Chemical Peels

Gary D. Monheit, MD

Disclosures

Skin Therapy Letter. 2004;9(2) 

In This Article

Abstract and Introduction

Abstract

With so many new peel preparations on the market today, the dermatologist must ask himself basic questions concerning the products. The most important question is directed to the medical literature rather than the advertising or marketing campaign so common among market-driven cosmetic products. Since all peeling agents—superficial, medium depth and deep—are derived from basic chemicals known to cause exfoliation, destruction and/or inflammation of skin in a controlled manner, the clinician must ask what is new and better about the product. Peeling agents, regardless of their "proprietary" new name, fall into chemical families. The clinical evaluation of these generic agents is well documented in our literature as to efficacy, technical care and safety. In addition, combinations of peeling agents have been presented in the dermatologic cosmetic literature with scientific clinical trials and histology. These include: 1) The Gordon-Baker phenol peel; 2) Combination medium depth peeling; 3) Glycolic acid formulations. It is the responsibility of the dermatologic surgeon to be in control of his chemicals and his products. It is thus necessary for him to understand all the products and the peel formulation and be sure it has undergone the test of objective scientific study with clear clinical evaluations and histology. Only then will we truly know the effectiveness of the agents we are using for exfoliating and resurfacing.

Introduction

The explosion of interest in chemical peeling and laser resurfacing on the part of dermatologists has paralleled the general public's interest in acquiring a youthful appearance by rehabilitating the photoaged skin. Advertising has further heightened the public's interest for cosmetic agents, over the counter chemicals and treatment programs that have entered the general market of products meant to rejuvenate skin and erase the marks of sun damage and age. Patients have tried most of these OTC home do-it-yourself programs and by the time they consult their dermatologist, they are ready for a more definitive procedure performed with either chemical peeling or laser resurfacing. It is the obligation of the physician to analyze the patient's skin type and the degree of photoaging skin, and thus prescribe the correct facial rejuvenation procedure. This should be the procedure or combination of procedures that will give the greatest benefit for the least risk factors and morbidity. Chemical peeling has been the tried and true basic procedure.

The approach to peeling photoaging skin has expanded beyond a one-stage procedure to now include preparatory medical therapy and post-treatment cosmeceutical topical therapy to maintain results and prevent further photodamage. It is up to the physician to fully understand the nature of skin and sun damage, protective techniques available, and active agents that work as cosmeceutical preparations. Having available multiple procedures to solve these problems will make his patients better candidates for the right procedure to restore and rehabilitate their skin.

Chemical peeling involves the application of a chemical exfoliant to wound the epidermis and dermis for the removal of superficial lesions and improve the texture of skin. Various acidic and basic chemical agents are used to produce the varying effects of light-to-medium-to-deep chemical peels through differences in their ability to destroy skin. The level of penetration, destruction and inflammation determines the level of peeling. The stimulation of epidermal growth through the removal of the stratum corneum without necrosis consists of light superficial peel. Through exfoliation, it thickens the epidermis with qualitative regenerative changes. Destruction of the epidermis defines a full superficial chemical peel inducing the regeneration of the epidermis. Further destruction of the epidermis and induction of inflammation within the papillary dermis constitutes a medium-depth peel. Then, further inflammatory response in the deep reticular dermis induces new collagen production and ground substances which constitutes a deep chemical peel.[1] These have now been well classified and usage has been categorized for various degenerative conditions associated with photoaging skin based on levels of penetration. The dermatologist, thus, has tools capable of solving problems that may be mild, moderate or severe with agents that are very superficial, superficial, medium-depth, and deep peeling chemicals.

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