Peeling Back the Layers

Top indications and agents for superficial chemical peels

Superfical Chemical Peels

Whether you are addressing acne and pigmentation concerns or simply seeking to brighten lackluster skin, superficial chemical peels have been proving their worth for hundreds of years. “Superficial chemical peels are very affordable, effective and the recovery time is quick, which is why they are so popular,” says John Kulesza, chemist and founder of Young Pharmaceuticals. On the following pages, physicians discuss how they’re using superficial chemical peels in their practices to address acne, unwanted pigmentation and photodamage.

Banishing Blemishes

Top Peeling Agents: Salicylic Acid, Glycolic Acid, Lactic Acid, Azelaic Acid

Acne is a top indication for superficial peels, particularly for patients with skin of color, says Kachiu Lee, MD, of the Main Line Center for Laser Surgery in Ardmore, Pennsylvania. “You aren't able to use lasers or deeper chemical peels on these patients, and there have been several randomized, controlled trials that have shown efficacy with both alpha and beta hydroxy acids in reducing acne lesions,” she says.

Pearl Grimes, MD, of The Grimes Center for Medical and Aesthetic Dermatology in Los Angeles, considers salicylic acid—a beta hydroxy acid—the most effective peeling agent for acne. “If you look mechanistically at how salicylic acid works, it decreases oil, which is why it’s the most efficacious peel for acne,” she says.

Salicylic acid is highly lipophilic, which allows it to reach the pilosebaceous unit, notes Dr. Lee. Another benefit of salicylic acid is that it has anti-inflammatory properties. “Salicylic acid is a chemical cousin of aspirin. It’s one of the best known dermatologic agents that is anti-inflammatory,” says Kulesza.

Alpha hydroxy acids (AHAs), such as glycolic acid and lactic acid, are less lipophilic, and therefore less likely to reach the pilosebaceous unit. Yet they also have been shown to be highly effective in improving acne “We don’t know the exact mechanism by which AHAs help acne, but we know that they help exfoliate the skin by decreasing the cohesion between the cells, and that itself can potentially help with acne,” says Dr. Lee.

The benefit of offering glycolic acid peels to acne patients often comes down to cost. “For teenage acne, salicylic acid is better, but glycolic acid has been used for acne for a long time. It’s less expensive than salicylic, and you can put the patient on a salicylic acid home product to maintain their skin between peels,” says Angelia Inscoe, CEO of Induction Therapies, maker of the A Method Peel Center, which offers concern-specific peels with pre- and post-peel kits.

Lactic acid has similar efficacy to glycolic acid, “but it’s a little gentler,” says Dr. Lee. “So it’s good for patients who have more sensitive skin.”

Peeling patients with sensitive and even rosacea-prone skin is becoming more common thanks to new formulations and peeling agents that offer anti-inflammatory benefits. “Azelaic acid is a wonderful medication to treat acne and rosacea,” says Kulesza. “Many people don’t realize that if you mix azelaic acid with a solvent, such as alcohol, you can create a solution that lightly peels the skin and has an anti-inflammatory effect. Another ingredient is mandelic acid, which is a large, heavy molecule that does not penetrate very deeply. It works very superficially and has some antibacterial properties. That’s why blended peels containing salicylic acid, azelaic acid and mandelic acid can be used on patients who have very sensitive or rosacea-prone skin.”

Peeling Away Pigment

Top Peeling Agents: Glycolic Acid, Lactic Acid, Tretinoin

Dr. Grimes, who specializes in pigment concerns, utilizes superficial peels for patients struggling with melasma, post-inflammatory hyperpigmentation (PIH) and dyschromia associated with photoaging. “Superficial peels are very good if you just want to treat the pigmentation component of photoaging,” she says. “But if someone has deeper rhytids in addition to dyschromia, you need a deeper peel.”

Her top peeling agents for pigmentation concerns are AHAs, salicylic acid and tretinoin. “What I like about a tretinoin peel is that it’s less aggressive. The peeling is very, very superficial. It is not an inflammatory peel,” says Dr. Grimes.

Melasma is a top indication for superfical peels in Dr. Lee’s practice as well. She performs glycolic or lactic acid peels combined with a homecare regimen, which includes daily sunscreen and a hydroquinone or nonhydroquinone lightening agent.

Kulesza notes that lactic acid is a good option for unwanted pigment. “In addition to having an exfoliating effect on the skin, it also modestly inhibits pigment production,” he says. “Other ingredients often used in peels targeting melasma include resorcinol, a chemical cousin of hydroquinone used in the Jessner peel, and arbutin, which comes from the bearberry plant and is also a chemical cousin of hydroquinone. If you use arbutin at a high enough level, it will have a peeling effect.”

The Jessner peel is a combination of salicylic acid, lactic acid and resorcinol. “These peels really target pigment, and they can be layered,” says Inscoe. “So it’s something you can stack together to give the patient a deeper peel, while a one-layer Jessner peel is safe for Fitzpatrick skin types 4 and 5.”

Superficial peels alone are not effective for long-term treatment of melasma. But when combined with home care, they can boost treatment efficacy. “After compliance, one of the biggest difficulties in using topical treatments is penetration,” says Dr. Lee. “If you use a peel beforehand to thin out the stratum corneum, then the topicals can penetrate much better into the skin.”

Dr. Grimes calls daily topicals the “workhorses” of melasma treatment. “What that patient is doing every day affects their melasma more so than the peel. You can’t just peel and not have them on a daily regimen,” she says.

To further enhance peel outcomes, Dr. Lee performs a very superficial microneedling treatment and then applies the peel. “This was popularized by our colleagues in India who treat a lot of skin-of-color patients with melasma,” she says. “It’s difficult to safely use lasers on these patients, and there’s really good data on the use of superficial peels combined with microneedling to help with pigmentation for improvement of melasma.”

