Peelings: how, when and why!

Definition:

It is an abrasion of the epidermis or the derma done with chemical means, generally strong acids, or physical as cold or a laser source or radiofrequency. 

A little bit of history…

Peelings meant as treatment of the skin to improve its aspect, to deeply take care of it, or just for a simple major cleanliness, are known since the ancient Ages.

In the ancient Egypt the cares of the skin trough exfoliated substances were already known, which were basically mildly acid that gave back a more smooth skin: flower’s powder and grinded plants, citruses’ juices as oranges and lemons, but also milk, were all used a lot. Cleopatra used to get wet in the donkey’s milk.

In the late middle Ages, professionals existed. They executed peeling at home and also, for example, took care of eyebrows’ depilation which had to be.. high, thin and well done!! Texts, where it is told about other substances which “clean every spot”, exist.

In the modern Ages, in order to get to the origin of the modern medical treatment, we have to get back to the end of the XIX century, when a German Dermatologist, Doctor Unna, started the modern treatment trough different types of peelings, in particular with resorcin and salicylic acid, but also with deeper peelings as phenol and trichloroacetyl acid, all peelings with a very common use.

In particular the peeling with phenol has been widely studied and experimented by numerous dermatologists and plastic surgeons as the English Mac Kee, or as Gassè who refined the occlusive technique after the peeling.

But it is in the 70’s and 80’s that the peeling with trichloroacetyl, salicylic or lactic acid gained more and more notoriety, but especially the first example of the alpha hydroxide, the glycolic acid, starts to be used on a large scale.

Numerous searches, inherent to soft peelings with their miraculous applications, are due to the American Doctor Scott.

Where and how peelings act?

Skin is a very complex organ, maybe the most complex of the whole body, and it has a lot of functions, among the many the main one is to act as a barrier against the elements outside the human body. It is surely the most represented organ in the brain and also one of the most important sexual organs: just think about the blushing due to embarrassing moments or the desire, and think of the smell it emanates which largely conditions our emotions.

It is composed of three fundamental layers: the epidermis, the derma and the subcutaneous.

Besides, we need to remember that the cutaneous annexes inevitably tend to the diminution and reduction of the function by the time goes by.

The cells of the skin come from deep layers and then they get more superficial, keratinized and hard after a while, till they come off from the superficial cutaneous layer.

The complete cycle lasts about 25-30 days. More you get old, more these cells accumulate and give thicknesses, spots and so on.

Besides, there are different types of skin, especially based on its own color. This will result very important in the selection of patient and in the indication that every peeling inevitably has.

Peelings have different goals: first of all they accelerate this turnover, this cellular replacement. Then, they remove dead and deteriorated cells, and it is for this reason that certain peelings are particularly active on cutaneous spots.

In the end, they also have an inflammatory action, which stimulates, according to still unknown mechanism, the production of collagen: after a certain amount of time from the application, the skin treated with peeling reveals itself more turgid and tonic. So, they are fundamental in every treatment of cutaneous revitalization.

Obviously, these mechanisms of action are not always all present at the same time in different types of peelings: some of them have the major clearing action, in some others the major action is the production of collagen and so on.

Then, collateral effects are possible. Sometimes important, most of the time momentary but rarely they can be also definitive. Among these the hyper and hypo pigmentation are the ones that scare the most.

Obviously, more the peeling is deep and aggressive, more the indications and the patient have to be rigorous, because the complications are more frequent.

In my opinion, if it is possible, it is always better to prefer a not very invasive peeling, repeated more times, rather than a very aggressive one done in one session.

Peelings’ indications:

So, peelings are especially advisable for the rejuvenation of the skin, when the first signs of keratosis and cutaneous aging start to be evident.

Another wide chapter is represented by cutaneous dyschromias, spots, especially the ones due to the age.

Also some cutaneous diseases can take advantages from peelings in a very important way, especially the vulgar acne and its results, the rosacea and the seborrhoeic dermatitis.

Some colleagues use peelings also similar to stretch marks, but in my opinion in this case they are not worthy.

Different types of peelings: 

Peelings can reach different depths of skin and so a first classification is based on the depths of action: (famous is Doctor Rubin who was the first who suggested it)

• Preparatory Peeling: very superficial, for deep cleanliness of the skin almost always before another treatment.
• Superficial Peeling: it creates an injury of the most superficial layer of the epidermis till the basal layer.
• Medium Peeling: it gets deeper, usually till and not apart from the papillary derma.
• Deep Peeling: they involve necrosis of the whole epidermis, of the papillary epidermis to get till the reticular derma. 

Superficial Peeling:

Alpha and beta hydroxide acids (in general)

Mask at the retinoic acid 5 – 10%

Glycolic acid 30 – 50%

Salicylic acid

Mandelic acid

Jessner’s solution (from 1 to 7 layers)

Trichloroacetyl acid 10 – 15%

Combination of more peelings

Medium Peeling:

Trichloroacetyl acid 25 – 35%

Combination of more peelings in particular with the TCA

Deep Peeling:

Trichloroacetyl acid 35%

Phenol (Molding Mask)

Xeroderm (always based on phenol)

Which peelings do I prefer? from the weakest to the strongest …. 

