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the mechanisms of action can vary depending on the active substance or substances contained in the peel &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Superficial peels act on the epidermis&#44; without penetrating the basement membrane&#46; They stimulate keratinocyte renewal from the basal layers of the epidermis and produce a reactive inflammation in the upper dermis that stimulates neocollagenesis by activating fibroblasts that synthesize new collagen &#40;types I and IV&#41; and elastic fibers&#46; They can act on the dermis by direct induction of type <span class="elsevierStyleSmallCaps">i</span> collagen synthesis by fibroblasts or by indirect mechanisms&#44; through the action of keratinocyte-derived factors that secondarily stimulate collagen production by dermal fibroblasts&#46; Glycolic acid peels have been reported to induce the release of interleukin-1&#945; in the epidermis&#44; with particularly high levels in the area of the basement membrane&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">1&#44;2</span></a> The term <span class="elsevierStyleItalic">very superficial</span> is used to refer to those peels that only produce mild desquamation of the corneal layer&#59; these are often called <span class="elsevierStyleItalic">home peels</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Medium peels affect the whole of the epidermis and the papillary dermis&#44; and can penetrate to the upper reticular dermis&#46; In this case&#44; skin regeneration occurs from the cells of the follicular epithelium&#44; which generate new layers of epidermis and stimulate the synthesis of collagen and elastic fibers&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Finally&#44; deep peels eliminate the epidermis and penetrate to the mid reticular dermis&#46; The majority of these peels produce protein coagulation&#44; observed clinically as frosting&#46; In these cases&#44; epidermal regeneration also develops from the cells of the follicular epithelium and there is intense synthesis of collagen and elastin that can persist for years after performing the peel&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The main indications for treatment with chemical peels include the following&#58; melasma&#44; ephelides&#44; postinflammatory hyperpigmentation&#44; photoaging&#44; under-eye circles&#44; acne vulgaris&#44; rosacea&#44; and scars&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Although complications &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41; are rare when peeling is performed using the correct technique for the active substance&#44; a number of factors must be taken into consideration to minimize the risk&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The medical history and dermatologic examination will help to ensure correct patient selection&#46; Skin preparation is an important step that contributes to achieving a more homogeneous effect and thus a more predictable result&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The type of acid employed&#44; the vehicle&#44; concentration&#44; number of layers&#44; and contact time are some of the factors that determine the depth of action of the peel and possible complications&#46; In the case of glycolic acid&#44; the pH and degree of neutralization are also relevant factors &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The dermatologist should have knowledge of the peeling agents described below&#44; as these are some of the most widely used&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Jessner Solution</span><p id="par0055" class="elsevierStylePara elsevierViewall">Jessner solution is a combination of resorcinol&#44; salicylic acid&#44; and lactic acid in 95&#37; ethanol&#46; Several layers are applied&#44; producing a frost that indicates epidermal changes similar to those achieved with tretinoin&#46; The possibility of allergic contact dermatitis to resorcinol can limit the use of this product&#46; Combination with trichloroacetic acid &#40;TCA&#41; has been shown to produce a nonsignificant increase in efficacy in melasma and acne scars and to reduce postinflammatory erythema&#46; However&#44; no studies have demonstrated the efficacy Jessner solution alone in these indications&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">&#945;-Hydroxy Acid Peels</span><p id="par0060" class="elsevierStylePara elsevierViewall">&#945;-hydroxy acid peels are characterized by their ease of use and low risk of complications&#44; even in dark skins&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">7</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Glycolic acid peels have a keratolytic effect &#40;they reduce corneocyte cohesion and increase thickness of the stratum granulosum&#41; and favor epidermal renewal&#46; The epidermolytic effect is only observed at high concentrations after long contact periods&#46; These are some of the most widely used peels for their anti-inflammatory and antioxidant properties&#46; Additionally&#44; they are able to induce dermal remodeling by stimulating fibroblasts&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Lactic acid is an &#945;-hydroxy acid with a similar mechanism of action to glycolic acid&#44; as it causes breakdown of the desmosomes between corneocytes and induces desquamation and melanin dispersion&#46; In addition&#44; it increases the synthesis of collagen and glycosaminoglycans and inhibits tyrosinase&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Salicylic acid is a &#946;-hydroxy acid that&#44; at concentrations of 3&#37; to 5&#37;&#44; has keratolytic and acantholytic effects mediated by rupture of keratinocyte membranes&#46; The keratolytic effect explains the improvement seen in alterations of pigmentation&#46; In addition&#44; its lipophilic nature gives it a high affinity for the pilosebaceous unit&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">11</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Several studies have shown that the hydroxy acids have anticarcinogenic potential&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">12</span></a> A study performed in mice irradiated with UV light and subsequently treated with various types of peel &#40;35&#37; glycolic acid&#44; 30&#37; salicylic acid&#44; 10&#37; and 35&#37; TCA&#41; versus a control group &#40;no peel&#41; showed that the different agents were all able to reduce tumor formation&#46; The application of peeling agents was found to delay the appearance of skin tumors and to significantly reduce the number of tumors compared with the control group&#44; with no differences between the different agents&#46; Furthermore&#44; the immunohistochemical markers of photodamage&#44; such as mutated p53&#44; were expressed in the basal and middle layers of the epidermis of the controls&#44; whereas the epidermis in peel-treated animals hardly expressed this mutation&#46; A fall in prostaglandin 2 synthesis was also observed&#44; which was interpreted as a prevention of UV-induced immunosuppression&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pyruvic Acid</span><p id="par0085" class="elsevierStylePara elsevierViewall">Pyruvic acid is an &#945;-keto acid that is transformed to lactic acid&#44; but it has certain peculiarities that give it a medium potency&#44; as it can produce epidermolysis in less than a minute&#44; with rapid penetration into the dermis&#46; It has antimicrobial and sebo-regulatory properties and it induces collagen and elastic fiber synthesis&#46; The vapors given off can cause irritation&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Phenol</span><p id="par0090" class="elsevierStylePara elsevierViewall">Phenol is classified as a deep chemical peel&#46; It shows rapid percutaneous absorption and high penetration into the reticular dermis&#44; being one of the most predictable in terms of dermal penetration and neocollagenesis&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">14</span></a> This agent is usually applied using the Baker-Gordon formula&#44; which combines 3<span class="elsevierStyleHsp" style=""></span>ml of 88&#37; phenol with 2<span class="elsevierStyleHsp" style=""></span>ml of distilled water&#44; 8 drops of septisol&#44; and 3 drops of croton oil&#46; The croton oil is responsible for deep penetration&#46; This peel is