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Chemical peels

Mariam Ahmed Baqi , M.D

2014

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- Also known as Chemo exfoliation.

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- Removes the outer layer of the skin, enhances the overall function and appearance of skin.

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Basic concepts

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Fitzpatrick �skin �type

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Glogau Classification of photoaging

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Indications of chemical peels

  • Photodamage ( AK ).
  • Rough texture.
  • Fine lines.
  • Hyperpigmentations.
  • Enlarged pores.
  • Comedonal acne and acne vulgaris.
  • Acne scars.
  • Keratosis pilaris.
  • Ichthyosis.
  • Enhanced penetration of topical products.

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Types of peels

  • Based on depth of penetration.

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  • Very superfcial peels : stratum corneum +/- upper stratum spinosum .
  • Superfcial peels : entire epidermis +/- pap. dermis .
  • Medium depth peels :entire epidermis +/- upper reticular dermis .
  • Deep peels penetrte the midreticular dermis.

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Factors influencing the peel

  • Chemical peel agent .
  • Concentration .
  • Acid pH .
  • Application time .
  • Technique .
  • Quantity .
  • Skin preparation .
  • Skin characteristics .

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Mechanism of action

  • Keratolysis: disruption of corneocyte adhesion by breaking desmosomes.

Eg: Lactic and glycolic acid.

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  • Keratocoagulation: denaturation of keratinocytes surface protein.

Eg: TCA.

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  • Net effect: desquamation and accelerated epidermal Renewal.

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Neutralaization

  • Some require termination of activity by neutralization.

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  • By a base like sodium bicarbonate solution (10–15%) or water to dilute the acid, which raises the pH and inactivates the acid.

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Neutralization

  • Self-neutralizing acids: dont require a base for termination of activity.

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  • spontaneously terminated shortly after application by water and other components in the skin, which dilute and neutralize the acid.

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Neutralization

  • Lactic acid varies in its requirement for neutralization.
  • In low concentrations such as 15%, lactic acid is self-neutralizing.
  • Higher concentrations such as 45%, requires neutralization by a base.
  • Manufacture protocol.

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Advantages of Superficial Peels

  • Inexpensive
  • Appropriate for all Fitzpatrick skin types
  • Multiple conditions treated simultaneously
  • Appropriate for face and body

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Disadvantages of Superfcial Peels

  • Require multiple treatments
  • Cannot remove scars completely

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Chemical peel products

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Chemical peel products

  • Alpha hydroxyl acids .
  • Beta hydroxyl acids.
  • Trichloroacetic Acid.
  • Jessner’s and blended peels.
  • Retinoids.
  • Enzymes.

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Alpha hydroxyl acids.

  • From fruits.
  • Glycolic (sugarcane).
  • Malic (apple).
  • Tartaric (grapes).
  • Mandelic (almonds).
  • Lactic (milk).
  • Phytic (rice).

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  • Used in topical care in low concentration (10% or less) and less acidic PH (3.5 or greater).

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Glycolic acid peel

  • Clear colorless solutions or gels.
  • Needs neutralization.
  • Variable tolerance.
  • Light protocol : low strength (13-20%) , short duration

(1-2min).

  • Intense protocol : high strength (70%), longer duration ( up to 7 min).

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Lactic acid peel

  • Gentle.
  • Hydrating ( lactic acid lactate).
  • Very superficial.
  • Up to 50%.
  • Frequently combined with other superficial peels.

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Chemical peel products

  • Alpha hydroxyl acids .
  • Beta hydroxyl acids.
  • Trichloroacetic Acid.
  • Jessner’s and blended peels.
  • Retinoids.
  • Enzymes.

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Beta hydroxyl acids.

  • Salicylic acid.
  • Dervived from willow tree bark, wintergreen oil and sweet birch.
  • Up to 30% in sup. Peels.
  • Lipophilic : penetrates and dissolves sebum.
  • Excellent for acne.

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  • Anti-inflammatory: sensitive conditions like rosacea.
  • Milder than alpha hydroxyl acids.
  • Self neutralizing.
  • Pseudofrost.
  • Pure vs combined peel.

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  • SA 14%.
  • Resorcinol 14%.
  • Lactic acid 14%.
  • Ethanol.

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  • SA 20%.
  • Mandelic acid 10%.

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Salicylic acid pseudofrost vs GA.

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Chemical peel products

  • Alpha hydroxyl acids .
  • Beta hydroxyl acids.
  • Trichloroacetic Acid.
  • Jessner’s and blended peels.
  • Retinoids.
  • Enzymes.

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Trichloroacetic Acid

  • Synthetic form acetic acid and chlorine.
  • Superficial ( 20% ) to deep peel.
  • Self neutralizing.
  • true frosting (not wiped off).
  • Level 1: faint white, patchy erythema. Desired.
  • Level 2 : visible whitening, some erythema.
  • Level 3: opaque whitening, deeper than intended peel.

