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CHEMICAL PEELS
Chemical peels involve
the application of chemicals to wound the skin to a desired depth
so that with healing, wrinkles, irregularities of contour and
pigmentation become less prominent. In other words, old imperfect
skin is removed, unveiling a fresher, clearer, smoother looking
complexion. Chemical peels are usually performed on the face
where the good blood supply aids healing. Many doctors prescribe
tretinoin (vitamin
A acid) creams for 2 - 6 weeks prior to peeling as this seems
to improve healing, especially after medium-depth and deep-depth
peeling. If there is a risk of pigmentation, hydroquinone
(a skin lightening) cream is sometimes also included.
The recovery after
medium and deep-depth chemical peeling is hastened and the risk
of developing postinflammatory hyperpigmentation (increased pigmentation)
can be reduced by using tretinoin
and hydroquinone
lightening creams, respectively, 2 - 6 weeks before the procedure.
Different chemicals penetrate the skin to different degrees.
Generally, the higher the concentration the greater the penetration
with the sole exception of phenol which is stronger when diluted.
Chemical peels are classified into three types:
- Superficial chemical
peels.
- Medium-depth chemical
peels and.
- Deep-depth chemical
peels..
Superficial
peels
Superficial peels penetrate the epidermis predominantly or may
extend slightly into the papillary dermis. Multiple peels (3
- 6 peels) are necessary to induce the production of collagen.
The discomfort is mild so no anaesthesia or sedation is necessary.
Recovery is also very fast, hence they are sometimes also called
"office-peels" and serious complications are rare.
Superficial peels are suitable for all skin types.
Agents used
- 10 - 20% trichloroacetic
acid (TCA).
- Alpha-hydroxy acids
(AHAs) - glycolic acid, lactic acid.
- Jessner's solution
(contains salicylic acid, lactic acid and resorcinol).
Benefits
- Improve the texture
of sun-damaged skin.
- Improve fine lines
and mild wrinkles.
- Improve uneven pigmentation.
- Reduce pore size.
- Improve acne
vulgaris (pimples) and oily skin.
Medium-depth
peels
Medium-depth peels penetrate into the papillary dermis and upper
reticular dermis. The benefits are more pronounced than multiple
superficial peels and one or two peels are usually sufficient.
Medium-depth peels are very suitable for skin phototypes
I and II. They can also be used in darker skin types but patients
have to be warned about the possibility of temporary hyperpigmentation
(especially in skin phototypes
III and IV skins) which may require treatment with hydroquinone-containing
lightening creams. Although, medium-depth peels are more painful
than superficial peels, anaesthesia is usually not necessary.
Oral or occasionally, intramuscular sedation may be used in patients
who are very anxious or have a low pain-threshold. The only exception
is the medium-depth phenol peel which requires the same sedation
or anaesthesia as the deep-depth phenol peel (see the next section).
Agents used
- Full-strength phenol
(88%).
- Trichloroacetic acid
(TCA) 35 - 45%.
- Combination peels
- Jessner's solution
and TCA 35%.
- Glycolic acid and
TCA 35%.
- Solid carbon dioxide
and TCA 35%.
Benefits
- Improve mild to moderate
wrinkles.
- Improve mild to moderate
sun-damage.
- Improve uneven pigmentation.
- Remove actinic
or solar keratoses (precancers).
- Improve mild scars.
Deep-depth
peels
Deep-depth peels penetrate to the mid-reticular dermis. Only
one peel is sufficient and microscopic studies suggest that the
benefits of deep-depth phenol peels may last as long as two decades.
However, phenol is a toxic chemical so full blood counts, liver
and kidney function tests, urine tests and an electrocardiogram
(ECG) of the heart must be done before the procedure. Pain is
severe so general anaesthesia or nerve blocks alone or with intravenous
(IV) sedation is necessary. The electrocardiogram (ECG), blood
pressure and blood oxygen must be monitored throughout the procedure.
Hypopigmentation (lightened skin) is common after deep-depth
peeling so this treatment is not very suitable for people with
skin phototypes
IV - VI. Deep chemical peels are being replaced by laser
resurfacing which does not have toxicity problem of phenol.
Agents used
- Baker's formula phenol
peel (50%).
- Trichloroacetic acid
(TCA) 50% is rarely used.
Benefits
- Improve moderate to
severe wrinkles, especially those around the mouth.
- Improve blotchy and
sun-damaged skin.
- Remove actinic
or solar keratoses (precancers).
- Improve scars.
How long do the
benefits of a chemical peel last?
It is important to understand that the effects of a chemical
peel will not last forever because the ageing process will continue.
