Chemical Peel
Chemical peel (chemexfoliation) is a skin-resurfacing procedure in which a chemical solution is applied to the skin to remove the top layers to grow back to a smoother and younger looking skin. Chemical peeling has been used for centuries to improve signs of ultraviolet light-induced sun damage. Over the last 30 years, the science behind chemical peeling has evolved, increasing our understanding of the role of peeling ingredients and treatment indications. The depth of peels is directly related to improved results and to the number of complications that can occur.
Chemical peels can improve the skin‘s appearance. In this treatment, a chemical solution is applied to the skin, which makes it “blister” and eventually peel off. The new skin is usually smoother and less wrinkled than the old skin.
Chemical peel can be done at different depths –light, medium or deep- depending on your desired results. Each type of chemical peel uses a different chemical solution. Deeper chemical peels produce more-dramatic results but takes longer recovery times.
Light chemical peel
This type of chemical peel removes the outer layer of the skin –epidermis- and is used to treat fine wrinkles, photodamaged areas, acne, uneven skin tone and dryness.
Medium chemical peel
This solution removes skin cells from the epidermis and penetrate and induce histologic changes with the papillary dermis (up to IRD)- upper part of dermis- to treat wrinkles, acne scars and uneven skin tone.
Deep chemical peel
A deep chemical peel removes skin cells from the epidermis and from portions of the mid the dermis (up to URD) to treat deeper wrinkles, scars of precancerous growth.
Chemical peel can be done on the face, neck, or hands.
They can be used to:
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Treat fine wrinkles caused by sun damage and aging
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Reduce age spots, freckles, and dark patches (melasma) due to pregnancy or taking birth control pills (using Tretinoin peel or combination of Superficial peel+ Hydroquinone)
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Improve the appearance of mild scars
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Treat certain types of acne & acne scars, Actinic Keratosis
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Treat papular Xanthelasma
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Improve the look and feel of skin
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Infraorbital hyperpigmentation: Infraorbital darkening has a multifactorial etiology, including hyperpigmentation, periorbital fat pseudoherniation, fine wrinkling, and reticular veins. Chemical peels are ineffective for pseudoherniation and veins, but microneedling combined with 10% TCA improved hyperpigmentation in >90% of patients. Four weekly 3.75% TCA and 15% lactic acid peels resulted in excellent improvement in >90% of patients at 6 months of follow-up. GA 20% and lactic acid 15% showed 73% and 56% improvement in periorbital melanosis
The difference between satisfactory versus excellent results depends on the selection of the proper peeling agents and the understanding of gentle versus aggressive application technique during their use.
-Superficial peels are effective for freckles, epidermal melasma (blotchy facial pigmentation) and epidermal hyperpigmentation.
-Moderate-depth peels can reduce senile lentigines (small brown patches).
-Nevi, dermal melasma, dermal post-inflammatory hyperpigmentation and seborrheic keratoses respond poorly to superficial and medium-depth peels.
-For deep rhytids, combined peeling with laser resurfacing or mesotherapy, microneedling, might be performed only by the qualified doctor Specialist
Superficial Peels: popular Substances : Tretinoin peels, Salicylic Acid, Trichloroacetic Acid TCA, Jessner & Modified Jessner Solution, Glycolic Acid 50% & Pyruvic Acids 40%(require neutralisation with 10% Sodium Bicarbonate, with water or Saline dampened cloth
Medium Depth Peels: examples include; Brody peel (dry ice+TCA 35%), Monheit peel (Jessner+ TCA 35%), Coleman peel (GA 70%+TCA 35%). Analgesia is unnecessary for any medium-depth peel if the operator is experienced in performing the peel rapidly and smoothly. Medium-depth peels should not be used elsewhere than on the face or the scalp because of the risk of scarring.
Complications & Risks:
Chemical peeling procedure ideally should be carried out under the strict supervision of Specialist doctor and after through clinical assessment to determine the depth of the peel, the substance & its concentration according to the indication & assessment.
Serious complications could happen when non qualified persons take the chance! Damages like skin burns, prolonged erythema, erosions, scarring, acne flare, infections ( reactivation of Herpes, Candida, Staph aureus), PIH (Chemical peels increase epidermal turnover and decrease epidermal melanin), skin hypopigmentation and Cardiotoxicity (as with Phenol 88%, hence requires cardiac monitoring) or ocular exposure to the chemicals (Saline eyewash bottles should be immediately available).
Special common conditions
Melasma:
Disproportionately affects darker Fitzpatrick skin phototypes; therefore, laser or deep peels present a risk for PIH. Superficial peels in combination with hydroquinone offer a safe alternative. In a randomized study of 40 Indian patients, Sarkar et al69 compared hydroquinone 2%, tretinoin 0.05% cream, and hydrocortisone 1% cream to 6 30% GA peels performed every 3 weeks. The GA group showed significant improvement compared to bleaching cream only. Other clinical studies document the efficacy of LA, JS, and tretinoin peels for melasma
Photo-rejuvenation
Medium-depth peels induce histologic and clinical improvement in parameters of photoaging, in particular lentigines, fine wrinkles, sallow discoloration, and actinic keratosis directly related to peel depth
Measures to reduce PIH risk
Pre-peel
Medium-depth peels are not recommended for Fitzpatrick skin phototypes >IV because of the risk of PIH. This risk may be reduced by prepeel preparation with hydroquinone for 1 month & peeling during the winter season.
For superficial and medium peels, pretreatment with topical tretinoin for 2 to 4 weeks enables a more uniform frosting and improves healing time.
