Chemical Peeling

Chemical Peel Treatment

Chemical peel treatment is a procedure whereby chemical agents are applied to the skin surface to produce controlled destruction of the portions of the epidermis and/or dermis. There will be improvement of skin texture, superficial wrinkles due to regeneration of the epidermis and dermis by the migration of the uninvolved adjacent epithelium and adnexal structures.

Peels have metabolic, caustic and toxic actions. Depending on the depth of penetration they are classified as very superficial, superficial, medium depth, and deep peels. Chemical peel treatment is the most commonly performed procedure in today’s aesthetic practice. In recorded history, ancient Egyptians were one of the first ones to use chemical agents as peels. They used animal oils, salt and alabaster.1,2 Cleopatra used sour milk for bathing to get a glowing skin. Sour milk as we now know has lactic acid, an alphahydroxy acid.

Greeks and Romans used pumice, myrrh, frankincense, mustard, and sulfur as lightening agents and to improve wrinkles. In Europe, Fox, Hebra and Unna described their experiences with peels. In 1882, Unna a German doctor described his experience with resorcinol, phenol, trichloroacetic acid (TCA), and salicylic acid. By the late 1980s, the popular “no downtime,” “lunchtime peels” with superficial agents such as alpha hydroxy acid (AHA) became widely available.

Chemical peels form an important part of the cosmetic dermatologist’s armamentarium even into day’s age of lasers and lights.

Classification of Peels According to Chemical Composition

Group of natural acids found in food Natural source

Alpha hydroxy acids – Hydroxyacetic acid–Glycolic acid (GA) Sugarcane 2-Hydroxypropionic acid–Lactic acid (LA) Sour milk Monohydroxysuccinic acid–Malic acid Apples Dihydroxysuccinic acid–tartaric acid Grapes Citric acid Citrus foods Beta hydroxy acids Salicylic acids Willow bark, wintergreen leaves and sweet birch Alpha keto acids Pyruvic acid Trichloroacetic acid Retinoic acids Resorcinol Phenol

Type of peel Histological level Agents

Very superficial Exfoliation of stratum corneum, without any epidermal necrosis Glycolic acid 30%–50% applied for 1–2 minutes Jessner’s solution applied in 1–3 coats Low concentration resorcinol 20%–30% applied briefly (5–10 minutes) TCA 10% applied in one coat Superficial Necrosis of part or all of the epidermis anywhere between stratum granulosum to basal cell layer Glycolic acid 50%–70% applied for a variable time (2–20 minutes) Jessner’s solution applied in 4–10 coats Resorcinol 40%–50% applied for 30–60 minutes TCA 10%–30% Medium depth Necrosis of the epidermis and part or all of the papillary dermis Glycolic acid 70% applied for a variable time (3–30 minutes) TCA 35% TCA 50% (Not used frequently) Augmented TCA (CO2 + TCA 35%, Jessner’s solution + TCA 35%, Glycolic 70% + TCA 35%)

Deep Necrosis of the epidermis and papillary dermis, which extends into the reticular dermis Phenol 88% Baker Gordon Phenol formula Indications of chemical Peel treatment According to the Type of Peel (Table 63.5 and 63.6)

 1. Glycolic acid peels (GA)

• Acne—comedonal and papular, papular pustular

• Post acne scars—erythematous and superficial depressed scars

• Melasma—However, epidermal melasma responds the best in a higher concentration of 50% or 70% with the repeated number of sessions at 2–4 weeks interval.

• Postinflammatory hyperpigmentation

• Fine lines

• Photoaging

Glycolic acid peels can be done as early as 2 weeks and as late as 4–6 week gap. Around 4–8 sessions are adequate for mild to moderate acne. In cases of photoaging, dyschromia, melasma number of sessions may go up to 10–12. Maintenance peels are done as and when required (Fig. 63.1).

II. TCA peels

Superficial Peel

• Acne scars

• Superficial depressed acne scars, ice pick scars

• Postinflammatory hyperpigmentation

• Melasma

• Freckles

• Lentigines

 Classification of chemical Peel treatment Based on the Histological Depth of Necrosis of the Skin6

Type of peel Histological level Agents Very superficial Exfoliation of stratum corneum, without any epidermal necrosis Glycolic acid 30%–50% applied for 1–2 minutes Jessner’s solution applied in 1–3 coats Low concentration resorcinol 20%–30% applied briefly (5–10 minutes) TCA 10% applied in one coat

Superficial Necrosis of part or all of the epidermis anywhere between stratum granulosum to basal cell layer Glycolic acid 50%–70% applied for a variable time (2–20 minutes) Jessner’s solution applied in 4–10 coats Resorcinol 40%–50% applied for 30–60 minutes TCA 10%–30%

