All about it

 

THE TRUTH ABOUT PEELS

Catherine DE GOURSAC, MD

Member of the Board of Directors of AFME, SNME, Member of the Scientific Council of SFME

First of all an explanation

Peeling comes from the word English " to peel "or peel. It is a medical procedure designed to regenerate the skin, which appears younger, smoother and free of imperfections. The peel acts by exfoliating the skin cells, from the stratum corneum to the reticular dermis, depending on the strength of the peel.  However, the name has been extended to the application of active ingredients with a targeted action such as pigmentary peelings or anti-acne.

In general, the word "peeling" refers to chemical treatments, even though we can speak of mechanical peeling when exfoliating with physical agents:  la dermabrasion and the microdermabrasion which act in a mechanical way, thee laser which acts by abrasion, lhical peels will be the only subject of this article. The majority of chemical peels are therefore intended to rid the skin of a thickness that will depend on the chemical exfoliant chosen.

In the general public's mind, this desquamation will refine a skin that is already refined when it is aging, and they do not distinguish between exfoliation of the stratum corneum and treatment to boost the dermis.

It has been found that this exfoliation will stimulate the fibroblasts by sending growth factors and thus stimulate neo-collagenesis, which will increase the thickness of the epidermis and dermis.

A reminder of the basic principles

Any chemical injury to the surface or deep layers of the skin triggers a cascade of responses leading to skin repair.

Epithelial repair: lThe restoration of a normal epithelium results from the migration of epithelial cells and requires a certain density of skin appendages (hence the danger of treating areas with few appendages, such as the neck or décolletage)

Dermal repair: formation of granulation tissue. The fundamental substance is depleted over the years, and the dermal repair caused by the peel will restore the granulation tissue, which is made up mainly of glycosaminoglycans (including hyaluronic acid), fibronectin, collagen and elastin.

The remodeling phase: on identified a strong local release of growth factors which favors the remodeling of collagen and allows a thickening of the different layers of the dermis with a delayed effect between 2 and 3 months.

Microcirculation:  he neo-angiogenesis is proportional to the initial inflammation and the rejuvenating effect is also significant. To reduce this post-peel skin erythema, LEDs are of great benefit. However, the more persistent the erythema, the greater the rejuvenation.

How to choose your peel:

Peels are generally distinguished according to their depth of action, which can be superficial, medium or deep. The parameters for choosing the type of peel are numerous, including the type of lesion to be treated (acne, dilated pores, blurred complexion, hyperpigmentation, fine lines, etc.), the patient's phototype, the possibility or not of social eviction, and the risk of sun exposure.

 

Superficial peels  This type of peel acts essentially from the stratum corneum to the basal layer of the epidermis.

Focus on the active ingredients.  These are generally the peelings based :
  1. d'AHA (AlphaHydroxyAcids) as acid lacticmandelic, tartaric ...)
  2. or Beta-Hydroxy-Acids (salicylic acid).
  3. Other active ingredients such as phytic acid or azelaic acid are part of the superficial peels.
  4. It should be noted that the choice of active ingredients will be made according to the clinic: helioderma, pigmentary spots, oily skin or acne ....
  5. Note that trichloroacetic acid (TCA) dosed at 15% also falls into the category of superficial peels. The desquamation is light.
Indications. The superficial peel is intended to treat
  1. fine lines,
  2. blurred complexion,
  3. epidermal pigmentations linked to the sun (lentigo, superficial melasma),
  4. photoaging beginning,
  5. ephelides,
  6. acne still evolving.

It is a soft, painless peeling, without social eviction. The desquamation will be fine and therefore not very visible, especially if the skin is very moisturized.

Peelings average.  The medium peel acts down to the papillary dermis to remove the epidermal layer and the upper part of the dermis.

Active ingredients.

The Jessner Solution is a chemical peel combining lactic acid, salicylic acid and resorcinol in a base ethanol, but it is less and less practiced. The peeling at the TCA (trichloroacetic acid derivative) is particularly used in various concentrations, especially at 30%. It acts by coagulating the proteins of the epidermis resulting in a "icing" which translates the necrosis and the desiccation of cells epidermal before reaching the dermis where it is neutralized. Unlike AHAs, the intensity of its effect can be modulated via its concentration and the quantity deposited (number of layers applied to the skin). It is important to pay attention to the quality of the bleaching: light flaking = relatively discreet desquamation, uniform icing = plaque peeling. The time of social eviction can be predicted very accurately according to the intensity of the bleaching.

Indications. This type of peeling is indicated in the treatment of :

    1. deep epidermal and superficial dermal lesions,
    2. especially signs of helioderma of the face,
    3. lentigos,
    4. actinic keratoses
    5. of the fine lines the bar code of the upper lip.
    6. progressive acne,
    7. wrinkles,
    8. and sagging skin.

Deep peels.  The deep peel is a more aggressive phenol-based peel. It has an action up to the middle reticular dermis.

Active ingredients.

