Light Chemical PeelsMany people don’t relish the idea of two weeks in hiding while waiting for their new skin. Less drastic types of peels were introduced in the 1980s, using trichloroacetic acid (TCA). This procedure hurts when performed, but peels more superficially than when phenol is used. The epidermis and superficial dermis peel, healing in five to eight days. The more superficial the peel, the fewer wrinkles are removed.TCA concentrations range from 15 percent to 50 percent, alone or in combination with other chemicals. Higher concentrations result in deeper peels. The TCA peel is useful for pigmentation irregularities, such as sun-damaged skin and discoloration from pregnancy. It helps wrinkles and other sun damage. Acne and large pores are improved. Even some premalignant conditions can be corrected.Literally dozens of factors can be altered in the TCA procedure, resulting in different levels of peeling. The thickness of the skin, the pre-peel use of creams, the type of cleansing the day of the peel, the TCA concentration, how hard the chemical is rubbed in, how many strokes the surgeon uses to apply the peel, and how the peel is cared for afterward all affect the result. The TCA peel is part art and part science.To try and achieve better results, TCA has been combined with dry-icepeels, Jessner’s solution (resorcinol, salicylic acid, lactic acid, and ethanol), methyl-salicylate, and glycolic acid. None of the combinations is better than TCA alone.In the 1990s, Zein Obagi, M.D., the Beverly Hills dermatologist, added a blue dye, glycerin, a thickening base, and soap to the TCA. He could better judge the depth of this ‘‘blue peel.’’ In the hands of experienced doctors, the results became more predictable.Many people do not want any downtime. Not only does it take nearly a week for the TCA peel to heal, but there can be two weeks of redness afterward.TCA Peels Are the ‘‘Long Weekend Peels’’TCA peels require extensive preparation. Patients must ‘‘reprogram their DNA’’ with at least two weeks of tretinoin in order to achieve an even peel. In addition to the tretinoin, two weeks of a pigment reducer (hydroquinone) is helpful. You won’t actually see any lightening of the skin, but the drug turns off brown pigment production in the skin. Without it, the pigment-producing cells can go wild after the peel, leading to splotchiness. These two drugs remind me of the chemicals used on lawns to get the grass all growing the same way! The actual peel hurts. My wife usually swears at me during the peel and makes some weak threats. I often prescribe a mild narcotic such as codeine, and the anxiety drug Valium, to be taken an hour before the procedure. Prior to the peel, the face is washed with soap. I then remove the oils from the skin with nailpolish remover (acetone). I apply the TCA with a fine gauze pad, stroking the skin repeatedly until the chemical soaks in. I carefully observe the skin as the chemical causes frosting—a reaction of the acid with keratin, a protein in the skin.I peel the forehead first, then allow the patient a few minutes until the pain lessens. Next, I sequentially peel the cheeks, the nose, the lips, and the chin. Last are the eyelids. The neck can be peeled with a lower concentration of TCA. Cool saline compresses are applied to the skin for about ten to fifteen minutes, until the frosting subsides. Once this happens, there is usually no more pain.Now comes the fun part. The first evening after the peel, the skin looks reddened and sometimes gray. The face is washed twice a day and a moisturizer is applied. The next day, it looks dry; by the third day, the skin looks strikingly like that of a molting reptile.By the fourth day after the peel, the skin begins to flake off, in much the same way a bad sunburn does. By the fifth day, the peeling is usually complete and makeup can be applied. Older people usually look red rather than gray. If the peel is purposely deepened, as is required for the treatment of wrinkles, healing can take as long as fourteen days.The redness of the skin will persist for two to six weeks. After the skin has peeled, the patient is again given tretinoin and hydroquinone. The darker the skin color, the longer hydroquinone is used after the peel. I encourage the long-term use of tretinoin.Any peel can cause scarring, if performed too deeply. And any peel can injure the cornea if splashed into the eye. A nurse has a bottle of eyewash in her hand during the procedure, in the event of any such accidental spillage.Though TCA peels are superficial, bad results can still occur. Brown pigment can return after unprotected sun exposure (hyperpigmentation). I have seen this effect in olive-complected people, particularly if they scratch their skin during the weeks following the peel. Sometimes the peel will not fully remove brown pigment. In this case, it may be repeated in six to eight weeks. I’ve seen more than one allergic reaction to various skin creams after the peel. The protective layer of the skin has been thinned, and creams that were previously tolerated may cause problems now. Itching is common. It is treated with Benadryl tablets and hydrocortisone cream.Scratching is the curse of the peel. It can rip off the delicate new skin and lead to infection. Infection can cause scarring. Trim those long fingernails after a peel!The effects last between one and two years, depending on the type of skin care that is used and the amount of sun damage sustained. If desired, the peel can then be repeated.New PeelsChemical peels are constantly being tinkered with. In one new peel, TCA is blended with glycolic acid. Other peels use a whole chemistry set. I’m sure there are many possible peeling agents and many combinations that really do work. But I’m wary of ‘‘new’’ peels that have not been thoroughly studied, for both short-term effects and long-term complications.If You Can’t Hide for a Week, Consider a Glycolic Acid PeelWith glycolic acid, a series of progressively stronger peels, applied for increasing amounts of time, can improve skin tone and color. The skin gradually acclimates to the acid, allowing its beneficial effects to occur without actual peeling. It might be called the no-peel peel! It gives the skin a reddish hue, similar to that simulated with makeup. Adult-type occasional acne is reduced.With glycolic acid peels, you can literally go back to work the same day. They have subtle results at best, when used in low concentrations. In one study, patients who underwent six 20-percent glycolic peels on one side of the face and microdermabrasion on the other side thought the glycolic acid side looked better, but their doctors could not see a difference between the sides. In another study, the skin’s appearance improved after five monthly 30-percent glycolic peels, but not quite as much as with one 35-percent TCA peel. Elasticity and water content increased with both treatments, but the TCA peel showed more improvement of wrinkles. After the study, patients chose to continue with glycolic acid peels, as opposed to TCA peels, presumably because less pain and downtime was involved.Glycolic peels are the ‘‘lunch-hour peels.’’ But they are not really peels—true peeling would be considered a complication. During this office procedure, the skin is prepared with two weeks of home glycolic acid products. No peel can be performed if the patient has used the drug Accutane or steroids in the past year. (Some people think the time frame should be two years.) Both drugs impair healing. Peels should be performed with great care, or not at all, on anyone with healing problems. Women who get herpes infections should take an antiviral such as Valtrex from the day before the peel until the skin has healed. Severe scarring will result if a herpes outbreak occurs before the skin has healed.The peel begins after all traces of makeup have been removed. Some doctors first scrape the skin with a blade to remove the dead upper layers of skin. Then a 20-percent to 70-percent solution of glycolic acid is applied. In salons, no more than 10 percent should ever be used by aestheticians. The acid is applied for two to seven minutes. The actual peel stings a little. Since the goal of this type of peel is no downtime, I usually start with a low concentration of acid, applied for a short time. The peels are performed every two to four weeks, increasing either the concentration or the amount of time the acid is applied. The face is carefully observed while the acid is on the skin. If any swelling or blistering occurs, the peel is immediately stopped. While the goal is no peeling, blistering or flaking can occur.This peel is a well-thought-out procedure. While the acid is relatively strong, small amounts are applied. The peel is stopped by spraying a weak base on the face, so weak that it could even be sprayed into the eyes without harm. When the acid is neutralized, a small amount of heat is produced, along with water and oxygen, causing the acid to foam. The face is sprayed with the neutralizer until there is no more foaming. A moisturizer is then used.The face is slightly red for several hours, after which makeup can be applied. The skin occasionally blisters, although a skilled physician gradually increases the strength or duration of the peel to avoid this result. I’ve had a few patients who developed allergic reactions to the moisturizer used after the peel. Since the upper layers of epidermis have been removed, any chemical can better penetrate the skin: substances that were well tolerated with an intact skin can now cause allergies. My worst complication was in a woman who scratched her forehead after the peel had healed, causing a staphylococcus infection and scarring.The latest twist on the glycolic peel is citrate peel boosters. Solutions containing some combination of citric acid, mandelic acid, the amino acid arginine, and the lighteners kojic acid and arbutin, pretreat the skin prior to the peel. At an American Academy of Dermatology meeting, texture, pigmentation, and acne improved after booster peels. The chemicals may indeed improve the peels, but the results have yet to be published.Salicylic Acid PeelsIn 1998, 30-percent salicylic acid peels were developed. This is a beta hydroxy acid dissolved in alcohol and water. These peels cause fading of pigment spots, decreased surface roughness, and reduction of fine lines. They are particularly effective when patients have acne, as salicylic acid is the chemical in many acne scrubs. However, the peels have never been particularly popularDermabrasionIn 2005, there were 42,000 dermabrasion procedures in the United States, a 34 percent decrease from the prior year. Only 2,800 were performed in men.Preparation for dermabrasion is the same as for deep chemical peels. Again, local anesthesia with intravenous sedation or general anesthesia is used. Dermabrasion is performed with a device similar to a Black & Decker sander, which physically removes the top layers of skin. There is less heat injury with dermabrasion than with the laser, so there is less lightening of the skin. But this older technique is more difficult for the surgeon to learn than the laser. It is also very risky. Eyelids have been ripped off with the dermabrader. I prefer to reserve dermabrasion for the upper and lower lips, where it is great at decreasing the ‘‘lipstick bleed’’ wrinkles. I also use dermabrasion for sanding acne scars off the face. (For this problem, the deep chemical peel has no role.) Dermabrasion is equivalent to the laser in effectiveness, but the laser is probably safer.Topical Aminolevulinic AcidThis drug is a relatively new addition to the skin care world. A solution of 20- percent aminolevulinic acid is painted onto the skin. The chemical is absorbed into the skin cells; precancerous and cancer cells absorb more of the chemical than normal cells. A specific type of light (such as intense pulsed light) is shined on the face, purposely causing the production of free radicals that destroy the cells that are growing fastest—namely the bad ones. For about five days the skin is swollen and red. Afterward the skin looks better and has fewer precancerous growths.Usually patients have two treatments, spaced a month apart. When compared with intense pulsed light alone, the addition of topical aminolevulenic acid significantly improves skin rejuvenation. Side effects include swelling, redness and flakiness of the skin.The CostThe average cost of a chemical peel is $850. Of course, this takes into account glycolic peels, which cost about $200 each, as well as TCA peels, at $900, and phenol peels, at $2,000. Laser peels cost $2,500 on average. Dermabrasion runs $1,400.