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Aesthetics Journal

Aesthetics

Delving beneath
the surface of
peels and lasers
Skin resurfacing using chemical peels and lasers of different modalities are
popular and effective methods of rejuvenating skin, as well as treating some
skin complaints. Allie Anderson speaks to practitioners about how they
should be used in aesthetic clinics
They say youth is wasted on the young, and this is
perhaps particularly true in relation to the skin. Until
the age of around 30, most people are relatively
carefree when it comes to looking after their skin,
since, to a great extent, the skin appears to look after
itself. The process of skin cell renewal is reliable and
consistent, and crucially its relatively rapid.1 With age
and poor treatment of the skin, however be it sun
exposure, smoking, or lack of an adequate skincare
regime successful skin cell renewal becomes more
challenging.1
SKIN REJUVENATION
During skin cell renewal, firstly, the outermost layers of
the epidermis (the stratum corneum) are shed naturally
through a process called desquamation.
New cells are then formed beneath that gradually
make their way towards the surface, in a process called
keratinisation,1 meaning that damaged skin is renewed
regularly. Second, fibroblasts in the dermis deposit wellstructured and plentiful collagen fibres, which keep the
skin plump and elastic.2 As a result, the face retains the
characteristics of youthful skin, despite behaviours that
will, in time, degrade its health. As we age, however,
these youth-prolonging mechanisms become less
effective. The matrix that holds the stratum corneum
together becomes denser, enabling the cells to build
up, and consequently making desquamation more
difficult and keratinisation slower.1 Moreover, collagen
synthesis begins to decline during our 20s and 30s,
and the collagen that is produced is increasingly
fragmented and degraded thereafter, causing the skin
to weaken and lose elasticity.2 Although taking care of
the skin from a young age will go some way to staving
off the tell-tale signs of facial ageing, they are inevitable.
But for those wishing to turn back the clock, an effective
method of rejuvenation is skin resurfacing, the goal of
which is to bring new skin to the surface by mechanical
or chemical removal of the topmost layer. Perhaps

paradoxically, resurfacing entails controlled injury to the skin in order to improve its
appearance. This can be performed by peeling or the application of lasers: a third
option dermabrasion is not discussed herein.
PEELS
In a peeling treatment, chemicals are applied to the skin so that the epidermis peels
away, revealing fresh skin beneath. As well as proving effective in combatting and
reversing visible signs of skin ageing such as fine lines and wrinkles; dull, rough
skin; enlarged pores; uneven tone; and areas of pigmentation peels can be used
to treat acne and resulting scarring, rosacea and pigmentation disorders such as
melasma and chloasma.3 Peel solutions are categorised in part by how deeply they
penetrate into the skin, ranging from superficial (or micro/light), medium and deep
peels, with results typically improving as penetration depth increases.4
Superficial peels these commonly contain either alpha-hydroxy acid (AHA),
such as glycolic acid; or beta-hydroxy acid (BHA), such as salycilic acid, at
various concentrations.5
Glycolic acid the preferred treatment at James Willis Faces is a glycolic acid
solution, supported by a robust homecare regime both in preparation for and
following the peel itself. We have a mandatory two-week home preparation period
that comprises a simple but effective five-step procedure, one of which involves
a little bit of glycolic acid, explains managing director and therapist Alison Procter.
That routine is maintained for around six months after treatment as well. For the peel
itself, we provide a series of six glycolic peels of increasing strength, one a week for
six weeks, and the effects are very impressive. The first peel is normally 40% glycolic
acid concentration, and based on a number of factors such as the patients age, skin
type, the severity of the complaint and the desired result as well as how the patient
reacts to the mildest solution subsequent peels will contain an added exfoliant
(proteolytic enzymes), a higher concentration (70%) of glycolic acid, or both.
Salycilic acid this formulation is often favoured when treating patients with
skin of colour. Dermatologist Dr Marina Landau says, For a superficial peel I
might use the BHA salycilic acid, which is less inflammatory and can therefore be
used relatively safely on darker phenotypes. Published evidence suggests that
such superficial peels are the best and sometimes the only option for Fitzpatrick
skin types IV and above.6 This is because deeper peels carry an increased risk
of post-inflammatory hyperpigmentation, to which darker skin types are more
susceptible.7 Salycilic acid has been shown to elicit more marked long-term

Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015

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Aesthetics Journal

improvements with fewer side effects, and is better tolerated, than


glycolic acid in patients with acne.3
Naturally derived acids a holistic approach to skincare is
imperative to the Diane Nivern Advanced Skincare and Medical
Aesthetics clinic, and this is reflected in the resurfacing treatments on
offer. The peels I use mostly comprise acids that are naturally derived,
as opposed to synthetic, laboratory-standardised chemicals. That
fits more comfortably with our ethos, which entails a whole-person
approach to skin health and skin rejuvenation, Nivern explains.
These peels will normally contain naturally occurring citric, malic or
lactic acid, combined with ingredients that help to feed, peel and
restore the skin at the same time. These include centella asiatica,
which has numerous applications in cosmetology and is known for its
wound healing properties; it promotes the proliferation of fibroblasts
and increases collagen synthesis, inhibiting inflammation and thereby
ensuring newly formed skin is stronger.8 Nivern reports that the
system she uses produces good results in cohorts of patients with
wide-ranging complaints, including: ageing skin; younger people with
congested skin; men with ingrowing hairs; people with adult-onset
acne or acne pitting and scarring; and irregular pigmentation in black,
Asian and Chinese patients.
Medium-depth peels whereas superficial peels, as their name
suggests, penetrate superficially, medium-depth peeling inflicts
controlled injury down to the papillary dermis.9 Most peels are
epidermal in nature, says Dr Tahera Bhojani-Lynch from The Laser
and Light Cosmetic Medical Clinic. If you get a little bit through to
the dermis, you produce more collagen; the new skin is a bit tighter
and it gives you some additional effects. An often-used ingredient
is trichloroacetic acid (TCA) at strengths of between 15% and 40%
concentration. Because the peeling agent penetrates more deeply
(according to its concentration), these effects are typically achieved
with one treatment, where a series of treatments is needed with a
more superficial peel. A comparative study found that single TCA
(35%) peels generate significantly greater improvement in cheek
wrinkles and are associated with higher patient satisfaction than a
series of 30% glycolic peels, although the former is associated with
much greater discomfort.10 According to Dr Bhojani-Lynch, a moderate
TCA peel is her go-to treatment to reverse signs of ageing in patients
who have more severe sun damage, and is safe and effective for
darker skin types at a low concentration.6 You could use a mild TCA
peel and repeat it over two or three weeks to get the effect of a
moderate peel, but you would need to exercise caution, she adds.

Aesthetics

therefore there is a significant risk of hypopigmentation, even in


lighter-skinned patients.11 The advantage, says Dr Bhojani-Lynch, is
that you can get the more advanced results associated with deeper
penetration. Caution is crucial because of the toxicity profile of
phenol, which is rapidly absorbed and can cause serious harm.12
As its a much more painful procedure than shallower peels, sedation
or anaesthetic may be required.13 Most phenol peels are only done
on very small areas, like under the eyes and across the top lip and
they tend to be performed in hospitals where there are resuscitation
facilities, adds Dr Bhojani-Lynch. In fact, UK guidelines recommend
phenol peels are carried out by an experienced surgeon or
dermatologist on Care Quality Commission-registered premises.13
APPLICATION OF PEELS
The procedure tends to be more or less standard, regardless of the
type of peel. First, the face is fully cleansed, often with an acetoneor alcohol-based solution to degrease the skin. A barrier gel may
also be applied to the more delicate areas, such as the nasolabial
folds. The practitioner applies the peel and, with many types of
peels, determines how long it is left on by observing the patients
response and monitoring changes in the skins appearance. Were
looking for flushing, redness, and frosting of the skin, where it goes
very pale, explains Nivern, at which point we would immediately
neutralise and wash off the peel. However, not all peel treatments
have a visible endpoint that indicates that it has reached optimum
success. Procters glycolic system involves the peel being left on the
treatment area for a set time of 10 minutes (assuming it is tolerated),
before neutralising the acid with warm water sponges. After this,
and depending on the specific protocol, a combination of serums,
moisturisers and most notably a high-SPF (30 to 50+) sun cream
is applied. Practitioners interviewed concurred that strict, continued
use of sun protection and lifelong UV avoidance is the most
important factor in the success of any resurfacing treatment, and in
preventing and minimising complications.14
CONSIDERATIONS
Occasional side effects and complications are possible, as outlined
below:

