Having been around for over a hundred years, chemical peels cannot be called something new. Nevertheless, they are certainly still extremely popular. In fact, peels of all kinds topped the list of the ten most commonly performed cosmetic procedures in the U.S., reaching a total rate of nearly 850,000 treatments per year at the turn of the new millenium.
Whether used by themselves or combined with other rejuvenation techniques, chemical peels, particularly "lunchtime peels," the subject of this chapter, figure prominently in most anti-aging treatment regimens and are arguably the paradigm "lunchtime beauty fix." And if the predictions of the cosmetic surgical gurus are correct, they are expected to remain appealing for many years to come, despite advances in other areas of facial and neck rejuvenation.
Why Are Chemical Peels So Appealing?
There are many reasons for the unflagging popularity of chemical peels among both physicians and patients. For patients it is the plain fact that they work so well, and that they require no surgery. For physicians, they have a long, proven track record of patient safety spanning many decades of continuous use and are backed by a very substantial body of scientific data attesting to their efficacy. Moreover, they are versatile in their applications, addressing a host of different kinds of common age-related as well as other skin problems. What's more, they are readily obtainable, relatively inexpensive and require no high-priced, high-tech gagdetry to use.
Nowadays, unlike several decades ago, physicians have a fairly wide array of peeling agents to choose from. This means that your doctor is better able to tailor treatments to your individual needs. Rather than relying upon one chemical alone, s/he can select different peeling agents to treat differing skin areas. This choice will depend upon the specific area being peeled, as well as the particular problems needing treatment. For example, your face may require one agent to treat sallowness, your neck and chest a different one to manage roughness and scaliness, and arms and legs, still a third for fading "liver spots" or other discolorations.
The Basic Concept Behind Peels
Chemical peeling, as its name clearly suggests, is the application of a chemical agent to the skin with the intent to produce a controlled peeling, ie. scaling or exfoliation. Nearly all currently used peeling agents are acids. Physicians often refer to the scaling as desquamation. But whatever you call it, the skin response for "lunchtime peels" is similar to the kind of stinging, flaking and peeling that you would experience after a sunburn.
Peels work not only at the surface of the skin, but also below it. Surface exfoliation is responsible for the skin smoothness, luster, tone and texture that typically result. Below the surface, the healthier-looking, rosy glow that often follows is the result of new blood vessel formation in the dermis (a process known as neovascularization). The lasting skin plumping and anti-wrinkling benefits of chemical peels are felt to result from the stimulation of dermis collagen synthesis and elastic fiber production, as well as to enhanced production of dermal matrix material (the gelatinous, cementing substance that supports and binds the collagen and elastic fibers together).
Types of Peels
Peels are generally classified as superficial, medium and deep, corresponding to the depth of penetration of the applied acid. A good rule of thumb is that the more deeply penetrating the peel, the more effective it will be for rejuvenation, but the longer the post-operative downtime and the greater the possibility of complications. Potential post-treatment complications include the development of persistent pigmentary irregularities of the skin and possibly scarring. Consequently, the deeper the peel the more closely it needs to be monitored in order to minimize the chance of untoward reactions. Such problems are generally attributable to deeper peels and rarely result from superficial "lunchtime" peels.
Superficial Peels
The emphasis here will be on superficial peels and freshening peels, the so-called "lunchtime peels," which are also occasionally referred to as "prom peels," when they are used for drying up teenage acne blemishes. Superficial peels are a popular part of many anti-aging regimens, and with good reason. Overall, the chemicals used are relatively safe and non-toxic and are associated with few complications when applied under strict medical supervision; the peels are versatile enough to effectively treat a wide range of different skin problems;
Superficial peels typically affect only the outermost layer of the skin, the horny layer (or stratum corneum ) of the epidermis and occasionally involve the uppermost portion of the remainder of the epidermis, as well. Although scaling and flaking are common after a superficial peel, the depth of skin penetration is by design so limited that other manifestations of more intense inflammation, such as blistering, oozing, crusting and scabbing, which are typically seen with medium and deep peels (see below), are seldom encountered. And unlike many other kinds of rejuvenation procedures, including the deeper chemical peels, superfical peels tend to be well-tolerated by all skin types, even by very darkly pigmented persons.
Lunchtime peels make a great stand-alone treatment for individuals who are just becoming interested in facial rejuvenation and are not yet ready to commit themselves to applying at-home preparations or to undergoing other more extensive in-office procedures. Likewise, they make an ideal complement to many other topical and surgical techniques when a more aggressive antiaging regimen is desired.
