What is Chemical peel?

1. What is Chemical peel?

It is a office procedure where a chemical agent is applied on the skin, leading to destruction of the epidermis & or dermis, thereby peeling the skin.  This leads to regeneration of the skin from the nearby upper & lower skin giving a smooth even skin.

2. What are the agents used as Chemical peels?

Trichloroacetic acid (TCA), Alpha hydroxy acids (glycolic acid), Jessner’s solution, Alpha keto acids (pyruvic acid), phenol, Beta hydroxy acids (Salicylic acid).

Classification of chemical peels:

1. According to the area & mode of application:

• Regional peel. (b) Full face peel.
• Mask peel (occluded). (b) Maskless peel (unocculded)

 

2. According to the depth of peeling
3. Very superficial:

Removes the uppermost layers of skin.

Agents: TCA 10-15%, Glycolic acid (GA) 20-35%, Jessner’s 1-3 coats, Salicylic acid (15-30%), Tretinoin.

1. Superficial :

Removes the upper layer of skin

Agents: TCA 15-20%, GA 50-70%, Jessner’s 4-10 coats, Salicylic acid (40%)

1. Medium :

Removes the upper & middle layer of skin

Agents: TCA 35-50%, GA 70%, Phenol 88%.

Combinations: CO2 snow+TCA (35-50%), Jessner’s+TCA 35%, GA 70%+TCA35%.

1. Deep :

Removes the upper & deeper layer of skin

Agents: Phenol 88%, Baker’s/Gordon’s phenol formula.

 

 

2. How does chemical peel act?

Here depending upon the type of the peel upper & lower layer of skin is destroyed (controlled chemical burn). This is achieved by coagulation & precipitation of the proteins in the skin. This induces re growth of skin & from adjacent uninjured skin, leading to new skin. Deep peels remove the deeper layer of skin, leading to production of new deeper layer of skin.

Factors affecting the depth of peel:

1. The peeling agent.
2. The concentration of the peeling agent.
3. Number of coats of the agent that are applied.
4. The technique of application (painted on or rubbed in).
5. Priming of the skin before the peel.
6. Cleaning & degreasing of the skin before the peel.
7. The type of the skin (thin or thick).
8. The anatomic location of the peel.
9. The duration of the contact with skin.
10. Altered skin surface (hypertrophic or atrophic).

 

4. Who can undergo chemical peeling?
5. Active pimples to remove the pimples, white & black heads.
6. Superficial pimple scars
7. Post pimple dark spots.
8. To remove the tan, dark marks over face, arms, back
9. Fine wrinkles on face
10. Facial rejuvenation

A thin skinned fair complexioned young female is an ideal patient.

5. Who should not do chemical peel?
6. History of herpes labialis (cold sore)
7. Uncooperative patient & patient with unrealistic expectations.
8. Below angle of jaw, on neck, below thyroid cartilage.

 

Pre peel procedure: Selection of the patient is important. Fair complexion, less oily, thin skinned female is a better patient for chemical peeling than a dark, oily thick skinned male. For chemical peeling the patient should be willing to alter their physical & social life style & follow instructions that are essential for proper healing & post operative skin care (especially avoiding sunlight post procedure).

A complete medical, surgical history & detailed examination of the skin has to be undertaken. Ideally a psychiatric opinion should be obtained. Photo documentation is imperative; patient should be old & intelligent enough to understand about chemical peeling. Patient & nearby relatives should be explained in detail about the procedure, its limitations, risks, complications & alternative methods of treatment available. Both the patient & the relative should be explained how the patient will look during the first few days after the peeling.

Before peeling the following steps have to be carried out:

1. Selection of the depth of the peel:

(a). Determine the colour complexion (fair, wheatish, semidark, dark)

Fair patients are ideal for superficial & medium depth peels. Other three types can be peeled but chances of post-inflammatory darkening are higher in them.

(b). Asses the depth of the lesion (epidermis, dermis or both).

2. Priming: Priming or preparing the skin before the peel gives better results. This can be achieved by using tretinoin cream (0.025% or 0.5%) or Hydroquinone cream (2-4%) other lightening agents two to four weeks before the peel.
3. Test peel: A small 1/1 inch square area in the post auricular region is used for test peel with 10% TCA or 20% GA, two weeks prior to full face peel so as:

(a).To detect any adverse reaction.

(b).Make the patient familiar with the sequelae of the procedure.

(c).To use this time to prime the skin with Tretinoin.

What is the procedure? Patient is asked to wash the face with soap & water thoroughly before the procedure. Face is scrubbed & cleaned with degreasing lotion to remove excessive oil, as it interferes with the peeling, leading to inadequate penetration of the chemical.

Freshly prepared chemical is applied with cotton bud or a cotton swab or with a brush, evenly & uniformly until a pearly white frost appears (Salicyclic acid,TCA or Phenol peel). Frosting does not appear in GA peel. Patient experiences mild pain, redness & burning sensation immediately on application of GA, which subsides within few hours.

Termination of TCA/Salicylic acid peel to be done after appearance of even frost, by cold water sponge & washing the face with cold water.

Termination of GA peel is done by washing with cold water within 1-5 minutes. Here time factor is important. More time we keep the GA peel it will peel more.

Full face peel: Here chemical is applied to full face

Advantages: No different color zones on face as it is peeled fully giving fresh full new facial skin

Disadvantages: Mild pain, discomfort, burning sensation etc, which is temporary.

Regional peel: The method of application is same as in other peel, but here only affected areas are peeled.

Advantages: Pain, discomfort, swelling etc are minimum. Safe, quick, inexpensive. Difficult sites respond well (A part of face, eyelids, armpits etc).

Disadvantages: Sometimes different color zones can be seen over the face if we do regional peel on face.

Post peel care: Patient is asked wash face with soap & water regularly & apply moistourising cream regularly. This is continued for 7-10 days to avoid crusting & to remove the dead dry skin.. There will be mild pain swelling of the face for few hours initially. White frost or the redness will turn to black crust within a day & finally desquamates within 7-10 days. There will be sense of tightening, cracking during peeling. After peeling, a new slightly red skin appears. Patient is asked not to pick the crusts as it leads to scarring. Patient is asked to avoid sunlight strictly for 1 to 4 months to avoid darkening of skin. Patient is instructed to use sunscreening agent (with a minimum SPF of 15 & above) every 4 hrs over the face, with additional protection like broad brimmed hat, scarf, umbrella or helmet.

How frequently does one require chemical peel? No set rules, once in 2 to 4 weeks depending on the requirement.

What are the complications?

1. Appearance of herpes simplex infection.
2. Secondary infection.
3. Persistant redness.
4. Milia.
5. Temporary dark or white spots in some areas if skin is peeled more.
6. Rarely skin thickening like scarring or Keloids can occur over forehead, jaw line & neck areas if deep peeling is done.
7. Darkening of existing birth marks can happen in dark skin individuals.

Chemical peeling definitely improves the quality & texture of the skin, thereby improves the pimples, scars, colour & complexion of skin.