Phenol or phenic acid applied on the skin, will cause the total destruction of the epidermis to the deep dermis by "chemical burn".  We now have peelings with phenol called attenuated and we can juggle according to the mapping of the face of the patient in intensity of phenol for example: a deep phenol on the upper lip, a medium phenol on the chin and a soft phenol on the cheeks.

Indications

The phenol peel is considered a "chemical facelift": it allows to treat in one session :perioral and periocular wrinkles, marked skin photoaging, acne scars, rhomboidal chin.... It is intended for patients who can bear the heavy after-effects total social eviction for 10 days, with residual erythema for several weeks (this is why I no longer treat men because make-up is essential). Young women with multiple acne scars are an excellent indication because the effectiveness of phenol is clearly superior to the laser and they know how to mask the erythema like no one else. The results obtained are unparalleled at the present time. The consequences are to be well described to the patients with detailed informed consent and it is necessary during the first consultation to detect the people who will not support them psychologically.

The bright yellow bismuth subgallate is applied to the treated surface and will be kept for 6 days.  The edema is important in certain areas, including the peri-ocular area.  Therefore, the patient is immobile for at least 8 days.  Residual erythema is intense the first few days, then the skin accepts makeup after 5 days after the subagallate has peeled off.  In all, it takes several months to recover a skin without erythema.  The LEDs allow to considerably reduce the duration of the erythema. The result is optimal after 6 months: the more the inflammation is strong, the better the result will be delayed.

The deep peel is therefore reserved for highly motivated patients with a phototype less than or equal to 3 and for experienced and well trained practitioners.

Deep chemical peel

The truth and falsehood of peels

"The peel appears to be the most consensual aesthetic medical procedure for non-initiated patients. .

True: A study has shown that this is the first gesture of entry in medical cosmetic procedures.

"Thin skin would be a contraindication because the peeling would refine the skin".

False: Insofar as the active ingredients allow the epidermis to dissolve (from the stratum corneum to the basal layer, depending on its intensity), the local release of growth factors in the dermis and epidermis ultimately leads to a thickening of the various layers of the skin. This should be explained to the patients as it shows them that each peel has a long-term benefit.

"The general public knows that we now have an extremely wide range of peels and that the same term covers entities as varied as actions.

False: For him, all peels are equivalent. However, anti-acne peels treat skin eruptions but also the healing phase and acne scars. Other peels act on pigmentation such as lentigines, ephelides, post-inflammatory pigmentation and melasma. Others improve the quality of the epidermis (blurred complexion, dilated pores, fine lines, etc.)

"We are witnessing a demonization of TCA and phenol.

True: However, we now know how to do a medical peel for TCA without causing social eviction and giving good results by repeating the sessions with low-dose solutions. As for the phenol peel, despite its disadvantages, it is the most active "chemical facelift" and we now have the possibility of graduating the strength of the peel.

In our practice

An initial consultation is essential before any act We will check that the patients meet the feasibility criteria of the medical-aesthetic treatment, explain the course of the treatment, the protocol, the consequences and the risks of side effects. Chemical peels are of essential tools in the therapeutic arsenal of the physician with an orientation I remind you that this is often the first step to enter into aesthetic acts. This act is performed at the office medical by a trained operator.

In my opinion, peels are essential in certain indications:

  1. In skin rejuvenation to treat: the fine lines of the lower eyelid, the bar code of the upper lip, the back of the hands.
  2. To accelerate the disappearance of hyperpigmented spots in case of melasma and chloasma but also in the treatment of post-inflammatory pigmentation and multiple lentigines.
  3. In the management of acneThis is particularly true for people with a high phototype when the healing process is too slow and leaves residual marks for too long.
  4. In the presence of permanent scars in women young people. The deep peel will have the most effective results.

 

My protocol for soft peels

For AHA peels (which we have abandoned for reasons explained below), you should plan several sessions spaced 3 weeks apart and use concentrations increasing glycolic acid (20% to 70%). Unfortunately, some beauticians have taken over this peel, which they use at very low concentrations for a minimal effect and as it is necessary to differentiate ourselves, we only use the stronger peels.Moreover, even if the side effects are not significant (mild erythema, skin dryness, moderate desquamation), the peeling with glycolic acid can cause unpredictable epidermolysis resulting in a few days of social eviction. TCA is reproducible, unlike glycolic acid which has a random effect.

My therapeutic strategies:   Po get a glow, we prefer TCA peels at 15% with 3 to 4 sessions at 1 month intervals depending on the degree of helioderma.  In generalthe patients are delightedbecause there is no social eviction and a visible "rejuvenation" in the long term.

