December 2007’s Featured Archive Article:

At-Home and In-Spa

Breakthroughs in peel technology

The emergence of the superficial, lunchtime skin peel occurred in the early 1990s and became popular by the mid-1990s. The next wave of newer skin rejuvenation techniques, including microdermabrasion, non-ablative laser and light therapies, hit the market shortly thereafter and temporarily dampened the enthusiasm for topical skin peels. As time goes by, however, and the “newer” techniques begin to age, the appeal of superficial peels is increasing once again. Why? Because superficial chemical peels consistently provide real, measurable benefits to skin. They work. And, they are customizable to meet the needs of all clients, and enhance outcomes and overall satisfaction when combined with other cosmetic procedures.

So push aside your microdermabrasion and light devices, and make room once again for topical superficial peels. They’re the ideal “therapeutic” treatment for the spa because they provide significant, beneficial effects for most skin types and problems (aging, acne, pigmentation); they promote additional spa visits (peels are frequently performed in a series of six or so); and they’re safe when handled properly. Superficial peels are customizable and controllable to meet the needs of individual clients when professionals vary the peel’s strength and duration, and the number and frequency of additional peels. Now, with the increased desire to extend spa-like skin treatments to the home, your customers can incorporate home peels to further increase skin benefits and overall satisfaction.

Spa peels

Many of the peels used in the spa setting are designed to stimulate epidermal cell turnover and dermal repair without injuring skin. The most commonly used agents are alpha hydroxy acids (AHAs) such as glycolic acid, lactic acid and mandelic acid. According to the Cosmetic Ingredient Review panel’s recommendations pertaining to esthetician use of AHA peels, the maximum suggested concentration of glycolic acid or lactic acid is 30 percent with a minimum pH of 3.0.1 In addition, the application of the peel is recommended to be short and discontinuous; the use of a neutralizer to terminate the action of the peel provides important flexibility and control over the procedure. Physician-performed peels are not limited in concentration or pH.

Salicylic acid is another commonly used peeling agent, which is usually used on acne-prone skin. Its use in anti-aging is controversial. While salicylic acid serves to exfoliate the skin, it’s also been shown to cause dermal thinning—an effect that opposes the desired anti-aging action of skin plumping and volume building.2 Nonetheless, salicylic acid remains popular for use in skin care because of its exfoliative effects for hyperkeratotic conditions.

Expected outcomes

Benefits from peels can be dramatic, especially when peels are performed in a series over a period of time. They work for anti-aging regimens, to stimulate repair of sun-damaged skin, which reduces fine lines and wrinkles and improves skin firmness, and to help increase the volume-building GAGs (glycosaminoglycans, such as hyaluronic acid) in skin.

Peels are also beneficial when used with skin lighteners at home to hasten the removal of hyperpigmentation such as freckles, age spots and melasma. Because both increased pigmentation and increased retention of cells (a.k.a. hyperkeratinization) cause hyperpigmented skin, reducing melanin production and facilitating the removal of existing, thickened age spots can lighten the skin. (Diligent use of sunscreen and sun protection is a must to keep clear skin from repigmenting.)

Similarly, acne-prone skin can benefit from regular peels. The peels help to remove the plugs that cause acne. No clogged pores—no acne. And, with a peel series, combined with at-home AHA skin care, the skin will become smoother and brighter with reduced post-inflammatory spots.

Seeing a difference

Your clients can experience significant textural softening and smoothness in as little as one peel. However, it is important to understand, and have your clients understand, that it may take a few or several peels before results are visually noticeable. The number of AHA peels needed to achieve success depends on the type and severity of the condition being treated. Patients with acne or melasma may require only a few peels in combination with home care treatments to see a strong improvement. Whereas, patients with photoaged, wrinkled or extensively hyperpigmented skin may require a longer series of peels. Once the desired effect has been achieved, the daily use of topical AHAs in combination with “maintenance” peels several times per year, can maintain peel results.

Who are your peel customers?