very painful and is associated with a risk of cardiac arrhythmias and of kidney and liver toxicity&#59; it must therefore be performed in the operating room under sedation and with continuous monitoring of vital signs&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Trichloroacetic Acid Peels</span><p id="par0095" class="elsevierStylePara elsevierViewall">TCA is derived from acetic acid by the chloration of 3 hydrogen ions&#46; A particular characteristic of this agent is that it can induce coagulative necrosis of proteins and cells&#46; The depth of action depends on various factors&#44; most importantly the number of layers applied and its combination with substances that potentiate its action &#40;croton oil&#44; Jessner solution&#41; or that regulate its cutaneous penetration&#44; such as the saponins &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">As mentioned above&#44; TCA peels are usually classified into superficial&#44; medium&#44; or deep&#44; depending on their concentration&#44; although&#44; to be more precise&#44; the concentration actually determines the speed of skin penetration&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">15</span></a> In general&#44; higher concentrations penetrate more rapidly and denature greater amounts of protein&#44; producing a deeper peel&#59; they are also associated with a higher risk of complications&#46; Concentrations of 10&#37; to 35&#37; are typically considered superficial&#44; producing the elimination of superficial alterations of pigmentation&#44; superficial wrinkles&#44; and perhaps some scars&#59; concentrations of 35&#37; to 50&#37; are considered medium peels and improve deeper wrinkles&#44; pigmentation&#44; and scars&#44; and produce a marked improvement in skin firmness&#46;</p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Indications</span><p id="par0105" class="elsevierStylePara elsevierViewall">The main indications for TCA peels are listed in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46; Complications that can develop after a TCA peel are the same as those that encountered with other peeling agents&#46; One of the most important factors in the risk of complications is skin phototype&#44; with a higher risk of postinflammatory hyperpigmentation in the higher phototypes&#46; As with the majority of peels&#44; but in this case in particular&#44; prior preparation of the skin is recommended&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Characteristics</span><p id="par0110" class="elsevierStylePara elsevierViewall">TCA induces reepithelialization&#44; dermal remodeling&#44; and cosmetic improvement through the coagulation of dermal and epidermal proteins&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">16&#8211;19</span></a> This agent does not need to be neutralized&#44; because the irreversible protein coagulation induced by the chemical substance limits its penetration and also prevents its systemic absorption&#46; TCA presents rapid self-neutralization at the concentrations used for both superficial and medium peels&#46; This is observed as the slow formation of a white frost on the skin&#59; in the superficial peel this is a pseudofrost&#46; Neutralization occurs more slowly at concentrations over 50&#37;&#44; and the risk of greater penetration increases &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">The action of TCA on the epidermal cells induces the production of growth factors and cytokines&#44; including platelet-derived growth factor B&#44; tissue growth factor-&#945;1 and &#946;1&#44; vascular endothelial growth factor&#44; interleukin-1 and interleukin-10&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">20</span></a> Specifically&#44; platelet derived growth factor increases in the cytoplasm of keratinocytes immediately after contact with TCA&#44; but returns to normal levels within 24<span class="elsevierStyleHsp" style=""></span>hours&#44; when the epidermis is totally necrotic&#46; This release of growth factors before necrosis plays a role in the reepithelialization and dermal regeneration characteristic of TCA&#46; The only change identified in fibroblasts is an increase in the synthesis of keratinocyte-derived growth factor&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Mode of Use</span><p id="par0120" class="elsevierStylePara elsevierViewall">Prior to the application of TCA&#44; the skin is cleaned and degreased with alcohol or acetone to ensure uniform penetration of the agent&#46; Topical anesthesia is not recommended as this could cause vasoconstriction&#44; which would affect the concentration of the agent&#46; TCA is applied using cotton buds or gauze swabs and always in a sequential manner until the desired frosting is achieved&#46; Vaporized water or moisturizing cream can then be applied to relieve the burning sensation&#46; The peeling is sealed using retinol cream&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Commercial peels are available that combine low concentrations of phenol with salicylic and other components&#46; These peels are applied in exactly the same way as commented above&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The method of application of other peeling agents is similar&#44; with certain peculiarities&#46; In the case of glycolic acid&#44; successive layers are applied with a gauze swab or brush until the patient reports an intense stinging sensation&#44; the erythema is very intense&#44; or whitish areas begin to appear&#59; the peel is applied for a maximum of 3<span class="elsevierStyleHsp" style=""></span>minutes in the first session and longer in successive sessions&#44; depending on the tolerance of the patient&#46; In this case&#44; erythema is observed rather than a frost &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; with a whitish appearance in areas of greater penetration&#59; a grayish color indicates excessive penetration and must be avoided&#46; Glycolic acid peels are neutralized with bicarbonate solution&#44; which is applied until the patient states that the pruritus has resolved in all areas&#8212;pruritus indicates continued action of the acid&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">The peculiarity of salicylic acid peels is that the patient reports an intense but transient burning sensation early in the process&#46; Two to 4 layers are applied&#44; waiting a couple of minutes between each layer to see if pseudofrosting develops&#46; The appearance of a pseudofrost marks the end-point of the peel &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Fanning the patient should be avoided so as not to accelerate the crystallization process&#46; Salicylic acid peels are usually removed with water &#40;although this is not essential&#41; to relieve the soreness&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">A number of placebo controlled studies have shown that prior preparation with topical retinoids when using TCA peels will improve the regeneration process&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">21&#44;22</span></a> Combination with retinoids improves the results by reducing the risk of complications and by accelerating epidermal regeneration&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">22</span></a> This is due to its capacity to compact the corneal layer&#44; increase epidermal thickness&#44; increase glycosaminoglycan concentration&#44; increase vascularization&#44; and reduce melanin synthesis&#46; No standard prepeeling protocols have been drawn up for this agent&#44; but the use of retinoic acid or retinol for 3 or 4 weeks prior to the peel is sufficient&#44; in our experience&#44; to optimize treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">23</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">A new TCA combination called the ZO 3-Steps peel &#40;Industrial Farmaceutica Cantabria&#44; Santander&#44; Spain&#41; is now available in Spain&#46; The first step is the application of a 10&#37; solution of TCA combined with 5&#37; lactic acid&#44; 17&#37; salicylic acid&#44; and saponins to induce rapid neutralization&#46; The second step consists of the application of 6&#37; retinol&#44; followed by the avoidance of contact with water for at least 5<span class="elsevierStyleHsp" style=""></span>hours so as not to interrupt stimulation by the retinol&#46; In the third step&#44; a calming cream is