What types of chemical peels are there?
There are several types of chemical
peels each suited to different skin problems and types. Chemical peels also vary in strength and are classified as superficial,
medium, and deep according to the level of skin they reach.
The
superficial chemical peels include;
Alpha-hydroxy acid (AHA) peels - glycolic and lactic
acid peel. Glycolic acid is derived from sugar cane, and lactic acid is a naturally occuring acid in the body. These peels
can be performed at various concentrations to vary the strength of the peel. Their main role is to remove the top layers of
the skin and induce new collagen formation.
Beta-hydroxy
acid (BHA) peels - Salicylic acid is main ingredient found in these peels. These peels are generally used in oilier
skins or acne prone skins as they are oil soluble and penetrate deeper in this type of skin environment. Beta-hydroxy acids
are generally larger molecules than alpha-hydroxy acids and therefore may not penetrate as deeply in a normal (non-oily) skin
environment.
Blueberry smoothie peel -
a very light peel containing AHAs and BHAs as well as some physical exfoliants.
Purity
peel - A salicylic acid based peel .
Retinoic
acid peels . Retinoic acid is the ingredient found in well known skin products such as Retin-A or (tretinoin), although
in much less concentrations that in the retinoic acid peels. Retinoic acid helps to increase the turn-over rate of the skin
and make it behave more like a 'younger skin'. They can also help to reduce DNA mutations caused from UV exposure on the skin.
Benefit peel and Timeless peel - These are both retinoic acid based peels. The
benefit peel is the lighter of the two.
Jessner's
peel (a combination peel of salicylic acid, resorcinol, and lactic acid). This combination peel brings together a combination
of alpha and beta hydroxy acids (see above) as well as resorcinol, and the effects of each of these ingredients. Resorcinol
is a derivative of phenol ( a very deep peeling agent) and is good for resurfacing the skin. The depth of the peel, which
in most cases is superficial, is determined by the number of layers placed on the skin. The skin turns a frosty white colour
after treatment for a short time.
Trichloroacetic
acid (TCA) peel 10-20% - This is a peel that has been performed for many years. Performed at lower concentrations, TCA
peels provide superficial resurfacing of the skin to improve skin texture, wrinkles, and pigmentation.
Deep
sea peel - an natural organic, herb/plant based peel. Can produce deep exfoliation of the skin and significant peeling.
The medium depth chemical peels include;
Trichloroacetic
acid (TCA) 35% - at these concentrations, TCA peels can help with skin texture, wrinkles and pigmentation. A cost effective
alternative to laser resurfacing.
Phenol 88%*
- one of the strongest peeling agents available for severe wrinkling and sun-damaged skin. Can be cardiotoxic (people have
died having this peel!) and needs to be done under a general anaesthetic in most cases. There is significant whitening (and
sometimes over-whitening) of the skin from this peel.
Which
chemical peel is right for me?
Chemical peels induce a controlled wound to the skin, and
can replace part or all of the top layers of skin. The key determinants to which chemical peel is right for you are; the degree
of the skin problem/ageing/sun-damage, the skin type/colour, the amount of improvement you would like to achieve, and the
amount of recovery or downtime that is acceptable by you.
As a rule, the deeper the peel,
the more side effects, potential complications, and recovery are needed. Another rule of thumb is that the darker the skin
type, the more problems that may be encountered post-peel, especially pigmentation problems such as post inflammatory hyperpigmentation
where the treated skin may become darker than the untreated skin. Therefore, deeper peels in darker skin types must be considered
with caution and sometimes it may be better to perform a series of more superficial peels rather than one deep peel.
The degree of skin aging will also determine which peel to use. For younger patients
with less sun-damage, pigmentation and wrinkles, only superficial peels may be required. The opposite is also true.
Different skin problems also respond to particular peels. Acne, for example, responds
well to Jessner' s peel and salicylic (beta-hydroxy acid) peels. Salicylic acid peels and Jessner's peels (which also contains
salicylic acid) are very oil soluble and are able to penetrate deeper into pores and remove oil and sebum and are anti-inflammatory.
Both alpha-hydroxy acid and beta-hydroxy acid peels help exfoliate the skin. TCA peels, alpha-hydroxy acid peels, and
Jessner's peels are suited to pigmentation problems and sun-damage.
Wrinkles
can be best treated with TCA peels, or any medium to deep chemical peel. These peels can be a cost effective alternative to
laser resurfacing.
Parts of the body other
than the face can be peeled also. For example, you can have chemical peels on the chest and back for acne, or on the neck
and decolletage to help reduce sun damage.
How
can I prepare myself for a chemical peel?
Skin priming can be achieved by commencement
of a skin care products containing retinoic acid such as Retin-A (available by prescription only), as well as a topical lightening
agents such as hydroquinone, kojic acid or arbutin . This needs to be commenced at least 2 weeks prior (preferably more) to
peeling to help with uniform penetration of the peel, accelerated healing, and to reduce post-peel complications such as post-inflammatory
hyperpigmentation. Use of alpha-hydroxy acid cleansers/exfoliants in the weeks prior to chemical peeling can also help the
peeling agent (especially in evenness of penetration), but do not reduce the risk of post-inflammatory hyperpigmentation.
