Many of our clients have never experienced a chemical peel. Apprehensions are common and understandable. Even the term “chemical peel” may be frightening to a new customer. A simple rephrasing to “professional exfoliation treatment” can calm these fears, as most customers understand exfoliation. The key to a successful professional exfoliation outcome depends on selecting the appropriate treatment and gaining customer confidence and compliance with corrective homecare products.
Evolution of Exfoliation
The use of chemicals to treat the skin has evolved throughout history from poultices to modern day blended chemical peels. In our aesthetic educational programs, we learned that exfoliation originated as early as A.D. 3,000 with the ancient Egyptians bathing in sour milk (lactic acid) and wine (tartaric acid) to smooth the skin. The Greeks used limestone, mustard poultices, sulfur, and urine to exfoliate, while the Romans exfoliated with sour goat’s milk, alabaster, and red wine. The ancient Turks were far more daring, using fire to exfoliate and lighten the skin.
Today, many manufactures blend multiple acids such as trichloroacetic, retinoids, lactic, glycolic, salicylic , ascorbic, and kojic acids (amongst many others) to exfoliate the dead or compromised skin cells and uncover newer, healthier ones. With blended peels, we can treat multiple skin conditions, such as aging with hormonal breakouts or acne simultaneously with post-inflammatory hyperpigmentation. Some companies have added phenol to the blended solutions to provide antiseptic and anesthetic properties. Blended peels have the additional benefit of combining multiple acids at lower percentages that are able to produce similar results as a straight acid at a higher percentage but without a high level of inflammation and irritation.
Exfoliating Agents and Their Uses
Each exfoliating agent has a different mechanism of action, accompanied by varying benefits. The more educated the practitioner, the more effective the treatment program.
Alpha hydroxy acids (AHAs) are water-soluble acids that dissolve the desmosomes (fibrous bonds) that hold skin cells together. This allows for easier exfoliation.
Beta hydroxy acids (BHAs) such as salicylic acid are keratolytic, meaning that they digest surface cells. Beta hydroxy acids are lipid- or oil-soluble, making salicylic acid an excellent choice to clear the cellular buildup that clogs pores.
Trichloroacetic acid (TCA) is a chemical cauterant synthesized in a laboratory by combining three chlorine molecules with acetic acid, a mild organic acid derived from vinegar. Trichloroacetic acid dissolves aging cells to make room for newer, healthier ones. It is an excellent ingredient in chemical peels due to its ability to stimulate the fibroblast cells to produce collagen.
Phenol (carbolic acid), also known as phenic acid, is another chemical cauterant that dissolves cells. Additionally, phenol is an antiseptic and provides an anesthetic or mild numbing effect on the skin. Phenol is the numbing agent used in Chloraseptic® throat spray.
Resorcinol is a phenol derivative, often sourced from wood barks. It is commonly used as a flaking agent in chemical peels.
- Retinoids are a class of chemical compounds that are chemically related to vitamin A. Retinoids increase cell turnover, inhibit pigmentation (melanogenesis), hydrate, and stimulate collagen and elastin production.
- Retinoic acid has the extra cellular action of alpha hydroxy acids and the ability to penetrate epidermal and dermal cells internally. Retinoic acid encourages exfoliation while repairing or replacing damaged cells. Retinoic acid acts by binding to the retinoic acid receptor (RAR), which is bound to DNA as a macromolecule with the retinoid X receptor, enabling retinoic acid to affect cellular DNA by repairing damage and producing cellular renewal.
- Retinol is not as strong as retinoic acid and cannot interact with the retinoic acid receptors in the skin; it converts to retinoic acid by chemical reaction. Retinol binds with an enzyme called cytoplasmic, a retinol-binding protein that converts it to retinaldehyde. Retinaldehyde is then oxidized by retinaldehyde oxidase, which converts it to retinoic acid.
- Retinyl palmitate, retinol combined with palmitic acid, is the mildest form of vitamin A. It functions as an antioxidant. Before converting to retinoic acid, retinyl palmitate must convert to retinol, then to retinaldehyde.
Pyruvic acid, sourced from grapes, honey, apples, fermented fruit, and vinegar, is commonly used for medium-depth peeling. It provides antiseptic properties, stimulates collagen and elastin production, and reduces sebum levels.
Poly hydroxy acids (PHAs) are similar in action to alpha hydroxy acids, except they are less irritating. Poly hydroxy acids exfoliate, moisturize, improve tone and texture, and are excellent antioxidants. Gluconolactone and galactose are examples of poly hydroxy acids.
Enzymes can also be used for professional exfoliation. Common enzymes include pumpkin, pineapple, and papaya. Papain from papaya, bromelain from pineapple, and pumpkin extract are called proteolytic or protein dissolving enzymes that dissolve the keratinized layer of skin.
- Very superficial – low potency AHAs, under 10 percent TCA, low percent retinol, salicylic acid
- Superficial – AHAs, 10 percent retinols, Jessner Solution, 10 to 20 percent TCA (layer dependent)
- Medium depth – TCA over 25 to 30 percent, 35 percent TCA + Jessner, , 50 percent Pyruvic acid, various medium-depth blends
- Deep – straight Phenol- high percent, Baker-Gordon, TCA over 40 percent
*This list is intended to serve as a guideline for potential peel penetration.
