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Chemical Peels and Retinoids

Chemical peels and retinoid products are used for the purpose of skin exfoliation, and are not to be used for rosacea. Rosacea skin needs to be 'intact' and not to be further aggravated by any chemical or mechanical peels of the below listed means. The objective is to help your body get rid of dead skin cells and to make your body build new skin quicker. Various products available today such as Retin-A, Alpha Hydroxy Acid (AHA), Beta Hydroxy Acid (BHA), and glycolic acid are all designed to burn dead skin cells off. The active agent in all these products is fruit acids.

The problem with using fruit acids such as AHA and BHA is that either you get acids that are very weak that do not remove many dead skin cells and therefore you see little results, or they increase the strength of the acid, and once the acid has burned through the dead cells, it continues on and begins to attack your living skin. If this happens you may experience one or more of the following; burning, redness, irritation and light sensitivity. Another problem with using acids is that the dead cells do not come off immediately; your skin gets white, flaky, and tight as the dead cells fall off over the course of a few days. Using acids is not only uncomfortable; but it can at times do more damage than good.

Alpha hydroxy acids and beta hydroxy acids are simple organic fruit acids found in nature or synthesized in the laboratory. Beta Hydroxy acids are somewhat different from alpha hydroxy acids in their structure and mode of action. Salicylic acid, a common beta hydroxy acid, has been used for treating acne for decades. In fact, acne treatment remains the primary use for beta hydroxy acids. There are no studies showing that beta hydroxy acids are superior or even equal to alpha hydroxy acids in skin exfoliation or reducing fine wrinkles however for acne, beta hydroxy acids are clearly superior to alpha hydroxy acids.

Over the last decade, alpha hydroxy acids (AHAs) have increasingly appeared as ingredients in cosmetics intended to reduce the signs of aging in the skin. More recently, beta hydroxy acids (BHAs), or a combination of AHAs and BHAs, have appeared as ingredients in these skin care products. While both AHAs and BHAs act as exfoliants, it has been claimed that BHAs are effective in reducing the appearance of fine lines and wrinkles, and improving overall skin texture, without the occasional irritation associated with the use of AHAs.

BETA HYDROXY ACIDS

Beta Hydroxy Acid or BHA is a derivative of aspirin and is often used in skin care products to accelerate skin cell turnover and help clear pores. It can penetrate more deeply than Alpha Hydroxy Acid and is gentler.

Beta Hydroxy Acid is salicylic acid. This occurs in nature in sweet birch and in wintergreen leaves. Its effect on the epidermis and upper dermis are similar to those of Retin-A, but with less irritation. It is soluble in oil and can exfoliate oily skin areas, even within oil-rich pores. Therefore, it has a beneficial effect on acne, pigmentary disturbances, and sun damaged skin. Because it does exfoliate, use of sun protection is needed.

BHA ingredients may be listed on packaging inserts as:

  • Salicylic acid
  • Salicylate
  • Sodium salicylate
  • Willow extract
  • Beta hydroxybutanoic acid
  • Tropic acid
  • Trethocanic acid

Currently, the most commonly used BHA in cosmetics is salicylic acid. On rare occasions, citric acid is also listed as a BHA in cosmetic formulations; although, citric acid is more commonly considered to be an AHA.

The long-term safety of salicylic acid in cosmetics is being evaluated in studies initiated by FDA and sponsored by the National Toxicology Program. These U.S. government-sponsored studies are examining the long-term effects of both glycolic acid (an AHA) and salicylic acid on the skin's response to ultraviolet (UV) light. These studies have determined that applying glycolic acid to the skin can make people more susceptible to the damaging effects of the sun, including sunburn.

Until these safety assessments are completed, FDA advises that similar precautions be taken for the use of cosmetics containing AHAs and BHAs. These precautions are:

Test any product that contains a BHA on a small area of skin before applying it to a large area. If you use cosmetics with BHAs and experience skin irritation or prolonged stinging, stop using the product and consult your physician.

Follow the use instructions on the label. Do not exceed the recommended applications.

Avoid using BHA-containing products on infants and children.

Use sun protection if you use a BHA product.

The ingredients and concentration obviously play a very big role in determining the ultimate depth of the chemical peel. However, other variables can make a difference such as whether a pre-peel de-fatting preparation was performed, the amount of chemical applied, and the length of time the chemical was allowed to stay on the skin. Another important factor is which area will be treated. The variations in skin thickness can affect the ultimate peel outcome. For instance, the face usually heals far more rapidly and typically experiences far fewer complications (such as discoloration, scar formation and infection) than areas such as the backs of the hands or neck.

Chemical peels are classified as being SUPERFICIAL or DEEP. The superficial peels include the naturally occurring fruit acid peels, or the chemical resorcinol. These peels need to be performed about six times. The deep peels include the TCA (or trichloroacetic acid 35%) peels, which only need to be performed once.