Dr Albert Kligman who did the pioneering work on tretinoin
studied women who underwent deep phenol peels and then facelifts
1 1/2 to 20 years later. He examined the excess skin removed
during the facelift and noticed striking differences between
the peeled and unpeeled skin. The epidermis was more normal in
appearance, melanin was more evenly distributed and there was
no microscopic evidence of actinic
lentigines (age spots) and solar
keratoses (precancers) in the peeled skin. The dermis also
showed evidence of new collagen and elastin tissue on top of
a disorganised mass of deeper, presumably unpeeled dermis. These
findings suggest that the benefits of a deep phenol peel may
last as long as 2 decades (average of 5 - 7 years). There are
no data on the duration of benefit from medium-depth peels but
most doctors estimate that they last 1 - 2 years. The benefits
of multiple superficial peels, last only about 6 months so superficial
peels have to be repeated.
What to do before
a chemical peel
You must fully understand what the peel involves, what reaction
to expect after the peel and how to look after the peeled skin.
Much of this should have been provided by the doctor or his assistant
but do not be afraid to ask until you are clear about this.
Chemical peels are usually performed as outpatient procedures.
Clean your face with soap and water and do not apply any cosmetics
for 24 hours prior to a peel. Arrange for transport and someone
to accompany you home after medium- or deep- depth peels because
the swelling may close your eyes and if sedation is used. This
is not necessary after a superficial peel. You should also not
eat or drink for at least 6 hours before the procedure if you
are having a general anaesthesia or IV sedation.
- Anaesthesia and
sedation
- Superficial peels
- Anaesthesia and sedation is usually not required.
- Medium-depth trichloroacetic
acid peels are more painful - Oral or intramuscular sedation
may, occasionally, be used if the patient is very anxious or
has a low pain threshold.
- Deep-depth phenol
peels - Phenol peels are much more painful and require general
anaesthesia, local anaesthesia or nerve blocks alone or with
intravenous (IV) sedation. An anaesthetist will be present when
general anaesthesia is used and a qualified nurse or an anaesthetist
when IV sedation is used. The ECG (heart tracing), blood pressure
and blood oxygen need to be monitored during phenol peels.
- Peel application
In the clinic,
you will be asked to lay down on a couch with the head slightly
raised so that the peel solution will not get into the eyes.
You will probably be asked to put on a protective gown or sheet
and a hair-band may be used to keep the hair away from the face.
The doctor or his assistant begins by cleaning the skin with
a pre-peel cleanser or a degreasing agent such as alcohol or
acetone to remove surface oil and ensure uniform penetration
of the peel agent. The chemicals most commonly used for superficial,
medium- and deep-depth peels are glycolic acid (an alpha-hydroxy
acid), trichloroacetic acid (TCA) 35 - 45% and Baker's formula
phenol, respectively. The method of application, post-peel course
and after-care are described in greater detail below.
Superficial peel
with glycolic acid 20 - 70%
- The peel solution
is applied with a brush, cotton-tip applicator or gauze.
- It is left on for
3 - 6 minutes before neutralising with water or a solution containing
1% sodium bicarbonate.
- You will then be asked
to rinse your face with cool water until any stinging sensation
subsides.
- Your skin is cleansed
once again with the neutraliser to remove residual acid.
- A small amount of
soothing cream is then applied to your face.
- A small hand-held
fan or dry ice pack may be used to reduce the mild burning discomfort.
- The entire procedures
takes only about 10 minutes to perform.
- Peeling has to be
repeated for 4 - 6 times at 2 - 4 weekly intervals until the
desired result is obtained.
- The depth of peeling
depends on the concentration and the time the solution is left
on the skin before neutralising. With subsequent applications,
either the concentration of the peel solution or the time it
is left on the skin is increased.
- The main advantage
of glycolic acid peels is the short recovery time. Reactions
are mild, ranging from a sunburn appearance to slight weeping
and crusting and short-lived. Glycolic acid peels are often called
"lunch-time peels" or "office peels" because
the patient may even return to work immediately after the peel.
- The after-care is
very simple.
-
Medium-depth peel
with trichloroacetic acid 35 - 45%
- Trichloroacetic acid
(TCA) is usually applied with a piece of folded gauze or sponge
and a cotton-tipped applicator near the eyes. Some doctors use
cotton-tip applicators as in a phenol peel for the entire face.
- A frost appears within
a few minutes of application and this is accompanied by immediate
tightness, warmth and stinging. The discomfort is usually severe
for about 10 minutes and then subsides. It can be relieved by
applying a cool compress or a dry ice pack.
- The doctor may apply
a dressing to reduce post-peel discomfort or he may use an open
dressing method which involves soaking the face with cool water
several times a day followed by application of vaseline or an
antibiotic ointment.
