Chemical peels: prescription algorithm, application, types, indications

Anna Funikova, dermatologist, family doctor, head of the training center “Academy of Beauty Specialists”, medical director of the clinic “Academy of Health and Beauty” (Ukraine)

Since peelings use potent substances, deep specialized knowledge and caution are necessary even for aesthetic actions, not to mention working with patients with dermatological pathologies. Chemical peeling is not a treatment for dermatological pathology, but only accompanies it, accelerating recovery and reducing the number of cosmetic defects. First of all, it is necessary to make a correct diagnosis, prescribe the main treatment, and assess the risks of complications of cosmetic procedures. And only then – choosing the correct chemical agent for the procedure. If these rules are not followed, there is a high probability of complications, including exacerbation of the underlying disease. There are cases when treatment with certain drugs is incompatible with peeling.

ALGORITHM FOR CHEMICAL PEELING PURPOSE

Making a dermatological diagnosis

If you are not a dermatologist, be sure to refer the patient to a specialized specialist. Let’s be honest right away: you don’t really want to send your client to another specialist. The internal limitation for such a decision is the natural desire in business to earn money independently. But you just have to consider the background of such a decision for everything to fall into place.

Let us remember that chemical peeling is not a treatment, and dermatological problems can often have deep medical implications. Only a professional dermatologist can correctly and accurately detect the presence of a serious medical problem, diagnose it and determine contraindications. Starting peeling without such an assessment means unreasonably exposing yourself to moral, financial and legal liability. Unnecessary risks are not at all what will help in the task of being a successful cosmetologist.

Diagram 1.1 shows the choice of algorithm for a cosmetologist’s actions when a client approaches a dermatological problem. Let us also note that the probability of success with chemical peels without examining the patient by a dermatologist is 11%, while the risk of complications and problems with this approach reaches 89% - these are the figures shown by modern medical statistics.

Diseases for which peelings are contraindicated:

• allergic dermatoses (eczema, atopic dermatitis, pruritus, urticaria);
• acne stage 3–4;
• malignant neoplasm of the skin;
• keloid scars;
• vitiligo.

Diseases for which working with peelings requires special care:

• melasma of unknown origin;
• psoriasis;
• flat warts and papillomas in the area of peeling;
• Rosacea.

SELECTION OF PEELING, ITS CONCENTRATION AND PROGRAM

In the case of a dermatological patient, it is necessary to do a test. This test is carried out on that area of the face that is covered by hair or clothing, but is also sensitive (in the area of the temples, lower jaw, near the ears). When it comes to choosing a chemical peeling program, you should adhere to the following principles:

• you should not immediately move on to aggressive peelings;

FAQ

What medications cannot be combined with peelings?

1. Systemic retinoids throughout the entire period of their use, regardless of the dose and manufacturer (completely incompatible with peelings).
2. Antibiotics (both systemic and topical) increase photosensitivity, which must be taken into account (doxycycline and minocycline, for example, are more likely to cause phototoxicity than azithromycin). The use of topical retinoids and benzoyl peroxides enhances the penetration of peels. Long-term use of topical steroids can make the peeling procedure unpredictable and is therefore considered an incompatible process for peeling.

How long after the prescribed treatment can peelings be done?

If the prescribed treatment is combined with peelings, then the adaptation time to local drugs is two weeks or more (depending on the drug). Thus, any period up to two weeks after using drugs or undergoing treatment is suitable for prescribing chemical peels. In some cases, this time can be longer, and it depends both on the drugs themselves and on the individual characteristics of the body.

Is it worth (or necessary) to interrupt treatment during the peeling procedure or rehabilitation after it?

Most often, treatment has to be interrupted, starting from the peeling procedure and ending with complete rehabilitation after it (other drugs are used in post-peeling care). There are recommendations that topical medications should be discontinued 1–3 days before peeling. In our practice, given that the patient is fully adapted to local treatment, we do not make such an interruption.

How long after the peeling procedure can treatment be resumed?

Treatment should be resumed after complete rehabilitation after the peeling procedure, which implies the end of peeling and normalization of skin sensitivity.

