Keywords
Chemical peelAlpha hydroxy acidJessner peelSalicylic acidGlycolic acidMelasmaPhotodamageAcneBeta-hydroxy acidSuperficial peelsSkin peelsFacial peels8.1 Chemical Peels Used in Aesthetics
Alpha hydroxy acids (AHAs) are derived from natural fruit acids, are nontoxic, and classified as organic carboxylic acids. Carboxylic acid has one hydroxyl group attached to the alpha position (α) of the carbon atom (Coleman and Brody 1997). Beta hydroxy acids (BHAs) are lipid soluble and are also organic carboxylic acids with one hydroxyl group attached to the beta position (β) of the carboxyl group (Green et al. 2009). Alpha and beta hydroxyl acids are common sources of superficial chemical peeling agents in aesthetics. Superficial chemical peels are derived from acids of various sources including plants and vitamins (Ball Arefiev and Hantash 2012; Fabbrocini et al. 2009).
Superficial peels penetrate to the epidermis and are used alone or in combination with other treatments, such as facials or microdermabrasion , to enhance outcomes (Rendon et al. 2010). Superficial peels are used to refresh the skin and remove the stratum corneum through chemical exfoliation. Consultation with the patient should include side effects, benefits, and limitations of the superficial peeling agents. Management of expectations is important and the patient should understand that the effects are subtle and temporary, unlike the deep chemical peels that offer more clinically evident results because of histologic changes in the reticular dermis (Stegman 1982; Kligman and Kligman 1998).
A variety of superficial chemical peels are available in different strengths but some agents require neutralization to terminate their action, whereas others are self-neutralizing. Superficial peeling agents that are self-neutralizing include salicylic acid (SA), trichloroacetic acid (TCA), lactic acid (LA), retinoic acid (RA), and Jessner solution (Lee et al. 2018). Superficial peeling agents that require neutralization with water or sodium bicarbonate to avoid over penetration are glycolic acid (GA) and pyruvic acid (PA) (Lee et al. 2018).
Certain factors affect tolerability of peels such as the type of peeling agent, skin type, and concomitant use of skin care products (Rendon et al. 2010). Complications can be avoided through careful patient assessment and determination of risk factors such as (1) post-inflammatory hyperpigmentation, (2) frequent and intense sun exposure, (3) history of keloid formation, (4) extremely sensitive skin, and (5) darker skin type (Coleman and Brody 1997; Rendon et al. 2010).
Superficial chemical peels are popular and generally safe treatments used in aesthetic practice to address rough skin texture, fine lines, melasma, and photodamage (Alam et al. 2002; Abdel-Motaleb et al. 2017). Chemical peels are slightly more popular than microdermabrasion in the USA although both treatments yield similar results (Alam et al. 2002; ASPS 2017; Karimipour et al. 2010). Perhaps the characteristic peeling effect from a chemical peel provides visible assurance of perceived effectiveness to the patient.
8.1.1 Salicylic Acid (SA) Peels
Salicylic acid is a superficial peeling agent that is used for a variety of skin conditions including acne, melasma, and photodamage and is the only member of the beta-hydroxy acid family (Rendon et al. 2010; Abdel-Motaleb et al. 2017). Characteristics of SA include desmolytic action due to its ability to disrupt cellular junctions, rather than breaking or lysing intercellular keratin filaments as once thought (Arif 2015). Salicylic acid is able to reduce clogging of skin pores from accumulation of skin cells and keratin in the pilosebaceous unit and so is helpful in limiting acne (Abdel-Motaleb et al. 2017; Arif 2015; Habif 2016). Histologic results of SA peels demonstrate more pronounced dermal collagen and elastic fibers, positive alterations in epidermal thickness, and replacement of some skin defects with organized tissue that produces increased smoothness (Abdel-Motaleb et al. 2017).
Salicylic acid peels are safe for most skin types and are commonly used for acne because of its desmolytic properties (Arif 2015; Habif 2016). Salicylic acid peels self-neutralize and typically cause light peeling within about 2 days (Lee et al. 2018). Although the safety profile of SA peels is excellent, caution is recommended when using any peel due to the potential for irritation or inflammation (Lee et al. 2018).
8.1.2 Trichloroacetic Acid (TCA) Peels
Trichloroacetic acid (TCA) is used as a superficial peeling agent in the range of 10–30% although higher percentages are used as medium depth peeling agents (Fabbrocini et al. 2009; Rendon et al. 2010; Lee et al. 2018). Higher percentages of TCA are associated with more complications and are appropriate for discrete or smaller areas (Lee et al. 2018). Trichloroacetic acid is self-neutralizing and does not require water or bicarbonate to terminate its action (Fabbrocini et al. 2009; Lee et al. 2018). The TCA peels can be used alone or in combination with other peeling agents such as glycolic acid or salicylic acid depending on the desired effect and condition of skin (Fabbrocini et al. 2009; Rendon et al. 2010). The mechanism of action of TCA is to expel epidermal proteins and cause coagulative cellular necrosis (Fabbrocini et al. 2009; Abdel Hay et al. 2019). This action leads to superficial layers of skin peeling.
8.1.3 Lactic Acid (LA) Peels
Lactic acid is a mild AHA peeling agent commonly used to help reduce uneven texture, acne breakouts, and hyperpigmentation (Sachdeva 2010). The effects of these peels are optimal when used in a series every 1–2 weeks depending on skin response. Lactic acid peels do not require neutralization.
