M, Spencer J M , Pires L M, Amjeri J, Skover G. Dermatol Surg 2001; 27 : 943 – 949.
Zakopoulou N, Kontochristopoulos G. Journal of Cosmetic Dermatology 2006, 5, 249 - 253