The term exfoliation includes mechanical instruments or instruments that administer substances, such as brushing machines, microdermabrasion, and granular scrubs. There are various chemical and enzyme exfoliants available. This is an overview of exfoliating agents pertaining to chemical peels, the precautions, and pre- and post-care of skin.
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CHEMICAL EXFOLIATION
Chemical exfoliation involves the use of destructive compound agents that control-wound skin by dissolving the desmosome bonds in the stratum corneum, forcing skin to slough prior to the normal cycle of natural desquamation process. The depth of penetration in skin is dependent upon the type of chemical, the pH of the product, timing, and overall application protocol. Moreover, anatomical location, the health of the epidermis, and skin thickness influences the depth of the peel.1 Normal pH of the skin surface is between 5.5 and 6.5. Any applied agent that falls below or above that range can easily cause irritation.
Cosmetic chemical exfoliation requires a thorough understanding of the type and level of each peel along with the reason why it is chosen. Depending on the level of a peel, it may penetrate deeply enough into the epidermal layer to create a controlled wound, stimulating the fibroblast cells in the dermis. Fibroblasts are the cells that synthesize collagen, elastin, glycosaminoglycans, and proteoglycans which are major components of the extracellular matrix. They produce the structural framework of epithelial tissue and are essential for wound healing. Fibroblasts play a vital role in immune response to tissue injury. When choosing the type of peel, it is essential that there is an understanding of the skin type of the client and that a professional’s choice of peel is not going to create severe wounding.
Considerations
Cosmetic resurfacing exfoliating substances or procedures are intended for professional use only and have the intent of improving the aesthetic appearance of skin. One must be licensed and trained in the practice of this modality and understand the theory, safety, practical application, and potential reactions. Choosing the level of a peel is also determined by the environment in which they are performed as well as the scope of licensing for the practitioner. Established procedural guidelines for aestheticians were created by the Esthetics Manufacturers and Distributor’s Alliance (EMDA), a subsidiary of the American Beauty Association, to ensure safety and consistency in the use of alpha hydroxy acids (AHAs).2 Aestheticians are allowed to use a maximum of 30% acid with a pH no lower than 3.0. A lower pH may be more aggressive and cause potential irritation or other side effects.
INDICATIONS
For the aesthetician, indications include sun damaged skin (actinic keratosis), acne vulgaris types I and II, pigmentation abnormalities, aging skin, and fine wrinkles. In the medical setting, indications may include severely photodamaged skin containing numerous lesions, pigmentary disorders, deep wrinkles, premalignant skin tumors, deep scaring from acne, and more severe actinic keratoses, and lentigines on the forearms and back of hands.
Considerations & Precautions
Numerous factors will assist a professional in making the correct choice for performing a chemical peel. Prior to peeling, consider the appropriate peel selection, guidance, and aftercare that reduces the risks of complication before making a final decision.4
It is also recommended the practitioner review the stages of wound healing to completely understand the action of any peel on skin. During any exfoliating treatment, the acid mantle and skin barrier are disturbed and require time and proper post-care for healing and recovery.
Qualifying the Client
Prior to performing any advanced exfoliation treatment, the skin care professional should follow a guideline for qualifying a candidate. Are they a good candidate for a chosen modality? What are the indications? What would be a possible outcome of the chemical exfoliation treatment on this client? Chemical exfoliation, other exfoliating substances, or equipment that produce a deeper exfoliation should not be performed on a first-time client.
Contraindications
Any condition where there is danger of hypertrophic scarring or uneven healing should indicate that an alternative treatment may be required to prevent peeling into the dermis.3 A peel should not be performed when a client has any active infection (bacterial, viral, or fungal), a history of allergy to the peeling ingredient, had isotretinoin therapy within six months (for medium-depth and deep chemical peels), open wounds, or is pregnant.