THE SUPERFICIAL CHEMICAL PEELS:

Very Superficial:

This really isn’t a true peel, more of an exfoliation. The most superficial layers of the stratum corneum (at the top of the epidermis) is removed or thinned during exfoliation. Most chemical peels have a preoperative regimen of using exfoliating agents such as Renova, Tazorac or a strong glycolic acid cream for 2-4 weeks prior to the actual procedure. This helps the chemical peeling agents penetrate more deeply and evenly. The use of these exfoliants also have the obvious beneficial properties of smoothing out thickened rough areas, helping self tanners go on more evenly and helping other skin rejuvenation products reach deeper tissues. Additionally, there has been good evidence that vitamin A exfoliants can help stimulate collagen deposition.

Superficial:

Superficial chemical peels remove skin through a portion or the entire epidermal layer. These are the “refreshing” forms of skin peels. They can also help with reducing the appearance of very mild blotchy skin discoloration, remnant acne discoloration and help cleanse the pores. This is the most common form of peel that you would find performed in a spa or by an aesthetician. Higher levels of glycolic acid are typically used by physicians falling toward the Medium range.

Resorcinol peels can cause a slightly deeper peel much like sunburn.

Superficial peels do not interfere with your normal everyday activities, so you need not take time off work or stay at home out of the public eye. In other words, these peels are a full treatment program over several months. The peels should be performed weekly, as they contain a concentration of ingredients which are far higher than those sold over the counter or applied by beauty therapists. It is also important not to abandon this treatment prior to having had the full course, because the treatments are cumulative and the previous one enhances each subsequent treatment. The ideal number of treatments is six. Several days after each of the peels, flaking or light peeling of the skin will occur. Subsequent weekly peels have their strength and length of application adjusted according to your individual previous response. It may be important to combine the regular applications at the clinic with an ongoing treatment, which you perform yourself, using special creams, on a daily basis. After your treatment, it is recommended that you have a peel done every 2 to 3 months as on-going maintenance.

Active ingredients used in mild to moderate chemical peels: Glycolic Acid (AHA), Salicylic Acid (BHA), Lactic Acid, Jessner's Peel (a combination of salicyclic acid, resorcinol and lactic acid mixed in ethanol), Resorcinol, TCA (Trichloracetic Acid) TCA is used in a variety of peeling regimens such as AccuPeel and the Obaji Blue Peel.

THE DEEP CHEMICAL PEELS:

The superficial peels extend 0.06mm to the papillary dermis, while the deep chemical peels extend 0.45 mm to the upper reticular dermis, causing extensive shedding of the upper skin layers. Your skin will look as if it has had a very severe sunburn, so most patients choose to remain at home and out of the public eye for 5-7 days. However you are welcome to leave the house, as long as you don't go out in the sun at all, exercise heavily causing excessive sweating, or move your facial muscles more than absolutely necessary, as this may cause premature peeling of the skin resulting in scarring. Your skin needs to be pre-treated for two weeks prior to the procedure, with Retin-A cream and hydroquinone cream. These creams prime the skin, and prevent hyperchromasia (darkening) occurring after the peel. The peel consists of a high concentration of trichloroacetic acid (TCA), which burns, when applied. For this reason, it must be applied in an operating room under very controlled conditions, so that treatment can be given to help prevent any pain. During the peel, your skin will blanche (whiten) and then turn pinkish in color. Over the next few days, the skin will peel extensively. It is important not to pick at it. You will be given clear instructions on your follow-up skin care program at home. Seven to ten days after the procedure, you will be advised to continue using hydroquinone cream, and permit the use of makeup once all the scabs have healed.

These complications can occur with the application of chemical peels:

  • Excessive redness and peeling of the skin
  • Infection
  • Hypopigmentation (lightening of the skin color)
  • Hyperpigmentation (darkening of the skin color)
  • Scarring

Active ingredients used in deep chemical peels: Baker’s Phenol.

Medium:
This type of peel goes through the epidermis, down into the upper most portion of the dermis known as the papillary dermis. Medium peels are the level when complications are more likely to start. In addition to the pre-peel use of exfoliants, the use of a skin bleaching agent, such as 4% hydroquinone, and a broad-spectrum sunscreen a month prior to the procedure, may be added for more aggressive forms of these peels, or for patients who already suffer from some form of skin discoloration. Inflammation from this level peel may temporarily produce an increase in skin tone. Medium peels are typically not appropriate for people with darker skin tones or of ethnic background again due to the risk of irregular pigmentation following the procedure.