- The TCA peel takes
about 15 minutes to perform.
- A touch-up peel may
be performed after 6 months, if necessary.
- Unlike glycolic acid,
TCA peels do not need to be neutralised. The depth of wounding
is related to the strength of the TCA and not the time it is
left on the skin.
- The recovery period
is longer and patients may have to remain homebound for about
1 week.
- The after-care is
extremely important in order to avoid complications.
-
- Deep-depth peel
with Baker's formula phenol
- The peel solution
is applied with one to three regular cotton-tip applicators.
To avoid toxicity, the doctor divides the face into 6 - 8 segments,
applying phenol slowly over 15 - 20 minutes to one segment at
a time. Phenol is not used on the eyelids. Dilution of phenol
by tears increases its potency so an assistant is at hand to
soak up any tears with a dry cotton applicator.
- The skin develops
a frost very rapidly, within seconds of the application.
- The doctor may tape
the skin for the first 24 - 48 hours to increase penetration
or apply an antibiotic ointment or vaseline.
- As with TCA peels,
the after-care is extremely important.
- You may be hospitalised
for 1 - 2 days after a full-face phenol peel.
- Generally, the peel
application is applied a little over the hairline, borders of
the lips, under the jaw and upper edge of the neck to avoid creating
transition lines between peeled and unpeeled skin. Tears rolling
down the cheeks can dilute the peel solution causing a streaked
appearance. In the case of phenol, dilution increases the strength
of the peel causing a deeper wound than is intended. An assistant
is therefore, at hand to soak up tears with a cotton-tip applicator.
Post-peel course
and after-care
It is very important
that you understand the changes that occur after a peel so that
you are not too alarmed. The after-care is especially important
after medium- and deep-depth peels and will be reiterated to
you or the person looking after you. Handouts may be given and
you should consult the doctor or his nurse whenever you are unsure.
- Care of the skin
after glycolic acid superficial peel
- There is immediate
redness after application of glycolic acid peel solutions which
lasts less than an hour.
- Slight redness, dryness
and peeling of the skin may occur, generally lasting less than
4 days.
- The irritation is
mild and can be reduced with the application of a cold compress
or a dry ice pack.
- Healing occurs after
2 - 4 days.
- A soothing cream is
usually prescribed until the skin has healed.
- You can return to
work almost immediately and wear cosmetics after 24 hours.
- Avoidance of the sun
is the main requirement and sunscreens should be used during
daylight hours and preferably, for life in order to delay ageing.
- You can start to use
the prescribed medicines such as glycolic acid creams or tretinoin
cream once the skin has healed which is usually between 3 - 7
days.
- The peel can be repeated
after 2 weeks for a total of 4 - 6 times in order to achieve
a smoother, brighter complexion.
- The benefits last
less than 6 months.
-
- Care of the skin
after a medium-depth TCA peel
- Immediately after
the TCA peel, the skin is red and may be slightly swollen.
- Most of the pain is
felt during the application itself but if it continues, use cold
compresses and dry ice packs. Over the first 2 days the skin
becomes deeply tanned and the tanned skin will peel of as a membrane
afterwards. It
is usually possible to return to work after 7 days.
- As in superficial
peels, it is very important to use sunscreens and avoid unnecessary
exposure to the sun.
- The benefits lasts
about 1 - 2 years.
-
- Care of the skin
after a deep-depth phenol peel
- The reaction after
a phenol peel is more severe.
- The skin begins to
swell within a few hours and the swelling usually shuts the eyes. Sleeping
with the head slightly elevated helps to reduce the swelling.
- Ice packs can be applied
(over the dressing, if necessary) and a simple painkiller such
as paracetemol may be taken to reduce the discomfort. The
dressing, if used, is usually removed after 1 - 2 days.The skin
usually looks raw and weepy like a second degree burn.
- Rinse the face with
cool water or apply wet compresses several times a day followed
by application of the antibiotic ointment or vaseline provided.
- The aim is to keep
the area moist and to soften and gently remove crusts that would
otherwise serve as a medium for bacterial growth.
- Healing occurs 10
- 12 days after a phenol peel.
- The benefits last
5 - 7 years.
General measures
Despite counselling by the doctor and/or his assistant, it is
not uncommon for patients to experience variable degrees of anxiety
after chemical peels. This is quite natural and you should not
hesitate to contact your doctor or his assistant if you are in
any way worried. The following are some general measures you
can take to help your face recover quickly:
- General post-peel
measures
- Do not pick or peel
off the skin. Loose skin can be trimmed with a sharp pair of
scissors.
