Peelings: how, when and why!

There is not best time to rejuvenate the skin with an ancient method, but very up to date: peelings. It is

a well known methodology that, if well conducted, can have even better results (with very low risks)

compared to modern techniques such as laser.

I will explain you a little bit of their background and how they work!

Definition

It is an abrasion of the epidermis or dermis done with chemical means, generally strong acids, or physical

as cold, with a laser source or radiofrequency.

They can be superficial, to “peel” the skin, medium, to reach the epidermis deeply and deep to be more incisive in

the rejuvenation, but with important possible side effects and a very long recovery!

A little bit of history…

Peelings are used to improve the aspect of the skin, to take care of it or just for a simple major

cleanliness. They have been known since the ancient Ages.

The ancient Egypt already knew how to take care of the skin through exfoliated substances, which were

basically mildly acid that gave back a smoother skin: they used flower’s powder and grinded plants,

citruses’ juices as oranges and lemons, but also milk. Cleopatra used to get wet in donkey’s milk.

In the late middle Ages, professionals executed peelings at home and also, for example, took care of

eyebrows’ depilation which had to be.. high, thin and well done!! There are texts, where it is told about

other substances, that “clean every spot”.

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: peelings that are very common today.

In particular the peeling with phenol has been widely studied and experimented by numerous

dermatologists and plastic surgeons as the English Mac Kee, or La Gassè who refined the occlusive

technique after the peeling.

But it is in the 70’s and 80’s that 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 entire body, and it has a lot of function.

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 desire, and think of the smell it spreads influencing

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 decrease and reduce

the function with the time.

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. The more you get old, the 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 appears more turgid and tonic. So, they are fundamental in every treatment of

cutaneous revitalization.

Obviously, these mechanisms of action are not always present together 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, side 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.

Indications

So, peelings are especially advisable for skin rejuvenation, when the first signs of keratosis and

cutaneous aging start to be evident.

Another wide chapter is represented by cutaneous dyschromia, 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 seborrheic dermatitis.

Some of my colleagues use peelings also for 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 and the papillary epidermis to get

to 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 used 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 after a while an

inflammatory reaction, that obliged to interrupt them, often 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 erythema 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 layers from 1 to 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 that can be compared 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 side 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 a 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, 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 cannot scratch yourself, nor

rip your skin… hydrate it a lot.

Trichloroacetyl acid

It is another active principle that has been used for many years.

They are crystals, that are diluted with the proper quantitative of water reaching a concentration that

goes 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 side 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 which a cutaneous necrosis will follow.

The skin will come off in wide layers, that must not be ripped off, otherwise scars will remain. 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 for acne and 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 and the seborrheic 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.

Vapors produced during its 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 that is getting more and more popular for the cutaneous rejuvenation but also

for the care of many cutaneous pathologies.

Besides the ones I described, there are many other peelings, more or less efficient.

The advice is always to address to a good doctor who will know what peeling suggest you according to

the person, to the skin and to the particular situation, beside the experience, which is very important for

the global safety of the treatment.