When it comes to medical-grade chemical peels, the options available on the market today may appear daunting. It is a skin care professional’s job to help clients navigate the best treatment options to suit their specific needs and concerns. Chemical peels are not one-size-fits-all. It is important to take into consideration the differences that make each client unique. Their skin is distinct to them. It is essential to have a thorough understanding of individual skin types, conditions, and suitability of specific treatments available to deliver successful results for clients.
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CHEMICAL PEEL CLASSIFICATION
Chemical peels are classified by their depth or penetration of skin. They are divided into three categories – light (superficial), medium, and deep. The depth to which a peel penetrates when applied to skin bears an effect on the clinical outcomes the client will achieve. Essentially, a chemical peel is a method of rejuvenating skin by removing the keratin layer of dead skin cells sitting within the epidermis, and in some cases, extending into the papillary dermis. The mechanism of a chemical peel is to initiate a controlled injury to skin. This injury stimulates epidermal growth, collagen induction, an overall tightening effect, and a more even distribution of melanin. Clients will see real change within skin after undergoing a deeper chemical peel. The deeper a chemical peel is, the higher the risks are for potential complications, as well as a longer healing time or downtime associated with the peel. Skin care professionals need to understand how each type of peel operates navigate and guide clients through any adverse reactions should they arise.
LIGHT CHEMICAL PEELS
Light peels are an excellent option for clients who are looking to speed up their cellular turnover without a lengthy downtime. Typically, a light peel will reduce the appearance of fine lines and wrinkles, treat acne, improve overall skin tone, and give clients that highly sought-after glow. Superficial peels are suitable for all Fitzpatrick phototypes and may be performed safely every two to four weeks. Some common superficial peels include the use of glycolic acid, salicylic acid, Jessers solution, mandelic acid, lactic acid, retinoic acid, and a 10% to 35% trichloroacetic acid. When using a glycolic acid peel, neutralize the peel after a certain amount of time by using either water or sodium bicarbonate. The other peels listed do not require neutralization. Jessners and modified Jessners peels are a blend of resorcinol, salicylic acid, lactic acid, along with ethanol. Clients will not experience actively peeling skin after applying one of these lighter peels. They may experience a certain amount of flaking specifically around the mouth and nose, but they will not undergo a process where their skin actively peels off in sheets like with a medium or deep peel.
MEDIUM-DEPTH CHEMICAL PEELS
If a client is looking to address deeper acne scars, static wrinkles, melasma, and actinic keratosis, a medium-depth chemical peel is the ideal option. This type of peel removes skin cells from the epidermis and penetrates the papillary dermis. Medium-depth peels have the potential to lead to an adverse reaction, such as post-inflammatory hyperpigmentation and are not suitable for clients who have a Fitzpatrick score greater than IV. Generally, all medium-depth peels undergo the same histological effects. Post-peel day three, the client will typically see epidermal necrosis and full re-epithelization after day seven. After 30 days, regeneration of collagen will occur and after 90 days. Thickened collagen bundles will be present in the dermis post-peel. Medium-depth peels can be performed in a series with each treatment being spaced four to six weeks apart to achieve the client’s desired results.
Typically, medium-depth peels consist of a 35% to 50% trichloroacetic acid (TCA), include other acids, as well as a Jessners solution and phenol. TCA at this strength causes epidermal necrosis and dermal protein denaturation. This is why “frosting” may appear after applying a TCA peel at this strength. When applying this type of peel, skin care professionals should use some kind of degreaser to cleanse skin. Then begin by evenly applying the peel with a saturated gauze, brush, or cotton tipped applicator over the areas to be treated and taking care to avoid any mucous membranes. Waiting two to five minutes between each layer of the peel is essential in order to visually inspect how the client’s skin is reacting to the solution applied. Frosting occurs because the peel coagulates the proteins within skin. Skin blanches and turns white in the area coagulation occurred. One should note that they will not always see this phenomenon. Sometimes there is confusion over the difference between frosting and crystallization. Crystallization can occur with a salicylic acid peel. Crystallization can give skin a white appearance; however, the crystals that form on skin can be easily wiped away. Frosting on the other hand cannot be removed from skin.
There is an exciting new class of peel that entered its scene on the aesthetic market several years ago. This class is a type of medium-depth peel that does not contain TCA and, therefore, is suitable and appropriate for all Fitzpatrick types. They are referred to as depigmentation systems. These peels are ideal for clients struggling with all types of melasma. The mechanism of action is focused on inhibiting tyrosinase which is the enzyme responsible for melanin formation. They are also effective at treating acne, scarred skin, dull skin, and enlarged pores. They will often contain some blend of high potency hydroquinone, retinol, salicylic acid, kojic acid, arbutin, niacinamide, vitamin C, azelaic acid, or phytic acid. The application is unique compared to alternative peels on the market. The client will wear the peel as a mask that is applied to the area to be treated typically for eight to 12 hours before removal. Clients will notice their skin flaking for approximately two weeks post-peel. Full results are achieved after strictly following the combined at-home system four to six weeks post-peel.