PEEL DEPTH

Potential side effects/complications3


Transient burning
Irritation
Erythema

Before deep peel

Two months after deep peel

SUPERFICIAL

Scarring (rare)
Post-inflammatory Hyperpigmentation
(PIH) (rare)
Infection (rare)

Pigmentary changes
Infection
Allergic reactions
Images courtesy of Dr Marina Landau

Deep peels more aggressive peels containing phenol are now


rarely used in the UK, because of the increased risk of complications
and adverse effects, when compared with superficial and mediumdepth peels.11 These occur because phenol is a stronger solution
and penetrates several layers causing a second-degree burn;

MEDIUM AND
DEEP PEELS

Compromised skin healing


Hypersensitivity
Lines of demarcation between treated
and untreated areas
Scarring
Persistent redness

Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015

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The practitioners expertise is an important factor in preventing


complications: they should identify patients who may be more at
risk (those with PIH and keloid scars and people who are deemed
potentially uncooperative), and select a peel depth that balances
desired results with possible adverse events for each patient.3
Contraindications include isotretinoin, used to treat severe acne;
guidelines suggest waiting six months after discontinuing the
medication before undergoing chemical peeling.15 Notwithstanding,
anecdotal evidence shows overwhelmingly that superficial and
medium-depth peels are, for the most part, safe and relatively
free of complications, hence their popularity. Chemical peels
are an important part of my treatment armamentarium, and I feel
comfortable with this procedure because it has a long history,
comments Dr Landau. Research supports this view, suggesting
that dermatological uses date back as far as the 1870s.16 Dr Landau
adds, Patients understand the idea of renewing the skin by
peeling off the old layers and the clinical results are impressive.
LASERS
The core component of laser resurfacing is heat, and most often uses
light waves for its creation. When a wavelength of light is applied
to the skin, it targets substances in the skins molecules called
chromophores, which absorb the light and turn it into heat energy.
Different light wavelengths penetrate at different depths and target
particular chromophores haemoglobin for vascular lesions,17 melanin
for pigmented lesions,18 and water for lines and wrinkles. 19 Generally
speaking, two types of lasers are used in skin resurfacing: ablative and
non-ablative.
Ablative lasers Ablative lasers cause wounding to the skin and,
consequently, removal of its outermost layers, thereby stimulating
renewal of collagen-rich skin beneath.
Non-ablative lasers Non-ablative lasers also work by boosting
collagen production, but they bypass the top skin layers and conduct
heat deeper in the dermis. Targeting water chromophores, a cellular
reaction is triggered that stimulates the production of collagen and
elastin, thus firming and plumping the skin.20
Fractional lasers A more recent development, the fractional laser
is commonly used as an intermediate treatment between the former
two, working at both the epidermal and dermal layers. The laser
beam is divided into thousands of minuscule columns, each intensely
targeting a tiny fraction of the skin at a time while leaving surrounding
tissue unharmed. This promotes faster healing than the traditional
laser procedures, in which the whole area is exposed.21 Consultant
dermatologist and medical director of sk:n clinics, Dr Firas Al-Niaimi,
offers a combination of full-area, fractional, ablative and non-ablative
treatments, using erbium-doped yttrium aluminium garnet (Er:YAG)
and carbon dioxide (CO2) as their media. Depending on the severity
of the condition treated, the patients age and skin type, and the
downtime request, we can choose the most appropriate laser, he
comments. The fractional non-ablative laser has a shorter downtime,
but it will require a number of treatments because the effects are not
as dramatic as ablative. But if someone has a severe form of wrinkling
or acne scarring, and does not mind downtime, then obviously the
ablative resurfacing will be quicker and give better results.
Radiofrequency lasers These (non-ablative) lasers use
radiofrequency (RF) energy, rather than light energy, to generate
the heat required to affect the resurfacing process. Lucy Xu,
treatment director at Premier Laser and Skin, explains, The system
we use utilises gold-plated isolated microneedles to deliver

