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Skin treatments are definitely not a new concept. Ayurvedic medical traditions and skincare have been traced back to over 5,000 years ago in India and South Asia, while the concept of skin peeling can be traced back to Ancient Egypt.

Popularized by Samantha Jones (Kim Cattrall) in Sex and the City, skin peeling is an extremely popular aesthetic procedure. According to a Daily Mail article published in May 2014, aesthetic chemical skin peels are back in vogue. As the old adage goes, beauty is pain. The popularity of chemical peels continues to grow, despite the overly simplistic portrayals of skin rejuvenation and peels.

With so many types of peels available on the market, the process of choosing the right treatment can be daunting. In this article, we will discuss about the chemical peels of different depths and their effects on the skin. Plus, we will review the dual action peels that can build the dermis while restoring the components in the epidermis.


Patient goals

The purpose of chemical peeling is to enhance the skin structure. Chemical peels are able to destroy the epidermal or dermal layer of the skin and accelerate the exfoliation process. In addition, chemical peels can exert their actions through lysis or protein coagulation. Chemical peels can be categorized into 3 major groups: Superficial peels, medium peels, and deep peels. Superficial peels (which penetrate into the epidermal layer) is the most common peeling procedure. Medium peels can penetrate into the papillary dermis. Deep peels are able to penetrate deep into the reticular dermis. While not as common as superficial and medium peels, deep peeling is slowly gaining popularity in Europe.

Types of Chemical Peels

Medium peels

Sometimes referred to as trichloromethane carboxylic acid and trichloroethanoic acid, trichloroacetic acid (TCA) was first introduced in 1880 and regained popularity in the 1960s. Commonly used in the aesthetic industry, TCA can be used alone or in conjunction with other peeling agents. Being non-stable and non-homogenous, TCA aqueous solution has an inconsistent concentration. This results in side effects and uneven results. Stable, easy-to-use adjuvant formulations have been developed in order to achieve optimal treatment outcomes.

When used in high concentrations, such as a 40% solution, TCA may induce necrosis in the dermal layer. Other than that, scarring and post-inflammatory hyperpigmentation may also occur. In contrast, TCA peels with a lower strength, such as a 20%, solution, is not as efficacious. They are effective against fine wrinkles and lines, but not deep scars and wrinkles. Treat patients with Fitzpatrick skin types 4 to 6 cautiously. TCA peeling solution is able to denature protein, causing keratocoagulation and inducing the death of keratinocytes. This is indicated by the presence of a white frost. During the re-epithelialization process, skin collagenases will occur, replacing abnormal keratinocytes with the healthy ones. A pharmacist can prepare a TCA solution extemporaneously by diluting 15g of TCA with a sufficient amount of water to make a solution of 100ml. The process is known as a weight in volume (w/v) dilution. Some of the major brands of TCA peels include ZO Controlled Depth Peel, Obagi Blue Peel, UniDeep, Easy TCA, and Skin Tech Only Touch. Manufacturers that produce combination TCA peels include PCASkin, Triplex, AlphaBeta and gloTherapeutics. A combination formulation often consists of salicylic acid, glycolic acid, kojic acid, azelaic acid and lactic acid.

Deep peels

Originally used as a disinfecting agent, phenol was introduced around 2 centuries ago. It has been used as an anesthetic agent since the 20th Century. In the 1940s and 1950s, phenol peels (and combination peels that contain phenol) faced backlash and were rejected by practitioners. Thanks to research by Figureido (Portugal), Vigneron (France) and Deprez (Spain), phenol peels are reintroduced into practice. Within 36 hours after application, phenol acts by dissolving the epidermal layer and restructuring the basal layer. Additionally, the production of melanin is reduced. The elastotic layer in the papillary dermis will be destroyed and at the same time, new collagen fibers are produced in the grenz zone. This forms an effective network of elastic fibers.

For normal skin, the regeneration process takes about 6 weeks to complete. After using a phenol peel, the treated area may appear red for a few weeks (or months). When needed, reassure and educate the patients. They should be informed of the fact that new blood vessels are being developed. The histological changes induced by phenol peels can last for up to 15 years. Hence, a single phenol peel is sufficient for durable skin rejuvenation. Skin Tech Lip and Eyelid Formula is 1 of the popular phenol peels. Practitioners may create their own blend of peels.

1. Deep Peel Combinations
Deep chemical peels can be used in combination with other aesthetic procedures such as chemical denervation, mesotherapy, dermal fillers, laser skin resurfacing, microdermabrasion and microneedling. Examples of deep peel combinations are Skin Tech Easy Phen Light (consisting of phenol and TCA), Vitality Institute VI Peel (containing phenol, salicylic acid, tretinoic acid, and TCA), and Perfect Peel (which contains phenol, salicylic acid, retinoic acid, TCA, kojic acid, and glutathione).

Conclusion

With so many treatment options available, practitioners may find themselves wondering, “what is the best option for my patients?” There is no simple answer to the question. When selecting the most appropriate peel, there are a number of factors that need to be taken into consideration. For example, the main skin concern, treatment expectation, medical history, and the Fitzpatrick skin type. During the consultation, check if the patients have previously undertaken a peeling procedure. If so, were they happy with the results? Keep in mind that no 2 patients are alike. The treatment outcome may vary among patients. Therefore, prior to the treatment, it is important to discuss the expected outcomes. In addition, it is important to tailor the treatment to their needs. For example, if the patients have work commitments and are required to work on the next day, then a deep peel (which has a longer recovery time) may not be suitable. All these factors should be taken into account when choosing the right peel.

Perhaps more importantly, the financial implications and budget should be discussed before commencing the treatment. The prices of chemical peel vary greatly depending on the type and the brand. If their budget is not enough to achieve their desired outcomes, practitioners should highlight this before starting the treatment. Consider combining the peeling procedure with other treatment modalities such as chemical denervation, mesotherapy, dermal fillers, microdermabrasion, microneedling and laser skin resurfacing. This may help to optimize the treatment outcomes.