For Fitzpatrick skin phototypes IV to VI, expert consensus recommends tretinoin cessation 1 week before the peel to prevent overpenetration and PIH. Pretreatment for 2 weeks with hydroquinone 2% is more effective than tretinoin 0.025% in decreasing PIH.
Post-Peel
1-Postpeel management focuses on expediting healing and preventing infection. For edema and mild discomfort, ice packs can be used. Gently soaking and cleansing the skin followed by application of white petrolatum for 3 days enables reepithelialization; afterward, patients may continue petrolatum or switch to an emollient cream.
2-Patients with a history of herpes simplex virus should receive prophylactic antiviral medication for 7 days post-procedure until completely reepithelialized. Herpes simplex virus infection often presents on day 2 or 3 when reepithelialization commences, with increased pain, itch, or discomfort. Pustules suggest bacterial or candidal infection, warrant culture and initiation of empiric therapy
3-Sun protection is paramount. Physical sunscreen barriers should be used until reepithelialization.
4-Patients should be discouraged from picking at or peeling exfoliative skin.
Dr. Nadia Yousri, OB&GY Surgeon, Aesthetic Gynaecology & Sexual Health Consultant, FRCOG, MRCOG, PhD, MSc & DFFP, Harley Street, London. A member of IPS since 2019
YouTube: Dr. Nadia Yousri: https://youtu.be/PdTObUhTnyo
References:
-Chemical Peel (Deep, Medium, Light). Starkman SJ, Mangat DS. Facial Plast Surg Clin North Am. 2020 Feb;28(1):45-5
–Chemical peels: A review of current practice. O’Connor AA, Lowe PM, Shumack S, Lim AC. Australas J Dermatol. 2018 Aug;59(3):171-181
–Chemical Peeling: A Useful Tool in the Office. Truchuelo M, Cerdá P, Fernández LF. Actas Dermosifiliogr. 2017 May;108(4):315-322
–Depth Map for Face and Neck Deep Chemical Peel Resurfacing. Sterling JB, Lee KC, Wambier CG, Soon SL, Landau M, Rullan PP, Brody HJ.Dermatol Surg. 2020 Sep;46(9):1204-1209
–Medium-depth Trichloroacetic Acid and Deep Phenol-Croton Oil Chemical Peeling for Facial Rejuvenation: An Update. Atiyeh B, Oneisi A, Ghieh F. J Craniofac Surg. 2021 Nov-Dec 01;32(8):e745-e750
–Advanced chemical peels: Phenol-croton oil peel. Wambier CG, Lee KC, Soon SL, Sterling JB, Rullan PP, Landau M, Brody HJ; International Peeling Society. J Am Acad Dermatol. 2019 Aug;81(2):327-336.
–Comparative study of buffered 50% glycolic acid (pH 3.0) + 0.5% salicylic acid solution vs Jessner’s solution in patients with acne vulgaris. In Jae J, Dong Ju H, Dong Hyun K, Yoon MS, Lee HJ. J Cosmet Dermatol. 2018 Oct;17(5):797-801
–Commentary: salicylic acid peels versus Jessner’s solution peels for acne vulgaris: a comparative study. Monheit G. Dermatol Surg. 2013 Feb;39(2):253-4.
–Chemical peels in active acne and acne scars. Kontochristopoulos G, Platsidaki E. Clin Dermatol. 2017 Mar-Apr;35(2):179-182.
–Efficacy and safety of superficial chemical peeling in treatment of active acne vulgaris.
Al-Talib H, Al-Khateeb A, Hameed A, Murugaiah C. An Bras Dermatol. 2017 Mar-Apr;92(2):212-216
-Interventions for acne scars. Abdel Hay R, Shalaby K, Zaher H, Hafez V, Chi CC, Dimitri S, Nabhan AF, Layton AM. Cochrane Database Syst Rev. 2016 Apr 3;4(4):CD011946
–A Combination Approach to Treating Acne Scars in All Skin Types: Carbolic Chemical Reconstruction of Skin Scars, Blunt Bi-level Cannula Subcision, and Microneedling-A Case Series. Rullan PP, Olson R, Lee KC. J Clin Aesthet Dermatol. 2020 May;13(5):19-23. Epub 2020 May 1.
–Chemical peeling for acne and melasma: current knowledge and innovations.
Conforti C, Zalaudek I, Vezzoni R, Retrosi C, Fai A, Fadda S, Di Michele E, Dianzani C. G Ital Dermatol Venereol. 2020 Jun;155(3):280-285.
-Chemical peeling for treatment of Melasma, pigmentary disorders and hyperpigmentation : Indications, effectivity and risks. Borelli C, Fischer S. Hautarzt. 2020 Dec;71(12):950-959
–Chemical peeling for acne and melasma: current knowledge and innovations.
Conforti C, Zalaudek I, Vezzoni R, Retrosi C, Fai A, Fadda S, Di Michele E, Dianzani C. G Ital Dermatol Venereol. 2020 Jun;155(3):280-285.
–Tretinoin peel: a critical view. Sumita JM, Leonardi GR, Bagatin E. An Bras Dermatol. 2017 May-Jun;92(3):363-366
–Augmentation and eversion of lips without injections: The lip peel. Wambier CG, Neitzke IC, Lee KC, Soon SL, Rullan PP, Landau M, Simão JCL, Sterling JB, Brody HJ; International Peeling Society. J Am Acad Dermatol. 2019 May;80(5):e119-e120
–Mesotherapy, Microneedling, and Chemical Peels. Lee JC, Daniels MA, Roth MZ. Clin Plast Surg. 2016 Jul;43(3):583-95
–Rejuvenation of the skin surface: chemical peel and dermabrasion. Branham GH, Thomas JR. Facial Plast Surg. 1996 Apr;12(2):125-33.