EPANDING THE CONTENT OF AN OUTLINE using notes.pptx
Part 3 chemical peels-2-51.pptx in cosmetic surgery and esthetic
1. AGENDA
• Classification of chemical peels
• Effect, Indication, Contraindication
• Preparation/Application
• Transient/Persistent Complications: how to avoid or treat it
2. Classification of chemical peels
• Very superficial light peels
Necrosis up to the level of stratum corneum
TCA 50%, Glycolic acid up to 50%, Salicylic acid 20-30%
• Superficial light peels
Necrosis through the entire epidermis up to basal layer
TCA 10-30%, Glycolic acid 50-70%
• Medium depth peels
Necrosis up to upper reticular dermis
TCA 35-50%, TCA 35% + Glycolic acid 70
• Deep peels
Necrosis up to mid reticular dermis
Baker-Gordon phenol peels
4. Peelings: indications
• Upper epidermal defects, such as melasma, require superficial peels, e.g. Glycolic acid peel
• Superficial dermal defects, such as photoaging skin, require medium-depth peels, e.g. blue peel
• Deeper defects, such as acne scars, deep perioral rhytides, require deep peels, e.g. Baker Gordon solution
5. Classification Of Chemical Peels
The depth of the peel depends on following factors:
1. Chemical product
2. Concentration
3. Number of coats
4. Skin type
5. Skin condition
6. Classification Of Chemical Peel
The depth of the peel determines:
1. Patient's inconvenience during and after the procedure
2. Recovery time
3. Risk of adverse effects
4. Result
7. Classification Of Chemical Peel
A. Superficial peels
• Controlled necrosis in the epidermis up to basal layer
• All skin types
• Downtime and minimal complications
Alpha hydroxy acid
Salicylic Acid
Trichloroacetic acid (TCA) 10-25%
Jessner solution
Carbon dioxide
8. Classification of chemical peels
B. Medium-depth peels
• Controlled necrosis through the entire epidermis up to the papillary dermis
• Penetration depth: 0,45 mm
Trichloroacetic acid (TCA) 15% + fruit acids
Trighloroacetic acid (TCA )23%+ ascorbic, citric and phytic acid
Trichloroacetic acid (TCA) 35% after
Glycolic acid 70% or
Jessner solution or
Solid Carbon dioxide
Trichloroacetic acid ( TCA) 50%
Glycolic Acid 70%
Pyruvic Acid 50%
9. Classification Of Chemical Peels
C. Deep peels
• Controlled necrosis up to the level of the mid-reticular dermis
• Penetration depth: 0,6 mm
• Longer downtime and higher risk for post-procedure complications
Baker-Gordon solution (penol peel)
10. Classification of chemical peels
D. Combined or modified chemical peels:
Blue Peel (TCA 15-20% + Obagi patented blue base), medium-depth peel
Easy Peel (TCA 15%+ fruit acid), medium-depth peel
Unideep Peel (TCA 23%+ ascorbic, citric and phytic acid), medium- depth
TCA 35% +
• Glycolic acid 70% or
• Jessner solution or
• Solid Carbon dioxide
Jessner solution (salicylic acid 14%, lactic acid 14%, resorcinol 14% , alcohol), superficial peel
Baker-Gordon solution (Phenol 88%, diluted in water, septisol, croton oil), deep peel
11. Classification Of Chemical Peels
The advantage of combined and modified chemical peels:
• Slower but deeper penetration into the skin layers
• Same efficacy as the single peels in higher concentration
• Less side effects and risk of complication
12. Superficial Chemical Peels
• Alpha Hydroxy Acid (AHA)
• Chemical agents classified under AHA:
lactic acid
glycolic acid
tartaric acid
citric acid
malic acid
• Concentrations: glycolic acid 10-50%
• Water soluble
• Very small molecules, can penetrate well through the skin
13. AHA, BHA and PHA.. what are they and what is the difference?
• AHA (alpha hydroxy acids) are acids that are derived from fruits, nuts, milk or sugars.