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TCA 20% 2 layers level 1 frosting.

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Chemical peel products

  • Alpha hydroxyl acids .
  • Beta hydroxyl acids.
  • Trichloroacetic Acid.
  • Jessner’s and blended peels.
  • Retinoids.
  • Enzymes.

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Jessner and blended peels.

  • allows lower percentage of each peel: more outcome, less side effects.
  • Additional ingredients:
  • Melanogenesis inhibitors: kojic acid and hydroquinones.
  • Hydrating agents: soy isoflavones.
  • Anti inflammatory: bisabolol.
  • Antioxidants: ascorbic acid.

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Blended peels

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Self neutralizing

Requires neutralizing

  • Has GA or high concentration of LA (45%).

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  • Terminates shortly after application.
  • Classical eg : Jessner’s peel.
  • Modified Jessner.
  • Pseudofrost.
  • Multiple layers.

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Jessner’s peel:� 6 layers with mild erythema and faint whitening.

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Chemical peel products

  • Alpha hydroxyl acids .
  • Beta hydroxyl acids.
  • Trichloroacetic Acid.
  • Jessner’s and blended peels.
  • Retinoids.
  • Enzymes.

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proteolytic enzymes

  • keratolysis.
  • Smelly.

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  • bromelain (derived from pineapple).
  • lactose (from sour milk).
  • papain (from papaya).
  • Pepsin.
  • pumpkin, tomato, and mushroom extracts.

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  • Require activation by water.
  • Warm pleasant sensation.
  • Applied for 2–10 minutes and then removed with water.

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contraindications

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Contraindications

  • Allergy to chemical peel .
  • Aspirin allergy (for salicylic acid peels).
  • Pregnancy or nursing .
  • Active infection (herpes).
  • open wound in the area .
  • Melanoma or BCC (or lesions suspected).
  • Dermatoses (e.g., vitiligo, psoriasis, and atopic dermatitis) in the treatment area.
  • Impaired healing (e.g., due to immunosuppression)
  • Bleeding abnormality (e.g., thrombocytopenia).
  • Isotretinoin (Accutane) use within the preceeding 6 months.
  • Tanning bed use pre and post procedure.
  • Unrealistic expectations .
  • Body dysmorphic disorder.

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Before you start..

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Preprocedure checklist

  • Review the patient’s medical and cosmetic history.
  • Aesthetic consultation.
  • Consent.
  • Pretreatment photography.
  • patient preparation:
  • D/C all peeling products 2 W prior.
  • D/C all retinoinds 2 W prior.
  • Start prophylactic antiviral for Pt with history of herpes (500mg bid) : 2 days before procedure until 3 days post procedure.
  • Instruction handout.
  • Sunblock .
  • +/- hydroquinone (2-6%).

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Lets start!

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Set up

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Peel steps

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Eye protect, petrolatum.

Gauze, cotton tips, brush.

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Safety zones

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Eye protection

petrolatum

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Face quadrants

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Peel direction

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So lets review one more time!

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Peel steps

  • Preperae the patients:
  • Position and drape
  • Clean and degrease the skin
  • Eye protection
  • Petrolatum

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  • Apply the peel :
  • 4x4 folded dipped gauze, cotton tips, brush.
  • Develop a system.
  • Monitor for endpoints (frosting, pain).
  • Terminate (endpoint, timing, complain).
  • Boost (optional)
  • Topical smoothening or targeted care products.

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Non facial skin

  • Fewer pilosebaceous units.
  • Slower reepethelization .
  • More prone to complications.
  • Less than 25% BSA per session.
  • Commonly uses : GA, LA, TCA.

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Treatment intervals

  • 2-4 weeks.
  • 6 treatments.

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complications

  • Pain
  • Prolonged erythema
  • Hyperpigmentation
  • Hypopigmentation
  • Infection (e.g : impetigo, candidiasis or activation of herpes simplex)
  • Milia
  • Vesiculation (epidermolysis) and crusting
  • Allergic reactions: urticaria, papules, anaphylaxis.
  • Salicylism ( v rare).

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Lets Test you!

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  • 39 year old African American lady.
  • Pigmentations of face for the past 7 years.
  • Tried topical bleaching creams, not satisfied.
  • Wants your opinion regarding chemical peels.

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  • Step one : full history.
  • Previous peels?
  • Bleaching treatments?
  • Pregnancy and lactations?

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  • Step 2: clinica exam.
  • Skin phenotype.
  • Analysis of problems.

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  • Step 3: Peel selection.

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  • Step 4 : peel session.

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  • Step 5 : choose your tool.

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  • Step 6: select a protocol for your peel.
  • Light protocol : low strength (20-13%) , short duration

(1-2min).

  • Intense protocol : high strength (70%), longer duration ( up to 7 min).

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  • Step 7 : neutralization.

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The end..��Thank you!

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