How are chemical peels performed?
In our opinion,
chemical peels are best performed by an experienced dermatologist. The skin is thoroughly cleansed with an appropriate cleanser
first. Vaseline is sometimes used to protect the peel from entering the eye. A fan may be present to help cool the skin for
comfort during the peel. Your eyes should be closed during the procedure.
The
chemical peel solution is then applied to the face. The procedure is timed, and you will be asked about your comfort level.
Neutralisation of the peel (generally with sodium bicarbonate) is performed at the end of the peel, or if there is an untoward
skin reaction, or if the pain is excessive.
The
peel is completed usually by placing sunscreen and a soothing balm on the face.
Are
there any medical problems that your doctor should be aware of prior to having a chemical peel?
Patients
with a history of, or a current infection of herpes simplex virus (cold sores) should ensure that their doctor is aware of
this before chemical peeling. If there is an active infection present, you may be asked to wait until it has passed prior
to having a chemical peel. Also if you have a history of cold sores, you doctor may place you on anti-viral medication as
a prophylaxis to an outbreak during your treatment.
If
you have a history of keloid (thick, pigmented scars) you may also be excluded from all but the most superficial of peels.
Patients with HIV/AIDS or immunosuppression should avoid chemical peels because this
may impair wound healing and increase the likelihood of infection and scarring.
Also those who have recently had a course of oral isotretinoin or accutane should avoid
chemical peels for at least 6 months before undergoing medium or deep chemical peels. Similarly, patients who have had a recent
face or browlift should wait at least 6 months.
What
are the complications or side effects of chemical peels?
As a rule, the deeper the peel,
the higher the rate of complications and the longer the recovery. Most superficial peels are safe and effective, where medium
and deep peels require more experience from the operator and more careful pre-peel preparation and post-peel care.
The
deeper the peel, the longer it will take to recover . The downtime can vary from a few hours (in the case of a light glycolic
peel) to a week for a 20% TCA peel.
Swelling - usually lasting up to three days,
but it is usually only associated with the deeper peels.
Pain
- again, this is only really seen with the deeper peels and may last for a few hours only.
Redness - most superficial peels produce a mild amount of redness that persists for
a few days only. Medium to deep peels can cause redness that can persist for up to a month.
Itchiness - This is only common after medium and deep chemical peels.
Ocular injury - Care must be taken during the procedure to avoid the peel from entering
the eye.
Allergic reactions - uncommon, although
peels such as the Jessner peel have a higher rate of allergy. Anti-histamines may be taken before, if an allergy is known,
or after.
Folliculitis /acne - this occurs
commonly as a result of the emollient creams used during healing. Antibiotics may be required to heal these eruptions.
Bacterial/fungal infection - is uncommon. It can, however, lead to scarring. This is
usually only associated with medium to deep peels.
Herpes
simplex recurrence - is common and needs to be treated with anti-viral medication to prevent spread and scarring.
Hyperpigmentation - dark patches over the peeled areas. This usually occurs over the
deeper parts of the peel and is a result of inflammation causing release of melanin/pigmentation from the skin (post-inflammatory
hyperpigmentation). This is usually temporary, although it can last for up to 2 years. Treatment usually involves a lightening
agent such as hydroquinone.
Hypopigmentation
- is a loss of pigmentation and usually occurs in darker skin types after peeling. This can be permanent sometimes.
Telangiectasia - are small red vessels under the skin and can become more prominent
with peeling. The vessels are easily treated with lasers such as the Gemini laser.
Milia - this are small white cysts that form about 2 to 3 weeks after the skin has
re-epitheliased (grown over). It can be due to blockage of the skin due to emoillent creams used after chemical peeling. They
can be removed with a needle or lancet.
Demarcation
lines - this is usually a result of medium to deeper peels, and the line of where the peel was used and the untouched skin
is noticeable even after the skin has healed.
Scarring
- a very uncommon complication of chemical peels. This is usually associated with a history of poor healing or keloid scarring.
Scarring is more likely the deeper the peel. A early sign of scarring is persistent redness and itchiness. This needs to be
treated with a topical steroid.
How can I minimise
the complication rate from chemical peels?
Patient selection is a very important part
of reducing the rate of complications. By choosing the right peel for each particular skin type, whilst considering the needs
of the patient, complications can be minimised. Darker skinned patients in particular, especially those of European, Asian,
Indian, Sri Lankan, or African backgrounds are more prone to pigmentation problems (either a gain or loss of pigmentation)
after a medium to deep chemical peel. It is possible to prepare the skin beforehand with hydroquinone and tretinoin which
help to reduce the rate of post-inflammatory hyperpigmentation (dark areas) post peel. This is particularly important for
the medium/deep peels and in darker skinned patients. This regime can be continued after the peel (2 weeks after) to further
reduce pigmentation problems.
Similarly, sun exposure pre and post peel should be
avoided or at least minimised. Sun exposure can lead to an increase in pigmentation problems also.
