Cosmetic
Peel Protocol

Skin resurfacing has been in use as a beauty treatment for thousands of years. In prehistoric times, rocks and shells were used to abrade the surface of the skin. In the Middle Ages, women would soak cloths in lime, mustard, or sulphur to rejuvenate the appearance of the skin and early papyruses document the use of acids and balms for chemical peeling in Egypt. In ancient Greece and Rome soured milk (lactic acid), fermented grape juice (tartaric acid) and lemon extract (citric acid) were used to clarify the skin. So effective are these ingredients that today’s peels frequently use these chemicals as their active ingredients.

WHY PEEL THE SKIN?
Many aestheticians consider chemical peels a ‘reboot’ for the skin, encouraging fresh, healthy skin to appear quickly. While at-home peel products usually provide very superficial exfoliation of the epidermis, chemical peels performed by aestheticians have a lower pH than at-home products so they can penetrate much deeper into the skin. The benefits a client can expect from a peel include: improvement in skin texture, an increase in skin cell turnover rate, improve the skin’s ability to hold moisture, encourage the production of collagen, reduce fine lines, decrease hyper-pigmentation, unclog pores and help clear up acne, leave the skin smooth and soft, make the skin tone more even, improve minor scarring and enhance the effectiveness of skin care.
A chemical peel cannot make dramatic improvements to deep wrinkles or very sagging skin, which requires lasers or cosmetic surgery for visible improvements.

TYPES OF PEELS
There are several popular methods of peeling the skin, each with different benefits and suitability for skin types.

Mechanical peel
Microdermabrasion manually exfoliates the epidermis to remove dead skin cells, debris and impurities. 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. Results are instant and the skin should feel smooth and soft. Depending on the depth of the microdermabrasion, clients can expect to have little to no redness to a considerable amount of redness. The deeper the treatment, the more flushed the skin will appear, although it all depends on the individual skin.
Two to three days following a microdermabrasion, clients can expect to experience a little dryness through to a light peeling. This usually only occurs in the first one to three sessions or if they have not had a microdermabrasion in some months. Microdermabrasion encourages collagen stimulation and a more rapid cell turnover in the skin and is recommended once a month for optimum results, but 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 peels
Chemical peels are a solution that may either be one alpha hydroxy acid (AHA) or beta hydroxy acid (BHA), or a combination of acids, which is 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 following are the combination of chemical peel compositions mainly used and their purposes.
• AHA and 15 percent TCA exfoliates the skin.
• 20 percent TCA and 49 percent phenol does skin tightening and leveling.
• Tretinoin, phytic acid and vitamin C help to build the skin matrix by encouraging collagen and elastin production.

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. Another critical factor to a peel 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.

Superficial: AHA peel
Known as a ‘lunchtime beauty procedure’ due to the fact that clients can return to work immediately after, the superficial peel is the most common chemical exfoliation and uses alpha hydroxy and beta hydroxyl acids such as glycolic, lactic, malic, tartaric, mandelic, citric, or salicylic acids. These chemical peels are beneficial for a mild resurfacing on a regular basis and do not require anesthesia.
A course of between six and ten treatments is usually recommended to achieve the best results. Superficial peels do not hurt and have virtually no recovery time. Skin may be slightly pink afterwards and mild flaking may occur but can be disguised with makeup.

Medium: Trichloroacetic acid peel (TCA)
A Trichloroacetic acid peel is generally used as a method to even out skin tone without a ‘bleached’ look, or any residual discolouration. The latest peels usually combine TCA with other products for maximum benefit, greatest safety profiles for all skin types and colours as well as better rejuvenating and skin conditioning effects. Medium depth peels give more dramatic results than superficial peels and can be used to treat sun damage, pigmentation and wrinkles; 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. Recovery time is usually around a week.

Deep: Phenol peel
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 layers, or dermal layers, of the skin. It may take three hours for a session and will require anesthesia. The results can be dramatic for sun damage, scarring and deep lines and wrinkles, however this type of peel is painful and the recovery time can take months.
The entire treated area will be swollen for a couple of days and will then scab and peel. The skin may also 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.