Superfical peels are especially useful for improving skin texture and evening out skin tones and blotchy pigmentation due to a variety of causes, including melasma (the so-called "mask of pregnancy"). They are also indicated for smoothing out coarse and roughened skin, diminishing skin dullness and sallowness; increasing luminosity; lightening or eliminating freckles and "liver spots;" unclogging whiteheads and blackheads; and temporarily tightening pores. They are also excellent for treating cases of mild chronic photoaging-related wrinkling and for thinning out scaly keratoses (common wart-like age- or sun-related skin growths), and for "drying up" acne blemishes (resulting from acne rosacea-- adult acne or acne vulgaris-- common acne) (see Chapter 9). Finally, they are useful for softening the appearance of, or sometimes even eliminating, certain kinds of scars (for more on treating scars, see Chapter 10).
For lunchtime peels doctors have a wide selection of agents to choose from. These days glycolic acid (in concentrations between 50% and 70%) , salicylic acid 30% (a beta hydroxyacid, which is frequently referred to as a "beta peel"), Jessner's solution (a combination of three exfoliating agents in low concentrations: salicylic acid, resorcinol, and lactic acid-- another alpha hydroxyacid), and low potency TCA (in concentrations ranging from 10% to 25%) are the most commonly used agents for superficial peeling.
Glycolic acid, the most commonly used superficial peeling agent these days, is one of several alpha hydroxyacids (AHAs), a group of naturally occurring substances often referred to as "fruit acids" because they are found in naturally in various fruits and other foods. (In nature, glycolic acid is found in sugar cane juice). Accordingly, I have coined the term "Fruit Washes" for the application of high concentrations of glycolic acid.
As mentioned earlier it is not uncommon for physicians to use combinations of these chemicals to treat different skin locations and different types of problems. For example, I find glycolic acid especially helpful for treating fine wrinkles on the face; beta hydroxyacid for more resistent crinkling around the eyes, upper lip and neck, and for clearing acne and temporarily tightening enlarged pores; and Jessner's solution for addressing sun damage in the decolletage area of the upper chest.
At the present time, we unfortunately still do not have the perfect peeling agent, a chemical that can meet all our antiwrinkling and anti-aging needs without irritating the skin at all. In an attempt to create the better solution, however, manufacturers have attempted certain modifications. You may have come across terms such as "buffered" or "partially neutralized, which simply means that certain chemical substances have been added to the basic acid formula to weaken the concentration of the free acid, making the solution less irritating and generally more tolerable. A partially neutralized solution of glycolic acid 70%, for example, may be expected to be more gentle and produce a more superficial peel than an otherwise comparable application of nonneutralized glycolic acid 70% solution, but it will not be quite as effective either, and that's the trade-off here. Nevertheless, buffered or neutralized solutions can be very useful for treating people with especially sensitive skin. Recently, the addition of strontium salts, such as strontium nitrate and strontium chloride to glycolic acid has also been found useful for decreasing stinging and burning and reducing irritation, and this peeling combination is enjoying increasing popularity.
What's Involved?
Prior to a peel, you will need to clean your skin with soap and water to remove any cosmetics and dirt. You are then further cleansed with a solvent solution of rubbing alcohol or a combination of rubbing alcohol and acetone (the main ingredient of nail polish remover) to ensure that the skin is fully degreased. These cleansing procedures are essential to ensure the even penetration of the acid.
Superficial peels seldom require any kind of prior anesthesia. Most people generally find the mild stinging, burning or itching associated with glycolic acid, Jessner's solution and low-concentration TCA peels tolerable. Although beta peels provoke a more intense burning sensation, this reaction subsides spontaneously in about three minutes since the main ingredient, salicylic acid, has its own anesthetic properties.
Peeling agents are applied by either cotton-tipped applicators, gauze sponges or sable brushes, depending upon physician preference and the amount of surface area needing to be covered. When glycolic acid is applied, the solution is left on until the skin flushes or you rate the burning or stinging experienced to be a number five on a subjective scale of one to ten (with ten being very uncomfortable and zero representing minimal or negligible sensation). For Jessner's, beta, and TCA peels, the end point is usually a whitening or frosting of the skin that is clearly visible to the physician.
Hand-held fans help cool down the burning sensation typically experienced with Jessner's solution or beta peels, especially when they are applied to the more delicate tissues around the eyes or sides of nose. In my experience, however, the fan is usually unnecessary with glycolic peels.
When the determined end point is reached, cool water compresses or mild alkaline solutions of baking soda are used to "neutralize" the peeling solution and stop the progression of the peel. Your physician may instruct you to rinse your skin immediately afterward with cool tap water as an added insurance that the chemical has been entirely removed.
Before you have any peel, you should inform your doctor if you have ever had a "fever blister" or "cold sore" (herpes simplex virus infection) on the lips or on any other area that is to be treated. A recurrent herpes infection, which can be triggered by the irritation of the peel, can lead to delayed healing, poor outcome and even scarring. To prevent an outbreak, your doctor can start you on one of the very effective oral antiherpes drugs currently available, such as Zovirax, Famvir and Valtrex. Therapy is usually begun a day or two before the peel and continued for a week or two afterward.