• They are hydrophilic (attracted to water) and break down the bonds between cells (desmosomes) to allow for
easier exfoliation. The most commonly used AHA are:
glycolic acid (derived from sugars) is degreasing and Is effective for controlling sebum production
mandelic acid (derived from bitter almonds) helps control pigment
citric acid (derived from citrus fruits and corn) is brightening and increases epidermal thickness
lactic acid (derived from milk and sugars) is antimicrobial, hydrating, and inhibits pigment
14. AHA, BHA and PHA.. what are they and what is the difference?
• BHA (beta hydroxy acids), the most common of which is salicylic acid, is derived from willow tree bark,
wintergreen oil or sweet birch.
• Because salicylic acid is lipophilic (attracted to oil) and keratolytic, it is able to penetrate the oils in the
skin and clear out follicles of excess debris and skin cells, making it especially effective in the treatment
of acne skin conditions.
15. AHA, BHA and PHA.. what are they and what is the difference?
• PHA (poly hydroxy acids) function the same as AHA, but cause less irritation due to their larger molecular
size.
• They are especially beneficial in treating sensitive skin types that may not be able to tolerate AHA, They
provide anti-inflammatory and antioxidant benefits as well as assist with exfoliation.
• Some common PHA are:
lactobionic acid (derived from lactose found in cow’s milk) is humectant, antioxidant and soothing
galactose is a sugar utilized in glycosaminoglycan and collagen synthesis, and cell migration, which
may enhance wound healing
gluconic acid (a naturally occurring ingredient in cells), also known as gluconolactone in skin care
products, is antioxidant and anti-inflammatory, while possessing AHA properties
16. Lycolic Acid Peel
• Alpha Hydroxy Acid = AHA
• Smallest molecular structure of the AHAs
• High penetration potential
17. Superficial Chemical Peels
• Effect in the skin:
Increasing desquamation, thinning the stratum corneum by exfoliation, reducing follicular
hyperkeratosis
potentiating the absorption of other therapeutic agents into the skin
increased reflectivity, luminous glow, youthful appearance s Stimulating the production of new skin
cells, e.g. Fibroblasts
Stimulating the synthesis of collagen 1 & procollagen 1, elastin and glycosaminoglycans. These
substances diminish during aging process
Increasing production of hyaluronic acid - skin moisture
Stabilisation of the acid protection sheath
27. Glycolic Acid Peel Contraindication
• pregnancy/ breastfeeding
• recent surgery/ wounds
• in treatment area active bacterial, viral or fungal infection
• tendency to keloid formation facial dermatitis
• very sensitive allergic skin
• application before puberty
• taking photosensitizing medication
• immunosuppressed patients
• unrealistic expectations
28. Preparation
• no extreme sun exposure 4 weeks before the treatment
• min. 2 weeks skin care containing AHA/ PHA
• no shaving or use of perfume at the peeling day
• photo-documentation before the first and after each 6 sessions
• herpes simplex prophylaxis if previous infections reported
29. Preparation Regimes
• Products containing tretinoin, hydroquinone or alpha hydroxy acid suppose to
reduce postinflammatory hyperpigmentation
help the skin heal faster
Reduce immediate reaction and downtime from the peeling agent to the peeling agent
Enhance the result by achieving better penetration
• There are controversial researches about the efficacy of pretreatment regimen. However the standard
hydroquinone- based bleaching agents are not without concerns and are not available in al countries
30. Preparation
Glycolic acid peel in treatment of melasma beneficiary effects of:
2-4 % Hydroquinone > 0.025-0.1 % retinoic acid
as priming agents in order to:
• Enhance the result of glycolic acid peel
• Decrease risk of post-peel hyperpigmentation
31. Preparation
• preoperative counseling and consent
• information through brochures, presentations and personal discussions
• the limitation of the procedure, need for several sessions for proper result
• transient complications as acid burn with epidermolysis, vesicle, crust and pain
• persistent complications as hypopigmentation, hyperpigmentation and superficial scar
• necessity of sun protection 4 weeks after peeling
32. Consent
• details about the procedure
• All possible complications
• Limitations of the procedure
Number of sessions to achieve the desired result
• patient’s and physician’s signature
• Date and time
33. Application
• Start with:
low acid concentration
high PH value
short duration of application time