CHEMICAL PEELING AGENTS
Glycolic acid is the most common peeling agent and comes in different strengths (30 – 90 percent) and different pH levels (levels of acidity) which determines the depth of the peel and intensity of the peel. It is used to treat fine lines, sun damage, improve skin texture and brighten skin.
Salicylic acid can penetrate deeper into the oil glands than other hydroxyl acids, causing exfoliation in the oily areas of the face and scalp, making it ideal for treating acne.
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 fruits such as papaya, pineapple, pumpkin and cranberry. They are antibacterial, promote cell renewal and can digest oil from spots (sebum) and dead skin. They can be used to treat acne, rosacea, dehydrated skin, hyperreactive and sensitive skin.
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 comes 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.
TCA or trichloroacetic acid 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.

LASER PEEL
Laser has the ability to emit light as a wave. When applied in a defocused pulse mode with proper spot size and power density, laser has the ability to ablate and excise the skin, without damaging the deeper structure. One or two passes of multiple pulses to achieve the desired level of vaporisation. In addition, the heat generated after laser application also improves collagen formation in the surrounding tissue.
There are several different kinds of lasers used for skin resurfacing and these include: Erbium Yag laser, CO2 laser and Fraxel Combination. Each laser differs in the pulse width and the depth of penetration and, as one would expect better results are achieved with deeper penetrating lasers.

Contraindications to a laser peel include: a tendency toward keloid or hypertrophic scar formation, isotretinoin within six months prior, people with scleroderma, burns or burn scars, prior ionising radiation to the skin, patients who had undergone recent rhytidectomy, dermabrasion or other procedures, bacterial or viral infection, impaired immune system, irregular pigmentation, vitiligo or psoriasis, recurrent infections and prior eye lift surgery.

WHO ARE PEELS SUITABLE FOR?
Because there are several ways to peel the skin, most skin types will be suitable for skin peels. However, greater precaution is required for patients with darker skin tones as very strong chemical peels can cause hyper-pigmentation on darker skin.
Pregnant and nursing women should not receive chemical peels since there are no studies about the effects of peels on fetuses or nursing babies. People who have been off Roaccutane for less than six months cannot get a chemical peel and those with herpes simplex need to be made aware that a chemical peel can trigger an outbreak, so if they have this virus they would be advised to take medication for it for a few days in the lead-up to the peel and a few days after.
Clients should also be asked if they have tendency to scar, are taking antibiotics, have cancer or an autoimmune disease, or have an open sore as they will not be suitable for a skin peel. As skin is much more prone to UV damage following a peel, it’s important to ensure the client understands the significance of regular application of high SPF sunblock.
Chemical peels are not recommended for individuals with excessive telangiectasia, infections, rashes, open lesions, eczema, sunburn, rosacea, asthma, pregnancy, lupus, distended capillaries, dermatitis conditions, psoriasis and other chronic skin disorders.

PRE-PEEL CONSULTATION
A pre-peel consultation enables clients to discuss any concerns freely and confidentially and is a chance to assess the current skin condition, discuss expectations of the treatment and perform a patch test to check for allergies. Following an assessment, a tailored treatment plan should be discussed for the client based off their skin type and desired results.
There are a few things that clients should be made aware of when planning their peel. Firstly, skin peeling is best performed in winter so that sunlight can be avoided while the skin recovers. For a deep peel, the client should factor in some recovery time (between 7-10 days) so it is generally it is best to avoid social activities.
Depending on the type of a peel, clients may be advised to stop using any products containing retinol. It is usually recommended that one week before a peel clients should avoid electrolysis, waxing, hair removal creams and laser hair removal. For a deep peel an antibiotic or anti-viral medication may be appropriate to prevent infection while skin is healing from the treatment.
Those with thick skin types or who have not previously exfoliated regularly may be encouraged to use topical skin care containing retinol, glycolic acid and bleaching agents six weeks out from the peel in order to thin the epidermis so the chemical peel can penetrate more effectively. To reduce irritation, clients should avoid excessive exercise, saunas, spas and hot showers. Retinol or AHA products should also be avoided for at least 10 days following the peel.

CHEMICAL PEEL AFTERCARE
As skin peeling will cause the skin to peel off and new skin to appear over the next one to 14 days, some follow-up care is required. Sun exposure must be avoided at all costs, so clients must wear a large-brimmed sun hat and a quality high SPF sunblock. They should also be aware that smoking after a chemical peel can cause unwanted side effects, including infection and scarring.

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