21 May Peel Back the Winter Skin
With summer looming soon in areas where the weather takes a hit from Old Man Winter, people are eager to show their arms, shoulders, legs and more. In areas where it is warm year long, an interest in “showing skin” is always front and center. Manicures and pedicures are giving us bright and sparkling nails. We can go a step further and offer our clients soft and fresh skin for the look and feel that they crave. Chemical peels are a popular way to remove layers of dead skin—Stratum corneum and encourage the deeper layers to turnover and improve collagen and elastin formation. Chemical peels were used in Cleopatra’s time when she bathed in sour milk to make her skin soft. Today, we know that the chemical she used was Lactic Acid—an Alpha Hydroxy Acid.
For facial skin, there are several safe and even deeper chemical peels performed to reduce wrinkles and soften the skin. When these peels are performed, layers of dead skin may visibly shed. My clients like to “peel like a snake” to see that something has happened. With chemical peels on the body, the turnover of the skin increases; however, the sheet-like shedding is unlikely. Regardless, the skin becomes softer and smoother.
The neck and décolleté are favorite areas for chemical peels. A caution in this area is scarring and keloiding. Aiming for the lightest peel reduces this risk. Deeper peels are contraindicated on the lower extremities due to higher risk of adverse events because this skin takes longer to heal, and the sebum-producing glands are much lower in concentration. Sebum is a softening and moisturizing agent. These peel areas are better-served with serial lighter peels. “Bacne” or acne on the back can improve significantly with the right chemical peel.
Categorizing the Skin
Typically, the skin is categorized based on it’s reaction to sun exposure. A rating scale by Dr. Thomas Fitzpatrick groups fair and light skin up to darkly-pigmented brown skin. The lighter skin tolerates stronger acids and the darker skin reacts with more adverse effects thereby requiring weaker acids. There are several chemical options for peeling of the skin. Peels are divided into the level of the skin that the peeling agent descends. These layers are superficial, medium and deep. Some peels can bridge groups depending on how many coats of the chemical are applied. Those pertinent to superficial peeling are Alpha Hydroxy Acids (AHA) like Glycolic Acid from sugar cane, Lactic acid, Citric acids from fruits and Malic acid from apples. Beta Hydroxy Acids (BHA) like Salicylic acid from willow bark are popular and effective but contraindicated in allergies to aspirin. We need to ask if the “allergy” is gastrointestinal irritation or a true allergy or anaphylaxis.Trichloroacetic acid is an analogue to vinegar and it can go deeper into the skin layers if the percentage in the peel is higher. Retinoic acid—familiar because of Retin A™– a Vitamin A-derived product and present in many OTC lotions to improve skin texture. It plays a key role in turnover in skin cells and studies show that it may prevent and cause regression in actinic keratoses and non-melanoma skin cancers.1,2 Resorcinol is a carbolic acid and popular in combination peels in low concentration.
Offering Chemical Peels
What is the best way to begin offering Chemical Peels? Learning the basics is key. Most commercial companies producing peels for professional use will offer education on the acids, client selection and rejection and the procedure itself. A wise recommendation is to start with a body peel because it is safe for non-facial skin and designed with a combination of acids to offer the best properties of each one. These will usually come in kits with all the chemicals needed. Most body peels will be very superficial to superficial. They will go no further than the Stratum basalis and are typically safe in all six of the Fitzpatrick skin groups from very light to dark skin. This means you only need one product. While many brands are available, two examples of these body-designed peels are PCA Smoothing Body Peel and Stacked Skincare TCA Multi-Acid Body Peel. No bias is intended; however, few brands are available. To purchase PCA products, you must go through an online peel class. The class includes 9 multilevel modules with quizzes. What about the current YouTube rage of the Baby Foot™? The acids in this are Glycolic, Lactic, Citric and Salicylic acids. It should be reserved for the feet only. So why is there less peeling on the body but Baby FootTM peels layers and layers of disgusting skin? The face has 7-10 layers of stratum corneum (dead skin), the neck has 10, the forearm has 16, the back of the hand has 25 but the sole of the foot has 55 and the heel has 86.4 These numbers vary but there is much more to see on the bottom of the foot.
Once a practitioner has full knowledge and an increasing comfort level with the individual acids and strengths appropriate for the area, a non-commercial blend may be considered.
One key piece of information to emphasize to your patients is that after a peel, sunscreen is mandatory. The freshly-denuded skin will be much more susceptible to UVA and UVB rays. SPF above 30 is preferred. Your clients will be ready for summer clothes and flip flops.
Written by: Dr. Christy Bennett
- Skin Cancer Prevention Strategies: Tried, True and New. RL Moy, S. Famini. Skin Cancer Foundation.
- Retinoids for prevention and treatment of AK’s. Ianez, et al. An Bras Dermatol. 2013, 88 (4):585-593
- Diagrams: Edited/iStockphoto-ttsz. Used with permission.
- Number of cell layers of the stratum corneum in normal skin – relationship to the anatomical location on the body, age, sex and physical parameters. Ya-Xian Z1, Suetake T, Tagami H. Arch Dermatol Res. 1999 Oct;291(10):555-9.