 Medium depth Necrosis of the epidermis and part or all of the papillary dermis Glycolic acid 70% applied for a variable time (3–30 minutes) TCA 35% TCA 50% (Not used frequently) Augmented TCA (CO2 + TCA 35%, Jessner’s solution + TCA 35%, Glycolic 70% + TCA 35%)

 Deep Necrosis of the epidermis and papillary dermis, which extends into the reticular dermis Phenol 88% Baker Gordon Phenol formula

Indications for chemical peel

• Photoaging

• Open pores

• Seborrheic skin

Deeper TCA Peels

• Keratosis pilaris

• Warts

• Xanthelasma palpebrum

• Dermal melasma

• PIH

• Fine wrinkles at rest

• Seborrheic keratosis

• Dermatosis papulosa nigra

The superficial TCA peels are done at an interval of 2–4 weeks. Around 4–8 sessions in total are sufficient to get the desired result. Maintenance peels can be done as and when required. Medium to deeper depth peels can be done as early as 6 months or preferably after a year

III. Salicylic acid

• Seborrheic skin

• Comedonal acne

• Inflammatory acne

• Erythematous acne scars

• Post inflammatory hyperpigmentation

• Warts

• Keratosis pilaris

 Contraindications of Chemical Peel Treatment

– Active herpes simplex infection

– Active bacterial infection

– Open wounds

– Active rosacea

 – Active inflammatory dermatoses (atopic dermatitis, psoriasis)

 – Patient on oral isotretinoin therapy

– Patient on photosensitive drugs

– Unrealistic, noncompliant patient

– For medium to deep peels if the patient has history of keloids or scarring or use of oral isotretinoin in past 6 months Patient Evaluation and Consultation

 Sequential Peels – Sequential peels are chemical peels using different chemicals sequentially as they may not be compatible in the same formulation. Due to the differences in the pKa of each chemical peel it is not practical to make a solution containing the combination of these agents. Hence the need for sequential peels. Sequential peeling also offers the advantage of deeper penetration of the second agent due to exfoliating action of the first peel applied. However, this method should be used with caution in skin of color. For example,

1. Salicylic acid 20%–30% applied sequentially with glycolic acid 35%.

2. Salicylic acid 20%–30% applied sequentially with TCA 10%–25%.

Salicylic acid is applied first and washed off after pseudofrost formation. This is then followed by application of glycolic acid 35% or TCA 10–25%. This helps better penetration of lower strength of glycolic acid or TCA with lesser side effects, thereby reducing the chances of postinflammatory

 hyperpigmentation.

1. Glycolic acid 70% applied sequentially with TCA 35% (Coleman’s peel). In darker skin instead of 35% TCA, 10%–25% TCA would be safer to use.

2. Jessner’s solution applied sequentially with 35% TCA (Monheit’s peel).12

Spot Peels – Spot peels are peels done only on a particular spot on the face or body, sparing rest of the area. For example, if the patient has a single or 2–3 papular acne then a spot glycolic peel of 35% or 50% only on the papules can be done. The advantage is that it has lesser side effects and reduces the cost of the peel for the patient.

Segmental PeelsSegmental peels consist of applying different peels in different cosmetic units of the face. For example, a patient of melasma on the cheeks and acne on the forehead can be treated by using a peel containing hydroquinone, glycolic acid, kojic acid on cheeks and a peel containing salicylic acid 20%–30% on the forehead. Hence, using two different types of peels for two different conditions at the same session helps the patient to get results faster.

 Body Peels – There are certain considerations when performing peels. Peels on the body differ from the face in the following ways:

– Pilosebaceous units from which re-epithelisation occurs are 30–40 times more on the face than on the neck, chest, back, dorsum of hands and arms. Hence healing is slower on the body areas.

– Chest, back are more prone to keloids and scars. So deeper peels should be avoided.

– Superficial peels show slower results and need to be repeated more often due to the risk of scarring by deeper peels.

– Large body area means larger absorption of the peeling agent, therefore a higher risk of systemic absorption, especially in phenol, salicylic, and resorcinol peels.

 complications

• Pain, burning sensation

• Pruritus

• Erythema

• Epidermal or dermal burns

• Edema

• Ocular injuries

Delayed complications

• Hyperpigmentation

• Hypopigmentation

• Persistent erythema

• Herpes simplex infection

• Bacterial infection

• Fungal infection

• Acneiform eruption

• Scarring

• Skin textural changes

• Demarcation lines

• Milia

• Systemic toxicity chemical