Tretinoic’s mask:

It is a gel that it is spread on the face and it is left on it till the complete drying process (about half an hour). It foresees changeable concentrations from 2-3% to10, but also 15%.

It contains the same active principle of certain lotions that were in fashion few years ago, which had very low concentrations (from 0.01 to 0.05%) and were suitable for acne and cutaneous aging.

Their problem was that they had to be applied for a very long time, months, and very often after a while an inflammatory reaction, that obliged to interrupt them, occurred.

With the mask this problem has been overcome and moreover, the time to see good results had shortened a lot.

It is one of the so called socializing peelings, because it provokes a dandruffy exfoliation, it does not provoke erythemas as a rule and you can immediately go back to work.

It is very good in order to give back shininess and turgidity to the skin, and as helper for cutaneous spots.

On the contrary, it is not advisable for wrinkles because they are too delicate.

The only true and absolute contraindication is pregnancy.

Jessner’s solution:

It is a solution in ethanol of 3 acids:

• Salicylic acid
• Lactic acid
• Resorcinol

It is spread on the face in following layers from 1 till 6, or also 7.

In this way it is possible to manage the penetration, going from a superficial peeling to a deeper one, even if it is very difficult it gets to the basal foil of the epidermis.

It is a peeling that I personally like a lot:

• It is very efficient in the cutaneous rejuvenation, giving a luminosity that other peelings difficultly can give.
• It is very efficient on spots, even the deepest ones, allowing to obtaining, with repeated peelings, results superimposable to more invasive peelings, but with an extremely lower percentage of complications.
• It can be used for neck and décolleté without worrying about exaggerated reactions.
• It can be used with success also on hands increasing a little bit the steps.

Well, it is a very ductile peeling, without serious collateral effects and important contraindications. We need to pay attention to patients allergic to the Acetylsalicylic acid, even if relevant reactions do not occur.

It can be executed once a month for cycle of 3-4 sessions per years.

It can also be associated to more invasive peeling, in particular the Trichloroacetyl acid as preparatory peeling.

As a rule it provokes a desquamation that starts from the 2nd-3rd day and goes on for 10 days. Most of the time it is visible even if never defacing. It is possible that friends ask what happened thought, but there will not be not any scabs or injuries of any kind. Generally red patches do not last and, with a bit of make up, you can show yourself off immediately. I would also put this one in the socializing peeling.

In the post peeling period the exposure to the sun needs to be avoided, you can not scratch yourself, nor rip your skin… hydrate it a lot.

Trichloroacetyl acid: 

It is another active principle in use since many years.

They are crystals which are diluted with the proper quantitative of water giving in this way the concentration from 10 to 35%.

It is also possible to have major concentration, but the penetration becomes faster and so it is harder to exceed with even important collateral effects.

If it is used at major concentrations it can give necrosis of the whole epidermis and get till the reticular derma.

It is uniformly spread on the face and it can manage to provoke that whitening of the skin called FROST, to whom a cutaneous necrosis will follow.

The skin will come off in wide layers which must not be absolutely ripped off, otherwise cicatricial injuries will form. Patients will have to be very… patient.. and carefully follow the instructions. Sun is forbidden!

It is not among the socializing peelings but we will not have damp injuries or anything else that need to be cleaned: also in this case we need to hydrate a lot.

It is a very advisable peeling for the chrono and photo aging, to improve small wrinkles (for example the code bar wrinkles of the lip) and cutaneous spots.

There are many versions of this peeling as the TCA gel mask, the easy peeling and the blue peel, but I personally prefer to use the pure crystal.

Pyruvic acid peeling:

The pyruvic acid is an alpha keto acid similar to the lactic acid. It belongs to a long list of substances present in nature and derived from fruit, as apples, and vinegar.

It has indications in the acne and in the seborrhoeic dermatitis because it has great sebostatic and antimicrobial properties.

On the derma it has great properties of stimulation of collagen, superimposable to the one induced by the trichloroacetyl acid, but with less invasivity.

It has a less keratinolitic action. For this reason the following desquamation to this peeling is clearly less, while the seboregulating action is more accentuated, so important in pathologies as acne.

It also has a mild depigmenting action.

The main indication is acne, also in the active phase, the rosacea, the seborrhoeic dermatitis.

It can be used also for melasma, chloasma and keratosis, but in this case it has fewer benefits.

Also peeling with the pyruvic acid is classified among the socializing peelings, because you can immediately go back to work.

Given off vapors during the application can result annoying and so it is better to use a fan to disperse them.

A regular hydration is useful in the post peeling period, a total solar screen.

It can be repeated every 25, 30 days.

Conclusions:

Peelings remain a method of more and more diffusion for the cutaneous rejuvenation but also for the care of much cutaneous pathology.

Besides the one I described, there are many others, more or less efficient.

The advice always remains the one to address to a good doctor who will know how to advice you for the best peeling according to the person, to its skin and to its particular situation, and also to the own experience, very important for the global safety of the treatment.