- Pat dry, do not rub
the skin.
- Avoid scrubs and abrasive
sponges such as Buf-puf as the skin is very sensitive at this
stage.
- Avoid astringents
and toners until advised otherwise by your doctor.
- Do not scratch. Ask
the doctor for some antihistamine tablets if itching is a problem.
- Take a simple painkiller
such as paracetemol for pain relieve and inform the doctor if
the pain is not relieved.
- Avoid excessive exertion
and alcohol which would increase blood flow to the skin and encourage
the development of telangiectasias
(broken capillaries) for at least 2 weeks after surgery.
- Avoid excessive talking,
laughing and chewing after deep-depth peels.
- Take a liquid diet
if the mouth is very swollen.
- Avoid excessive exposure
to sunlight and use a broad-spectrum sunscreen
until the redness has cleared and the skin has regained its normal
colour. Sunscreens should be used indefinitely thereafter, to
prevent further sun-damage.
- Moisturise the skin
regularly with the cream provided. You can resume application
of your prescribed creams after the skin has resurfaced but remember
that the skin will be more sensitive than usual.
- Make-up can be applied
to areas of skin that has resurfaced but remember that the skin
is more sensitive after chemical peels. If irritation occurs,
discontinue it.
- Avoid contact sports
where there is a risk of bumps or injury to the skin for at least
6 weeks.
- Contact your doctor
if there is redness, tenderness and a pus-like discharge from
the skin. It may indicate bacterial infection which may require
antibiotic treatment.
- Contact your doctor
if the skin becomes red, raised and itchy after it has apparently
healed as this may indicate the development of lumpy scars (keloids).
- Contact the doctor
immediately if blisters appear because it may indicate a recurrence
of herpes labialis or "cold
sores".
- Complications
Complications are
generally rare and can usually be treated and reversed.
- Pigmentary changes
People with skin phototypes
I - II skins are ideal for chemical peels. Darker skinned individuals
are more at risk of developing pigmentary problems like hypopigmentation
(lightened skin) or postinflammatory hyperpigmentation (darkened
skin). Hypopigmentation is common after deep-depth or phenol
peels which is why they are generally avoided in people with
skin phototypes
IV - VI, especially men because they cannot wear make up. It
may occur temporarily with more superficial other peels. Hyperpigmentation
may occur after superficial and medium-depth chemical peels in
darker skinned individuals, especially type III and IV skin phototypes. Hyperpigmentation
can be treated with lightening creams and may be averted by putting
susceptible individuals on hydroquinone lightening creams before
peeling and after the new skin has resurfaced.
- Scarring
Superficial peels are generally safe. Medium- and deep- depth
peels may occasionally produce scarring and should be avoided
in people with a tendency to develop abnormal or lumpy scars
(keloids). Scarring has been
reported after isotretinoin
treatment which is why medium and deep -depth peeling should
only be done 12 - 18 months after completion of isotretinoin
treatment.
- Infection
Bacterial, yeast and viral infections may occasionally occur.
Bacterial infections occur but are generally uncommon. Presumably,
this is because the peel agents themselves sterilise the surface
of the skin and there is a good supply of blood to the face.
The risk of infection can be reduced by soaking off crusts that
may otherwise provide a rich media for bacterial growth and by
following the doctors after-care instructions carefully. Bacterial
infections can be treated with oral antibiotics. Deep chemical
peels may reactivate herpes
labialis (cold sores) and cause scarring. Patients with a
past history of herpes labialis are usually prescribed an anti-herpes
drug such as acyclovir or famcyclovir 24 hours before and continued
for a total of 7 - 10 days to prevent a recurrence.
- Milia
These are tiny "whiteheads" formed when the new skin
grows over. They usually occur 2 - 3 weeks after the skin has
resurfaced and can be extracted by the doctor with a number 11
scalpel blade.
- Systemic side effects
This complication applies only to phenol peels. Unlike other
chemicals, diluted phenol actually penetrates deeper than full-strength
phenol and may enter the blood circulation to produce toxic effects.
The main effect is on the heart which may result in heartbeat
irregularities. This is why phenol must be applied slowly over
one segment at a time to allow the body to clear the phenol and
prevent the accumulation of toxic levels of phenol. The electrocardiogram
(ECG), blood pressure and blood oxygen must be monitored during
application of phenol. Blood test and urine tests have to be
done before a phenol peel to assess the function of the liver
and kidneys, both of which participate in the metabolism and
excretion of phenol.
- Poor patient physician
relationship
Patient dissatisfaction is a common complication and may be caused
by the doctor's failure to understand the patients desires or
unrealistic expectations on the part of the patient.
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