Dealing with infection preventatively is important here. For non-buffered glycolic acid and more commonly TCA peels, the use of antiviral medication (herpes prevention) started before the peel is performed is very helpful. The use of antibiotics is sometimes also used. It is absolutely CRUCIAL that you not pick at the peeling skin during the healing phase. This is a sure way to end up with an infection and long lasting problems such as scarring or skin discoloration. Often the use of emollients during the first few days is incorporated in addition to the continued use of sunscreen, and a very mild cleansing agent. Make-up is often avoided until the skin has fully peeled away. Buffered peels such as the M.D. Forte Glycolic Acid peels that range from 70-99% do not cause the type of significant noticeable peeling that you can see with peels such as AccuPeel. However, a series ranging from 6-12 Forte peels compared to usually 1 of the AccuPeel are utilized. Skin sensitivity, degree of skin concerns, time down, and cost will determine the selection.

Examples of chemicals used for a medium peel include: Glycolic Acid 70%+ (non-buffered), TCA 35-70%, combination peels such as solid CO2 followed by medium strength TCA, and glycolic acid followed by TCA.

Deep:

This peel goes through the epidermis, papillary dermis and into the deeper portion of the dermis known as the reticular dermis. These peels are not a simple procedure. Absorption of the active ingredient, phenol, has been known to cause cardiac arrest and even death. Patients who undergo phenol peels should be placed under general anesthesia and on full cardiac and pulmonary monitoring. This is one of those procedures that emergency back-up is going to determine the outcome if something goes wrong. An anesthesiologist should be present, and preferably have this procedure done in a surgical setting, not just a room adjacent to the doctor’s office. The down time from this procedure is obviously the longest, 2-3 weeks is generally required before you want to be seen in public. Due to the depth of the peel leaving deeper tissue exposed, there is an increase in photosensitivity to the sun.

Examples of ingredients used in deep peels include: Baker’s phenol alone or under occlusion by tape.

This medication is used in the treatment of acne. It reduces the formation of pimples and promotes quick healing of pimples that do develop. Using this medication more frequently or in excessive amounts does not improve the results, but may increase side effects. Avoid applying near the eyes, mouth, or open cuts since this medication can irritate sensitive skin. Acne may appear to worsen when the medication is first used. It may take three to six weeks before the full benefits of this medication are seen.

Immediately after applying, the skin may feel warm or mild stinging or redness may occur. Some peeling of the skin may occur. These effects should subside as your skin adjusts to the medication. If they persist or become bothersome, inform your doctor. This medicine may also increase sun sensitivity.

This medication can increase sensitivity to sunlight, wind and cold. Avoid prolonged exposure to the sun and sunlamps. Wear protective clothing and use an effective sunscreen. This medication should not be used during pregnancy only if clearly needed. It is not known if tretinoin appears in breast milk. Consult your doctor before breast-feeding. Use mild soap when washing your face. Do not wash face excessively. Abrasive soaps, cleansers, medicated creams or lotions can increase skin irritation. Consult your doctor or pharmacist about their use. Use other acne preparations with caution while using this medication.

Tretinion is becoming largely supplanted by copper peptide technology such as that found in Neova and by Kinerase, which produce similar effects in the skin without the side effects that Retin-A displays.

RETINOL

RETINOL (retinyl acetate, retinyl alcohol) is a naturally occurring form of vitamin A and is found in many fruits and vegetables with an orange, yellow, or red color. Cosmetic chemists have recently been successful in stabilizing retinol--which is light-sensitive--for topical application. It is biologically active, and some of it is converted by the skin to tretinoin, accounting for its anti-aging changes in skin similar to those produced by Retin-A--such as accelerating epidermal cell renewal and improving fine lines by forming new collagen in the upper dermis--but with less or no irritation. Additionally, retinol functions as a natural humectant, attracting moisture and increasing the water content of the epidermis. Since water is the plasticizer of the skin, retinol use improves skin appearance and performance.

Retinol is the active ingredient in the AFIRM products. These products are similar in their action to Retin-A and Renova, with the 1X AFIRM being similar to Retin-A 0.025% Cream, 2XAFIRM similar to Retin-A 0.05% Cream and Renova, and the 3XAFIRM similar to Retin-A 0.1% Cream. Their difference is that they are much less irritating and drying than similar strengths of Retin-A and Renova.

DIFFERIN®

DIFFERIN® (adapalene gel) Gel 0.1% is a topical retinoid analogue indicated for the treatment of acne vulgaris. Its active ingredient, adapalene, is an original chemical entity discovered and developed by Galderma.

Used for the topical treatment of acne vulgaris, DIFFERIN® Gel significantly reduces both inflammatory and non-inflammatory lesions. In clinical trials, DIFFERIN® Gel has proven to be as effective as tretinoin 0.025%, and with low cutaneous irritation.

During the first few weeks of treatment, itching, dryness, redness, burning, or peeling may occur. Exposure to sunlight, including sunlamps, should be minimized during the use of Differin®. Use of sunscreen and protective clothing over treated areas are recommended when exposure cannot be avoided. As with other acne medications, over-exposure to extreme wind or cold, or use of irritating skin care products may aggravate the skin.

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