Peeling Agents5
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Chemical Peeling Agents
General Overview |
Action of Chemical Acids • The strength and action stem from the pH, not the percentage of the acid • Chemical peels are either acid or alkaline and produce a controlled wound • Keratolytic, accelerating the desquamation process • Alpha hydroxy acids are water-soluble and require neutralizing as a single layer peel • Beta hydroxy acids are oil-soluble, self-neutralizing, and may be layered • Combined agents, for example lactic acid and salicylic acid, must be neutralized • Penetration varies according to the concentration and pH value of the acid solution. Peels can be superficial and medium to deep • Signal fibroblasts to heal the wound, accelerating collagen synthesis • Soften skin, help heal acne, and reduce the appearance of scars, pigment, wrinkles, and other skin imperfections • Some reduce inflammation (vasoconstriction) • May be mixed with other agents (acids) to produce a more intense affect
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Alpha Hydroxy Acids (AHAs)
Superficial
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• These acids are water-soluble molecular structures found in edible fruits, nuts, and milk • Hydroxyl groups may be naturally found in tissues of the body and take part in energy metabolism as well as in the formation of proteins and carbohydrates (galactose and gluconic acid) Indications: Thick, oily acne, aging, and hyperkeratinized skin Contraindications: Extreme sensitivity, isotretinoin use, and pregnancy
Malic Acid Source: Apples • Creates a medium-depth peel • Firms and tones Indications: Atrophic skin andelastosis Contraindications: Allergy to apples and grapes, isotretinoin use sensitizing agents, and pregnancy
Lactic Acid (LA): Source: Soured milk • A film former that leaves more moisture behind • Good for lipid-dry skin and a mild tyrosinase inhibitor. May be introduced at around four weeks into the preparation for pigmented skin • Peel depth varies with pH value of product • Quite tolerant for higher risk Fitzpatrick types III to VI • Exfoliating, hydrating, and regenerating • Watch for milk intolerance
Glycolic Acid (includes newer acids such polyhydroxy and lactobionic): · Originally patented by Dr. Van Scott and Dr. Ruey Yu in 1968 · Considered hygroscopic and hydrophilic, attracting water from both skin and the surrounding atmosphere. · Glycolic acid may not be effective if skin is very lipid dry. It is recommended to prepare skin by rebuilding the skin barrier defense systems first, which could take about three weeks. The cells will be more responsive, have better realignment of the spinosum layer, and undergo a more balanced desquamation process · It is not a tyrosinase inhibitor · Depending upon the pH, glycolic acid can be mild to deep in peel strength · With the smallest alpha hydroxy acid molecular structure, it allows for deeper penetration · May stimulate the formation of important substances often deficient in aging or photoaging skin. It can be supportive of newer lactobionic acids that molecularly link hydrating components; for example, one molecule of galactose attached to one molecule of gluconic acid
Glycolic & Lactic Acid Polymers • 5% and 2.3 pH, 20% and 2.0 pH, and 30% & 1.7 pH • More natural to skin and a more precise treatment providing even penetration with less irritation • Glycolic acid molecules are linked into strands and permeate skin along the lines of propagation of the skin’s natural polymers, elastin, and collagen.
Mandelic Acid (alpha-hydroxybenzenaecetic acid): Source: Almonds • Fewer side effects due to its large molecular size • Antibacterial • Desquamating Indications: Noninflammatory grades I to II acne (open and closed comedones), inflammatory grade III (10 pustules or less), pigmentation, and photoaged skin
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Beta Hydroxy Acids
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Salicylic Acid (nontoxic beta hydroxy acid) • Derived from wintergreen and bark of the sweet birch, it has existed for over 100 years • The difference between alpha and beta hydroxy acids considers the positioning of the hydroxy group on the carbon chain of the acid. Alpha indicates the group is on the first carbon atom, whereas beta means that the group is on the second carbon atom • Supports metabolic function and reduces reactive oxygen species • It is keratolytic due to its larger molecular structure; however, is considered less irritating than an alpha hydroxy acid and does not alter skin barrier properties • Lipid-soluble, it penetrates the top of the follicle dissolving comedo material (lipid plugs) • Antiseptic, however, does not kill Cutibacterium acne bacterium • Sometimes formulated with other acids and agents such as alpha hydroxy acids and resorcinol (Jessner’s solution) • May be layered and is self-neutralizing Indications: Oily skin, noninflammatory acne grade II and III, sun damage, and rough and calloused skin Contraindications: Aspirin or salicylic sensitivity, pregnancy, isotretinoin use, antibiotic use, laser surgery within the past 12 weeks, use of other keratolytic products (discontinue their use prior to using salicylic), keloid, and herpes simplex virus. Must take precaution prior to application. Potential post-inflammatory hyperpigmentation on Fitzpatrick IV to VI
Pyruvic (acetyl formic acid) Medium-depth peel Indications: Photoaging, inflammatory acne, moderate acne, scars, and actinic keratosis
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Jessner’s Solution (Combined Agents) |
