Skin Care Including Chemical Peeling

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Chapter 2 Skin Care Including Chemical Peeling

Zoe Diana Draelos

Skin is the defining boundary of our personal space, a self-renewing organ, the first line of defense against systemic infection, and an indicator to others of our chronologic age. It is a barrier that weathers with advancing age and the insults of ultraviolet (UV) radiation to become wrinkled, discolored, and uneven. Skin care includes cleansing, moisturizing, and photoprotection, while chemical peeling is a method for improving the appearance and function of aging skin.

Summary

1. Chemical peeling is the controlled removal of the stratum corneum, epidermis, and/or superficial dermis to improve skin texture and pigmentation.
2. Superficial chemical peeling with hydrophilic glycolic acid or lipophilic salicylic acid is intended to produce mild exfoliation of the stratum corneum.
3. Medium-depth chemical peeling with trichloroacetic acid preceded by a superficial chemical peel is useful in improving facial dyspigmentation.
4. Deep chemical peeling with phenol is useful in improving superficial facial rhytids, but inevitably produces skin lightening.
5. Chemical peel is contraindicated in patients who have been treated with systemic tretinoin within the previous 6 months and as a treatment of keloids.
6. The skin barrier can be visualized as a brick wall consisting of the protein-rich corneocytes functioning as the bricks held in place by intercellular lipids as the mortar.
7. Cleansers are designed to remove environmental dirt, sebum, bacteria, and fungal organisms from the face while leaving the intercellular lipids and stratum corneum barrier intact. Modern cleansers contain synthetic detergents (syndets), such as sodium cocoyl isethionate and sodium laureth sulfate, which maintain skin hygiene, but prevent damage to the intercellular lipids.
8. Moisturizers decrease transepidermal water loss, creating an environmental optimal for barrier repair. They create an occlusive barrier to evaporation (petrolatum, dimethicone, mineral oil) or functioning as a humectant to attract water from the dermis to the viable epidermis and stratum corneum (glycerin, propylene glycol, sorbitol).
9. Estrogen replacement therapy and oral contraceptives predispose the patient to hyperpigmentation following chemical peel.
10. Sunscreens can be added to moisturizers to prevent UVB- and UVA-induced photodamage and photocarcinogenesis.

Introduction

Skin is the defining boundary of our personal space, a self-renewing organ, the first line of defense against systemic infection, and an indicator to others of our chronologic age. It is a barrier that weathers with advancing age and the insults of ultraviolet (UV) radiation to become wrinkled, discolored, and uneven. Skin care includes cleansing, moisturizing, and photoprotection, while chemical peeling is a method for improving the appearance and function of aging skin.

The skin is composed of three layers: the stratum corneum, epidermis, and dermis.

The stratum corneum forms the skin barrier and is composed of two distinct anatomic units:

• protein rich cells (corneocytes);
• skin lipids that hold the corneocytes together (Fig. 2.1).
image

Fig. 2.1 Stratum corneum. The stratum corneum is visually modeled as a brick wall with the bricks representing the corneocytes and the mortar representing the intercellular lipids.

Structural damage to the corneocytes or to the lipids results in a defective barrier. With the aid of an electron microscope, it is possible to see the covalently bound lipid layer between the corneocytes forming an organized watertight seal over the body (Fig. 2.2).

image

Fig. 2.2 Intercellular lipids. The intercellular lipids that surround the corneocytes provide waterproof characteristics to the skin barrier.

Barrier damage occurs when:

• the intercellular lipids are removed, typically by the chemical insult of soaps;
• the corneocytes are physically removed, such as through aggressive scrubbing or the use of chemical peels.

The health of the skin is therefore ultimately dependent on the non-living stratum corneum. The underlying viable epidermis and dermis form the cellular renewable layers of the skin, accounting for its strength and distensible characteristics.

The most important role of the stratum corneum is to modulate the water content of the skin, which should be approximately 30%. Too much water creates maceration and too little water decreases the elastic properties of the skin and creates skin surface wrinkles of dehydration.

Equilibrium between the external climate and internal environment of the body occurs at about 70% humidity; however, the average humidity of a conditioned environment is 20–30%. Therefore, there is a constant net loss of water from the skin to the air (i.e. transepidermal water loss). If this water loss becomes excessive, the skin recognizes that a barrier defect has occurred, resulting in a rapid burst in the synthesis of intercellular lipids (ceramides, sterols, and fatty acids).

Deliberate wounding of the skin, such as the insult induced by chemical peeling, results in a profound, but controlled, damage to the skin structures, requiring the proper selection of skin care products to optimize the cosmetic result.

Indications

Fair complected patients:

• dyspigmentation
• poor skin texture

Relative contraindications

• Patients with dark skin (Fitzpatrick types IV and higher)
• History of consumption of oral retinoids within the past year
• Radiated skin.

Contraindications

• Hypersensitivity to chemical peels
• Keloid formation within 6 months after cessation of oral retinoids
• Evidence of poor healing.

Skin peeling is a controlled removal and renewal of the various layers of the skin, depending on the depth of the wound:

• superficial peels wound the stratum corneum and possibly the upper layers of the epidermis;
• medium-depth peels wound the stratum corneum, epidermis, and superficial dermis;
• deep chemical peels wound the stratum corneum, epidermis, and mid-dermis.