Aesthetics Journal

Before

Aesthetics aestheticsjournal.com
After

Results following treatment with the Lumenis Ultrapulse CO2 laser. Images
courtesy of Joseph Niamtu II DMD

RF energy to the deep, middle and upper level dermis and the
epidermal layer. This creates controlled thermal damage that
generates a tightening effect, and triggers a healing response in
the dermis to boost collagen production.
APPLICATION OF LASERS
Machines typically either have a rolling motion, whereby the head is
rolled over the skin in a number of passes; a stamping motion, where
the hand-piece is moved up and down between adjacent areas of
skin to be treated; or a scanning-type mode. The skin is numbed with
a topical solution for around 45 minutes: for full resurfacing, which
is more painful and requires greater downtime, local anaesthetic is
injected. Next, the skin is thoroughly cleansed and when goggles are
in place to protect the patients eyes, the treatment is applied. The skin
is lasered one area at a time based on the lasers spot size, although,
according to Dr Al-Niaimi, best results are achieved by treating the
entire face to avoid visible demarcation. The face is divided into
so-called sub-units. At a minimum, you would treat an entire sub-unit
the whole nose or the whole mouth unit or, for optimum results,
you treat the entire face, but you use a blending technique, he
explains. This involves applying a milder form of laser to the rest of the
face, feathering the borders with low-pulse energy and density.22 As
with peels, post-laser aftercare centres on sun protection. In addition,
regular cleansing and moisturising is essential using occlusive
ointments following ablative procedures and lighter moisturisers
for non-ablative. A good antiseptic is the key component of good
aftercare to prevent infection, explains Dr Al-Niaimi. Patients are able
to return to work the day after a RF resurfacing treatment, adds Xu.
COMPLICATIONS
Types of complications include:
Erythema
PIH
Infection
Scarring
Swelling
Severe itching
Acne
The severity of each complication can be classified as minor,
intermediate or major and will vary depending on the type of patient
and concern treated, as well as the strength of the laser used.22,23

Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015

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Notwithstanding, most devices and types of laser are deemed


