The Progressive Peel: The Combined Jessner, TCA, Retinoid Peel

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6 The Progressive Peel

The Combined Jessner, TCA, Retinoid Peel

James E. Fulton, Jr.

Introduction

In our evolution of chemical peeling for all skin types we have developed the progressive peel. This is a multiple coat peel in four steps, allowing the operator to watch the skin and adjust the peel to the skin’s reaction. Some patients will require three or four coats of each progressive peel solution I, II, III and IV. Other patients will develop the end point of the rosy red hue with a white frost with several coats of progressive peel I or II. This gradual progression of the peel allows the operator to stop at a safe end point. The step-by-step process avoids alabaster white, yellow or grey frost that may occur with high concentrations of TCA (45–55%) applied in one or two coats. Historically, the suggestions of other progressive peelers still apply (Box 6.1).

Box 6.1

Suggestions from Eller and Wolff – (1941)

• A patch test maybe done if there is a history of an untoward reaction.
• Preliminary to any procedures the skin should be thoroughly cleansed and degreased. The skin is cleansed with soap, followed with hot towels for 15 minutes. Then, the skin is cleansed with ether to remove any remaining grit.
• The solution is applied over the entire face with a cotton applicator every 10 minutes for 3 to 8 applications.
• The pain maybe lessened by drying with a fan.
• During the period of applications, the patient should drink five or six glasses of water.
• The next day the skin assumes a darkish hue, becomes parchment-like or mummified and, then, exfoliation begins on day three or four.
• Emollients are not to be used until exfoliation is under way.

This chapter will be an overview of this progressive peel. We outline the step-by-step skin rejuvenation program (Box 6.2) for the improvement of complexion problems, fine lines and/or blotchy dyspigmentations in 155 patients. This illustrates what types of patients will benefit from the progressive peel. Afterwards, you will be able to conduct your patients through this step-by-step program to a freshened complexion. Previous authors in this textbook have also discussed skin preconditioning before the peel and more penetrating peels are covered in later chapters (see Box 6.3).

Box 6.2

Step-by-step skin rejuvenation

• Step I avoid free radical generators

♦ No sun – no smoking – no sugar

• Step II use your daily skin care program

♦ Buffing grains, skin toner, vitamin A lotion

• Step III add microdermabrasions, photo facials
• Step IV add Jessner, TCA, retinoid peels
• Step V add laser, dermasanding, phenol

Box 6.3

Key features

• The more coats that are used the deeper the peel, so multiple coats of a 15% TCA can mimic the results of one or two coats of 30% TCA
• If too much surface area (face, arms and chest – 20% of the body’s surface area) is exposed to several coats of salicylic acid (14% in ethanol) that is left on the skin (as in the classic Jessner peel) eight to twelve hours later the patient can develop severe nausea, vomiting, dizziness and tinnitus from salicylism.

Method

• Patient selection

Skin Analysis

The skin analysis is the starting point for this rejuvenation process. The patient is classified by their Fitzpatrick skin type, plus, the extent of wrinkling, blotchy dyspigmention, sallow color, telangiectasia, pebbly appearance and the presence of skin lesions such as actinic keratoses. The overall score dictates the extent of skin rejuvenation required (Box 6.4). These findings correlate with the Rubin photo aging index. Rubin Level I is characterized by epidermal findings that maybe corrected with an aggressive topical skin care program alone. Rubin Level II is associated with papillary dermal findings which require a daily skin care program plus the progressive peel. Ruben Level III is with reticular dermal level changes which may require deeper rejuvenations such as laser resurfacing, dermabrasions or phenol peels. These will be covered in later chapters.

Box 6.4

Skin aging index

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Informed Consent

The risks and benefits of this step-by-step skin rejuvenation program and the risks and benefits of alternative treatments including no treatment at all are discussed with the patient. All their questions are answered. These peels are contraindicated in some patients (Box 6.5). The degree of skin damage is determined and further documented with digital photography. Each patient signs the informed consent.

