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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.

Chemical Peels

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

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  1. Skin Cancer Prevention Strategies: Tried, True and New.  RL Moy, S. Famini.  Skin Cancer Foundation.
  2. Retinoids for prevention and treatment of AK’s. Ianez, et al.  An Bras Dermatol.  2013, 88 (4):585-593
  3. Diagrams: Edited/iStockphoto-ttsz.  Used with permission.
  4. 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.


  • Jessica Manges, ARNP

    Jessica Manges is a n Advanced Registered Nurse Practitioner who is board certified through the ANCC. She graduated in 2010 from the University of South Florida with her Masters in Nursing and did her BSN at The University of Tampa. As a nurse she worked at Tampa General Hospital and specialized in medical/surgical nursing. Upon graduating with her masters she started in dermatology and then went on to specialize in aesthetic medicine. She has years of experience in injectables and an artistic eye for achieving the most aesthetic results. She has a passion for skin care and loves learning advancements in anti-aging medicine.  Jessica keeps up with the latest techniques and products in the industry. Jessica believes in teaching the skills of a thorough consultation to create the most comprehensive treatment plan so that you are able to achieve the best results for your clients.  She has treated thousands of people to include Botox, dermal filler, Sculptra, PDO threads, plasma and Kybella. She also is a certified aerial yoga teacher so brings a calming atmosphere to the teaching environment, making you comfortable while learning these new skills.

     

  • Dr. Shana Hughes, DMD

    Shana graduated from the University of Louisville’s School of Dentistry in 2011 before founding The Tooth Booth, a cosmetic dentistry boutique practice in 2012.   Since it’s opening, Dr. Hughes has added implant dentistry & facial aesthetics to her practice model.

    Dr. Hughes has been a facial aesthetics injector since 2013.  Since that first injectables certification course, she has taken countless courses all over the nation with some of the aesthetic industry’s very best.  After first introducing neurotoxins and hyaluronic fillers as added services for her patients, she has since added professional skincare, Sculptra, Kybella, and PDO threads.  Dr. Hughes was named an Allergan Ambassador for their 2019 Summit.
    She prides herself on her commitment to learning & perfecting her skills.

    Shana began training others in injectables in 2018.  She is an asset to the MedAesthetics team in that she can help give insight to practitioners who are looking to integrate aesthetics into their current practices just as she did in her earlier career.  Her personal experience at The Tooth Booth means she can aid injectors in the business and marketing aspects of the injectables industry.

     

  • Erin Hennessey, DNP, APRN, FNP-C

    Dr. Erin Hennessey founded Blush Aesthetics in January, 2017. With a passion for skin health and wellness, her special interests include healthy skin maintenance, acne and rosacea management, laser treatments, injectables and education.

    Erin attended Case Western Reserve University graduating with the distinction of Summa Cum Laude earning a Bachelor of Science in Nursing. After working for twelve years in Pediatric Intensive Care caring for trauma and burn patients, she furthered her education at Case Western Reserve University, completing her MSN with focus in family nurse practitioner certification. She completed her clinical rotations at the Cleveland Clinic and University Hospitals in Cleveland. She then went on to complete her Doctorate in Nursing Practice and doctoral nursing fellowship in Dermatology.

    Erin is a Certified Nurse Practitioner by the American Association of Nurse Practitioners, an active member of the Ohio Association of Advance Practice Nurses, The American Society for Laser Medicine and Surgery, Sigma Theta Tau and the Dermatology Nurses Association.

     

  • Christopher Dunn, DDS

    Christopher graduated from the University of Colorado with his undergraduate degree Bachelor of Arts and Sciences 1986, was accepted at University of Colorado dental school and graduated in 1990. He had a hospital position at Swedish Medical center in the head and neck trauma unit and has since been working in private practice since 1991.

    He enjoys cosmetic dentistry and the immense happiness a beautiful smile can provide for his patients. Patients frequently comment afterward, “ If I could just get rid of the wrinkles”, this led him to pursue adding the skills of Neuromodulators such as Botox and Dysport and hyaluronic acid based dermal fillers to complement the improved smile. He has a passion for sharing knowledge and techniques and feels continued learning and improvement is the hallmark of a good clinician. He enjoys reading and researching all areas of fitness, health, and the art of staying healthy and looking younger.