  1. During the first peeling I treat in a very light way, the flaking is hardly discernible. Thus, patients learn to manage the aftermath of dry skin with almost invisible flaking with a good cosmetological strategy.
  2. The following peels will be reinforced a little (number of applications in the session more important): to arrive at a discreet frosting in order to preserve this non-eviction social so necessary to the current life but by coaching them well on the cosmetology post act in order to dissolve these fine scales in the days which follow.
  3. I also use peels for their anti-acne target (salicylic acid, glycolic acid and lactic acid with low Ph) in the daily care of patients. They allow them to better manage their social life by controlling their rash and accelerating their healing. Just after the peels, they do a 10 minute LED session in red and blue which will accelerate the healing of the rash and sterilize by the blue light which is bactericidal. Patients are looking for an anti-eruption effect but also to accelerate the healing process which can take several months, especially on high phototypes.
  4. TCA peels are also essential for me to fight pigmentation in my daily practice given the increasing increase in melasma (due to endocrine disruptors and estrogen-like substances?). I optimize them by associating several specific peelings in the same session with always a first passage of TCA at 15%, then immediately after the 2 or 3 chosen peelings and I finish by an application of hydroquinone with a high concentration mixed with a commercial mask which will be kept several hours.  These peels are only effective when accompanied by a drastic cosmetic strategy.

My protocol for medium peels

The TCA peel at 30% is quite painful. That is whythe chosen solution is applied, areas by areas, near a ventilation system to reduce the sensation of cooking. In practice, we do not apply anaesthetic cream which would prevent the right penetration of the solution. The slow implementation of the peeling as well as the fact of treating small areas from time to time offer a better tolerance. The TCA allows an à la carte application because the degree of icing obtained allows to determine the depth of action and the duration of the social eviction according to the patients' agenda. The physician can insist on certain areas such as peri-oral areas and perorbital and apply the solution in a non-aggressive way on the remains of the face to achieve a full face" peeling. As soon as the desired frosting appears, the practitioner can neutralize the peel with a compress soaked in water. A white pitting (flaky frosting) does not lead to any social eviction provided that the patient applies highly emollient creams for 15 days to dissolve the scales. A light, white frosting that is not very intense, gives a desquamation more difficult to camouflage and lasts 10 days. On the other hand, a clear white icing leads to brownish oxidized crusts which fall off around 6/7° day. The more concentrated the solution and/or the greater the number of applications, the shorter but more intense the duration of social eviction. Moisturizing, anti-inflammatory, healing and antipigmentation are the key to the success of medium peels with TCA to reduce the risk of pruritus and cosmetic acne.

The risk of post inflammatory hyperpigmentation is not negligible on high phototypes. It is therefore necessary to frame the peeling with products hydroquinone-based.

This truly "customized" peel optimizes patient satisfaction. It is a must in our practice.

My protocol for deep peels

The first consultation 2 to 4 weeks before the peeling session. We will examine the skin, determine the phototype and the feasibility of the peel on the patient as well as his psychological strength because he will be in total eviction for a long time. We will be able to determine the strength of the phenol peel (as I remind you, we have at our disposal the possibility to modulate the strength of the phenol). Cosmetological supervision will be prescribed. Skin preparation is done with hydroquinone depigmenting creams such as Kligman's depigmenting trio. This will allow the melanocytes to rest and prevent post inflammatory hyperpigmentation. It should be reapplied 3 weeks after the end of the intense erythema. A treatment oral preventive The necessary herpes medication must be continued throughout the healing process. If we are working on areas of high edema (eyelids), corticosteroids can be prescribed to limit it. Analgesics are proposed for the hours following the treatment.

At the session: Before applying the product, a local anaesthetic is necessary to reduce the burning sensation. The application is slow, small area by small area over about 1 hour. As soon as the application is finished, a occlusive mask to keep for 24 hours on the treated area(s) in order to optimize the action of the peeling and especially to protect the skin of any external contamination before returning home.

During the week following the treatment : This mask is removed after 24 hours. A regenerating powder of bismuth subgallate of yellow color is then placed on the treated areas. It will be kept for about a week. The patient should have a supply of powder at home to apply after each night, when rubbing with the pillow will cause parts of the mask to fall off.

On the 6th or 7th day: The removal of the powder is done at the end of this period with Vaseline at home. Vaseline must be applied in a thick layer which will dissolve the crust formed by the bismuth subgallate over several hours. The operation is likely to last more than 12 hours. The skin can then be made up from the 3ème or 4th day during the weeks after the procedure to mask the redness.

Suites:  Post-peel erythema can last for several weeks, even months. To considerably reduce the duration of the erythema, a few sessions of LEDs will be of great help for their anti-inflammatory and healing action. A single session is sufficient, but this deep peeling requires a total social eviction for about ten days as well as a sun block with the application of a sun block in the months following the treatment.

Final results are obtained between six months and one year later. It is a heavy procedure but its effectiveness gives it a very natural lifting power for people with very damaged skin (especially by the sun) and very motivated.

Conclusion

The peels cover an extremely varied entity that is personalized not only for each patient but also according to the time of year and also by area. In the sense that you can do one type of peel for example anti-wrinkle in the perioral area, another anti-acne peel on the forehead and yet another to treat melasma on the cheeks. The most important thing is to know the indications and to master the technique, taking care of the patient before, during and after the procedure.

 BIBLIOGRAPHY

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