RESULTS

Now we summarize in detail the entire algorithm for prescribing chemical peeling for a dermatological patient:

• Appeal stage. A basic level of cosmetological knowledge allows you to even visually determine the presence of dermatological problems.
• Initial decision stage. Here, either the cosmetologist sends the patient to a dermatologist, or independently undertakes to determine methods of solution. In the second case, the chance of success, according to statistics, comes down to 11% against an 89% risk of complications and further legal, financial and reputational losses.
• The stage of diagnosis by a dermatologist allows you to understand whether cosmetic treatment will be effective, and will also provide an opportunity to avoid any actions and methods that could harm the patient.
• The stage of identifying contraindications relieves the cosmetologist from the risk of using drugs, actions and methods that are harmful to the patient.
• Treatment or refusal. If the combination of contraindications and the diagnosis itself indicate the impossibility of safely achieving a result, then the only right choice for a cosmetologist is a justified refusal to use peelings. This path will not only allow you to avoid completely unnecessary problems, but will also provide reputational compensation from the loss of a client. If treatment turns out to be possible, then it will be based exclusively on methods and methods that are safe for the specialist and the patient.
• The final result. In the case of the correctly chosen algorithm (when cosmetological treatment was considered acceptable) actions, the cosmetologist will achieve the desired result. Otherwise, the client will face complications, problems and lack of results, which in any case promises professional problems for the cosmetologist.

USING PEELINGS FOR ACNE

The use of chemical peels for acne is aimed at reducing inflammation, and most importantly, at preventing or reducing the severity of post-acne scars, reducing the number of comedones and post-inflammatory pigmentation, as well as reducing skin oiliness and the appearance of pores.

In this section, we consider exclusively acne peels, while post-acne peels will be discussed separately.

Acne problems solved with chemical peels:

• increased skin oiliness;
• open and closed comedones;
• persistent post-inflammatory hyperpigmentation;
• stagnant post-inflammatory spots;
• superficial atrophic scars.

To correct deep acne scars, it is necessary to use peelings with long-term rehabilitation and penetration to the dermis. Therefore, post-acne correction should be carried out only after all inflammation has completely gone away, otherwise the main complication will be the activation of the process.

Pre-peeling preparation for acne

In pre-peeling preparation, preparations containing 2% hydroquinone, 0.25% retinol or 0.1% adpalene azelaic acid 15–25% can be used.

The duration of pre-peeling preparation is 2–3 weeks, while the sun protection factor remains mandatory for use throughout the entire period.

Retinoids should be discontinued 2-3 days before your scheduled procedure to avoid irritation.

A week before peeling, it is necessary to exclude invasive procedures (including cleaning), and the patient should also be warned against independent actions of a traumatic nature (picking the skin, pressing, scratching, etc.).

CHOOSING PEELING FOR ACNE

To treat acne, we use peelings that do not create deep trauma, have a pronounced sebostatic effect and are characterized by a minimal rehabilitation period. The main criterion for choosing a peeling agent is its lipophilicity, antibacterial and sebostatic properties, and even its effect on testosterone activity in the skin.

Our current preference is for combination formulations that reduce the concentration of each agent (thereby reducing the risk of complications) but increase overall effectiveness.

Peelings used for acne:

• salicylic acid (aqueous-alcoholic solution or gel 10–30%);
• mandelic acid (aqueous-alcoholic solution or gel 40–50%);
• retinol peels;
• lactic acid (aqueous-alcoholic solution in a concentration of up to 50%);
• Jessner's solution;
• pyruvic acid (aqueous-alcoholic solution 40–50%);
• azelaic acid.

Characteristics and properties of the solutions used

Salicylic acid has high lipophilicity, keratolytic and anti-inflammatory properties. May penetrate into the pilosebation apparatus. It has a good safety profile for dark phototypes, self-neutralizes, and when using aqueous-alcohol solutions does not require rinsing (when salicylic acid is washed off, the peeling is reactivated, as a result the procedure becomes more active). It can cause areas of depression and, as a result, the formation of crusts in places of pustules and excoriations. Salicylic acid is included in most combination peels and has a high degree of compatibility with other peeling agents.

Rehabilitation does not last long - 5-7 days, peeling is of a fine-plate nature (non-colored), and calorified crusts may appear in places of pustules. For salicylic acid, the occurrence of frost is normal and does not indicate an abnormal deepening of the peeling.

Mandelic acid has good tolerability and antibacterial properties. Suitable for oily, sensitive skin, fights post-inflammatory pigmentation. With an increase in concentration above 30%, the risk of complications increases. This is why when choosing an almond peel, you should always start with minimal concentrations, increasing them as you go, and never starting with maximum concentration levels. The pre-peeling preparation must contain a product containing mandelic acid (washing product, lotion, serum). Mandelic acid as a peeling agent combines well with salicylic and azelaic acids.

Rehabilitation does not last long - 5-7 days, peeling is fine-plate in nature (uncolored), there are no crusts, and the appearance of frost indicates a violation of the procedure protocol, in which case urgent use of a neutralizer is necessary; in other cases, it is possible to use water as an effective neutralization.