one layer application
34. Application
• Label al products clearly or put in different types of bowls to distinguish them easily from each other
• Put the peeling agent, as much as you need, into a glass bowl
• Use an acid resistant brush or a sterile gauze to apply the peeling agent onto the skin
• Prepare an electric fan or cooling machine to reduce discomfort during the procedure
• Position the patient comfortably in the supine flat position. Head should not be higher or lower than trunk to
avoid the peeling from flowing into eyes or mouth
35. Application
• Cover the hairs with a disposable hair
• Protect the lips and eyelids with an occlusive ointment, e.g. petroleum jelly
• Let the patient keep the eyes closed during the complete procedure. Optionally apply one cotton pad
soaked in normal saline on each eye
• Protect the ears with small cotton balls
• Cover the neck and shoulders with towels
36. Cleansing/Decreasing
• Thorough cleansing and degreasing of the skin Is very important for an even and deep penetration therefore
the agent
• Most chemical peel agents are not lipid soluble, cannot penetrate into the skin, if skin is olly
1. Wash the face with a cleansing/foaming gel for oily skin
2. Remove excess fat with an alcohol based toner for superficial peels and sensitive skin
3. Use additionally acetone for medium-depth and deep peels or for patients with normal or oily skin
• To enhance the result of chemical peels a mi crodermabrasion can be performed just prior to the peeling (
for advanced practitioners only)
• Microdermabrasion = much deeper penetration of the agent into the skin
37. Application Of The Peeling Agent
• Start with the least sensitive parts of the face and finish with most sensitive parts ( upper lips, below the
eyes)
• Apply an even layer with same thickness and no gaps on the entire treatment area
• Make sure in case of thin fluids, the product does not move into eyes, ears, mouth, neck etc,
• Start a timer as soon as you start applying the peeling agent
• Observe the skin during the whole procedure and the application to recognize adverse reactions on after
time
38. Observe skin reaction
Reaction (frost/pseudofrost/erythema)
Frost:
• Whitish color on the skin
• Bright white in superficial peels
• Grayish white in deep peels
• Keratin agglutination
• End point/ end stage
• TCA/ Jessner solution/ Phenol
Pseudofrost:
• Whitish color on the skin
• Crystallization of the acid
• End point/ end stage
• Salicylic acid
Erythema:
AHA peels show either no change of skin color or only mild to severe erythema
39. Neutralization
• Neutralization of chemical peeling agent is very important
Neutralize when therapeutic end point time is achieved
• Fluid bicarbonate is the ideal neutralizing pbuffer agent for AHA peels
• Cold water can replace bicarbonate if this is not available
• Neutralizing diminishes the burning sensation
• Alpha hydroxy acids have a low acidity value >cannot induce enough coagulation of the skin proteins 5
cannot neutralize itself
• No neutralizing agent required for salicylic acid, Jessner solution, TCA and phenol, because they are self-
neutralizing
• Salicyclic acid needs about 2-3 minutes until it neutralizes itself and burning sensation diminishes.
44. Application
PEELING AGENT INDICATION 4 MIN.
35%
3 MIN.
52, 5%
4 MIN.
70%
GLYCOLIC ACID
GLYCOLIC ACID
MELASMA
POST ACNE SCAR
BEST RESULT
BEST RESULT
46. Salicylic Acid Peel
• Beta hydroxyacid = BHA
• High lipid penetration potential
• good for acneiforme skin conditions
47. Salicylic Acid Peel
• Belongs to the group of beta hydroxy acids
• Derived from willow bark, wintergreen leaves and Sweet birch
• Larger molecule than alpha hydroxy acids 2 keeps the acid in the upper skin surface - more effective in the
uppermost layers
• Most common concentration used: 20-30%
• A newer chemical agent is beta-lipohydroxy acid, a salicylic acid derivative
48. Salicylic Acid Peel
• Effect in the skin:
Lipid soluble = ideal to treat seborrhea and acne
Salicylic acid penetrates into skin pores, unclogges, solves sebum & comedones = comedolytic
Strong keratolytic
Regulates the sebaceous glands
Salicylate has an anti-inflammatory and anesthetic effect > decreased erythema and discomfort
49. In Sal Acid Peels, cristals are visible on the skin
as a white film and must not be mixed up with frost
Salicyic Acid Peel
50. Other Superficial Peels
• Superficial Peel
Jessner solution
• Formerly called Coombe’s formula
• Pioneered by Dr Max Jessner
• Jessner solution is a chemical peel containing: salicylic acid 14% lactic acid 14% resorcinol 14% in
ethanol base