• Original Jessner’s solution developed by Max Jessner in the 1930s • Medical: 17% salicylic acid, 17% resorcinol, and 17% lactic acid • Modified: 14% salicylic acid, 14% resorcinol, and 14% lactic acid in ethanol • Self-neutralizing (cannot be rinsed once applied) • Control depth of penetration by applying multiple layers • Resorcinol may show antibacterial and antiseptic properties • Blanching occurs during the process • Layered and self-neutralizing Indications: Hyperpigmentation, fine lines, wrinkles, pigmentation, and sun damage Contraindications: Allergy to aspirin, resorcinol, hypersensitive skin, isotretinoin, in treatment for herpes simplex virus, pregnancy, and use of retin-A
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Medical Trichloroacetic Acid (TCA)
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• First used in 1882 by Dr. P.G. Unna, trichloroacetic acid was made from carbolic acid obtained from coal tar • Self-neutralizes and causes protein coagulation called blanching • Considered a medium-depth peel, depending on strength • Flexible agent that can be used at variable strengths (medium to deep) • May be blended in a smaller concentration with another acid such as salicylic to obtain effective results Indications: Most fine lines, wrinkles, and light brown spots and deeper lines, wrinkles, and shallow scars (adjust strength) Contraindications: Isotretinoin use, keloids, can produce dyschromia on Fitzpatrick IV to VII, and active treatment for herpes simplex virus Precautions Do not perform unless well-educated in procedures 1. Adhere to client safety and precautionary measures 2. Client should not be using retin-A, isotretinoin, or other strong exfoliants 3. Thoroughly cleanse skin 4. Defat (degrease) with prepping solution 5. Apply peel with miniature fan brush or gauze 6. Alpha hydroxy acids must neutralize 7. Beta hydroxy acid peels cannot neutralize. Apply recommended number of layers. The more layers, the stronger the peel 8. Combined peels of lactic acid and salicylic acid must neutralize 9. Results also depend on the pH of product 10. Apply post-peel agents as prescribed 11. Thoroughly instruct client on post-care and homecare regimen. Hydration is critical 12. Post-treatment will vary according to each peel and the client’s skin. |
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Resorcinol (phenol derivative, frosts) |
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Deep Peeling Agents |
Phenol: Indications include harsh skin imperfections such as acne scars, blotchiness, and coarse wrinkles. It can take four to six weeks to heal, or more with sensitive skin
Baker-Gordon formula for major photodamage. |
Pre- & Post-Peel Care: General Guidelines1
Follow precise directions specified by the type of peel.
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Pre-Care (Qualifications & Considerations) |
Post-Care |
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· Determine the overall health of the client and perform a thorough skin analysis · Verify the condition of skin and medical and skin care history · Determine the Fitzpatrick skin phototype and the degree of photoaging · Limit ultraviolet exposure using a broad-spectrum sunscreen to avoid tanning · Avoid waxing, electrolysis, and dermabrasion for a minimum of three to four weeks prior to peeling · Discontinue retin-A or harsh skin ingredients · When there is a history of recurrent herpes simplex virus infection, medium-depth and deep chemical peeling requires a systemic antiviral treatment · When performed in a medical setting, follow the directives from the physician. · Follow the protocols for preparation of the skin prior to applying the chosen peel |
· Follow instructions indicated by the specific peel and be aware of any allergic reaction · Document results · Avoid ultraviolet exposure and wear a sunscreen · Client should be instructed to use a mild cleanser and avoid rubbing, scrubbing, scratching, or picking skin · Apply a gentle moisturizer per instructions · Avoid makeup until the re-epithelization has taken place · Compliance is important to avoid any complications
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Since chemical peels can vary vastly in terms of concentration, pH, and type, it is essential that professionals are trained in the safety measures and considerations before performing a peel and its pre- and post-care. When executed properly and with the right strength and penetration, chemical peels provide various benefits for skin.
References
- O’Connor, Alicia A, Patricia M Lowe, Stephen Shumack, and Adrian C Lim. “Chemical Peels: A Review of Current Practice.” Australasian Journal of Dermatology 59, no. 3 (2017): 171–81. https://doi.org/10.1111/ajd.12715.
- Staff, American Spa. “Know the Standards.” American Spa, May 1, 2002. https://www.americanspa.com/treatments/know-standards.
- Pugliese, Peter, and Alexandra Zani. “Exfoliation and Peels.” Chapter 13. In Advanced Professional Skin Care: Medical Edition, 301–13. Bernville, PA: Topical Agent, LLC., 2005.
- Brody, Harold J. Chemical Peeling and Resurfacing. St. Louis: Mosby, 2008.
- Zani, Alexandra J. “Peels Concepts and Considerations.” DERMASCOPE, March 7, 2014. https://www.dermascope.com/treatments/peels-concepts-and-considerations.
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Alexandra J. Zani is an international educator, licensed instructor, speaker, author, and researcher in the professional skin care industry. Academic background includes cell biology and medical technology. Zani is on the Education Commission of the International Association for Applied Corneotherapy, is a member of NCEA (National Coalition of Estheticians, Associations, and Distributors), and is certified in Oncology Esthetics and the Pastiche Method of Skin Analysis. Zani is the owner and director of AEsthani Skincare Institute, LLC in Greenville, South Carolina and is also co-founder of Intellective Aesthetics, dedicated to post-graduate aesthetics studies.
