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Therapeutic Strategies

Superficial Chemical Peels

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

Superficial chemical peeling is indeed a dermatologic art. It is the skillful use of acidic substances to carefully remove the stratum corneum and superficial epidermis to achieve an improvement in the appearance of the skin. The improvement may be in skin texture and/or skin pigmentation. The goal of this commentary is to provide a basic outline for the formulation and administration of superficial chemical peels.

Objective

Superficial chemical peeling involves the use of mild acids to obtain a variety of desired results based on the patient's expectations and the physician's therapeutic objectives. The desired goal may be simply to induce exfoliation of corneocytes that have failed to desquamate, resulting in smoother application of facial foundation. In this case, a mild acid with short contact time would be in order.

Superficial chemical peels of this type can also be used to enhance penetration of other dermatologic agents, such as hydroquinone for pigment-lightening purposes or retinoids for antiaging purposes.

Chemicals

Superficial chemical peeling involves the use of mild acids to remove surface corneocytes that make up the stratum corneum. Chemical dissolution of bonds at various levels of the stratum corneum and epidermis determines the depth of the peel. By definition, superficial chemical peels do not enter the dermis or the lower layers of the epidermis. The two major acids that are used for this purpose are glycolic acid and salicylic acid.

Glycolic acid is a water-soluble alpha hydroxy acid of small molecular weight that rapidly penetrates into the skin. It is obtained from fermented sugar and as such is known as a fruit acid. It can be both buffered and neutralized to limit its penetration into the skin. I prefer to use undiluted, unbuffered peeling solutions, since they are easier to formulate and more predictable in their effect on skin.

Salicylic acid is commonly referred to as a beta hydroxy acid. It is a phenolic oil soluble compound with a rich dermatologic history. Salicylic acid is a potent keratolytic able to penetrate into the milieu of the pore, but it self-neutralizes by crystallizing on the skin surface. Thus, it provides a nice contrast to glycolic acid in its therapeutic effects. It can be used as a peel for patients with acne, due to its ability to loosen comedones, and for patients with sensitive skin, due to its anti-inflammatory and self-neutralizing qualities.

A more aggressive superficial chemical peel can be achieved through a combination of salicylic acid, lactic acid, resorcinol, and ethyl alcohol. This solution is known as Jessner's solution and is sometimes used to enhance the penetration of 25-35% trichloroacetic acid to achieve medium-depth peeling.

Formulation

Superficial peels can be easily self-formulated by the dermatologist.

Glycolic acid can be purchased from chemical supply houses as a 70% saturated solution. This solution can be used directly on the skin for an aggressive superficial peel or diluted with water. I prefer to dilute glycolic acid to concentrations of 20%, 30%, 40%, 50%, and 60%. These dilutions can be used to titrate the desired depth of peeling for each patient:

  • Glycolic acid 20% to 30% provides a mild exfoliation for the patient with virgin skin. Patients who are using high-potency retinoids, such as tazarotene, will obtain a more aggressive peel
  • Glycolic acid 40% to 50% can be used as a step-up peel for patients who began their treatment with 20% to 30% glycolic acid 3 weeks previously
  • Glycolic acid 60% to 70% is an excellent treatment for the patient wishing to improve skin dyspigmentation or fine wrinkling. This type of peel will also enhance penetration of hydroquinone and retinoids to speed antiaging therapy

Salicylic acid is purchased as a white crystalline powder. The powder must be dissolved in benzyl or ethyl alcohol due to its oil solubility. I prefer benzyl alcohol, since it is not quite as fragrant or volatile as ethyl alcohol. I dilute my salicylic acid peels to 10%, 20%, 30%, 40%, and 50%. Peel strengths of 10% to 20% are solutions, but 30%, 40%, and 50% strengths are shake lotions, since somewhere between 20% to 30% salicylic acid becomes a saturated solution.

  • Salicylic acid peels of 10% to 20% are excellent for acne patients with dry skin, while salicylic acid peels of 30% to 40% may be used in oily complected acne patients.
  • 30% salicylic acid is probably the maximum strength recommended for uncontrolled rosacea patients.
  • Salicylic acid 40% to 50% may be used in the patient who wishes more aggressive peeling.

In general, salicylic acid does not produce as deep a peel as a similar concentration of glycolic acid.

In addition to self-formulating peel products, several commercial skin peels are available. These commercially marketed peels employ buffers and other pH adjusters to decrease peel potency and the resulting erythema.

Application Technique

The equipment required to administer a superficial salicylic or glycolic acid peel is minimal. The peel solution should be dispensed from a dark glass bottle into a small glass. I prefer to use a shot glass. Approximately 2 cc is enough to cover the entire face.

The peel solution is best applied with a rectal swab dipped into the glass and rapidly rubbed over the face, being careful not to drip the peel solution. I prefer to put 2 or 3 coats over the patient's face, inquiring as to the degree of discomfort.

When the patient reaches a pain level of 4 or 5 on a 10-point scale, I neutralize with ice-cold water in a stainless steel bowl and 2 disposable wash clothes. The skin is completely rinsed at least 3 times, taking care to thoroughly remove the acid from the corners of the nose and mouth.

The face is then patted dry and a bland moisturizing cream applied, if the patient desires.

Patient-Selection Criteria

Careful patient selection is the key to the success of any peel. Both salicylic and glycolic acid can be used without difficulty in Caucasian patients, but patients of color should be peeled with caution. Low concentrations of glycolic and salicylic acid should be used to prevent postinflammatory hyperpigmentation. When in doubt, begin with a salicylic acid peel in darker skin colors to prevent problems.

It is also important to determine the state of the skin that is undergoing superficial chemical peeling. Patients who use retinoids, undergo frequent facials or microdermabrasion, engage in salon laser procedures, or use waxing as a method of hair removal may experience unpredictable deeper peel penetration due to loss of the stratum corneum. Obtaining a cosmetic procedure history is important to obtaining reliable superficial peel results.

Summary

Superficial chemical peeling is an important part of the dermatologic armamentarium. These peeling techniques are some of the easiest to master, since the depth of penetration is limited to the stratum corneum and the superficial viable epidermis. Glycolic and salicylic acid peels in a variety of strengths can be formulated in the office to customize the peel for the specific patient's needs. Superficial peels can be used to improve skin texture through exfoliation and may enhance the penetration of antiaging compounds, improve dyspigmentation, and decrease fine wrinkling.

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