applied&#46; Exfoliation with this type of peel is very predictable and occurs on the third to fifth days&#46; The aim of combining distinct chemical agents in a single peel is to increase efficacy and tolerance compared with the agents when used separately&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Experience in a series of 9 patients with melasma and photoaging treated with a single session of ZO 3-Step peel revealed clinical improvement with a high degree of safety&#46; In patients with melasma&#44; a marked increase was observed in luminosity and a reduction in skin roughness and seborrhea at 1 month after performing the peel&#46; In patients with photoaging&#44; improvement was observed in fine wrinkles&#44; macules&#44; telangiectasias&#44; and sebaceous hyperplasia&#46; The majority of patients reported an excellent improvement&#44; similar to the results reported by the dermatologist&#46; It should be noted that follow-up was only of a month and&#44; as melasma shows a high tendency to recurrence and can occasionally deteriorate after performing a peel&#44; these treatments must always be performed with maximum attention to safety &#40;correct preparation&#44; preferably in patients with stable&#44; inactive melasma&#41; &#40;<a class="elsevierStyleCrossRefs" href="#fig0020">Figs&#46; 4&#8211;6</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">Combined peels have the advantage of acting on several pathways&#44; with a synergic effect between the distinct components &#40;exfoliation with the cocktail of acids&#44; dermal stimulation with the retinol&#41;&#44; minimizing possible side effects by using lower concentrations&#44; and accelerating regeneration&#44; which shortens the recovery period&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Combinations of TCA with other cosmetic procedures have also been investigated&#44; showing synergic effects&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">24</span></a> TCA has been used in methods of skin rejuvenation in combination with other techniques such as botulinum toxin injection or ablative carbon dioxide laser&#46; It has also been combined with other peeling agents such as phenol&#44; Jessner solution&#44; or tretinoin&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">17</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">In conclusion&#44; chemical peels continue to be safe and effective tools that improve a number of cosmetic skin conditions without significant economic outlay&#46; To optimize the cosmetic result and avoid the possible complications associated with peelings&#44; it is essential to know the correct indications&#44; to transmit realistic expectations to the patient&#44; and to have in-depth knowledge of the technique for the application of each agent&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Ethical disclosures</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Protection of human and animal subjects</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this research&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Confidentiality of data</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors declare that they followed their hospital&#39;s regulations regarding the publication of patient information&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Right to privacy and informed consent</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors obtained informed consent from the patients and&#47;or subjects referred to in this article&#46; This document is held by the corresponding author&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of Interest</span><p id="par0185" class="elsevierStylePara elsevierViewall">M&#46; T&#46; Truchuelo is a consultant for Industrial Farmaceutica Cantabria&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">The other authors declare that they have no conflicts of interest</p></span></span>"
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          "titulo" => "Jessner Solution"
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          "titulo" => "&#945;-Hydroxy Acid Peels"
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          "titulo" => "Pyruvic Acid"
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    "fechaAceptado" => "2016-09-17"
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            3 => "Trichloroacetic acid"
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            0 => "Peeling"
            1 => "Melasma"
            2 => "Fotoenvejecimiento"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chemical peeling is a common treatment in cosmetic dermatology&#46; A peel that has been used for many years is trichloroacetic acid&#46; Its adverse effects have for a long time been a major limitation&#46; We present a practical review of the characteristics&#44; mechanisms of action&#44; indications&#44; and complications of superficial chemical peels and of peeling with trichloroacetic acid&#46;</p></span>"
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      "es" => array:2 [
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las exfoliaciones qu&#237;micas &#40;m&#225;s conocidas como peelings qu&#237;micos&#41; son tratamientos utilizados frecuentemente en dermatolog&#237;a est&#233;tica&#46; En concreto el peeling con &#225;cido tricloroac&#233;tico se ha utilizado desde hace a&#241;os y una de sus principales limitaciones cl&#225;sicamente era sus efectos secundarios&#46; Presentamos una revisi&#243;n pr&#225;ctica de las caracter&#237;sticas&#44; mecanismos de acci&#243;n&#44; indicaciones y complicaciones de los peelings en general&#44; tanto los superficiales como el peeling con &#225;cido tricloroac&#233;tico&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Truchuelo M&#44; Cerd&#225; P&#44; Fern&#225;ndez LF&#46; Chemical Peeling&#58; A Useful Tool in the Office&#46; Actas Dermosifiliogr&#46; 2017&#59;108&#58;315&#8211;322&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Factors that determine the peeling action of trichloroacetic acid&#46; Source&#58; Vavouli et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a></p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Glycolic acid peel&#46; Erythema prior to neutralization with aqueous bicarbonate solution for the patient&#39;s insupportable feeling of pruritus&#46; Erythema&#44; indicated by the arrows&#44; was mild in this case&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Photos at baseline and 10 days after a ZO 3-Step peel&#46; Changes include increased luminosity&#44; uniformity of skin color&#44; and improved skin texture&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of Peel&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Active Substance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Superficial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#945;-hydroxy acids&#58; glycolic acid &#40;derived from cane sugar&#41;&#44; lactic acid &#40;derived from milk&#41;&#44; malic acid &#40;derived from apples&#41;&#44; citric acid &#40;derived from fruits&#41;&#44; tartaric acid &#40;derived from grapes&#41;&#46; Acids with a higher molecular weight&#44; such as mandelic acid and benzilic acid &#40;derived from glycolic acid&#41;&#46; &#946;-hydroxy acids&#58; salicylic acid<br>Trichloroacetic acid&#44; 10&#37;-35&#37;<br>Jessner solution<br>Tretinoin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Medium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Trichloroacetic acid&#44; 35&#37;-50&#37;<br>Pyruvic acid&#44; 40&#37;-70&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Deep&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Trichloroacetic acid&#44;<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>50&#37;<br>Phenol&#44; 88&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Classification of the Types of Peel According to The Depth of Action&#46;</p>"
        ]
      ]
      7 => array:8 [
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          0 => array:3 [
            "identificador" => "at2"
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        "tabla" => array:1 [