     

     

  • Hanieh Khorshidi NP-BC

    Meet our aesthetic provider, Hanieh Khorshidi NP-BC.  Hanieh graduated from George Mason University, in Fairfax, Virginia with her degree as a Board Certified Nurse Practitioner.  She has been practicing for over 10 years. Starting off as an Operating Room Nurse, Hanieh worked and trained among some of the best plastic & cosmetic surgeons throughout the Midwest and Northeast regions of the United States, gaining a profound appreciation for patient safety, advocacy, and education.  Her passion for patient safety and education extends to her career in aesthetics, as she has been awarded with Medical Aesthetics Certifications including Master Injector for her use of cosmetic injectables in both basic and advanced injection techniques.  Hanieh currently owns and operates a Practice in Arlington, Virginia.  She prides herself on having a diverse and well-rounded understanding of both the business, and aesthetics of the cosmetic industry. Her approach is admirable in its respect for the artistry involved in injectables. Hanieh believes in a personalized, natural approach to all aesthetic treatments ultimately producing outstanding outcomes for her patients in the safest manner possible.

     

     

  • Dr. Luis Linan, MD

    Dr. Luis Linan is a board-certified OB/GYN in El Paso, Texas.  He attended the University of Texas in Austin and graduated in 1982 with a BA in biology.  He went on to study at Texas Tech School of Medicine where he graduated in 1989.  After two years of general surgery residency, he completed his OB/GYN residency at Texas Tech University Health Science Center in El Paso.  From 1994-1995 he was clinical faculty at Texas Tech HSC in the department of OB/GYN.  Since 1995 Dr. Linan has been in private practice and in 2007 he began doing sclerotherapy treatments.  In 2011 his practice expanded to medical aesthetics where he now performs treatments for neurotoxins and fillers.

     

     

  • Erika Barry, NP-C, MSN, CCRN

    Nurse Practitioner

    Erika Barry received her undergraduate training from the University of Miami where she obtained a Bachelor of Science in Nursing and Health Studies, May 2006. She received her Master’s Degree from The Johns Hopkins University in May 2011. While completing her graduate degree at Hopkins she began to explore her interest in anti-aging and plastic surgery. After graduating from Hopkins in 2011 she moved to San Francisco, California to accept the coveted position as a surgical nurse practitioner at The University of California, San Francisco. At UCSF, she was fortunate to work with the urology and plastic surgery teams at UCSF Medical Center located at the Parnassus Campus in the heart of San Francisco.

    After four years as a surgical NP at University of California, Erika moved to DC to work in outpatient cosmetic surgery. She is now the lead injector at the elite Hela Medical Spa in Georgetown, DC. At Hela she is the “master” of Botox, dermal filler, and Kybella. She has trained over 200 nurses, physicians, physician assistants, and nurse practitioners in aesthetics and injectables. Her personal teaching moto, “safety always, always, comes first”.

  • Angela Coton, PA-C, MPAS

    Aesthetic Specialist

    Angela is a nationally board-certified and North Carolina state licensed Physician Assistant who has been practicing since January 2010. She graduated cum laude with her Bachelor of Arts in English Literature from the University of Illinois, Urbana- Champaign in 2000. After 10+ years working in both the corporate business environment and managing a medical aesthetics spa, she realized her true gift was in patient care. She returned to East Carolina University in 2007 to pursue her Master of Science in Physician Assistant Studies.

    After graduating from ECU in 2009, she relocated to the North Shore of Boston to study Facial Plastics and Otolaryngology with seven renowned surgeons. Her supervising physician Dr David Chrzanowski is a board certified facial plastic surgeon and she gained immense knowledge in facial anatomy and aesthetics in addition to skincare science. Angela’s background in facial plastics and the science of aging combined with her desire to make people feel good about themselves led her to pursue aesthetic medicine. Her favorite tools to improve patient’s natural beauty is through minimally invasive techniques of neuromodulators (Botox/ Dysport/Xeomin) and dermal fillers to prevent wrinkles and restore collagen loss. She is dedicated to maintaining the highest standards of patient safety and values the importance of educating her patients on the options that will allow them to be the most naturally vitalized and get the most for their money.

