Using 3% retinol peeling and cosmeceuticals for the aesthetic wellness of the oncological patient after precautionary endocrine treatment: A case series

Roughness, sagging, and skin rash are common in patients with breast cancer treated with LH‐RH analog plus tamoxifen or aromatase inhibitors as adjuvant postsurgical endocrine therapy. The use of topical retinol (vitamin A) has shown to be an efficacious cosmetic treatment.


| BACKG ROU N D
A relevant proportion of women with diagnosed breast cancer receive LH-RH analog plus tamoxifen or aromatase inhibitors as adjuvant postsurgical endocrine therapy. 1,2A remarkable rate of these women experiences dermal issues including roughness, sagging, and skin rash having remarkable consequences on their mood and quality of life. 3,4A growing number of these patients are seeking gentle and effective therapy to recover their damaged skin. 3eling with retinol is a topical treatment that is widely used to reverse the atrophy of natural skin. 5Retinol applied to human skin penetrates the dermal surface, to be oxidized to retinoic acid, inducing lower skin irritation, and, thus, with improved tolerability. 5Retinol has been shown to induce the production of glycosaminoglycan, which retains substantial water, and to promote epidermal thickening, increase fibroblast growth, increase collagen, improve fine wrinkles associated with natural aging, 5 and reduce irritation from photoaging, 6 improving the overall skin condition. 7tric acid increases chondroitin sulfate content in skin building volume to plump and firm on sun-damaged skin. 8Acetyl tyrosinamide significantly improves skin thickness. 9α-bisabolol, α-bisabolol oxide A and B are components extracted from chamomile 10 having anti-inflammatory and antibacterial properties, allowing the reduction in cutaneous burns healing time in guinea pigs.Vitamin E (αtocopherol) ameliorates UV-induced skin damage. 12 advanced retinol peel formulation containing retinol 3%, NeoCitriate® 4% (triethyl citrate 4%), Aminofil® 0.1% (acetyl tyrosinamide), bisabolol, and vitamin E acetate 1%, in a vehicle alcoholic solution has been developed for skincare (NeoStrata® ProSystem) 13 to exfoliate, improve the appearance of fine lines and wrinkles, and plump and firm skin, while promoting a bright, even complexion.The fragrance, oil, and color-free alcoholic solution contains a photo stabilizer and is packaged in an opaque unit dose vial to protect retinol.
The use of the advanced retinol peel formulation in subjects with acne, melasma or hyperpigmentation, photodamage, and skin of color was efficacious and well-tolerated as cosmetic treatment under physician supervision and delivered significant improvements in rough skin texture, uneven skin tone, and coloring, fine lines, visible pores, acne blemishes, and skin sensitivity (sting, itch, and burn). 14

| C A S E S PR E S E NTATI O N
Four women (aged 42, 44, 45, and 49 years) underwent surgeon for infiltrating ductal or lobular breast cancer (stages pT1-pT2, pN0-pN1, and M0) between October and December 2012.Premenopausal women received precautionary endocrine therapy with tamoxifen 20 mg/day and LH-RH analog (1 vial per month) while postmenopausal received an aromatase inhibitor (letrozole or anastrozole) for 5 years.During this therapy, they experienced iatrogenic xerosis, skin firmness, and loss of luminosity.They had a skin level of hydration, lightness, softness, elasticity, smoothness, and tonicity perceived as poor and causing clinically important stress to both women both from their subjective point of view and from physician's assessment (Figures 1A,2A,3A,4A).
When they had completed their adjuvant therapy by a minimum of 6 weeks, their dermatologist proposed the treatment with the advanced retinol peel formulation after signing their informed consent to receive aesthetic treatment and publish the photographs of their head and neck between October and December 2017.
The topical treatment with the advanced retinol peel formulation was gently administered at the Studio Medico Belmontesi four times once every 4-6 weeks after cleaning the face with a facial cleanser and the application of a prepeel cleanser at the dermatologist ambulatory.The women were then observed for 10 min to rub in excess peel solution.When back at home, women softly washed off any remaining peel after 3-4 h, for a light peeling effect on their sensitive skin.Patients continued skin cleaning of visible flake and peel in the following 3-7 days when sun exposure was avoided lightly applying an SPF 50 sunscreen.
The effectiveness of the treatment was evaluated through the visual examination of the photographs and asking patients their feeling about the condition of their skin.Since this was not a study, but a report of four cases observed in our normal clinical practice, no assessment scales were used to assess the effectiveness of dermatological treatment.

| OUTCOME AND FOLLOW-UP
All women showed a clear improvement in skin appearance since the end of the first application of the advanced retinol peel formulation and continued until the end of the 24 weeks observation period Two patients reported a temporary mild dryness and one of them reported redness, too.

| DISCUSS ION
These are the first four cases showing the effective use of an advanced retinol peeling system in women with skin-damaging related to adjuvant endocrine therapy.Skin appearance is particularly important for women, and some of them feel as "not fully recovered" after successful breast surgery and adjuvant therapy because they feel like elders.The availability of an advanced peel formulation allows the peeling with retinol possible in women with particularly sensitive skins, as women treated for breast cancer.The absence of adverse events confirms the feasibility of enlarging its use to a wider population.
Our observation stopped after 24 weeks and, to date, we do not know the long-term effects of the advanced retinol peel formulation.All patients are continuing their aesthetic treatment and are periodically evaluated.
F I G U R E 1 Lateral view of patient 1 before (A) and after (B) the treatment with the advanced retinol peel formulation.