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Agent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mechanism of Action&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#945;-hydroxy acids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low concentrations &#40;5&#37;-10&#37;&#41; produce corneolysis<br>High concentrations &#40;50&#37;-70&#37;&#41; induce epidermolysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Jessner solution &#40;resorcinol<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>lactic<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>salicylic<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ethanol&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Corneolysis&#44; increasing the effect of other keratolytic agents&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Trichloroacetic acid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Coagulative necrosis of dermal and epidermal proteins&#44; keratolytic effect &#40;desquamation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Phenol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Coagulation of dermal and epidermal proteins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Mechanism of Action of the Distinct Peeling Agents&#46;</p>"
        ]
      ]
      8 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Source&#58; Nikalji et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">4</span></a></p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Immediate</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Persistent erythema&#44; edema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Pruritus&#44; irritation&#44; burning sensation&#44; pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Late</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hyperpigmentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hypopigmentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Depigmentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Demarcation lines&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Vesicles&#44; blisters&#44; scabs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Milium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Acneiform rash&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Infections &#40;herpes reactivation&#44; bacterial&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Medium and deep</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Atrophic scars&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cardiac arrhythmias &#40;phenol&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Laryngeal edema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Exacerbation of a dermatosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Infectious toxic shock syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">General Postpeeling Complications&#46;</p>"
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        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; GA&#44; glycolic acid&#59; MASI&#44; Melasma Area and Severity Index&#59; TCA&#44; trichloroacetic acid&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Melasma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Superficial TCA significantly improves MASI<br>No significant difference in efficacy compared with GA&#46;<br>Faster response to TCA than to GA<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">25</span></a><br>In some studies&#44; fewer sessions were necessary with TCA than with GA&#59; other studies showed no significant differences in number of sessions<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">26</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Photoaging&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Increased dermal collagen&#44; glycosaminoglycans&#44; and elastin<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">27</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Scars&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate or marked improvements in acne scars of up to 70&#37; in patients undergoing several peeling sessions with TCA &#40;mean&#44; 6 sessions&#41;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">28</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Under-eye circles&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Superficial TCA at a concentration of 3&#46;75&#37;&#46;<br>Mean of 4 weekly sessions&#44; with improvement already visible in the first session&#44; and progressively increasing<br>Induces lightening of skin tone and remission of the hyperpigmentation by the elimination of melanosomes secondary to the elimination of keratinocytes&#44; as well as tyrosinase inhibition and thinning of the epidermis and dermis<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Frictional melanosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A condition characterized by incontinentia pigmenti and melanophages in the dermis&#46; Safe and effective management with 15&#37; TCA<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">27</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Other indications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Actinic keratosis and actinic cheilitis<br>Xanthelasma<br>Flat warts<br>Seborrheic keratosis<br>Acanthosis nigricans<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">17&#44;28</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Main Indications for Trichloroacetic Acid Peels&#46;</p>"
        ]
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      10 => array:8 [
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        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
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            "identificador" => "at5"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Erythema with spotted frosting&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Epidermis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">More diffuse whitish frost with erythematous spots&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The papillary dermis has been reached&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Homogeneous frost without erythema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The papillary dermis has been penetrated to reach the reticular dermis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Relationship Between Dermatologic Signs and the Depth of Peeling With Trichloroacetic Acid&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:28 [
            0 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Biological effects of glycolic acid on dermal matrix metabolism mediated by dermal fibroblasts and epidermal keratinocytes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "Y&#46; Okano"
                            1 => "Y&#46; Abe"
                            2 => "H&#46; Masaki"
                            3 => "U&#46; Santhanam"
                            4 => "M&#46; Ichihashi"
                            5 => "Y&#46; Funasaka"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Exp Dermatol"
                        "fecha" => "2003"
                        "volumen" => "12"
                        "numero" => "Suppl 2"
                        "paginaInicial" => "57"
                        "paginaFinal" => "63"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14756525"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A comparative histologic study of the effects of three peeling agents and dermabrasion on normal and sundamaged skin"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "S&#46;J&#46; Stegman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Aesthetic Plast Surg&#46;"
                        "fecha" => "1982"
                        "volumen" => "6"
                        "paginaInicial" => "123"
                        "paginaFinal" => "135"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7180716"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Exfoliating chemical peels"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Z&#46; Obagi"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "LibroEditado" => array:3 [
                        "titulo" => "The art of skin health restoration and rejuvenation"
                        "paginaInicial" => "205"
                        "serieFecha" => "2015"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "4"
              "referencia" => array:1 [
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Practical Dermatology
Chemical Peeling: A Useful Tool in the Office
Peeling químico, una herramienta útil en la consulta
M. Truchueloa,
Autor para correspondencia
maytetd@yahoo.es

Corresponding author.