Box 6.5

Contraindications to the progressive peel

• Pregnancy
• Breastfeeding
• Active infection
• Obsessive picker

• The step-by-step skin rejuvenation program (Box 6.2)

There are five steps in the rejuvenation program. Step I of the rejuvenation process must be accomplished by the patient themselves. Free-radical generators such as sun worship, cigarette smoking and excessive refined carbohydrates in their diet must be avoided. If the patient plays golf or tennis in the sun every day or continues to smoke, the program will not work. The results will not last. If the patient continues to smoke, the collagen will be destroyed faster than it can be rebuilt. The ingestion of excessive sugars speeds up the glycosylation process in the dermis and makes the collagen more susceptible to hydrolysis.

Step II is the daily skin care program using cleansing granules, alpha hydroxyl acid toners and vitamin A conditioning lotions to accelerate the production of new skin cells. These three skin care formulations are used daily. However, patients with dry skin or who live in a dry climate start slowly, skipping days as needed to avoid retinoid dermatitis.

Step III is glycolic acid peels combined with microdermabrasions. This abrasion keeps the skin moving so it will not accommodate to step II. This step can be repeated every 2 to 4 weeks.

Steps II and III will continue for 4 to 16 weeks depending upon the skin type (Box 6.6) For example, the skin conditioning must be longer in the darker skin types to reduce the possibility of dyschromias.

Box 6.6

Length of preconditioning before the peel

• Caucasian: 4–6 weeks
• Mediterranean: 8–10 weeks
• Asian/Indian: 12–14 weeks
• Afro/American: 16–20 weeks

Step IV will be the application of the progressive peel. This will be adequate rejuvenation for the patients with a moderate skin aging index.

Step V, the phenol peel or equivalent may be required by some patients with a higher skin aging index. These procedures are covered in later chapters.

• The progressive peel

As a continuum of the skin rejuvenation process, the progressive peel is added after the skin has adjusted or accommodated to the initial two steps of the five-step program. The acute phase of retinoid dermatitis with the excessive peeling has passed. Although the skin may still be mildly flaking it will accept the peel safely; whereas, the resting untreated skin may not peel or the dermatitic skin seen during the initial phase of topical treatment with corrective skin care products is so raw that burning may develop. This process of preconditioning has been discussed in more detail in previous chapters.

Step IV: The Progressive Peel

After completing steps I, II, III of their skin care program the patient is ready for step IV, the progressive peel. They wash their face to remove any residual make-up, remove contact lenses and ear rings. Again, the peel program is outlined for them.

Tray Setup

A standard tray set up is important so nothing will be missed (Figure 6.1). Well-marked containers are used for the four peel solutions. Folded 3″ × 3″ cotton gauze is used to scrub in the chemical solutions. Five or six mL of each solution is poured onto the gauze which is rung out before the application begins sp the solution does not drip, cotton tipped applicators are available for small areas that require touch-ups or for around the eyes or temple areas. An eye wash solution is always on the tray to irrigate the eyes, if necessary. A bottle of water is on the tray to remind the patient to drink 4 or 5 glasses during the day to flush out any penetrating chemicals.

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Figure 6.1 The tray set-up. The peel tray is always set up in a standard fashion with well marked bottles. 3″ × 3″ cotton gauzes and cotton-tipped applicators are available. The eye wash solution is always close at hand. The four bottles of the Progressive Peel are clearly labeled. (The progressive peel ProPeel®, Vivant Pharmaceuticals, Inc. Miami, FL)