The depth of the peel is controlled by the strength of the acid applied to the skin surface and the length of time for which the acid is left in contact with the skin.

Chemical peels are a carefully controlled wounding of the skin and are designed to improve cosmetic appearance.

Any part of the body can be subjected to a chemical peel, but the face produces the most dramatic and reliable results. This is because the facial skin is thin and it heals with minimal scarring. The face is the only body site where a deep chemical peel is performed.

Superficial chemical peels produce little effect on any area other than the face where they are used to produce a mild exfoliation improving skin texture. This improved skin texture is appreciated by the patient as increased facial shine (sometimes referred to as radiance) and smoother facial cosmetic application.

Medium-depth chemical peels may be performed on the entire body, but are most frequently used on the neck, chest, and arms. Typically, higher concentration acids are used on the face with a reduced concentration applied to any other body area.

Chemical peels produce the best results in fair complected individuals (Fitzpatrick type I and II) with predominantly pigmentary photodamage. Darker skin types (Fitzpatrick type III and higher) are more challenging to treat with chemical peeling because the inflammation induced by the superficial or medium-depth peel may result in unsightly post-procedure hyperpigmentation. Darker skin types also more frequently exhibit hypertrophic scarring and keloid formation, predisposing to an undesirable outcome.

Deep chemical peels are never performed on darker skinned individuals because the acid may damage the melanocytes, resulting in permanent hypo- or depigmentation, unless hypopigmentation is part of the aesthetic goal.

A chemical peel can be performed for a variety of indications:

• superficial chemical peels can be used to enhance exfoliation, improve skin texture, and minimize comedonal acne;
• superficial peels damage the skin barrier and may be used to enhance the penetration of topical medications, such as hydroquinone skin lightening cream or tretinoin, and
• a superficial chemical peel is the first step in performing a medium-depth peel, allowing deeper penetration of the acid into the skin;
• medium-depth peels are used to improve defects in skin pigmentation (such as lentigenes and melasma), and fine lines around the eyes and upper cheeks;

The best indication for chemical peeling is to improve facial pigmentation.

A medium-depth peel will not improve deeper rhytids around the mouth and folds on the face, such as the nasolabial and melolabial folds. It is not possible to successfully improve facial folds with any type of chemical peel, but deeper rhytids around the mouth and on the lateral cheeks can be improved with a deep chemical peel, possibly combined with a facelift procedure or the use of injectable fillers.

In my opinion, the best indication for chemical peeling is in the improvement of facial pigmentation. The precise ability to control the depth of the peel by proper acid selection yields excellent pigment removal without further dyspigmentation or scarring. Although laser resurfacing is sometimes used for pigmentation improvement, the laser does not afford the control of chemical peeling. Chemical peeling is an art combining visual assessment of the peel depth produced by the different types and strengths of acid left on the skin for varying intervals. This allows clinicians to adapt the chemical peel to the varying degrees of pigmentation in the treated area.

Preoperative History and Considerations

A detailed history must be obtained prior to a chemical peeling procedure to ensure an optimal outcome and result longevity.

Individuals who have been treated with systemic retinoids should not undergo a chemical peeling procedure for at least 6 months to 1 year, depending on the depth of the chemical peel desired. This is because systemic retinoids such as isotretinoin reduce the activity of sebaceous glands and thereby increase susceptibility to hypertrophic scarring, which can be disastrous in the case of a chemical peel where the entire face is wounded.

A history of oral hormone supplementation is also important. Estrogen replacement therapy and oral contraceptives predispose the patient to facial hyperpigmentation. In some individuals, dyspigmentation may rapidly return following a facial peel if exogenous estrogen is consumed. Discontinuation of the estrogen for at least 3–6 months prior to the procedure and after the procedure is advantageous, but not always feasible. Women who are not able to discontinue their estrogen should be advised that the pigmentation may return and counseled on the proper use of photoprotection.

It is also worth inquiring about the patient’s skin care regimen. Patients who are using prescription topical retinoids, such as tretinoin, adapalene, or tazarotene, will experience much deeper and more rapid penetration of the acid into the skin. Although retinoids are used prior to medium and deep chemical peels to enhance penetration, they may produce a much deeper peel than expected or desired in patients wishing only a superficial chemical peel.

Patients may also be undergoing microdermabrasion, spa-administered chemical peels, or other aesthetician procedures that damage the skin barrier, enhancing acid penetration and yielding unexpected results.

Operative Approach

The peeling procedure for superficial, medium, and deep peels is somewhat similar, each deeper peel building on a more superficial skin wounding (Table 2.1).

Table 2.1 Chemical peel technique comparisons.

image

Superficial peels

Superficial peels usually consist of either a glycolic or salicylic acid solution applied to the face in three coats. Glycolic acid superficial peels are water-soluble (hydrophilic) in contrast to salicylic acid peels, which are oil soluble (lipophilic).

Glycolic acid peels

Glycolic acid peels in concentrations of 10% or less may be applied by unsupervised aestheticians in a spa setting, but concentrations of 20% or higher should be applied by a physician or in a carefully supervised setting.

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