Retinol peels are used for comedonal acne, as well as for patients who tolerate retinol well. Peeling causes severe exfoliation (large-plate transparent peeling), and retinoid dermatitis is possible. It goes well with salicylic peeling, sometimes a combination with Jessner peeling is used.

Rehabilitation has a long period - up to 10 days, peeling is large-plate in nature (uncolored), crusts do not appear, and there are no manifestations of frost.

Lactic acid, according to the mechanism of its effect, is characterized by a superficial effect on the skin (manifested in the “soaking” of keratinized keratinocytes). This mechanism of action is not always suitable for acne, when there is hyperkeratosis of the excretory duct of the sebaceous gland. Empirically, lactic acid for the treatment of acne is used either in combination (Jessner's solution) or in mono form in low concentrations on an aqueous-alcohol basis (high concentrations can lead to the risk of complications such as epidermolysis).

Rehabilitation has a short period - 5-7 days, peeling is fine-plate in nature (uncolored), crusts do not appear, and the appearance of frost indicates a violation of the procedure protocol, in which case urgent use of a neutralizer is necessary; in other cases, rinsing with water is possible as an effective neutralization .

Jessner's solution is a combined composition that includes 14% salicylic acid, 14% lactic acid, 14% resorcinol. Peeling has a pronounced anti-inflammatory effect, fights post-inflammatory pigmentation, and is highly lipophilic. Jessner's solution does not require neutralization, has a long exposure (4–10 hours), due to resorcinol it can cause systemic intoxication, and in the presence of liver damage it can increase hyperpigmentation.

Rehabilitation has a long period - 10-12 days, peeling is large-plate in nature (colored), crusts do not appear, and the appearance of frost is due to salicylic acid. The occurrence of frost is normal and does not indicate an abnormal deepening of the peeling (due to salicylic acid).

Pyruvic acid has the property of deep penetration and requires mandatory neutralization, the depth of penetration depends on the exposure time. In high concentrations it can cause epidermolysis. It fights well against post-inflammatory hyperpigmentation and congestive spots, as well as dull complexion.

Rehabilitation does not last long - 5-7 days, the peeling is fine-plate in nature (non-colored), crusts do not appear, and the appearance of frost indicates a violation of the procedure protocol, and in this case, urgent use of a neutralizer is necessary, although peeling always requires neutralization.

Azelaic acid has a very mild effect, has virtually no recovery period, and reduces skin oiliness by reducing the activity of alpha-5 reductase. It is rarely used alone (except for the first stage of acne or when acne is combined with rosacea); it is more often used in combination with salicylic and mandelic acids.

TECHNICAL FEATURES

When working with patients with acne, photographic documentation of the skin before and after is essential. For all these peels, a degreaser is used, and for peels that require neutralization, a neutralizer must be prepared initially.

An important point is that most acne peels are not applied to the periorbital area. This is done to prevent the effect of drying the skin (applies to salicylic and mandelic acids in their pure form).

POST-PEELING CARE FOR ACNE TREATMENT

As practice shows, patients do not experience severe tightness and dryness of the skin when using peels based on salicylic, mandelic, pyruvic and lactic acids. Therefore, post-peeling products should not have a dense texture; the mandatory use of a sun protection factor is also required.

When using Jessner peels and retinol-based peels, dryness and tightness during the rehabilitation period can be pronounced; at this time, the use of dense silicone protectors is indicated.

POSSIBLE COMPLICATIONS

In the case of correctly carried out pre-peeling preparation, with a correct diagnosis and taking into account all possible contraindications, complications practically do not arise. If mistakes were made at at least one of the stages (including minor ones), then there is a risk of the following complications:

• exacerbation of acne as the underlying disease;
• the appearance of closed comedones;
• severe retinoid dermatitis (typical only for retinol);
• post-inflammatory pigmentation (characteristic only of Jessner's solution or for areas where epidermolysis has occurred).

USE OF CHEMICAL PEELINGS FOR ROSACEA

Previously, a disease such as rosacea was a contraindication for chemical peels, but now compounds have appeared on the market that can be used for this pathology. When choosing a peeling, we must consider several important points:

• peeling should not lead to severe skin irritation (should not have the first phase of neurogenic inflammation);
• should not cause vascular growth, but at the same time have high permeability;
• alcohol should not be part of the peeling.

Azelaic acid has these properties.

Peeling can be mono- or polycomponent, but it must meet all the qualities mentioned above. Pre-peel preparation is also required for at least 2-3 weeks. Due to the fact that pharmacy chains today have the widest range of available drugs containing azelaic acid, there will be no problems with the correct selection of the drug for pre-peeling preparation.