safe and effective, balanced against the pain and downtime of
the procedure itself. Most complications have been shown to
be caused not by device malfunction, but by errors on the part
of the practitioner.24 In the hands of experienced and reputable
aestheticians, one can expect these complications to be minimal.
CONCLUSION
Skin resurfacing by application of chemical peels or lasers is
a popular choice for patients. Like any aesthetic procedure,
especially those that cross over into the realm of medical treatment,
it is essential that clinicians fully understand the complexities and
potential pitfalls of these options. In capable hands, however, skin
resurfacing can be a safe and effective treatment and therefore,
a valuable addition to the practitioners toolbox.
FURTHER READING
Dr Firas Al-Niaimi, Laser complications in aesthetic procedures, Aesthetics, Volume 1/Issue 11,
October 2014.
REFERENCES
1. Howard, D., Skin Exfoliation 101, (Los Angeles: International Dermal Institute) <www.dermalinstitute.
com/uk/library/28_article_Skin_Exfoliation_101.html>
2. SmartSkincare.com. Skin collagen: more than meets the eye. <www.smartskincare.com/
skinbiology/skinbiology_collagen.html>
3. Rendon, M et al., Evidence and Considerations in the Application of Chemical Peels in Skin
Disorders and Aesthetic Resurfacing, The Journal of Clinical and Aesthetic Dermatology. 2010
Jul; 3(7): 32-43. <www.ncbi.nlm.nih.gov/pmc/articles/PMC2921757/>
4. Landau, M., Chemical peels, Clinics in Dermatology. 2008 Mar-April; 26(2):200-8. <www.ncbi.
nlm.nih.gov/pubmed/18472061>
5. www.paulaschoice.com/expert-advice/nonsurgical-skin-care-treatments/_/what-does-achemical-peel-do
6. Sarkar, M et al., Chemical peels for melasma in dark-skinned patients, Journal of Cutaneous
and Aesthetic Surgery. 2012 Oct-Dec; 5(4): 247-253. <www.ncbi.nlm.nih.gov/pmc/articles/
PMC3560164/>
7. Ho, SG and Chan, HH., The Asian dermatological patient: review of common pigmentary
disorders and cutaneous diseases, American Journal of Clinical Dermatology. 2009;10(3) 153-68.
<www.ncbi.nlm.nih.gov/pubmed/19354330/>
8. Bylka, W et al., Centella asiatica in cosmetology, Advances in Dermatology and Allergology.
2013 Feb; 30(1): 46-49. <www.ncbi.nlm.nih.gov/pmc/articles/PMC3834700/>
9. Monheit, G., Chemical Peels, Skin Therapy Letter. 2004;9(2). <www.medscape.com/
viewarticle/469514_3>
10. Kitzmiller, WJ et al., Comparison of a series of superficial chemical peels with a single midlevel
chemical peel for the correction of facial actinic damage, Aesthetic Surgery Journal/The
American Society for Aesthetic Plastic Surgery. 2003 Sep-Oct;23(5):339-44. <www.ncbi.nlm.nih.
gov/pubmed/19336097>
11. Healthwise, Chemical Peel, WebMD (Atlanta). <www.webmd.com/beauty/peels/chemical-peel>
12. Health Protection Agency., Phenol Toxicological overview. Gov.uk (London) 2007. <www.
gov.uk/government/uploads/system/uploads/attachment_data/file/338247/hpa_phenol_
toxicological_overview_v2.pdf>
13. Department of Health., Review of the Regulation of Cosmetic Interventions, Call for Evidence.
Gov.uk (London) 2012.<www.gov.uk/government/uploads/system/uploads/attachment_data/
file/216906/Call-for-evidence-cosmetic-procedures.pdf>
14. Nikalji, N et al., Complications of Medium Depth and Deep Chemical Peels, Journal of
Cutaneous and Aesthetic Surgery. 2012 Oct-Dec; 5(4): 254260. <www.ncbi.nlm.nih.gov/pmc/
articles/PMC3560165/>
15. Monheit, GD and Chastain, MA., Chemical peels, Facial plastic surgery clinics of North America.
2001 May;9(2):239-55, viii. <www.ncbi.nlm.nih.gov/pubmed/11457690/>
16. Brody, HJ et al. A History of Chemical Peeling. Dermatologic Surgery. 2000 May;26(5): 405-409
17. Farhadieh, R, Bulstrode, N and Cugno, S., Plastic and Reconstructive Surgery: Approaches and
Techniques, John Wiley & Sons, 2015.
18. Ashton, R and Leppard, B., Differential diagnosis in dermatology, Radcliffe Publishing, 2005.
19. Patil, UA and Dhami, LD., Overview of lasers, Indian Journal of Plastic Surgery, October 2008; 41
(Suppl): S101-S113. <www.ncbi.nlm.nih.gov/pmc/articles/PMC2825126/>
20. Fodor, L, Elman, M, Ullmann, Y., Aesthetic Applications of intense pulsed light, 2011. Chapter 2,
Light Tissue Interactions, p.11-20.
21. Ngan, V., Fractional laser treatment. DermNet New Zealand Trust, 2015. <www.dermnetnz.org/
procedures/fractional.html>
22. Macrene, R et al., The spectrum of laser skin resurfacing: Nonablative, fractional, and ablative
laser resurfacing, Journal of the American Academy of Dermatology. 2008 May; 58(5): p.719-737.
23. Tanna, T., Skin Resurfacing Laser Surgery Treatment & Management, Treatment, Complications,
Medscape. 2014. <emedicine.medscape.com/article/838501-treatment#d13>
24. Zelickson, Z et al., Complications in cosmetic laser surgery: a review of 494 Food and Drug
Administration Manufacturer and User Facility Device Experience Reports. Dermaologic Surgery
Journal/The American Society for Dermaologic Surgery, 40 (4) (2014), pp. 378-82.

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Truchuelo M et al, Journal of Cosmetic Dermatology, 2014. 2Cameli N et al, Dermatological Experiences, 2012.

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