Skin Rejuvenation

Top Peeling Agents: Glycolic Acid, Lactic Acid, Retinoids

In addition to reducing acne breakouts and lifting unwanted pigment, superficial peels can provide immediate skin brightening and plumping. “A superficial AHA peel is a great treatment for a younger patient, someone in their 20s or maybe their early 30s, and it’s a great skin rejuvenation treatment for people who want no downtime,” says Dr. Lee. “But if the patient has a little more photodamage, superficial peels may not be as effective as a medium or deep chemical peel or a laser treatment.”

As with pigmentation concerns, performing a superficial peel prior to starting a patient on an antiaging homecare regimen “is going to allow all of your active ingredients to penetrate better and work faster,” says Inscoe.

Glycolic acid, thanks to its low cost and long track record in skin care, is the most popular agent for skin rejuvenation. “It’s great for a lunchtime peel where you just want to refresh the skin. It’s really inexpensive and it’s tried and true,” says Inscoe. “You can use it in varying strengths, and you can step up the level of aggressiveness. It targets pigment. It targets collagen. It targets clogged pores and it brightens the skin.”

The A Method by Tina Alster, MD, offers a 3 percent retinol peel called the Reti-Refine, specifically formulated for photodamage and skin rejuvenation. “It’s all trans retinol and it has 18 amino acids in there, and it’s really gentle,” says Inscoe. “There’s no stinging or burning because it has the amino acids, which are calming to the skin. It’s a great peel for rosacea and for patients with sensitive skin.”

Prepping the Skin

Preparing the skin for a superficial peel can help improve the efficacy of the peel and reduce the risk of PIH in skin of color. Dr. Lee starts all superficial peel patients on a retinoid and a sunscreen. “Putting them on a retinoid helps the peel be applied more evenly. There’s also evidence that using a retinoid beforehand helps speed the rate of healing,” she says. “I tell everyone to use sunscreen as well. I want them in the habit of using sunscreen, because their skin is going to be more sensitive after the peel.”

When performing superficial peels, Dr. Lee has her patients use their retinoid right up to the day of the peel. “If I’m doing a medium or a deeper peel on a darker skin patient, I will have them stop it beforehand because we don’t want the medium peel to penetrate too deeply,” she says.

Conversely, Dr. Grimes has her patients stop their retinoid use at least 10 days prior to peeling. “A retinoid can make any peel go deeper, so you have to be extremely careful about that in your priming. If you’re treating pigment in skin of color, less is more,” she says. “I don’t want excessive peeling, because I can give them PIH and make them worse. If it’s photodamage, you have a much broader window of safety because it’s a lighter-skinned individual.”

Dr. Grimes puts all patients with pigmentation concerns on a daily skin lightener. “The peels work much better if you put the patient on a lightener first. This decreases the likelihood of PIH as well,” she says.

For acne, she starts the patient on benzoyl peroxide, a retinoid and a topical antibiotic prior to peeling. “I may use azelaic acid in combination with the retinoid or topical dapsone,” says Dr. Grimes. “If that patient has a lot of PIH as well as the acne, then I’m going to get them on a topical lightener as well.”

Healing Support

Following a superficial peel, Dr. Lee has patients return to their normal homecare regimen and apply daily sunscreen. “There are some companies that offer restorative masks or phyto-corrective gels designed to restore moisture to the skin and calm the redness or inflammation, so they can use something like that if they want. But it’s not absolutely necessary,” she says.

Dr. Grimes counsels patients to use a bland cleanser and bland moisturizer, such as like Cetaphil/CeraVe, for two to four days following the peel as well as sunscreen. “If the patient is having any undue irritation, you can use some hydrocortisone lotion,” she says.

Peeling Safely

Superficial peels, by their very nature, are quite safe but not without risk. “Superficial peels can only penetrate through the epidermis, so there is a very low risk of scarring or permanent hypopigmentation,” says Dr. Lee. “Where I do err on the side of caution is in people with skin of color because if you start penetrating a little deeper, even if it’s just in the epidermis, there is a higher risk of PIH. I’m also cautious when peeling people with very sensitive skin. I tend to start slow and work my way up to make sure their skin can tolerate it.”

The peeling agents that warrant the most caution are TCA and glycolic acids. “With glycolic acid and lower-strength TCA peels, if you don’t neutralize them or you apply too much of them, you can get permanent scarring and hypopigmentation,” says Dr. Lee.

You also need to know the pH of your glycolic peel. “The pH affects the aggressiveness and effectiveness of the glycolic acid peel,” says Dr. Lee.

The concentration of glycolic acid relative to pH is calculated using the Henderson-Hasselbalch equation. “If a peel is 30 percent glycolic acid and has a pH of 1, that’s a true 30 percent glycolic acid peel,” explains Inscoe. “If the pH is 3, you’re only getting about 18 percent and if it’s a pH of 2, you’re getting about 22 percent of that glycolic acid. You have to know the pH to ensure that you’re getting that full percentage of acid.”

To ensure safety, Dr. Lee peels to clinical endpoints. “With the salicylic acid peels you’re supposed to get a pseudo-frosting type of color and glycolic acid is supposed to be a little pink,” she says. “Before you offer these peels, you should be trained to understand what the clinical endpoints are and how to recognize them so you know when to stop the peel.”
Those new to peeling can seek out training through professional associations, manufacturers or more experienced practitioners.

“I like superficial peels. I can manipulate the depth to control the level of injury, and you have a high level of safety,” says Dr. Grimes. “There’s certainly a place for medium-depth peels but, more often than not, for pigment, repetitive superficial peels will work just as well.”

Inga Hansen is the executive editor of MedEsthetics.

Image copyright iStock.com/Razvan

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