  • Jennie Kowaleski, PA-C

    Jennie attended Seton Hill University in Pennsylvania where she obtained her Bachelors of Science degree in Physician Assistant studies. She later completed her Masters of Science in Physician Assistant Studies, Education and Leadership, from A.T. Still University. Jennie began her PA-C career in Urgent Care and internal medicine, later developing a passion for aesthetics. She began working in the field of skin care and aesthetics in 2010. She has become very proficient in facial contouring and enhancement with various injectables such as botulism toxins, dermal fillers and Kybella. She has a vast knowledge and multiple certifications for use of state of the art lasers.

    Jennie’s philosophy to skin care and aesthetics is simple. She wants to achieve natural, beautiful results working in all levels of comfort and ability. Jennie works as a private trainer teaching other health care professionals in injectable techniques.

  • Meredith Harris, NP

    Meredith pursued undergraduate studies in Physiology and Neuroscience at the University of California and later completed a second undergraduate degree in nursing at Loma Linda University. In 1998, Meredith graduated Magna Cum Laude from the University of Pennsylvania as a Nurse Practitioner in Women’s Health. After years of caring for women, Meredith found her career niche in the sub-specialty of aesthetic enhancements.

    In 2017 Meredith was recognized with an Award of Excellence for the Best in Nursing by the American Health Council. As a member of the International Society of Plastic and Aesthetic Nurses and The National Academy of Dermatology Nurse Practitioners she continues to pursue advanced training and knowledge to keep her on the leading edge of the aesthetic market. Meredith travels extensively to teach and train new and advanced injectors throughout the country.

  • Mr. Waseem Garbia, PA-C

    Mr. Garbia graduated from George Mason University in Fairfax, VA. He then attended Jefferson College of Health Sciences in Roanoke, Virginia and graduated with his degree and certification in Physician Assistant studies and has been practicing for over 14 years. Waseem has worked in many different settings including general and plastic surgery, emergency medicine, critical cardiology and aesthetics.

    He is a certified master injector and is a national aesthetic medical trainer. Waseem has a vast knowledge in cosmecuticals, injectables and lasers and has a passion for long-term skin enhancement. Having experience with launching several medical spas, Waseem enjoys teaching and sharing his knowledge in technique as well as meeting business objectives.

  • Dr. Christy Bennett, DO

    Dr. Bennett is Board Certified in Family Medicine by the American Board of Family Medicine. She completed an Allopathic Internship & Residency in Family Medicine at the University of Oklahoma-Tulsa in 2000 and entered into a private practice. She received her undergraduate degree from the university of Tulsa in 1978 in Medical Technology. Dr. Bennett practices family practice medicine, operates a concierge injectable business and serves as Medical Director for a Medical Spa in Tulsa, OK.

    Dr. Bennett has been an instructor in aesthetic medicine for over 9 years specializing in the areas of Injectables, Sclerotherapy, Microdermabrasion & Chemical Peels. Dr. Bennett has authored numerous teaching materials & presentations in the areas of aesthetic medicine and has attended national and international symposiums on aesthetic medicine.

  • Dr. Jeffrey Ayers, DO

    In 1985 Dr. Ayers graduated from Westmont College in Santa Barbara, CA with his BA in Biology. He then graduated from medical school in 1989 from Des Moines University. From 1989-1992 he completed his Family Medicine Residency at the US Naval Hospital Camp Pendleton. From 1992-1995 he served the US Navy in Sasebo, Japan as a staff family physician and chief of the family advocacy program.

    In 1995 Jeff and his family relocated to the Salt Lake City area where he continues to work with Intermountain Healthcare as a staff family physician. In 2005, Dr. Ayers added non-surgical medical aesthetics to his areas of practice. Today, Dr. Ayers practices family medicine as well as serving as medical director for the National Institute of Medical Aesthetics and Elase Medical Spas.

    Dr. Ayers also trains for the use of neurotoxins, dermal fillers and laser resurfacing.

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