, P. Cerdáb, L.F. Fernándezc
a Clínica Grupo Pedro Jaén, Madrid, Spain
b Dermatóloga en la Clínica Dra. Paz Cerdá, Zaragoza, Spain
c Clínica Dermatológica Cosmética (CDC), Valladolid, Spain
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Factors that determine the peeling action of trichloroacetic acid&#46; Source&#58; Vavouli et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a></p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Chemical peeling consists of the application of a chemical substance to the skin in order to produce desquamation of the stratum corneum and normalization of the epidermis with remodeling of the skin&#44; leading to improvement in a number of skin alterations&#46; They are one of the most commonly used cosmetic procedures&#44; as they can produce a considerable improvement in quality of the treated skin after a short and&#44; in some cases&#44; very mild recovery period&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Chemical peels are traditionally classified as superficial&#44; medium&#44; or deep according to their depth of action &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; In addition&#44; the mechanisms of action can vary depending on the active substance or substances contained in the peel &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Superficial peels act on the epidermis&#44; without penetrating the basement membrane&#46; They stimulate keratinocyte renewal from the basal layers of the epidermis and produce a reactive inflammation in the upper dermis that stimulates neocollagenesis by activating fibroblasts that synthesize new collagen &#40;types I and IV&#41; and elastic fibers&#46; They can act on the dermis by direct induction of type <span class="elsevierStyleSmallCaps">i</span> collagen synthesis by fibroblasts or by indirect mechanisms&#44; through the action of keratinocyte-derived factors that secondarily stimulate collagen production by dermal fibroblasts&#46; Glycolic acid peels have been reported to induce the release of interleukin-1&#945; in the epidermis&#44; with particularly high levels in the area of the basement membrane&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">1&#44;2</span></a> The term <span class="elsevierStyleItalic">very superficial</span> is used to refer to those peels that only produce mild desquamation of the corneal layer&#59; these are often called <span class="elsevierStyleItalic">home peels</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Medium peels affect the whole of the epidermis and the papillary dermis&#44; and can penetrate to the upper reticular dermis&#46; In this case&#44; skin regeneration occurs from the cells of the follicular epithelium&#44; which generate new layers of epidermis and stimulate the synthesis of collagen and elastic fibers&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Finally&#44; deep peels eliminate the epidermis and penetrate to the mid reticular dermis&#46; The majority of these peels produce protein coagulation&#44; observed clinically as frosting&#46; In these cases&#44; epidermal regeneration also develops from the cells of the follicular epithelium and there is intense synthesis of collagen and elastin that can persist for years after performing the peel&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The main indications for treatment with chemical peels include the following&#58; melasma&#44; ephelides&#44; postinflammatory hyperpigmentation&#44; photoaging&#44; under-eye circles&#44; acne vulgaris&#44; rosacea&#44; and scars&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Although complications &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41; are rare when peeling is performed using the correct technique for the active substance&#44; a number of factors must be taken into consideration to minimize the risk&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The medical history and dermatologic examination will help to ensure correct patient selection&#46; Skin preparation is an important step that contributes to achieving a more homogeneous effect and thus a more predictable result&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The type of acid employed&#44; the vehicle&#44; concentration&#44; number of layers&#44; and contact time are some of the factors that determine the depth of action of the peel and possible complications&#46; In the case of glycolic acid&#44; the pH and degree of neutralization are also relevant factors &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The dermatologist should have knowledge of the peeling agents described below&#44; as these are some of the most widely used&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Jessner Solution</span><p id="par0055" class="elsevierStylePara elsevierViewall">Jessner solution is a combination of resorcinol&#44; salicylic acid&#44; and lactic acid in 95&#37; ethanol&#46; Several layers are applied&#44; producing a frost that indicates epidermal changes similar to those achieved with tretinoin&#46; The possibility of allergic contact dermatitis to resorcinol can limit the use of this product&#46; Combination with trichloroacetic acid &#40;TCA&#41; has been shown to produce a nonsignificant increase in efficacy in melasma and acne scars and to reduce postinflammatory erythema&#46; However&#44; no studies have demonstrated the efficacy Jessner solution alone in these indications&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">&#945;-Hydroxy Acid Peels</span><p id="par0060" class="elsevierStylePara elsevierViewall">&#945;-hydroxy acid peels are characterized by their ease of use and low risk of complications&#44; even in dark skins&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">7</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Glycolic acid peels have a keratolytic effect &#40;they reduce corneocyte cohesion and increase thickness of the stratum granulosum&#41; and favor epidermal renewal&#46; The epidermolytic effect is only observed at high concentrations after long contact periods&#46; These are some of the most widely used peels for their anti-inflammatory and antioxidant properties&#46; Additionally&#44; they are able to induce dermal remodeling by stimulating fibroblasts&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Lactic acid is an &#945;-hydroxy acid with a similar mechanism of action to glycolic acid&#44; as it causes breakdown of the desmosomes between corneocytes and induces desquamation and melanin dispersion&#46; In addition&#44; it increases the synthesis of collagen and glycosaminoglycans and inhibits tyrosinase&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Salicylic acid is a &#946;-hydroxy acid that&#44; at concentrations of 3&#37; to 5&#37;&#44; has keratolytic and acantholytic effects mediated by rupture of keratinocyte membranes&#46; The keratolytic effect explains the improvement seen in alterations of pigmentation&#46; In addition&#44; its lipophilic nature gives it a high affinity for the pilosebaceous unit&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">11</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Several studies have shown that the hydroxy acids have anticarcinogenic potential&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">12</span></a> A study performed in mice irradiated with UV light and subsequently treated with various types of peel &#40;35&#37; glycolic acid&#44; 30&#37; salicylic acid&#44; 10&#37; and 35&#37; TCA&#41; versus a control group &#40;no peel&#41; showed that the different agents were all able to reduce tumor formation&#46; The application of peeling agents was found to delay the appearance of skin tumors and to significantly reduce the number of tumors compared with the control group&#44; with no differences between the different agents&#46; Furthermore&#44; the immunohistochemical markers of photodamage&#44; such as mutated p53&#44; were expressed in the basal and middle layers of the epidermis of the controls&#44; whereas the epidermis in peel-treated animals hardly expressed this mutation&#46; A fall in prostaglandin 2 synthesis was also