The LA peels work by causing detachment of corneocytes from each other and subsequent desquamation of the stratum corneum (Dayal et al. 2017). Lactic acid peels are safe to use in darker ethnic skin types and produce a good response when used for acne, superficial acne scarring, and/or post-inflammatory hyperpigmentation (Rendon et al. 2010; Sachdeva 2010). Lactic acid is also a component of the Jessner peel solution and it works well in combination with other AHAs.
8.1.4 Retinoic Acid
Retinoic acid, or tretinoin (Retin-A®), is a vitamin A derivative and used as a topical preparation to treat acne and diminish the appearance of fine lines and hyperpigmentation (Manaloto and Alster 1999; Fulton et al. 1974). Tretinoin is not applied in the office setting as a peel but when used at home, it causes slight temporary peeling. Consistent use of tretinoin at home results in lightening of the skin, reduction of fine lines, thickening of the dermis, and the creation uniform cell configuration that leads to smoother skin (Manaloto and Alster 1999). The improvement of skin texture and reduction of fine lines are attributed to the increase in epidermal and dermal thickness and compaction of the stratum corneum (Manaloto and Alster 1999; Kligman et al. 1986; Draelos et al. 2016).
Tretinoin is applied once per day at bedtime. The most common side effects include mild erythema, light peeling or flaking, dryness, and irritation (Manaloto and Alster 1999; Fulton et al. 1974; Kligman et al. 1986; Thielitz et al. 2008). The initial light peeling and irritation typically resolve in 4–8 weeks and use of daily moisturizer can help decrease dryness (Manaloto and Alster 1999; Kligman et al. 1986) Tretinoin is applied for 8–12 months and then can be decreased to a frequency of twice a week for maintenance of skin improvement if desired (Kligman et al. 1986). If tretinoin use is discontinued, the effects diminish and eventually cease; therefore, continued maintenance use can be recommended (Kligman et al. 1986; Thielitz and Gollnick 2008).
8.1.5 Jessner and Modified Jessner Peels
The Jessner peel (JP) was formulated by Dr. Max Jessner M.D., a German dermatologist. Jessner peel was made popular by Dr. Monheit, M.D. when he combined TCA with the Jessner peel to make a powerful chemical peel for skin rejuvenation (Coleman and Brody 1997; Monheit 1989). The combination of TCA and JP is a frequently used combination peel because of their synergystic effect. The JP solution is a combination of salicylic acid 14%, lactic acid 14%, and resorcinol 14% in 95% ethanol and is commonly used as a superficial chemical peel (Coleman and Brody 1997; Fabbrocini et al. 2009; Grimes et al. 2005). The resorcinol component in the JP adds a skin lightening effect, and so it provides an added benefit in patients who have pigment concerns (Fabbrocini et al. 2009).
The advantages of the JP include an excellent safety profile, enhancement of the effect of the TCA peel, and minimal erythema and peeling in most patients (Fabbrocini et al. 2009). The disadvantages of the JP peel is increased desquamation in some patients and the solution must be stored in dark bottles to avoid oxidation (Fabbrocini et al. 2009). Jessner peel is available in one strength, but the depth of penetration into the skin can be increased by applying several layers during the peel process (Puri 2015).
The Modified Jessner peel (MJP) is the alternative version of the JP and is a solution of salicylic acid 17%, lactic acid 17%, and citric acid 8% in ethanol 95% (Fabbrocini et al. 2009; Grimes et al. 2005; Saleh et al. 2018). The MJP contains citric acid instead of resorcinol. Modified Jessner peel can be used on patients who have history of allergic reaction to resorcinol or increased risk of hyperpigmentation such as in darker skin types (Puri 2015; Saleh et al. 2018).
8.1.6 Glycolic Acid and Pyruvic Acid Peels
Glycolic acid (GA) and pyruvic acid (PA) peels are superficial peels commonly used in aesthetics. These peeling agents require neutralization with water or bicarbonate to stop the chemical action (Coleman and Brody 1997; Lee et al. 2018). End points for neutralization of these peels are onset of erythema or at 5 min if no erythema is noted (Fabbrocini et al. 2009; Lee et al. 2018).
The advantage of the GA peel is its effectiveness in treating photodamage. The GA peel has a quick application process, mild erythema and desquamation, and a short recovery period (Fabbrocini et al. 2009; Lee et al. 2018). The disadvantages of GA peels include a burning or stinging sensation during the peel application and the risk of ulceration if the peel remains too long on the skin (Fabbrocini et al. 2009).
The pyruvic acid (PA) peel can be used safely on darker skin types and it has short healing time with mild erythema and peeling. Pyruvic acid peels process on the skin for a short period of time, typically 3–5 min before neutralization (Fabbrocini et al. 2009). The mild effects of PA peels are ideal for patients who do not want extended desquamation and recovery. However, during application of the PA peel, patients might notice strong vapors and intense stinging until the solution is neutralized (Fabbrocini et al. 2009).
8.1.7 Superficial Peels
The table below is a summary of commonly used peeling agents, strengths, and timing. This table is not prescriptive and should be modified for the individual patient skin type and conditions (Fabbrocini et al. 2009; Lee et al. 2018).
Very superficial peeling agents |
• Glycolic acid: 30–50%, applied briefly (1–2 min) |
• Jessner solution: applied in one to three coats |
• Low-concentration resorcinol, 20–30%: applied briefly (5–10 min) |
• TCA 10%: applied in one layer |
Superficial peeling agents |
• Glycolic acid, 50–70%: applied for a variable time depending on skin response (2–5 min) |
• Pyruvic acid, 40–50%: applied for a variable time depending on skin response (3–5 min) |
• Jessner solution, Modified Jessner: applied in 4–10 layers |
• Resorcinol: 40–50%, applied for 30–60 min |
• TCA: 10–30% |
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