Chemical reaction

In the second of her two-part series, Balsam Alabassi discusses chemical peels and applications for skin of colour

In last month’s issue of Aesthetic Medicine, we examined the history of chemical peels, common types of peeling agents used in aesthetic practice and their classifications and clinical applications. This month, we will delve deeper into how this applies to treating skin of colour. Firstly, we will discuss the importance of priming the skin prior to a chemical peel.

PRIMING

Priming or prepping skin prior to performing a chemical peel can yield many benefits, such as creating an even and better distribution of the peel at the time of treatment, reducing risk factors such as hyperpigmentation, and reducing the wound healing time, thereby aiding skin recovery. It also creates positive skincare maintenance habits.1

Combination treatments with rejuvenating agents have been shown to deliver impressive results for various skin concerns, such as photoaging.2

CONSIDERATIONS WITH CHEMICAL PEELS

A detailed knowledge of skin anatomy and the mechanism of the wound-healing process is vital to safely treat.2

An in-depth consultation patient assessment with detailed medical and patient history is paramount prior to a chemical peel treatment to assess suitability whilst adhering to the exclusion criteria.

The consultation also serves to explore the patient’s ideas and concerns, including evaluation of psychological aspects to determine the motivation and goal, emphasising realistic expectations, particularly in social media-focused patients. A clear description of the treatment should be covered during the consultation, including the treatment procedure, undesirable side effects, recovery time, and aftercare instructions. The patient must be provided with information regarding the risks and the benefits of the treatment to establish informed consent.3

Contraindications to chemical peels include:

• History of allergic reaction to the peeling agent, or any known past or present allergies

• Active skin infections such as viral, fungal and bacterial

• Open wounds

• Skin conditions with pre-existing inflammatory dermatosis such as psoriasis, atopic dermatitis

• Non-adherent patient with regards to aftercare instructions

• Medication with photosensitising properties. The use of isotretinoin within six months previous to the attended chemical peel treatment.

• Unmet and unrealistic patient expectations

It is important to consider patients with abnormal scarring and keloids, atrophic skin, patients with immunosuppression, uncontrolled diabetes, as well as patients with Fitzpatrick III-VI as they may be prone to pigmentation or dyschromatopsia.4

COMPLICATIONS OF CHEMICAL PEELS

A number of factors may determine the risk of a complication. These include:

• Product selection

• The procedure performed

• The depth of the peel in relation to the skin concern or skin colour

• Inappropriate patient selection

• The skill of the practitioner.

Such complications can include pigmentary changes, post-inflammatory, hyperpigmentation or more persistent and very difficult to treat hypopigmentation, bacterial infections such as staphylococcus, streptococcus, pseudomonas), viral (herpes simplex), fungal skin infections, allergic reactions, milia, acneiform eruptions, demarcation lines and scar formation.

Careful product and patient selection and robust adherence to aftercare instructions, including the use of sunscreen, can minimise the risk of complications.1

THE RISE IN POPULARITY OF BLENDED PEELS

Blended or combination peels have gained an increase in popularity due to their ease of application, decreased risks and increased recovery, enabling a wider demographic of patients to be treated. Combination peels can yield a higher and earlier therapeutic response with a cost-effective approach that enables ongoing maintenance leading to greater patient satisfaction.5

Combination peels are not a new concept as the Jessner’s Peel was developed by Max Jessner, MD, in 1860. The appeal of the Jessner’s Peel was the use of different substances that combined caustic, metabolic, and toxic effects.1

SO, WHAT IS THE DEAL WITH A BLENDED PEEL?

These are a collection of acids at lower concentrations and advanced formulations with medium depth penetration. Blended peels are more controlled in their penetration than straight acid peels. They are formulated at lower percentage concentrations and with enhanced delivery systems, melanogenesis inhibitors, antioxidant ingredients, hydrating and rejuvenating agents, making them an allinclusive peel for all Fitzpatrick skin types. Their formulations enable them to create and deliver clinical outcomes with a lower risk of inflammation or complications.6

There are a number of blended peels on the market. These include the VI peel, The Perfect Peel, the BioRePeel Cl3 and PRX-T33, to name a few.

The VI peel portfolio, for example, is made of medical-grade peels, which penetrate the papillary dermis, resulting in specific regenerative changes. All VI peel preparations are self-neutralising with light to medium penetration depth, depending on the application technique.

The peel is formulated for all skin tones to address skin concerns with percentage acids of <15%. They also do not require pre-treatment of the skin. However, patient assessment is advisable.

All VI peels are formulated using synergistic blends of TCA, phenol, retinoic acid, and salicylic acid at lower individual concentrations. This combination allows the VI Peel to penetrate the dermis without the destruction or longer healing time that a straight acid would incur, yet achieving the desired outcome. The blended VI Peel formulations have added nutrients such as antioxidant vitamin C and ingredients for pigment suppression and acne control, allowing the peels to address conditions that standalone may not be suitable.1

Once the treatment is completed, the patient is armed with an aftercare kit to ensure successful and safe completion.