observed&#44; which was interpreted as a prevention of UV-induced immunosuppression&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pyruvic Acid</span><p id="par0085" class="elsevierStylePara elsevierViewall">Pyruvic acid is an &#945;-keto acid that is transformed to lactic acid&#44; but it has certain peculiarities that give it a medium potency&#44; as it can produce epidermolysis in less than a minute&#44; with rapid penetration into the dermis&#46; It has antimicrobial and sebo-regulatory properties and it induces collagen and elastic fiber synthesis&#46; The vapors given off can cause irritation&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Phenol</span><p id="par0090" class="elsevierStylePara elsevierViewall">Phenol is classified as a deep chemical peel&#46; It shows rapid percutaneous absorption and high penetration into the reticular dermis&#44; being one of the most predictable in terms of dermal penetration and neocollagenesis&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">14</span></a> This agent is usually applied using the Baker-Gordon formula&#44; which combines 3<span class="elsevierStyleHsp" style=""></span>ml of 88&#37; phenol with 2<span class="elsevierStyleHsp" style=""></span>ml of distilled water&#44; 8 drops of septisol&#44; and 3 drops of croton oil&#46; The croton oil is responsible for deep penetration&#46; This peel is very painful and is associated with a risk of cardiac arrhythmias and of kidney and liver toxicity&#59; it must therefore be performed in the operating room under sedation and with continuous monitoring of vital signs&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Trichloroacetic Acid Peels</span><p id="par0095" class="elsevierStylePara elsevierViewall">TCA is derived from acetic acid by the chloration of 3 hydrogen ions&#46; A particular characteristic of this agent is that it can induce coagulative necrosis of proteins and cells&#46; The depth of action depends on various factors&#44; most importantly the number of layers applied and its combination with substances that potentiate its action &#40;croton oil&#44; Jessner solution&#41; or that regulate its cutaneous penetration&#44; such as the saponins &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">As mentioned above&#44; TCA peels are usually classified into superficial&#44; medium&#44; or deep&#44; depending on their concentration&#44; although&#44; to be more precise&#44; the concentration actually determines the speed of skin penetration&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">15</span></a> In general&#44; higher concentrations penetrate more rapidly and denature greater amounts of protein&#44; producing a deeper peel&#59; they are also associated with a higher risk of complications&#46; Concentrations of 10&#37; to 35&#37; are typically considered superficial&#44; producing the elimination of superficial alterations of pigmentation&#44; superficial wrinkles&#44; and perhaps some scars&#59; concentrations of 35&#37; to 50&#37; are considered medium peels and improve deeper wrinkles&#44; pigmentation&#44; and scars&#44; and produce a marked improvement in skin firmness&#46;</p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Indications</span><p id="par0105" class="elsevierStylePara elsevierViewall">The main indications for TCA peels are listed in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46; Complications that can develop after a TCA peel are the same as those that encountered with other peeling agents&#46; One of the most important factors in the risk of complications is skin phototype&#44; with a higher risk of postinflammatory hyperpigmentation in the higher phototypes&#46; As with the majority of peels&#44; but in this case in particular&#44; prior preparation of the skin is recommended&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Characteristics</span><p id="par0110" class="elsevierStylePara elsevierViewall">TCA induces reepithelialization&#44; dermal remodeling&#44; and cosmetic improvement through the coagulation of dermal and epidermal proteins&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">16&#8211;19</span></a> This agent does not need to be neutralized&#44; because the irreversible protein coagulation induced by the chemical substance limits its penetration and also prevents its systemic absorption&#46; TCA presents rapid self-neutralization at the concentrations used for both superficial and medium peels&#46; This is observed as the slow formation of a white frost on the skin&#59; in the superficial peel this is a pseudofrost&#46; Neutralization occurs more slowly at concentrations over 50&#37;&#44; and the risk of greater penetration increases &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">The action of TCA on the epidermal cells induces the production of growth factors and cytokines&#44; including platelet-derived growth factor B&#44; tissue growth factor-&#945;1 and &#946;1&#44; vascular endothelial growth factor&#44; interleukin-1 and interleukin-10&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">20</span></a> Specifically&#44; platelet derived growth factor increases in the cytoplasm of keratinocytes immediately after contact with TCA&#44; but returns to normal levels within 24<span class="elsevierStyleHsp" style=""></span>hours&#44; when the epidermis is totally necrotic&#46; This release of growth factors before necrosis plays a role in the reepithelialization and dermal regeneration characteristic of TCA&#46; The only change identified in fibroblasts is an increase in the synthesis of keratinocyte-derived growth factor&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Mode of Use</span><p id="par0120" class="elsevierStylePara elsevierViewall">Prior to the application of TCA&#44; the skin is cleaned and degreased with alcohol or acetone to ensure uniform penetration of the agent&#46; Topical anesthesia is not recommended as this could cause vasoconstriction&#44; which would affect the concentration of the agent&#46; TCA is applied using cotton buds or gauze swabs and always in a sequential manner until the desired frosting is achieved&#46; Vaporized water or moisturizing cream can then be applied to relieve the burning sensation&#46; The peeling is sealed using retinol cream&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Commercial peels are available that combine low concentrations of phenol with salicylic and other components&#46; These peels are applied in exactly the same way as commented above&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The method of application of other peeling agents is similar&#44; with certain peculiarities&#46; In the case of glycolic acid&#44; successive layers are applied with a gauze swab or brush until the patient reports an intense stinging sensation&#44; the erythema is very intense&#44; or whitish areas begin to appear&#59; the peel is applied for a maximum of 3<span class="elsevierStyleHsp" style=""></span>minutes in the first session and longer in successive sessions&#44; depending on the tolerance of the patient&#46; In this case&#44; erythema is observed rather than a frost &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; with a whitish appearance in areas of greater penetration&#59; a grayish color indicates excessive penetration and must be avoided&#46; Glycolic acid peels are neutralized with bicarbonate solution&#44; which is applied until the patient states that the pruritus has resolved in all areas&#8212;pruritus indicates continued action of the acid&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">The peculiarity of salicylic acid peels is that the patient reports an intense but transient burning sensation early in the process&#46; Two to 4 layers are applied&#44; waiting a couple of minutes between each layer to see if pseudofrosting develops&#46; The appearance of a pseudofrost marks the end-point of the peel &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Fanning the patient should be avoided so as not to accelerate the crystallization process&#46; Salicylic acid peels are usually removed with water &#40;although this is not