What is Peeling?
Peeling or chemical exfoliation is a therapeutic technique that involves the application of a chemical or caustic irritating agent over the skin, with intention to remove the epidermis and the variable parts of the dermis, these layers are being replaced with new ones with improved cosmetic qualities. The final product is the rejuvenation of the skin and the disappearance of preexisting injuries such as sun spots, keratosis, wrinkles and scars.
According to the type of component used, a different benefit is obtained, such as the increased of collagen, depigmentation of spots or control over the oil and bacteria of the skin suffering from acne.
What kinds of Peeling exist?
Peelings can be described according to depth achieving at a superficial level, medium-deep and deep, the first two can be done in consultation while deep peelings need to be done in an operating room under anesthesia or sedation.
A superficial peeling affects the epidermis. It reaches a depth of about 0.06 mm. They are alpha hydroxy acids peelings. The medium-deep peelings affect the entire epidermis and papillary dermis reaching a depth of 0.45 mm.
The most conventional of this group is the trichloroacetic acid of 20-35%, also the glycolic acid of 70% applied for a variable time between 3 to 30 minutes. Deep peelings, act on the medium reticular dermis, over the units of pilosebaceous residues and the excretory conducts of the sweat glands from which the epidermis regenerates. The phenol and the trichloracetic acid on 50-70% of concentration.
How is it treated?
Before the treatment, is necessary to prepare the skin, in order to minimize adverse effects such as hypo-or hyperpigmentation, delayed epithelialization and prolonged erythema.
For this, topical substances shall be applied in the days or weeks prior to the peeling, the most used are the retinoic acid and alpha hydroxy acids such as glycolic acid, as a way to thin the epidermal barrier, increase uniformity and improve the substance penetration, to hasten the healing and reduce side effects and possible complications. Depending of the type of skin exists the possibility of hyperpigmentation after the peeling, a hydroquinone cream, will be used two weeks before treatment, 1 or 2 times per day.
Depending on the condition of wrinkles, acne or problem being treated, Dr. Rafael Spagnuolo will advise a superficial peeling, medium-deep or deeper.
Before starting the peeling, you should thoroughly clean and degrease the skin, either with alcohol, acetone or both, in this way PH is homogenized of all the skin to be treated to obtain an even result.
The procedure consists of the controlled application of a chemical, (previously selected according to the skin type and condition to be treated) on the skin causing their exfoliation. After treatment the patient will have a redness and flaking skin (more intense and lasting the deeper the peeling). In superficial peelings, the patient has a reaction similar to sunburn that disappears within 3-4 days. In the case of medium-depth peeling reaction lasts 7 to 10 days.
The number of treatments required will depend on the patient´s response and the type of peeling applied. In medium- depth peelings a single application is sufficient to appreciated significant changes. The new regenerated skin is smoother and less wrinkled.
Following the re- Epithelialization, a treatment must be followed with skin lightening creams, like the one made before the peeling and avoid sun exposure up to 6 weeks to avoid the risk of post-inflammatory pigmentation.
What types of substances are used?
The choice of the substance to use will take place by Dr. Rafael Spagnuolo, depending on the depth of the pathology, and the skin phototype. It is preferable to perform several medium peelings than only a deep one. Furthermore, the repeated application of a superficial peeling can match the results of a medium peeling.
In the case of the superficial peelings, we may choose between Glycolic Acid 30-50% dose, trichloroacetic acid on 10-20% dose, ascorbic acid, retinoic acid and salicylic among others. For medium-deep peelings Dr. Rafael Spagnuolo will use a 70% glycolic acid dose or trichloroacetic acid on 20-35% dose. Deep peelings are performed under anesthesia or sedation, in these cases using Phenol or trichloroacetic acid on 50-70% doses and the modified formula of Fhenol Baker-Gordon.
How the peelings act?
The substances used in superficial peelings, mostly act as auto- regulators and stimulants as they increase skin flaking and cell renewal. They intervened decreasing the cohesion between the corneocytes causing the flaking. Some acids also act as antiviral, phenylpropanoid and bactericides, being ideal for the treatment of acne, much more in the case of the salicylic acids that exercise its keratolytic action even within the pores.
The substances used in the middle-deep peelings are stronger acids which produce the coagulation of proteins and they neutralize themselves as they pass through the layers of the skin, unlike the superficial peelings that always must be neutralized and due to its smaller molecular size can pass through the entire skin. The greater the amount of acids used the greater the effect, in the case of the trichloroacetic acid is easily controllable, as it cause by the change of color in the skin during application due to protein coagulation.