The Progressive Peel: Step I

We use the modified Jessner solution both to clean the face and to treat the complexion at the same time. Others will use Septisol® and acetone cleansers before the application of the Jessner solution. We do not use these additional cleansers; yet, the endpoint of the erythematous blanch remains the same. As the moistened gauze of lactic acid, salicylic acid and citric acid is applied on the hair line of the forehead the operator talks the patient through the procedure. The patient controls the fan and is told to hold it close to the face if the burning sensation becomes too intense (Figure 6.2). The application of these peels progresses from the forehead to the cheeks and, then to the center of the face and across the chin, lips, and nose. Three or four coats are applied until moderate erythema develops or the burning sensation becomes intense. The patient continues with the fan for several minutes until the burning sensation fades. To avoid salicylism the patient is well hydrated with fluids and the surface area of the peel is limited to a face, neck and décolleté. The patient drinks a glass of water between steps. (See the video presentation for the actual steps of the procedure.)

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Figure 6.2 The fan. Note that the patient controls the fan. This allows them to control the pace of the procedure and extent to the burning. The closer they hold the fan to the face the faster the TCA solution evaporates. This reduces the pain sensation

The Progressive Peel: Steps II and III

If no significant erythema or blanching has occurred the operator advances to step II. The TCA 7.5% and salicylic acid 2% solution is applied in the same fashion as in step I. After three or four coats the operator observes for erythema and blanching. The patient relates to the operator the extent of the burning on a scale of 1 to 10 and holds the fan accordingly. A significant erythema, blanching or burning sensation indicates the end of step II. If this has not developed, the operator progresses to apply the solution of step III: TCA 15% and salicylic acid 4% in multiple coats. Blanching will usually occur after two or three applications (Figure 6.3).

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Figure 6.3 The foggy-red blanch of the progressive peel. After several coats of the progressive peel the skin develops a foggy-red blanch. This is the end-point of the peel. The blanch will fade in ten to fifteen minutes and begin to peel in three to four days

The Progressive Peel: Step IV

This high dose retinoid (retinyl propionate 10%) is applied as a blender with the 3″ × 3″ gauze at the end of the peel. Only one or two coats are needed. The extent of the uniform application can be checked with the UV lamp (Wood’s lamp) as the retinoids are fluorescent.

• Post peel procedures

The patient is told to drink an additional four glasses of water during this initial day and to wash off the retinoid in the shower four to five hours later with a mild cleanser. No occlusive ointments are applied until three days later when the peeling begins. However, the patient can use a light moisturizing cream or sunscreen the next day. The desquamation always begins in the perioral area and progresses across the face to the hairline (Figure 6.4). At that point the peeling edge is kept moist with the application of an aloe vera, petrolatum-based recovery ointment (Recovery Ointment, Vivant Pharmaceuticals, Miami FL). The patient is allowed to cut off excessive scale and moisturize but they are told not to pull or pick off this scale as this manual debridement may damage the new skin and result in reactive hyperpigmentation. A sunscreen-based moisturizer is applied to the new skin for several days until the skin can tolerate the gradual reimplementation of the skin care program. In patients with dyschromias, the application of a bleach cream is started around post peel day 8 or 9 in an attempt to block the dyspigmentation on day 17 to 20.

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Figure 6.4 The facial peeling process. (A) Day 0; (B) day 1; (C) day 3; (D) day 5; (E) day 7; (F) day 10. With any of these peels the desquamation begins on the third day and, then, progresses across the face like a wave. By the seventh day the peel is close to the hairline. The patient is reminded not to pull off the scale ahead of schedule. Note the freshened complexion that comes from underneath by the tenth day. The bleaching program must be reinstituted to prevent a recurrence of the dyspigmentation

This progressive peel can be repeated monthly if the patient is on an aggressive rejuvenation program or three to four times annually on a more relaxed schedule.

• Progressive peel: extra strength

If the patient does not peel on the first progressive peel or the patient has very oily skin or lives in a humid climate the operator may choose to the extra strength formula. The solutions of step I and step IV are the same, but the solution for step II is TCA 10%, salicylic acid 4% and phenol 1%. Step III is TCA 20%, salicylic acid 8% and phenol 2% (ProPeel® Extra Strength, Vivant Pharmaceuticals, Miami, FL). This program should not be attempted by the operator until they are familiar with the standard progressive peel.

