The skin cell cycle
As we age the natural rate of skin cell renewal slows. By the time we reach our thirties, it takes around 28 days to complete a full cycle. As a result of this slowing, the skin is thicker and the appearance is more dull. In addition, over time our sebaceous glands become less active and the skin becomes drier. Skin peels accelerate the skin renewal process by exfoliating dead, dull skin cells, revealing fresh, skin cells beneath. For this reason, many clients consider peels a ‘quick fix’ to younger looking skin. Likewise, many estheticians consider peels a ‘reboot’ as the treatment removes dead, dull skin and can help products to penetrate, encouraging better results.
The types of skin exfoliation
Manual exfoliation comprises a physical scrubbing action of the epidermis using brushes, sponges, washcloths, loofahs. Products with ground nutshells, coffee bean or crushed apricot kernels as exfoliating ingredients are also common, yet because these ingredients can cause microscopic tears in the skin, skin specialists prefer rounded spheres or beards, which are gentler to the skin. Another very popular form of mechanical exfoliation is microdermabrasion.
A chemical peel uses an alpha (AHA) or beta hydroxy (BHA) acid solution to shed dead skin cells from the surface. Another form of chemical peeling uses enzymes like papain (papaya extract) or bromelain (pineapple extract) to break down the lipids that act like glue to hold the dead skin cells together. Peels are applied to the skin like a mask, then removed at the end of the treatment or left on to self-neutralise. They work by dissolving the top layers of the skin, creating a controlled wound and thus allowing the skin to regenerate itself.
The different types of chemical peels
There are three types of peel: superficial, medium and deep. These have varying percentages of active ingredients and different pH levels. The peel percentage indicates how much of the peeling agent is contained in the peel – the higher the percentage, the stronger the peel. Another critical factor is the pH level, which indicates how deep the peel will penetrate the skin; the lower the pH, the deeper the peel. A peel with a pH of less than 2.5 should be done by a doctor or nurse and a pH of 1 should only be performed by a doctor or surgeon. Peels with a pH of 3 are the most common in beauty salons.
It is often advised that clients start slowly with the peel process, in order to give the skin time to adjust and minimise irritation and side effects. For example, clients may have lighter peels over three months instead of one aggressive peel that could potentially damage the skin. Dependant on skin type, clients may consider commencing treatment with low level peels (for example lactic acid at between 20-30 percent) and gradually increase the peels strength over the series to up to 60 percent
Superficial peels are touted as a ‘lunchtime beauty procedure’ due to the fact that clients can return to work immediately after treatment. The superficial peel is the most common chemical exfoliation and incorporates alpha hydroxy and/or beta hydroxy acids. These are used to improve the appearance of pigmentation, acne scars or fine lines in all skin types and can be done on the face and on other parts of the body such as the hands and chest. A superficial peel may also be used to prepare the skin for a deeper peel. A series of superficial peels may be performed every week for six to ten weeks until desired results are achieved and then performed monthly thereafter to maintain desired results. These chemical peels are beneficial for a mild resurfacing on a regular basis and do not require anesthesia. Superficial peels do not hurt and have virtually no recovery time. The skin may appear slightly pink after treatment and mild flaking may occur but can be easily disguised with a pure mineral make-up.
Medium peels are used most often on the face usually combine Trichloroacetic Acid (TCA) with other products for maximum benefit, greatest safety profiles for all skin types and colours as well as better results. Medium depth peels give more dramatic results than superficial peels and can be used to treat sun damage, pigmentation and wrinkles and to even out the skin tone without the risk of a ‘bleached’ look that can result from a deep peel. However they will require a longer recovery time and have more side effects. Clients may experience more discomfort (burning and stinging sensations) which can last for 30 minutes to an hour after treatment. The skin may also become swollen, pink and itchy and will likely peel following treatment. Patches of brown and white skin may appear during the healing process, which usually lasts around a week. These types of peels can be performed every six months to a year to maintain desired results.
Deep peels are the strongest type of chemical peel available and usually use carbolic acid (phenol peels) or high strength TCA to penetrate the deeper (dermal) layers of the skin. Deep peels are performed by dermatologists and used to treat severe wrinkles, long-term sun damage, pronounced pigment changes, coarse skin texture and actinic keratosis (precancerous skin lesions) on the face. Due to their strong intensity, these skin peels are classed as surgery and are a once-off treatment only. A session will require anesthesia and may take up to three hours. While they produce dramatic results for sun damage, scarring and deep lines and wrinkles, they are painful and the healing process may take several months. The entire treated area will be swollen for a couple of days and will then scab and peel. The skin may also ooze and become quite itchy as it heals. The most common risks associated with deep peels are permanent hypopigmentation (patches of white or bleached looking skin) and scarring, therefore this type of peel is not done on darker skin types.
Clients should be aware of the limitations of each of the skin peel treatments. Chemicals peels are not to be used to remove or reduce the appearance of blood vessels on the skin, they cannot reduce pore diameter or remove keloidal scars (a firm, rubbery or shiny scar which is the result of an overgrowth of granulation tissue (collagen type 3) at the site of a healed skin injury which is then slowly replaced by collagen type 1.)