The ideal candidate for spa-strength AHA peels are those with a busy schedule that cannot afford one to two weeks of downtime to heal from the more extensive procedures frequently performed in doctors’ offices. With these so-called “lunchtime peels,” your clients will require minimal, if any, healing time. Makeup can usually be applied immediately after the peel, which enables a quick return to work or social events. Those who desire dramatic, overnight results may not be satisfied with AHA peels and should consider other treatments such as deep chemical peels, ablative laser, Botox injections and injectable volume replacement.

The optimal peel

Effective topical peeling agents penetrate the skin. The optimal peel incorporates acids in a vehicle designed to promote penetration without irritation. Concentration is important. Together with pH, these two factors determine the actual amount of acid that is bioavailable, or able to penetrate the skin’s barrier.3 The higher the pH, the more the acid is converted to a salt, with significantly reduced potential to absorb into skin. And, when you’re doing a peel, you want the acid to penetrate … not sit on the skin’s surface.

Irritation potential is an important consideration for spa clients. They don’t expect to leave with bright red, highly sensitive skin. Technologies exist to reduce the irritation potential of acids. One such technology, called amphoteric complexes, uses naturally occurring amino acids with alpha hydroxy acids to provide a gentler AHA delivery with reduced irritation potential.

Technique matters

In order to assure a favorable outcome, it is important to collect some information from your clients. What does their usual skin care regimen include? Do they use prescription retinoids? Do they use tanning beds?

All of these questions and others may impact the way you approach a peel. Pretreatment with exfoliating agents (for example: AHAs/PHAs, retinoids, salicylic acid) for several weeks prior to the peel make the skin smooth, and allow the peeling agent to penetrate more uniformly. However, these ingredients may also increase skin reactivity to the peel agent. Microdermabrasion prior to a peel will diminish skin barrier function and make the skin more susceptible to the peel, not to mention the stinging effect of AHAs! Likewise, use of degreasing agents (acetone, alcohol) immediately prior to the peel may increase the depth of penetration of the peeling agent.

Peel application technique may increase penetration of the peel, especially if abrasive rubbing or scrubbing is involved. Continued reapplication, or layering, of the peeling solution will lead to an increase in overall acid penetration.

Special considerations

All skin must be monitored carefully during a peel. Control is one key advantage of using AHA peels; an application of a neutralizing solution at the first sign of irritation or discomfort can rapidly terminate the peel. Certainly, if the skin starts to develop small, white patches or bumps, called blanching, the peel must be neutralized as this is a sign that the peel has reached the epidermal-dermal junction and is no longer superficial. There is likely to be a short healing period if this occurs; the skin will likely peel, and if hyperpigmentation is a concern, skin lightening products can be initiated when tolerated to help avoid this outcome.

Some skin types require special attention. Darker skin (usually Fitzpatrick types III, IV and V) has a much greater tendency to have undesirable pigmentation changes (hypo- or hyperpigmentation) from an aggressive peel.5 Hypopigmentation occurs very infrequently, and is difficult to treat. Hyperpigmentation may occur readily in clients prone to post-inflammatory hyperpigmentation. Adopting a safe, gradual approach to peeling helps avoid this condition. Use of bleaching agents (hydroquinone, kojic acid, azelaic acid) for several weeks before and after the peel can reduce the risk of post-inflammatory hyperpigmentation. The availability of AHA peels, which is controllable to a superficial level and neutralized at any time, has enabled clinicians to safely peel patients with darker types. However, caution is still advised.

Sensitive areas (e.g., around the eyes, the neck) require a gentler approach using lower peel concentrations or a shorter exposure. Areas with thicker and/or less sensitive skin (e.g., back, chest, or back of the hands) can tolerate stronger peels, a longer application time, or re-layering during the procedure.

Finally, skin may be more sensitive in drier climates or in the winter, which makes it more reactive. As a result, a lower concentration peel or a shorter contact duration may be necessary. Peels performed during the summer season or in sunny, southern climates require the more compulsive use of sunscreens post-peel to protect the skin and maintain the treatment’s benefits.