Results

In the 155 patients studied, the peel always begins in the perioral area on the third or fourth day and progresses out across the cheeks and onto the jaw line on the fifth to seventh day. In the patients with the more extensive areas treated the peel progresses across the chest and arms on the ninth to twelfth day and reaches the back of the hands around day fifteen. The new skin revealed a freshened complexion with an improvement of the fine lines, blotchy brown dyspigmentations and acne impactions. Their daily skin care program was gradually reimplemented to prevent a recurrence. This is especially important for dyspigmentations – as the blotchy brown color tends to recur around day eighteen to twenty, so the bleaching program is reinstituted on day seven to ten. Often, the bleaching gels are too irritating for the new skin so a hydroquinone, kojic acid and vitamin A cream formulation (2/2/2 Bleaching Cream, Vivant Pharmaceuticals, Miami, FL) is preferred.

Several cases studies will illustrate our results.

• Case study 1: acne vulgaris

This 17-year-old patient had developed acne at age 12 years on the nose, chin and forehead. As the condition progressed out across the face it became more inflammatory. Even with his daily skin care program he was unable to control the flare-ups. With the addition of two progressive peels his condition was controlled (Figure 6.5).

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Figure 6.5 Improvement in the acne patient. The progressive peel helps clear the acne impactions. The peel will add to the acne skin care regimen and improve the complexion. Several peels maybe needed

• Case study 2: dyspigmentations

This 28-year-old patient developed melasma after her pregnancies. The condition was only slightly improved with her skin bleaching program. With the addition of progressive peels to her program the melasma improved to the point it could be easily covered up with make-up (Figure 6.6).

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Figure 6.6 Improvement in dyspigmentation. Blotchy brown discolorations were improved when the progressive peel was added to the skin care program. Continual topical skin care was necessary to prevent a recurrence with sun exposure or hormone changes

• Case study 3: photoaging

This 42-year-old patient had begun to develop fine lines. Although, there was some improvement with botulinum treatments and a skin care regimen the most dramatic improvement came after three progressive peels (Figure 6.7).

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Figure 6.7 Improvement in fine lines. The sallow color and fine lines were improved with several progressive peels in addition to the daily skin care program

• Case study 4: actinic keratosis

This 53-year-old flight attendant was developing multiple actinic keratosis. She began the conditioning program with buffing grains, toners and vitamin A conditioning lotions. In addition, she underwent three progressive peels. The most prominent elevated keratotic lesions were treated individually with several additional coats of step III solution on a cotton swab (Figure 6.8).

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Figure 6.8 Improvement in actinic keratosis. Note the improvement in the actinic keratosis after using the daily skin care program and undergoing three progressive peels

• Case study 5

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Figure 6.9 Hispanic patient with melasma. (A) Before. (B) The second day post peel. Note the dumped pigment on the cheek and the start of the peel around the mouth. (C) The fourth day. (D) The eighth day after the peel. The patient will restart the bleaching program to prevent a recurrence

• Case study 6

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Figure 6.10 The picker. (A, B) Note the blanching with step I where the client had picked with the finger nail. The peel was completed with step IV. II and III were deleted. The skin was still blanched after 10 minutes, indicating a deep peel (C, D). An excellent peel at three days (E, F) Great results post-peel (G, H)

• Case study 7

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Figure 6.11 Blistering. (A, B) A melasma patient with an excellent rosy red blanch after steps I, II, III and IV. (C, D) Note the blister on the upper lip on post peel day one. This was drained with a needle. (E, F) Excellent results. The patient can now return to her skin care program to prevent a recurrence

• Case study 8

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Figure 6.12 This patient returned for a progressive peel every month to lighten the complexion

Complications (Box 6.7)