essential&#41; to relieve the soreness&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">A number of placebo controlled studies have shown that prior preparation with topical retinoids when using TCA peels will improve the regeneration process&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">21&#44;22</span></a> Combination with retinoids improves the results by reducing the risk of complications and by accelerating epidermal regeneration&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">22</span></a> This is due to its capacity to compact the corneal layer&#44; increase epidermal thickness&#44; increase glycosaminoglycan concentration&#44; increase vascularization&#44; and reduce melanin synthesis&#46; No standard prepeeling protocols have been drawn up for this agent&#44; but the use of retinoic acid or retinol for 3 or 4 weeks prior to the peel is sufficient&#44; in our experience&#44; to optimize treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">23</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">A new TCA combination called the ZO 3-Steps peel &#40;Industrial Farmaceutica Cantabria&#44; Santander&#44; Spain&#41; is now available in Spain&#46; The first step is the application of a 10&#37; solution of TCA combined with 5&#37; lactic acid&#44; 17&#37; salicylic acid&#44; and saponins to induce rapid neutralization&#46; The second step consists of the application of 6&#37; retinol&#44; followed by the avoidance of contact with water for at least 5<span class="elsevierStyleHsp" style=""></span>hours so as not to interrupt stimulation by the retinol&#46; In the third step&#44; a calming cream is applied&#46; Exfoliation with this type of peel is very predictable and occurs on the third to fifth days&#46; The aim of combining distinct chemical agents in a single peel is to increase efficacy and tolerance compared with the agents when used separately&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Experience in a series of 9 patients with melasma and photoaging treated with a single session of ZO 3-Step peel revealed clinical improvement with a high degree of safety&#46; In patients with melasma&#44; a marked increase was observed in luminosity and a reduction in skin roughness and seborrhea at 1 month after performing the peel&#46; In patients with photoaging&#44; improvement was observed in fine wrinkles&#44; macules&#44; telangiectasias&#44; and sebaceous hyperplasia&#46; The majority of patients reported an excellent improvement&#44; similar to the results reported by the dermatologist&#46; It should be noted that follow-up was only of a month and&#44; as melasma shows a high tendency to recurrence and can occasionally deteriorate after performing a peel&#44; these treatments must always be performed with maximum attention to safety &#40;correct preparation&#44; preferably in patients with stable&#44; inactive melasma&#41; &#40;<a class="elsevierStyleCrossRefs" href="#fig0020">Figs&#46; 4&#8211;6</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">Combined peels have the advantage of acting on several pathways&#44; with a synergic effect between the distinct components &#40;exfoliation with the cocktail of acids&#44; dermal stimulation with the retinol&#41;&#44; minimizing possible side effects by using lower concentrations&#44; and accelerating regeneration&#44; which shortens the recovery period&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Combinations of TCA with other cosmetic procedures have also been investigated&#44; showing synergic effects&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">24</span></a> TCA has been used in methods of skin rejuvenation in combination with other techniques such as botulinum toxin injection or ablative carbon dioxide laser&#46; It has also been combined with other peeling agents such as phenol&#44; Jessner solution&#44; or tretinoin&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">17</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">In conclusion&#44; chemical peels continue to be safe and effective tools that improve a number of cosmetic skin conditions without significant economic outlay&#46; To optimize the cosmetic result and avoid the possible complications associated with peelings&#44; it is essential to know the correct indications&#44; to transmit realistic expectations to the patient&#44; and to have in-depth knowledge of the technique for the application of each agent&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Ethical disclosures</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Protection of human and animal subjects</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this research&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Confidentiality of data</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors declare that they followed their hospital&#39;s regulations regarding the publication of patient information&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Right to privacy and informed consent</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors obtained informed consent from the patients and&#47;or subjects referred to in this article&#46; This document is held by the corresponding author&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of Interest</span><p id="par0185" class="elsevierStylePara elsevierViewall">M&#46; T&#46; Truchuelo is a consultant for Industrial Farmaceutica Cantabria&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">The other authors declare that they have no conflicts of interest</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chemical peeling is a common treatment in cosmetic dermatology&#46; A peel that has been used for many years is trichloroacetic acid&#46; Its adverse effects have for a long time been a major limitation&#46; We present a practical review of the characteristics&#44; mechanisms of action&#44; indications&#44; and complications of superficial chemical peels and of peeling with trichloroacetic acid&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las exfoliaciones qu&#237;micas &#40;m&#225;s conocidas como peelings qu&#237;micos&#41; son tratamientos utilizados frecuentemente en dermatolog&#237;a est&#233;tica&#46; En concreto el peeling con &#225;cido tricloroac&#233;tico se ha utilizado desde hace a&#241;os y una de sus principales limitaciones cl&#225;sicamente era sus efectos secundarios&#46; Presentamos una revisi&#243;n pr&#225;ctica de las caracter&#237;sticas&#44; mecanismos de acci&#243;n&#44; indicaciones y complicaciones de los peelings en general&#44; tanto los superficiales como el peeling con &#225;cido tricloroac&#233;tico&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Truchuelo M&#44; Cerd&#225; P&#44; Fern&#225;ndez LF&#46; Chemical Peeling&#58; A Useful Tool in the Office&#46; Actas Dermosifiliogr&#46; 2017&#59;108&#58;315&#8211;322&#46;</p>"
      ]
    ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Factors that determine the peeling action of trichloroacetic acid&#46; Source&#58; Vavouli et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a></p>"
        ]
      ]
      1 => array:7 [
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Glycolic acid peel&#46; Erythema prior to neutralization with aqueous bicarbonate solution for the patient&#39;s insupportable feeling of pruritus&#46; Erythema&#44; indicated by the arrows&#44; was mild in this case&#46;</p>"
        ]
      ]
      2 => array:7 [
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        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Pseudofrost after 3 layers of salicylic acid&#46;</p>"
        ]
      ]
      3 => array:7 [
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        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
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        "mostrarDisplay" => false
        "figura" => array:1 [
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Photos at baseline and 10 days after a ZO 3-Step peel&#46; Changes include increased luminosity&#44; uniformity of skin color&#44; and improved skin texture&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Melasma&#46; Improvement produced by a reduction in pigmentation and in variability of skin color 10 days after performing the peel&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "fig0030"