Mechanical peel or microdermabrasion manually exfoliates the epidermis to remove dead skin cells. It is performed using an instrument which combines suction and a wand made of diamond or small crystal (fine aluminium) particles to remove dead skin cells. The results are instant and the skin should be left feeling smooth and soft, so it is a treatment that has a lot of appeal for clients looking for a painless ‘quick fix’. Clients can expect to have little to no redness to a considerable amount of redness, depending on the individual skin type. Any redness can be covered with a pure mineral makeup. Two to three days following a microdermabrasion, clients often experience dryness, skin flaking or peeling. Usually these side effects occur in the first one to three sessions or if the client has not had a microdermabrasion for several months. One study suggests that aggressive microdermabrasion may be the most beneficial for skin rejuvenation. Researchers took skin samples from the arms of 40 people with sun-damaged skin before and after the participants had microdermabrasion with a coarse or medium-grit, diamond-studded wand. The researchers found that the course-grit diamond increased the production of compounds associated with wound healing and skin remodeling, as well as antimicrobial peptides that fight infection and substances that break down the skin’s structural proteins to let the skin rebuild. The skin also produced other substances that induce collagen production. These changes were not seen in skin treated with the medium-grit device.
For optimum results, most clients would respond well to a monthly microdermabrasion treatment, however it may not be a good choice for inflamed, sensitive or rosacea type skin. Contraindications to microdermabrasion include: active, uncontrolled or brittle diabetes, viral lesions, herpes simplex, shingles, eczema or seborrheic dermatitis, rosacea, oral blood thinners, vitiliago, skin cancer and auto immune disorders such as AIDS or HIV, visible, broken blood vessels, telangectasis and sunburned skin.
Chemical peeling agents
Alpha hydroxy acid (AHA) peels uses glycolic acid as the
peeling agent and comes in different strengths (typically from 30 percent – 70 percent) and different pH levels (levels of acidity) which determines the depth and intensity of the peel. AHA peels help to improve skin texture, encourage some collagen and elastin rebuilding and also help to minimally reduce acne scarring and skin discolorations. To maintain results, repeated treatments are necessary.
Beta hydroxy acid (BHA) or salicylic acid peels can work in a way that is similar to a glycolic acid peel, however as salicylic acid is a compound closely related to aspirin (acetylsalicylic acid), and it retains its anti-inflammatory properties, a deep BHA peel can be superior for many skin types because the irritation and inflammation are minimised. Salicylic acid is also lipid soluble, which means it can enter a cell by dissolving in the lipid portion of the membrane and diffusing through it. For this reason AHAs are a good peeling agent for blemish-prone skin with blackheads. The most common concentrations used today are 20 percent to 30 percent.
Lactic acid occurs naturally in human skin and is found in milk. It is less irritating than other AHAs and has a moisturising effect on the skin. It can be used to treat pigmentation and brighten dry or dehydrated skin, sensitive skin, rosacea.
Fruit enzymes are commonly derived from papaya, pineapple, pumpkin and cranberry. They are antibacterial, promote cell renewal and can also digest oil from spots (sebum) and dead skin. They are useful in treating acne, rosacea, dehydrated skin, hyperreactive and sensitive skin types.
Tartaric acid comes from grapes and is a less irritating and milder alternative to glycolic acid. It can help increase skin hydration and can be used to treat acne, photo-damage, rosacea, superficial pigmentation, eczema.
Malic acid is derived from apples and pears and is a weaker AHA than glycolic acid. It can be used to treat acne, photo-damage, rosacea, superficial pigmentation and eczema.
Citric acid is derived from lemons and oranges and works in the same way as tartaric and malic acids. It can be used to treat acne, photo-damage, rosacea, superficial pigmentation and eczema.
Trichloroacetic acid (TCA) is stronger than glycolic, penetrating deeper into the skin and is usually used for medium or deep peels. It can be used to treat skin tightening, fine lines and wrinkles, acne scars, large pores and hyperpigmentation.
Carbolic acid is found in phenol peels and is the strongest peeling agent available. It can be used to treat deep lines and wrinkles, scarring, severe sun damage.
What are clients looking for in a peel?
The benefits of peels are well known and very appealing to clients who are looking for rapid improvement in a variety of common skin concerns. Clients can be comforted by the fact that the advantages of increasing the skin cell turnover rate by chemical peels are numerous and include an improved skin texture, a reduction in fine lines under the eyes (crow’s feet) and around the mouth (smoker’s lines) as well as the wrinkles caused by photo-damage. Peels help to even the skin tone by decreasing hyperpigmentation, age spots, freckles and dark patches (melasma) due to pregnancy or taking birth control pills. Peels are also helpful in unclogging pores and helping to reduce the number of breakouts, soften the appearance of minor scarring and enhance the effectiveness of skin care. Chemical peels are also known to enhance the skin’s ability to hold moisture and encourage the production of collagen.