The complications with this step-by-step skin rejuvenation process have been minimal. By developing a rapport with the patients during the initial steps in the process the compliance was excellent. The patients did not pick off their peeling skin and secondary bacterial infection did not occur. The accelerated wound healing resulting from the preconditioning of the skin made possible complete reepithialization within 7 to 10 days. However, three patients developed mucocutaneous herpes simplex flare-ups which responded rapidly to oral antiviral medications. If the patient has a history of frequent herpes flare-ups, we now prescribe prophylaxis with acyclovir (200 mg three times daily for 5 days) starting the day after the application of the peel. No patients developed extended herpes lesions across the face as maybe seen with deeper rejuvenations. Five patients noticed a temporary acne flare-up which responded to the reimplementation of their skin care skin program. There were no cases of hypopigmenation or scarring.

Box 6.7

Complications of progressive peel (review of 89 patients)

• Herpes simplex: 3 patients
• Acne flare-ups: 5 patients
• Hyperpigmentation: 7 patients
• Hypopigmentation: no patient
• Scarring: no patient

Discussion

With the addition of the progressive peel to the step-by-step skin care program it is possible to significantly accelerate the skin rejuvenation process. Over time the skin accommodates or hardens to the stimulus of buffing grains, hydroxyl acid toners and vitamin A conditioning lotions just as it does to UV light or detergents. When the top layers of skin are stripped off with the Progressive Peel the daily skin care products become effective again. Also, new fibroblasts are formed and new collagen develops – which puff out the fine lines of aging.

The length of preconditioning before these peels varies with the complexion type. Dr Peter Aronshon always said, ‘White skin is a cake-walk’, meaning that peeling skin without color is easy – ‘white comes back white’. However, skin with color is a different matter, it can come back lighter or darker depending on the extent of the stimulus. In the darker complexioned patients preconditioning is much more important. The longer the skin is pretreated the easier it is to predict the final result after the peel. Also, during this preconditioning you can inform the patient about the complications. You can decide if they will tolerate temporary reactive hyperpigmentation and/or find out which patient maybe a management problem.

The major contraindication to these peels is the patients who are obsessive-compulsive pickers. They will try to convince you that they will cease picking after the peel, but the flaking of the skin drives them crazy and they can destroy your results in ten minutes in front of the mirror and, then, deny they did it.

As we have developed more experience with peels, we have decreased the strength of the TCA peeling solution. When the dermatologists initially began using TCA the usual strength was 40% to 45%. TCA turned out to be not as predictable as phenol. With phenol peels there is uniform penetration to a certain level; then, the action stops. This is not so with TCA. There are hot spots where the TCA will penetrate deeper for no apparent reason. These hot spots are less troublesome as the concentration is decreased. In our experience, we have gone from 45%, to 35%, to 25%, to 15%, and, now, to 7.5% TCA. We discovered during these dilutions that the results with TCA are coat dependent. Whereas, the results with alpha hydroxyl acids are time-dependent, and phenol results are cardio-dependent, TCA results are dependent on the number of layers applied. The more coats that are used the deeper the peel, so multiple coats of a 15% TCA can mimic the results of one or two coats of 30% TCA. These dilute peels take more time and more coats – which is exactly what we want – so we have more time to watch the blanch develop and we can discontinue applications at a predictable foggy-red blanch. The weaker strengths of TCA give us more time to think.

The operator must not only watch for the development of the white blanch, but, also, must watch the time for the disappearance of the blanch. The moderate level blanch should disappear in five minutes; whereas, a deeper level blanch may take ten minutes to fade. When the blanch takes 15 minutes or more to fade you know you are in trouble.

You will need to watch this patient closely as they may develop delayed wound healing and a potential for scarring with hypopigmentation or keloid formation. You can never go back, so it is better to err on the side of the light white. It is difficult to neutralize TCA to prevent this burn. Usually, by the time we see the deep white or yellow it is too late to neutralize. However, those with experience like Kim and Bill Cook can neutralize with a spray of bicarbonate solution within seconds of application. They can control the higher strengths. This takes practice.