Alpha hydroxy acids are ideal superficial peeling agents. They are known to offer the following advantages:

TCA, phenol and salicylic acid are potentially toxic agents and can harm the skin. AHAs are virtually nontoxic and many are found naturally occurring.
AHAs are versatile. They can target a wide range of skin conditions, which include acne and rosacea, actinic keratosis, age spots, fine lines and wrinkles, keratosis pilaris, melasma and other pigmentation problems, and superficial scarring. AHA peels can be used to treat these conditions on many different body surfaces including, the face, neck, back, chest, outer arms, back of hands, etc.
Almost every skin type can tolerate AHAs, including skin that is very sensitive (rosacea, eczema) and even darker skin (type IV or V).
AHAs enable the clinician to control several peel variables. AHA reactions can be neutralized and immediately stopped in the event that a patient starts having an adverse reaction or sensitivity.
Contraindications are minimal with AHA peels. Active herpes lesions, recent cosmetic surgery, open wounds, and Accutane® therapy within the past six to 12 months are some of the relative contraindications.
Complications are minimal. Neutralization can stop AHA reactions and prevent deep penetration and the resultant potential for complications.
AHAs are combined with other peels, microdermabrasion, non-ablative laser, and other cosmetic procedures (e.g., Botox®, filler substances, cosmetic surgery), as well as with home use of topical anti-aging therapies including home peels.

Home peels have arrived!

Be a part of the growing trend … get your clients started on home peels in combination with your spa procedures to improve cosmetic outcomes and continue the spa experience at home. They are designed to be safe and effective, usually offering about 10 percent of an AHA in a solution or gel vehicle, and may include a buffering emollient or neutralizing step to end the peel. Some peels on the market contain combinations with gentle poly hydroxy acids (PHAs) or less stinging AHAs, such as mandelic acid, allowing the formulations to safely exceed the 10-percent maximum recommendation from the CIR.

Formulated to enhance the benefits of home care products and spa procedures, home peels can provide excellent skin-smoothing and pigmentation-evening effects.

AHA comeback

The time-honored procedure known as the superficial AHA peel is making a big comeback in the physician, spa and home-use markets. It’s no wonder … these versatile procedures provide estheticians with the tools to rejuvenate the skin in a safe and effective manner. With a multitude of documented evidence demonstrating the significant improvements to skin texture, pigmentation, and acne, use of peels as part of cosmetic and therapeutic skin care regimens is essential for optimal skin care. Moreover, use of AHAs provides flexibility and control to the procedure, which enables customization for virtually any skin type. Because many other rejuvenation techniques function through different skin mechanisms (e.g., muscle paralysis, laser stimulation of dermal tissue, wounding, injected volume replacement), superficial peels provide synergy to help achieve the best cosmetic outcome. Whether in a spa, or at home with a client looking to extend the spa experience, superficial AHA peels offer important anti-aging and skin smoothing benefits in a well-controlled and safe manner.

References

34th Report of the CIR Expert Panel – “Safety of alpha hydroxy acid ingredients.” International J. Toxicol 1998: 17, supplement 1.
Yu RJ, Van Scott EJ. “a-hydroxyacids, polyhydroxy acids, aldobionic acids and their topical actions.” In: Baran R, Maibach HI, eds. Textbook of dermatology, third edition. New York, NY: Taylor & Francis; 2005; pp77-93.
Yu RJ, Van Scott EJ: “Bioavailability of alpha-hydroxy acids in topical formulations.” Cosmet Dermatol 1996; 9(6): 54-62.
Briden M.E. Alpha-hydroxyacid chemical peeling agents: case studies and rationale for safe and effective use. Cutis 2004; 73(suppl 2): 18-24.
Ditre CM. Building your practice with glycolic acid peels. Skin & Aging 1998; 48-53.

About Barbara A. Green

Barbara A. Green is a registered pharmacist in New Jersey and has been working for NeoStrata Company for more than 10 years where she oversees clinical studies and technology development. NeoStrata is a leader in AHA technology and was the first company to standardize the use of glycolic acid peels for the physician market. For more information, visit www.neostrata.com.