Aftercare, too, is crucial for a good result. Since treated skin may be particularly sensitive for a couple of days following peeling, it is important to avoid any potentially irritating creams. OTC or prescription items containing alpha hydroxyacids, vitamin A derivatives or vitamin C derivatives, for example, all of which tend to be somewhat drying or irritating, should therefore be avoided during this period. However, bland moisturizers to soothe the skin, and ordinary makeups, may be applied as desired unless otherwise prescribed by your doctor. Since healing skin is also especially sensitive to sun exposure, you should take special care to protect yourself from overexposure and to apply sunscreen regularly during this time.
Although chemical peels are not considered high-tech surgery in the conventional sense, they are nonetheless true medical procedures and are best performed and monitored by physicians in the office setting. Physicians must take into account the many factors that may impact positively or negatively upon the peel process and its outcome. For example, how vigorously the prepeel cleansing and degreasing is performed must be carefully considered. The more vigorously your skin is rubbed, the more deeply the peel acid is likely to penetrate and your doctor may wish to take advantage of this by purposely rubbing more vigorously over certain problem areas, such as deeper wrinkles, with intent to increase peel penetration in those regions.
Even the precise manner in which the solution itself is applied is important. "Painting" it on in light strokes keeps the peel more superficial, whereas briskly massaging the solution in or applying it in multiple layers can have the reverse effect. Here again, the doctor may opt to treat specific problem areas with brisker applications and more coatings in hopes of achieving greater benefit.
Lastly, varying the duration of skin contact time with the chemical can also be used to advantage. For some acids, particularly the AHAs (eg. glycolic acid), the depth of penetration is directly related to the length of time the acid is in contact with the skin-- the longer it is left on, the deeper the penetration. Selected problem areas may be chosen for longer contact times in hopes of improving results.
External factors may also affect treatment outcome, and these, too, must be considered when performing the peel. Climate, for example, is one such factor. The drier the climate, the drier the skin, and the more likely the treatment area is to be irritated and more deeply penetrated by the peeling solution. Conversely, the more humid the climate, the oilyer the skin, the more vigorous and meticulous the preprepping cleansing and the application need to be in order to achieve the desired response.
Season of the year is another factor. Winter's windy, chapping weather tends to make skin more sensitive and more easily penetrated by the acids, necessitating adjustments in the concentrations of the solution and the contact time. On the other hand, summer heat can lead to excessively oily skin and the need for a more vigorous degreasing to ensure adequate penetration of the peeling solution.
The way you ordinarily care for your skin can also play a significant role. You should be sure to inform your doctor if you regularly cleanse with alkaline soaps or cleansers containing abrasive particles, or lather up with polyester scrub sponges or wash cloths; use alcohol or witch hazel-containing toners and astringents as part of your make-up removal routines; enjoy vigorously towel-drying your skin after showering; or swim frequently in chlorine pools. All of these factors can promote skin dryness and irritation and therefore increase the potential for undesirably deeper penetration of the peeling solution.
It is important to note that when it comes to superficial peeling (as opposed to medium and deep peels, see below) one peeling session is seldom enough to effect any lasting changes. For this reason, a series of six to twelve peels spaced at biweekly or monthly intervals is usually needed to achieve optimal results. Interestingly, recent findings suggests that frequent, periodic superficial peels may actually yield similar overall improvements to those seen with medium-depth peels. After the initial series is completed, for maintenance, superficial peels may be scheduled at regular intervals of one to four months, as needed. The enormous trade-off for the more gradual improvement resulting from a series of superficial peels is no downtime from work or social activities.
Prices per session vary with the region of the country, location of the peel, size of the area being treated, and with specific chemical or combinations of acids used. They generally range from $150-$350. Taking convenience, cost and efficacy together, it's easy to see why these lunchtime fixes make such appealing peels.
Skin Freshening Peels
In your readings, you may come across the phrase "skin freshening" peel. This usually refers to applications of either glycolic acid in low concentrations, ranging between 20% and 50%, or of TCA in concentrations not exceeding 10%. Otherwise, the manner of pretreatment cleansing, application and postreatment care are pretty much the same as with superficial peels. They are frequently performed in salons as well as doctor's offices, and have sometimes been referred to as "salon peels."
Naturally, the lower concentrations of the peeling agents employed in freshening peels would not be expected to dramatically improve the skin or impact significantly on wrinkling, but a series of these skin freshening peels performed at regular intervals may be helpful for slightly smoothing the skin, increasing its luster, and somewhat lightening freckles and "llver spots."
When properly performed, skin freshening peels are usually so mild that you can expect to leave the session with at most a mild, temporary sunburnlike flush that may last for a few hours. Freshening peels typically run between $150-$200 per treatment.
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