The Perfect Peel adopts a similar approach to the VI peel, where an aftercare kit is also provided. However, its hero ingredient is glutathione. According to the manufacturers, combining glutathione into a medium-depth peel is an effective mechanism for allowing it to penetrate the stratum basale and spinosum to the melanocytes while also delivering a combination of acids and melanogenesis inhibitors, hydrating agents, and antiinflammatory and antioxidant ingredients.10

The BioRePeel Cl3, on the other hand, adopts a different mechanism of action and formulation. The BioRePeel is a biphasic peel. The hydrophilic phase consists of 35% trichloroacetic acid, salicylic acid, tartaric acid, citric acid and lactobionic acid. It is also formulated with ascorbyl glucoside, riboflavin and amino acids: arginine, glycine, proline, hydroxyproline, in addition to gamma-aminobutyric acid (GABA). The lipophilic phase includes a natural moisturiser squalane and isopropyl myristate that functions as a delivery vehicle.7

Although the BioRepeel is formulated with a high percentage of TCA (50% for the body formulation), the side effects are minimal.

This is due to the formation of trichloroacetate salt maintaining the action of TCA while minimising adverse effects (see diagram 1).

The penetration of the product is also facilitated by isopropyl myristate, which serves as a vehicle where the product is amphiphile in its properties, with both a hydrophilic and a lipophilic portion improving the permeability of hydrophilic molecules through a lipophilic barrier of the skin. The biostimulating complex increases the proliferative activity of dermal fibroblasts, leading to the production of collagen, especially types III and I.7

PRX-T33 is a biorevilalisation peel with a similar method of application to the BioRePeel. However, PRX-T33 combines 33% trichloroacetic acid with hydrogen peroxide to produce what the manufacturers term a new type of peel. The mechanism of the action of oxygenated water combined with the TCA minimises the aggressive effects of peeling (frost or exfoliation of the dermis), stimulating the dermis non-invasively.8

The advantage of blended peels is that they can create an exfoliating effect while rejuvenating skin. The added nourishing ingredients eliminate the need for acid neutralisation which is not possible with single-use peels. Utilising multiple acids blended at lower percentages enhances clinical outcomes and reduces the risk of undesirable effects. In addition, their formulations lend themselves to combination therapies, and some may be performed in the same appointment session. A multimodality approach can address a multitude of skin concerns, thereby increasing patient satisfaction. However, before adopting a multimodality approach, confidence in successfully treating the patient with standalone blended peel should be accomplished.6

CONCLUSION

Chemical peels are a staple part of the cosmetic practitioner’s toolbox; they are popular, relatively inexpensive, and generally, a safe method to treat a multitude of skin disorders with rejuvenating and skin refreshing benefits.

In addition, combining chemical peels with other resurfacing and rejuvenation procedures can provide a synergistic approach with favourable outcomes tailored to the patient’s individual skin goals. It is vital that chemical peel treatments are performed by trained professionals with an in-depth knowledge of skin anatomy, because their purpose is to induce controlled trauma and, therefore, in untrained and inexperienced hands, chemical peels may lead to skin damage.9

Consideration of potential complications and contraindications is paramount prior to commencing the treatment. Patient selection and in-depth consultation with a detailed medical history and appropriate skin priming are vital for a predictable and safe outcome. Checking the patient’s understanding with regards to the importance of aftercare instructions and a skincare regimen, including the daily use of broad-spectrum sun protection, plays an integral role in the treatment outcome.4

The versatility, safety, control, and predicted outcomes of blended peels positions them favourably in an everglowing aesthetic industry where patient expectations and time constraints are factors.

The blend of ingredients formulated with unique delivery systems and ease of use creates a powerful tool for skin transformation, thereby increasing patient satisfaction and retention. Their formulations enable combination therapies to be performed in the same treatment session, freeing up time for both the practitioner and the patient.

Achieving healthy, beautiful skin for patients is the ultimate goal of all aesthetic practitioners. Skin peeling treatments need to be supported by an effective skincare routine. It is vital to educate, enable and empower every patient to own their skin journey by providing a complete care solution to their skin health.

BALSAM ALABASSI

Balsam Alabassi is the founder of DermRefine Skin Clinic, Mayfair, London. She is an independent prescriber and an advanced skin specialist with a Level 7 qualification in cosmetic injectables as well an NVQ Level 4 in laser hair removal and advanced skin rejuvenation. With over 20 years of clinical pharmacy and leadership experience, her mission is to educate, enable and empower her patients to truly own their skin and skin health.