In the case of deep peelings, specifically the Phenol, it acts by enzymatic inactivation and protein denaturation, resulting in insoluble proteins. It acts on the cell membrane, modifying their selective permeability by varying their physical qualities and this change leads to a death cell. Phenol is also antiseptic, antifungal and anesthetic.
What are the results?
With the Peeling we achieve whiten spots, to refine the skin, to reduce the depth of wrinkles and acne scars, to improve scars, to treat acne, besides, avoiding the deep injuries it causes, and in all cases to increase cell regeneration.
The skin is tight, consistent, soft, smooth and reduces pores. The peeling does not correct the skin laxity when it needs a facelift, or vascular problems such as Telangiectasias (small dilated blood vessels), rosacea etc. In some cases hyperpigmentation may be resistant, depending on the peeling and is dangerous its implementation in skins race from eastern or black origin.
Who can be a candidate for this treatment?
The peeling is indicated in cases of physiological or actinic aging and for the treatment of acne and blemishes. However, superficial peelings can be used as a means to maintain a healthy, smooth, bright and free of impurities skin.
Patients with fair skin are ideal for this type of treatment, however, if the necessary precautions are taken before and after a chemical peeling, people of higher phototype can also get good results.
Dr. Rafael Spagnuolo will assess your case individually, but initially, it should be noted that superficial peelings can be used to treat all types of skin, even sensitive skin or rosacea. The ideal patient, in these cases, is one that seeks to rejuvenate the appearance of their skin as they improve the fine lines, dull skin tones, pigmentation, solar lentigo (blemishes), freckles and rough skin texture. These improvements are achieved after a series of treatments, and appear after about 6 sessions but it depends on each patient. Recovery time is minimal, but instead more sessions should be taken. Superficial peelings may also be used in complementary treatments of acne, superficial scars of acne, rosacea, melasma (tan or dark skin discoloration), keratosis pilaris (chicken skin) and wrinkles.
What areas can be treated?
Mainly, the peelings are performed on the face because it is the area of greatest concern to patients, but they can be applied to arms, neck, back of the hands or legs.
What contraindication has it?
Treatment should not be performed if the presence of any type of active infection such as herpes, warts, molluscum contagiosum (viral infection of the skin), impetigo ( a highly contagious bacterial skin infection), etc. and with treatment with Isotretinoin (medication used mostly for cystic acne ) or sensitive drugs.
In case of having planned an intense sun exposure, it is better to postpone or to avoid the treatment all together.
Pregnancy is not contraindicated in the peeling treatment with glycolic acid. During pregnancy and postnatal is common the outbreaks of acne due to hormonal change. The glycolic acid peeling compelled with other topical treatments during pregnancy or breastfeeding, can be a good treatment option. In the case of salicylic acid is contraindicated in pregnancy and breastfeeding and in people allergic to this substance.
What are the side effects?
Side effects depend on the substance being used, generally, we can mention:
• Excessive Erythema (redness of the skin). Pigment alterations, occurs mainly in high phototype kind and melasma.
• In any case, the side effects are mild and temporary.
• Epidermolysis: it is more frequent when the patient is applying topical retinoids such as in the treatment of acne and it has not been suspended. It manifests as crusts that will take one week to disappear. Treatment may be used like antibiotics or vaseline.
• Perioral Dermatitis: is treated with topical antibiotics (externally applied) for 3 weeks.
What care should be taken before a chemical peeling?
Treatment should not be performed if there is an infection. Neither should be done during the summer season.
Oral retinoids alter the stratum corneum (outermost layer of the epidermis) and therefore modify the penetration of the glycolic acid. Patients treated with this type of medication may suffer an increased reaction to these peelings. It’s best to leave a washout period between 4 to 8 weeks.
Other topical medications that also affect the depth of the peeling are the 5-fluorouracil or imiquimod.
Patients taking medications such as warfarin, heparin, aspirin, NSAIDs or vitamin-E may have bleeding and sores in the treatment areas.
In patients using photosensitizing medications, extreme precautions must be taken regarding photoprotection, for example in those taking tetracyclines, contraceptives…
What care should be followed after treatment?
• 50+ Photoprotection
• Regarding the makeup is better to avoid it in the first few days, but if the patient has no choice, due to work or social commitments, can do so, provided you remove the makeup at home later.
• Patients with recurrent herpes simplex should take oral prophylaxis, usually with valacyclovir 500 mg two days before, on the same day of treatment and two days later.