However, clients should be made aware that a chemical peel does have its limitations. It cannot make dramatic improvements to very deep wrinkles, sagging skin and bulges. Clients with those concerns should be gently but firmly informed that they will be more likely to gain the desired results from other kinds of cosmetic surgical procedures, such as laser resurfacing, a facelift, brow lift, eyelid lift, or soft tissue filler (collagen or fat).
How do you assess a client’s wants and needs?
Even a superficial peel should be carefully considered by the client and the therapist. It is important to ascertain exactly what the client’s skin concerns are. Ask the client what their main skin concerns are and what benefits they would like to achieve with treatment. By engaging in an honest and open discussion you can ensure they have a realistic expectation of the proceedure and you can minimise the risk of disappointment if the desired changes are unable to be achieved. It is also critical that the client is committed to the required pre-peel and post-peel skin care in order to maintain the best results.
Who are the best candidates for a peel?
Chemical peels are not for everyone. While superficial peels can be effective on many skin types, generally the best peel candidates are fair-skinned and light-haired patients with relatively mild skin imperfections and conditions such as early signs of photo-damage (freckles, sun spots and actinic keratoses) and/or concerns such as melasma, fine lines and mild acne. These candidates will need to have realistic expectations of wanting to rejuvenate their skin without the recovery time of harsher treatments.
Clients with darker skin may also have good results, but they are also more at risk of uneven skin tone after the procedure. The patient should be in good physical health and preferably a non-smoker. Individuals with heart problems are not ideal candidates as phenol poses a risk for heart conditions. Chemical peels are not suitable for those who are taking Roaccutane or have taken it in the previous 18 months and they must not have active skin infections, including most kinds of acne as these can increase the chances of scarring. Those with sensitive skin may experience adverse effects when in contact with AHA acids. These can include itching, skin irritation, blisters and chemical burns. AHAs should not be used too often at high concentrations because they can leave the skin quite dry and in some cases irritated. Clients with sensitive skin should be considered potential candidates for microdermabrasion treatment instead of skin peels.
Sun sensitivity is another major side effect of skin peels and microdermabrasions. Ensure that your client is aware that a high SPF broad spectrum sunblock must be used on a daily basis in order to protect the fresh skin cells after treatment.
Microdermabrasion – a peel alternative
Microdermabrasion is a hugely popular cosmetic technique and an excellent alternative to a chemical peel, particularly for those who are sensitive to AHAs. The treatment uses fine abrasive crystals and vacuum suction to painlessly remove the stratum corneum. It can help treat certain types of acne and improve blocked pores and is useful in reducing the appearance of fine lines, improving uneven skin tone, texture and elasticity and reducing the depth of raised and pigment scars. A series of four to five treatments are considered helpful in improving melasma and hyperpigmentation. It is particularly beneficial when used in conjunction with facial laser treatments as it helps turn over the dead skin cells from the laser treatment, increasing its results. Microdermabrasion can be done weekly or up to every eight weeks depending on the individual’s skin tolerance. Many clients have good results following a programme with weekly treatments for three sessions to obtain results, then change to a monthly regimen to maintain them.
A consultation prior to treatment is important. If the client has no history of hypo/hyper-pigmentation or keloid scarring in their family, a series of microdermabrasions could be considered an alternative to a deeper peel. However, the treatment is not suitable for deeper wrinkles and scars, deep hyperpigmentation problems (areas of darker pigment) or for those with broken capillaries as they can exacerbate them. Microdermabrasion risks are highest for patients with very sensitive skin or those with a history of inflammatory skin conditions such as rosacea or psoriasis. A client should be prompted to reveal if they have any undiagnosed lesions, recent herpes outbreaks, warts, stage 3 or 4 acne or active rosacea (which can be worsened), unstable diabetes (due to poor wound healing abilities)or auto-immune disorders as they are at higher risk of developing infections.
Post skin peel or microdermabrasion skin care
After a treatment a client should be warned not to pick at any scabs or flaky skin as it can delay healing or worse, cause scarring. The client should moisturise using a light preparation after a superficial peel, or thicker creams after a deeper peel.
Because peels and microdermabrasion treatments expose fresh skin cells, it is absolutely essential that clients understand that strict sun protection must be followed on a daily basis. Clients should also be instructed to avoid direct sunlight and tanning booths. And, as the skin may be sensitive after treatment, they should avoid products containing harsh chemicals, dyes, or perfumes until the skin has fully healed.
Pre-treatment creams containing tretinoin, alpha hydroxy acids, or hydroquinine are often recommended applied to the face at night for several weeks prior to the peel. These will exfoliate the skin and reduce pigmentation to improve the results from chemical peeling. They may also reduce the time needed for healing.
A word of caution
There can be too much of a good thing. Having too many skin peels or overly aggressive treatments can irreversibly thin the skin and may even permanently remove the skin’s natural protective pigment. Peels are designed to address common skin concerns, but once the desired results are achieved the treatment should cease, with only maintenance treatments performed as needed.
Skin peeling of any kind shouldn’t be self diagnosed, so don’t be swayed by client’s demands and make sure you get a thorough picture of your client’s individual skin needs. By knowing exactly what your client’s concerns are and the skin type you are dealing with, you greatly increase your chances of achieving the best possible results.