DEEP CHEMICAL PEELS
Deep chemical peels are most often reserved for physicians and fully penetrate and extend into the reticular layer of the dermis. These types of peels denature all the proteins within the dermis and take approximately two weeks to begin reepithelization. The erythema the client will endure after the peel can persist for 60 to 90 days. Higher concentrations of TCA and phenol are the hallmarks of a deep peel. One of the benefits of undergoing a deep peel is that it is unnecessary to repeat the procedure to obtain a full effect. The downside of undergoing this type of peel include increased risks and a lengthy healing time. The client will also need to have cardiac monitoring during this type of procedure to ensure that the high dose of phenol does not cause cardiotoxicity.
PREPPING THE CLIENT
Always prepare a client before they undergo a medium or deep chemical peel, otherwise the professional does a disservice to the client. Preparation for a peel is vital to ensure a good outcome and avoid complications, especially in higher Fitzpatrick skin types. Performing a thorough consultation and obtaining an accurate medical history is paramount prior to engaging in any sort of peel process. Listen to the client and ask questions about their lifestyle. Doing so will help to deliver the desired results the client is after.
While chemical peel clients should limit sun exposure, engaging in photoprotective activities, like wearing a broad-spectrum sun protection product, helps diminish melanocyte activity. Many prefer a mineral sunscreen that includes zinc or titanium dioxide. These work by reflecting the damaging ultraviolet rays away rather than absorbing the rays and dissipating them as heat through skin, as seen with chemical sunscreens.
Clients should follow a strict pre-peel regimen on pre-treating skin with some form of medical-grade retinol and hydroquinone for two to four weeks. This helps enable a more uniform application of the peel and improves healing time. The client will need to stop their retinol usage and avoid any exfoliating products three to five days prior to receiving their chemical peel. If a client has a history of herpes simplex virus, they should consult their physician and prophylactically take medication at the beginning of the day of their peel and continue taking the medication for one to two weeks post-peel.
AFTERCARE
Engaging in a conversation with the client regarding their post-care treatment is fundamental before proceeding. Clients need to have a real view as to what they are in for and what they can expect. If a client says they are a picker or are known to be a picker, a chemical peel is not going to be the best treatment option for them. If the client picks at skin before it sheds off naturally, they can cause scarring. It is absolutely normal to have areas of redness, swelling, and darkening of skin post-procedure. Showing clients some pictures of what they can expect will prepare them for the journey ahead. Whichever chemical peel option is chosen for the client, make sure to review both verbally and through the written instruction of what is expected of them during their post-peel aftercare to achieve the best results. Key points should include
- Follow the prescribed post-procedure regimen exactly.
- Avoid ultraviolet exposure and activities that induce heat for two to four weeks.
- Wear sunscreen religiously whether indoors or outdoors and reapplying every two hours.
ADVERSE REACTIONS
No one expects to have to deal with an adverse reaction from a chemical peel, but if skin care professionals know the risks involved, then they will be better prepared to deal should it arise. Prolonged erythema can arise from over-penetration of the peel or related to allergic contact dermatitis. If this occurs, the client may need to start a topical steroid for a short period of time. Clients can potentially scar if they rub, pick, or pull at their skin. This behavior can also lead to skin infections because the barrier function has been compromised. Encourage clients to keep their hands off their face and let their skin heal on its own without trying to assist the process. Hypo- or hyperpigmentation can also occur, and, therefore, ensure the peel type recommended is fitting for the client.
In summary, chemical peels can be extremely transformative for individuals battling acne, scarring, photodamage, and certain pigmentation disorders. Successful outcomes are reliant on the professional having an extensive knowledge about the types of chemical peels available and how to appropriately select the best option for each individual. When time is taken to research the best option and protocol for a client, the professional will be armed with all the tools they need to deliver excellent results.
References
- Lee KC;Wambier CG;Soon SL;Sterling JB;Landau M;Rullan P;Brody HJ; “Basic Chemical Peeling: Superficial and Medium-Depth Peels.” Journal of the American Academy of Dermatology. U.S. National Library of Medicine. Accessed March 29, 2021.
- O’Connor, Alicia A, Patricia M Lowe, Stephen Shumack, and Adrian C Lim. “Chemical Peels: A Review of Current Practice.” Wiley Online Library. John Wiley & Sons, Ltd, October 24, 2017. https://onlinelibrary.wiley.com/doi/full/10.1111/ajd.12715. Plensdorf, S., MD, Livieratos, M., MD, & Dada, N., MD. (2017). Pigmentation Disorders: Diagnosis and Management. American Family Physician, 96(12), 797-804. doi:https://www.aafp.org/afp/2017/1215/p797.html
- Soleymani, Teo, Julien Lanoue, and Zakia Rahman. “A Practical Approach to Chemical Peels: A Review of Fundamentals and Step-by-Step Algorithmic Protocol for Treatment.” The Journal of clinical and aesthetic dermatology. Matrix Medical Communications, August 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6122508/.
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Janet Dunleavy began her journey into aesthetics after battling a multitude of skin sensitivities including severe eczema. She received her aesthetician license in 2003 and obtained her registered nursing license in 2009. She has worked as a cardiovascular critical care nurse for more than 10 years. Her entry into the world of medical aesthetics began when she joined the team at OmniaPiel in 2017. She is trained in a variety of aesthetic services including neurotoxins, dermal fillers, microneedling, and medical-grade chemical peels. Her role at OmniaPiel is to her clients transform their skin by providing cutting edge, bespoke skin care treatments.