It is desirable that the peeling has a gel base. It does not require neutralization; it is washed off with plain water, and the exposure time is about 20 minutes.

POST-AKNE PROBLEM

The problem of post-acne is complex and extremely painful aesthetically and psychologically. Chemical peels can help achieve effective results. To solve this problem, the following peels are currently used: trichloroacetic acid in both standard and cross-use, a combination of dermabrasion and trichloroacetic acid, phenolic peels. All peels can be used with additional subcision.

The use of trichloroacetic peels should be carried out after complete leveling of inflammatory processes, otherwise the likelihood of exacerbation approaches 100%.

Pre-peeling preparation may include the use of preparations based on 2% hydroquinone, 0.25% retinol or 0.1% adapalene, azelaic acid 15–25%.

The duration of pre-peel preparation is 2-3 weeks, while the sun protection factor remains mandatory for the entire period of pre-peel preparation.

Retinoid use should be discontinued 2-3 days before the planned procedure to avoid irritation.

A week before peeling, it is necessary to avoid invasive procedures (including cleaning), and the patient should also be warned against independent actions of a traumatic nature (picking the skin, pressing, scratching, etc.).

The client must be warned about very long-term photosensitivity.

Application of cross-peeling

Cross-peeling (Chemical Reconstruction of Skin Scars) is a local application of a solution with a high concentration of trichloroacetic acid (35–50%) to the bottom of an atrophic stamped scar. Application is done with a needle or toothpick.

Peeling should be applied exclusively to the bottom of the scar; application to the periorbital zone and neck area is unacceptable. Usually a single application is enough, but sometimes a double application is necessary. The end point of the procedure is the appearance of white or gray frost at the bottom of the scar.

Neutralization is not required in this case, but brown crusts appear in the areas affected by the peeling (the darker the phototype, the richer the color). The method can be combined with subcision; the rehabilitation process lasts 10–14 days. In this case, the patient should be warned that independent removal of emerging crusts is strictly unacceptable. The patient should also be warned about long-term rehabilitation.

Trichloroacetic acid does not have systemic toxicity, the depth of peeling penetration correlates with the color of the frost, neutralization is not required, but can cause pigmentation in dark phototypes and patients prone to it.

Combination of dermabrasion and trichloroacetic acid

This procedure should be performed exclusively in a manipulation room, as there is contact with blood. The procedure works well on “carriage” scars or scars that have rounded edges.

For light phototypes, the procedure is much more effective and also entails long-term photosensitivity. Rehabilitation lasts up to 3 weeks, peeling occurs in large brown films.

For the procedure, it is necessary to use sandpaper sterilized in an autoclave (zero), sterile gauze, an ampoule solution of lidocaine and adrenaline and a 15% solution of trichloroacetic acid. The skin is disinfected, abraded with sandpaper until blood dew appears, then sterile gauze is applied for 3-5 minutes, soaked in a solution of lidocaine and adrenaline. Next, 15% trichloroacetic acid is applied in one layer, exposure until white frost appears. A 10% trichloroacetic acid solution is distributed evenly over the entire face to avoid demarcation lines. Then everything is washed with saline solution and covered with a healing cream based on hyaluronic acid and silicone or a special film. Sunscreens are applied only after complete epithelialization. During the first week, erythema is normal, but if erythema continues beyond this period, then topical corticosteroids may be used.

Correction with phenol

Phenol is the “gold standard” for the correction of post-acne scars. There are now various types of phenols on the market - from 5 to 60%. The higher the percentage of phenol, the more effective the procedure will be, but the risk of complications increases and the recovery time increases.

I would like to present to your attention the original technique that we use in the clinic. Pre-peeling preparation is standard, as for trichloroacetic peeling (see above).

For the procedure you need the following: 15% trichloroacetic acid, 20% phenol solution, 4% retinol cream.

Apply 15% trichloroacetic acid in two layers to the bottom of the post-acne scar using a toothpick or needle. Application is carried out until white frost appears (you can stop at pink frost). Up to five layers of 20% phenolic peeling are applied on top. Application is carried out very slowly - one layer is applied within 5 minutes to avoid a vascular reaction on the part of the patient. Phenol can be applied using abrasive techniques (rubbing in with gauze). The final frost is poured pink, with elements of white. After the last layer of phenol has dried, 4% retinol cream is applied. Neutralization is not required; the patient washes himself after 10–12 hours, after which he applies a silicone protector.

The duration of rehabilitation is up to 7 days, the number of necessary procedures is 2–3, but it is almost always possible to avoid hyperemia. The next procedure is carried out no earlier than a month after the previous one.

First published in Les Nouvelles Esthetiques 2017/№6