The method of application is also important. Obagi taught us to scrub in the TCA with abrasive cotton gauze, not even using the newer, gentler synthetic gauzes. Visualize scrubbing in the Jessner to strip off all the debris and dead cells and; then, strip further with the TCA saturated gauzes and, finally, add a few coats of a retinoid on the gauze at the end. No wonder with all this scrubbing we can obtain a good result with dilute TCA. The previous dermatologists would gently apply a few coats of TCA from a distance with a five inch cotton swab without pressure. With this conservative approach there could be streaking since the acid was not always applied uniformly.

Do not forget the fan that the patient holds. This is critical to these peels. The rapid dehydration of these solutions from the air flow recrystalizes these chemicals (especially the TCA) and stops the burning sensation. This eliminates the pain. During the initial applications of the solutions the patients are told not to hold the fan too close. The air currents may cause the peeling solutions to run. Later, have the patient hold the fan up close to evaporate the vehicle. Also, the fan blows off the fumes – so the patient (and operator) is not inhaling the vapors.

After the procedure, do not occlude the peel. Occlusive dressings or ointments may cover the residual peel solutions and reactivate the crystals. The patient will notice pain again and this reactivation will deepen the burn. To avoid this complication nothing is placed on the peel sites until after washing in the shower several hours later. It is only important to apply ointments during the 3 to 5 day postpeel period when the peeling is coming across the face like a wave. Any pulling or stretching of the skin at this point may split the epidermis and create a fissure. This may leave a permanent pigment change or scar so have the patient keep the peeling edge moisturized with a petrolatum-based aloe vera gel recovery ointment. The petrolatum will hydrate the skin and the aloe vera will stimulate the wound healing and reduce the erythema.

Finally, be aware of the toxicology. One of the safe things about TCA is its lack of systemic toxicity. Also, we know about phenol toxicity but we often forget about the toxicity of salicylic acid. If too much surface area (face, arms and chest – 20% of the body’s surface area) is exposed to several coats of salicylic acid (14% in ethanol) that is left on the skin (as in the classic Jessner peel) eight to twelve hours later the patient can develop severe nausea, vomiting, dizziness and tinnitus from salicylism. Have the client drink eight glasses of water during the first day. The progressive peel combination is safer as much of the salicylic acid is removed by the application of step IV – the retinoids. It is still wise to limit the surface area exposed in a thin sensitive female, especially, if they also have a compromised liver or kidney. If necessary, complete the peel on distant areas with TCA alone.

The retinoid for progressive peel step IV can be either retinyl propionate 10%, retinol 1%, retinyl aldehyde 0.5% or retinoic acid 0.1%. They are interchangeable.

In summary, we have discussed the benefits of the modified Jessner peel in combination with TCA and retinoids. It is an old standard that deserves another look. Remember to visit a practitioner who is doing these peels to help you develop a feeling for the different levels of rejuvenation before you add these tools to your armamentarium.

Further Reading

Brubacher JR, Hoffman RS. Salicylism from topical salicylates: Review of the literature. Journal of Toxicology Clinics. 1996;34:431-435.

Cook KK, Cook WR. Chemical peel of nonfacial skin using glycolic acid gel augmented with tca and neutralized based on visual staging. Dermatological Surgery. 2000;26:994-999.

Eller JJ, Wolfe S. Skin peeling and scarification. Journal of the American Medical Association. 1941;116:934-941.

Fulton J, Porumb S. Chemical peels: their place within the range of resurfacing techniques. American Journal of Clinical Dermatology. 2004;5:1-9.

Kligman DE, Draelos ZD. High-strength tretinoin for rapid retinzation of photoaged facial skin. Dermatological Surgery. 2004;30:864-866.

Rubin MG. Manual of Chemical Peels: Superficial and Medium Depth. Philadelphia: Lippincott, William and Wilkins; 1995.

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