Peeling

Ref. Leslie Baumann.Cosmetic Dermatology: Principles and Practice,

2nd ed, McGraw Hill Professional, 2008.

Slide by Supak Taboonpong, MD.

In training of MSc Derm, TU, Thailand
For presentation in class learning only

Superficial peels
Combination peels

Jessners peel
Resorcinol 14 g, salicylic acid 14 g, and lactic acid 14 g
in a sufficient quantity of ethanol (95%) to make l100 cc of solution
Reduce the concentration and toxicity of each of the individual
ingredients while increasing efficacy
Popularly used with other peels because it does not have to be
neutralized
Once the peel frosts, a second type of peel can be applied on top
(+) the depth of the overall peel

Jessners peel
Caution
resorcinol PIH (skin type IV++)
Contact dermatitis
Topical or oral steroids may be used to treat this uncommon s/e

Jessners peel
Prior to treatment, a thin layer of Vaseline or Aquaphor is applied to
the areas not intended for treatment, such as the nasoalar grooves,
where the solution tends to pool, and the lips.

1st coat is complete once frosting occurs (usually in 3 to 5 min).

Flaking for approx. 7 days.
If a deeper peel is desired, 2-3 coats may be applied.

Jessners peel
Excellent for acne patients because resorcinol is a well-known
treatment for acne.
Effective in rosacea because of salicylic acid.

Modified Jessners peel

Combinations + HQ and kojic acid
Omits resorcinol
For individuals that are sensitive to this component

Tretinoin peels
Melasma, acne, KP & photoaging
Induce (+) collagen deposition
Inhibit the MMP responsible for degrading collagen
Not available in US, off-label in Brazil
Orange color solution
0.25-1% tretinoin

Wash off the solution after 4 to 6 hrs

The peeling usually begins after 2 days.

1% tretinoin peel was compared to a 70%

glycolic acid peel
Tretinoin peel 4 hours
Glycolic peel- 3 minutes.
Equally effective at 3 months posttreatment
Tretinoin peel less erythema and desquamation

Side Effects of All Types of Superficial Peels

All Erythema, itching, peeling, (+)skin sensitivity& epidermolysis.
Resorcinol, salicylic acid, kojic acid, lactic acid& HQ ACD
Glycolic acid ICD
Excessive frequency, inappropriately high conc., or with a vigorous
skin preparation using acetone

 Must know the pH and conc. of free acid in the individual products in
order to compare strength and efficacy across products.
Extra caution when treating patients with darker skin types.
Start with the lowest conc. of free acid and slowly (+) the
concentration.

Medium depth peels

Superficial peel indications

Acne& rosacea
BHA All skin types
Resorcinol Skin type I, II& lighter type III
Do not treat rosacea patients with AHA & retinoids
Melasma
Jessners peels
Modified Jessners peels
Resorcinol Skin type I, II& lighter type III

Superficial peel indications

Photoaging& mild wrinkle : All of the mentioned peels can treat
photoaging, to choose the optimal peel to patients- consider
Patient history
Other concurrent pathology
The downtime that the patient can tolerate

Pretreatment for a medium-depth peel

Indication of medium depth peels

Severe acne
Photoaging

Medium depth peels

TCA 10%-40%
Pyruvic acid

TCA
Low strength TCA (10-15%)
Ameliorate fine wrinkles& dyschromia
Provide smooth& healthy appearance to the skin
Not improves deeper wrinkle/ scars

 Higher-strength TCA (35-40%)

Standard solution for medium depth peels for face & hands
Produces epidermal& dermal necrosis w/o serious systematic toxicity
S/E
Hyperpigmentation
Scarring
Not select Pt. with darker skin types

CAUTION
Higher-strength TCA (35-40%)
Strength : Wt/Vol
Diluted 50%TCA with water 25%TCA
(Get a solution stronger than 25% Wt/Vol TCA)

 Frosting: denatured protein completion of the peel

Time lag between the application& the appearance of the frost
40% TCA
5-7 sec
More dilute acid 15-20 min
* Avoid over tx

Healing time
TCA : 5-7 days
TCA + Jessners/ Glycolic acid : 7-10 days

Obagi
blue
TCA

Pyruvic acid
An alpha ketoacid lactic acid
Chemical peeling while providing hydration
Penetrates to the papillary dermis
(+) production of collagen& elastic tissue
Must not be used in high- /full strength conc. (potential for scarring)

Pyruvic acid
Success in Tx of moderate acne, photoaging& melasma
Conc. : 40-60% on facial skin previously prepared with topical
retinoids
2-5 min or when adequate frosting is observed, soak the face in
water. (More comfort than neutralizing by 10% NaHCO3 +water)
Well-ventilated room
Reepithelization in 1-2 wks
Erythema last for up to 2 mo

S/E of medium-depth peel

Warn the patient look terrible 10 days
First 2 days, skin slightly pink
Days 3& 4 Skin darkens
Days 5 Skin begins to peel off in sheets.
Days 10 Peeling complete
Erythema may last until day 14

CONTRA of medium-depth peel

Darker skin types
Recently treated with isotretinoin or topical radiation scarring
Recently treated for hair removal with lasers
Extra cautious: At mandible, necks, and chest

Warn the patient: lesion like solar lentigos will return (Melanocytes
reside below the level of the peeling)

After peeling
Sunscreen
Sun avoidance
HQ in the patient with darker skin
Antiviral med to Pt. with Hx of HSV

Combo of superficial& medium-depth peels

Coleman peel Glycolic acid followed by TCA
Monheit peel Jessners solution followed by TCA
Jessners solution: Reduce the cohesion of epidermal cells, allowing
better& more even penetration of 35% TCA solution
Effective in mild to moderate photoaging, including lentigines,
pigmentary changes& rhytides
Mild sedation& NSAIDs prior to procedure

Combo of superficial& medium-depth peels

Solid CO2 (dry ice) followed by 35% TCA (Dr. Harold Brody)
Solid CO2 causes interruption in the epidermal consistency& deep
penetration of TCA

Deep depth peels

No longer popular
Lasers& dermabrasion supplanted deep-depth peels
Superior results with fewer complications
Deep peels e.g. Modified phenol peels such as
Stone Venner-Kellson peel (composed of phenol, croton oil, water, olive oil&
septisol solution) from Delasco