        "etiqueta" => "Figure 6"
        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Photoaging&#46; Changes after a ZO 3-Step peel&#46;</p>"
        ]
      ]
      6 => array:8 [
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        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of Peel&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Active Substance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Superficial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#945;-hydroxy acids&#58; glycolic acid &#40;derived from cane sugar&#41;&#44; lactic acid &#40;derived from milk&#41;&#44; malic acid &#40;derived from apples&#41;&#44; citric acid &#40;derived from fruits&#41;&#44; tartaric acid &#40;derived from grapes&#41;&#46; Acids with a higher molecular weight&#44; such as mandelic acid and benzilic acid &#40;derived from glycolic acid&#41;&#46; &#946;-hydroxy acids&#58; salicylic acid<br>Trichloroacetic acid&#44; 10&#37;-35&#37;<br>Jessner solution<br>Tretinoin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Medium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Trichloroacetic acid&#44; 35&#37;-50&#37;<br>Pyruvic acid&#44; 40&#37;-70&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Deep&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Trichloroacetic acid&#44;<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>50&#37;<br>Phenol&#44; 88&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1406678.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Classification of the Types of Peel According to The Depth of Action&#46;</p>"
        ]
      ]
      7 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Agent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mechanism of Action&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#945;-hydroxy acids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low concentrations &#40;5&#37;-10&#37;&#41; produce corneolysis<br>High concentrations &#40;50&#37;-70&#37;&#41; induce epidermolysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Jessner solution &#40;resorcinol<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>lactic<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>salicylic<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ethanol&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Corneolysis&#44; increasing the effect of other keratolytic agents&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Trichloroacetic acid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Coagulative necrosis of dermal and epidermal proteins&#44; keratolytic effect &#40;desquamation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Phenol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Coagulation of dermal and epidermal proteins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Mechanism of Action of the Distinct Peeling Agents&#46;</p>"
        ]
      ]
      8 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Source&#58; Nikalji et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">4</span></a></p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Immediate</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Persistent erythema&#44; edema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Pruritus&#44; irritation&#44; burning sensation&#44; pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Late</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hyperpigmentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hypopigmentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Depigmentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Demarcation lines&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Vesicles&#44; blisters&#44; scabs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Milium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Acneiform rash&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Infections &#40;herpes reactivation&#44; bacterial&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Medium and deep</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Atrophic scars&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cardiac arrhythmias &#40;phenol&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Laryngeal edema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Exacerbation of a dermatosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Infectious toxic shock syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1406676.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">General Postpeeling Complications&#46;</p>"
        ]
      ]
      9 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
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            "identificador" => "at4"
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; GA&#44; glycolic acid&#59; MASI&#44; Melasma Area and Severity Index&#59; TCA&#44; trichloroacetic acid&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Melasma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Superficial TCA significantly improves MASI<br>No significant difference in efficacy compared with GA&#46;<br>Faster response to TCA than to GA<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">25</span></a><br>In some studies&#44; fewer sessions were necessary with TCA than with GA&#59; other studies showed no significant differences in number of sessions<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">26</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Photoaging&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Increased dermal collagen&#44; glycosaminoglycans&#44; and elastin<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">27</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Scars&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate or marked improvements in acne scars of up to 70&#37; in patients undergoing several peeling sessions with TCA &#40;mean&#44; 6 sessions&#41;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">28</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Under-eye circles&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Superficial TCA at a concentration of 3&#46;75&#37;&#46;<br>Mean of 4 weekly sessions&#44; with improvement already visible in the first session&#44; and progressively increasing<br>Induces lightening of skin tone and remission of the hyperpigmentation by the elimination of melanosomes secondary to the elimination of keratinocytes&#44; as well as tyrosinase inhibition and thinning of the epidermis and dermis<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Frictional melanosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A condition characterized by incontinentia pigmenti and melanophages in the dermis&#46; Safe and effective management with 15&#37; TCA<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">27</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Other indications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Actinic keratosis and actinic cheilitis<br>Xanthelasma<br>Flat warts<br>Seborrheic keratosis<br>Acanthosis nigricans<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">17&#44;28</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Epidermis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">More diffuse whitish frost with erythematous spots&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Homogeneous frost without erythema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The papillary dermis has been penetrated to reach the reticular dermis&nbsp;\t\t\t\t\t\t\n
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        "texto" => "<p id="par0195" class="elsevierStylePara elsevierViewall">We would like to thank Dr&#46; M&#46; Vital&#44; dermatologist and medical director of the Medical Affairs and Research Department of Industrial Farmaceutica Cantabria&#44; who participated in the review of this article&#46;</p>"
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