Chemical Peels: Understanding how they can be of benefit to your skin – By: Dr. Serena Cardoso DipPEC (SA), BHSc, MB BCh (WITS)

Chemical peels have long been used to reduce photoaging and other visible signs of aging. Through their exfoliating action they can improve skin’s appearance by reducing dryness, poor texture, acne, scars, pigmentation, photodamage, wrinkles, and fine lines[i].  The treatment involves creating a controlled chemical burn to remove damaged skin cells.

The different types of peels target different depths. Some very light peels can be done at home, superficial peels that can be done by highly trained skincare therapists or nurses and moderate to deep peels that are performed by doctors. The deeper the peel the greater the potential result and they need to be done less frequently but can come at the cost of longer downtime and potential for side effects.

Skin Diagram

Superficial peels are lovely lunchtime treatments that reduce pigment and dry skin. Some are also known as fruit acid peels because of their natural sources. Glycolic acid is made from sugar cane and salicylic acid was first isolated from the bark of willow trees, it’s also the chief constituent of oil of wintergreen[i]. Today the compounds are largely made in laboratories synthetically to ensure consistency and safety. They penetrate only into the epidermis (see figure 1) to a variety of depths so they can be low to medium strength depending on the concentration, the time it’s applied for and how many layers you apply. A superficial peel can go deeper and deeper if you leave it on too long or apply too many layers. This is one of the reasons we don’t recommend you try these at home and leave it to the skincare experts.

Combining peels with other agents or techniques like micro-needling can strengthen the peel’s effects. We watch the skin carefully when doing your peel because how the skin reacts, or “frosts” also tells us how deep we are.

The goal here is to treat problems confined to the epidermis with minimal downtime and side effects. With light superficial peels, you may have mild redness and swelling for a day, thereafter you might have a tiny bit of peeling. You may think at first your peel didn’t do much, but I recommend a light one every month as repeated peels produce significant results.  Superficial peels currently on offer include:

  • Azelan – the gold standard superficial peel for mild/moderate acne, a beta-hydroxy acid-based peel that’s great for acne as salicylic acid is lipophilic which means it effectively treats conditions involving excess sebum by carving right through its fatty acid structure. It also helps a little for sun damage and pigmentation.
  • Melanostop tran3x
  • Modified Jessner
  • Lactic Acid
  • Glycolic Acid

All these peels are combination peels that achieve higher, earlier and longer-lasting results at a reasonable cost versus a single solution peel[ii].

Moderate strength, superficial peels may result in a bit more downtime and you may be red and flaky for a week:

We use a variety of these superficial peels for various indications and custom plan them to your skin.

Medium depth peels like TCA ≤ 50% penetrate through the epidermis, reaching into the superficial dermis (which we call the papillary dermis – see figure 1). Historically 50% TCA was used and although very good for isolated xanthelasma has largely been replaced by safer and lighter medium-depth combination peels[iii].  Medium depth has been obtained with visualization of more “frosting” so they are a little more painful and you will be red and crusty afterward, peaking around 4 days with complete exfoliation by 10 days to 2 weeks. However, with that comes impressive results in skin texture, chronic photodamage (such as dry sunspots called actinic keratosis), blotchy pigmentation (melasma) and freckles. If you have done superficial peels and not quite seeing the results you hoped for you may need to plan some downtime and see your doctor for consideration of a deeper peel. Medium-depth peels can even be used as therapy for premalignant actinic (sun damage) changes[iv] . Fine wrinkles and superficial acne scars are also softened, however, deep wrinkles and scars may need other treatments.  Darker skins (Fitzpatrick IV-VI) are more prone to develop pigmentation complications (PIH) with these peels and should stick to light peels with skin prep.

Deep peels, like phenol peels and TCA ≥50%, are comparable to CO2 laser. Although they are very effective for deep wrinkles and scars they have quite a significant downtime (2 weeks) and potential for side effects like permanent pigmentation and burns.  Phenol peels need to be done with great care and cardiac monitoring. Phenol goes deep and is directly melanotoxic so most appropriate for very pale skins (Fitzpatrick I and II) only. The deeper you got the more painful these can be and may require painkillers or sedation. That being said, in highly trained and experienced hands they are still routinely done and remain the standard to reverse heavy lines[v].  Many doctors have performed these treatments for decades with beautiful results. Although a lot more cost-effective, they have largely been replaced with safer lasers where doctors have more control of the procedure. Lasers and radiofrequency also have collagen benefits and produce a “face-life bypass”[vi].

It is important to have your skin assessed before peels to determine the best peel for you and your skin. You may need to prepare your skin at home in advance for better results, fewer complications, and faster healing. Afterward, broad-spectrum SPF 50+ is essential to protect your new baby skin.

I would suggest starting with superficial peels once a month. In your twenties and thirties, this is a great place to start. As you get older or if you have deep acne scars and melasma you may need to be a bit braver, prepare for a couple of days of downtime and go a bit deeper. Fortunately, this means you won’t have to do peels as frequently and will still get amazing results. Alternating the two allows for recovery and healing. Allow your aesthetician and medical doctor to guide you accordingly.

[i] William H. Brown. Salicylic acid. Encyclopaedia Britannica. DOI: https://www.britannica.com/science/salicylic-acid. 2018; 17(5): 643-944.

 

[ii] Nofal, E. et al. Combination chemical peels are more effective than single chemical peel in the treatment of mild‐to‐moderate acne vulgaris: A split-face comparative clinical trial. Journal of Cosmetic Dermatology.

 

[iii] Tung, R., Rubin, M.G. Procedures in Cosmetic Dermatology Series: c

[iv] Fischer TC, Perosino E, Poli F, et al. Cosmetic Dermatology European Expert Group. Chemical peels in aesthetic dermatology: an update 2009. J Eur Acad Dermatol Venereol. 2010; 24(3): 281–292. 3.

 

Tse Y, Ostad A, Lee HS, et al. A clinical and histologic evaluation of two medium-depth peels. glycolic acid versus Jessner’s trichloroacetic acid. Dermatol Surg.1996;22(9):781–786

 

Baker TJ, Gordon HL. Chemical face peeling. In: Baker TJ, Gordon HL (eds). Surgical Rejuvenation of the Face. Maryland Heights, MO: C.V. Mosby;1986;230–232. 8.

 

Hassan KM, Benedetto AV. Facial skin rejuvenation: ablative laser resurfacing, chemical peels, or photodynamic therapy? facts and controversies. Clin Dermatol. 2013;31(6):737–740.

 

Glogau RG. Chemical peeling and aging skin. J Geratr Dermatol. 1994;2(1):30–35.

 

Nelson BR, Fader DJ, Gillard M, et al. Pilot histologic and ultrastructural study of the effects of mediumdepth chemical facial peels on dermal collagen in patients with actinically damaged skin. J Am Acad Dermatol. 1995;32(3):472–478. 9.

 

[v], Fulton, J.E. & Porumb S. Chemical peels: their place within the range of resurfacing techniques. Am J Clin Dermatol. (2004) 5: 179. https://doi.org/10.2165/00128071-200405030-00006

 

[vi] Fulton, J.E. & Porumb S. Chemical peels their place within the range of resurfacing techniques. Am J Clin Dermatol. (2004) 5: 179. https://doi.org/10.2165/00128071-200405030-00006