Setting Realistic Expectations for Clients
Clinicians occasionally experience customer dissatisfaction regarding the results of their chemical peel treatments. Many clients have unrealistic expectations for chemical peels, the biggest misconception being that the skin will always flake. While there is always exfoliation, it may be at the cellular level and not visible to the naked eye. Another issue that is often misclassified as an adverse reaction to a chemical peel is post-inflammatory hyperpigmentation (PIH). As clinicians, we need to educate our clients on expected outcomes from their treatments. Each person’s skin is unique. Never expect any two clients to have the exact same results. After reviewing realistic expectations, a consent form should be signed prior to each peel.
Common Reasons Why Skin Does Not Visibly Flake*
Many clinicians suffer frustration because a client expects to see flaking after a chemical peel. There are many reasons that flaking may not occur.
- The client may have an extremely impacted stratum corneum (corneocyte cohesion). It may take two or more treatments to break down the outer shell so the skin can begin to shed.
- A client with oily skin must be degreased thoroughly to enable the solution to penetrate adequately. Otherwise, the client may experience a sub-par treatment with little to no flaking.
- “Application technique failure” occurs when the clinician does not degrease the skin appropriately or apply the solution according to manufacture protocol, which can affect treatment outcome.
- The client may be so well exfoliated that their skin does not need to flake. They are still exfoliating at a cellular level, just not on a visual epidermal level.
- The environment can play a factor. In humid environments, the moisture in the air can inhibit exfoliation.
- Recent treatments by the client can be a factor. Have they recently had aggressive treatments that may account for a lack of or lower level of exfoliation?
- Client skin preparation prior to the peel is a large factor. Recent use of skin thinning topicals or systemic medications such as isotretinoin, antibiotics, recent sun exposure, and Fitzpatrick type are examples of factors that may affect flaking.
*This list is not intended to be all inclusive, but to be used for educational purposes.
How to Avoid Treatment Complications
The most effective way to avoid complications is to be informed. Schedule a pre-treatment consultation. Complete a thorough client intake form and conduct a complete skin analysis using a magnifying light and Wood’s Lamp. Apply a patch test of peel solution about the size of a dime in the area you plan to exfoliate. As most allergic reactions will occur within 48 hours, a consultation is best held one to two weeks prior to treatment, at the very minimum 48 to 72 hours prior to peeling. Always review any client sensitivities to all ingredients used in the peel and post-care regimen, and review any possible contraindications to your suggested treatment plan.
Dealing with Potential Complications
A chemical peel is an active treatment that can produce a histamine reaction, ranging from itchy skin to puffy eyes to extreme edema. Mild itchiness is often controlled by applying hydrocortisone cream and, if necessary, by taking an over-the-counter level anti-histamine. An allergic reaction may require prescription medication after an evaluation by a physician. Contact every client within 48 hours of treatment to answer any questions and resolve any concerns.
During the first week, the client should follow a simple skin care routine, including use of a gentle cleanser. Excess sun exposure is to be avoided; makeup may be worn as desired. Dark skin has easily stimulated pigment cells, making the addition of retinoid and pigment suppression products very important following the peeling process.A small amount of edema, especially around the
eye area, is not uncommon following a chemical peel. The client may choose to take Ibuprofen as an antiinflammatory, sleep with the head slightly elevated, and apply a cool compress to the area treated. Any discomfort should subside within 24 to 48 hours. If the client is not continuously exposed to the offending allergen, the reaction will subside naturally with time.
Remind the client to refrain from any activities such as exercise or using a sauna that induces heat. Activities such as baking, cooking over a hot stove, and overindulging with hot or alcoholic beverages can also induce thermal warming and should be limited for 72 hours. Heat sources can trigger perspiration, which creates the potential for blistering. Blistering creates a high potential for the development of postinflammatory hyperpigmentation.
The aesthetician must refrain from giving any form of medical advice. If the client is experiencing something more than a mild histamine reaction, he/she should be instructed to seek medical advice. For a severe allergic reaction that affects breathing, the client should call emergency personnel immediately.
Scope of Practice
An aesthetician’s regulations or “scope of practice” vary by state. Some regulations stipulate that a clinician is allowed to exfoliate the stratum corneum only; others state that an aesthetician is allowed to work in the entire epidermis. Some states prohibit certain peeling ingredients including retinoids, phenol, trichloroacetic acid, alpha hydroxy acids over 30 percent, beta hydroxyl acids over 20 percent, or peels with a pH under 3.0. Regulations can be updated at any time. Do you know your state’s current regulations?
Some state regulations are written to specify that any treatments outside of those that are specifically listed within the state’s code are “prohibited.” It is very important for all clinicians to understand the laws and codes that regulate their profession in their state.
In a medical practice, the aesthetician works under physician supervision. If an aesthetician applies a medium depth peel, they must realize that they are no longer working under an aesthetician’s scope of practice. The common understanding is that while an aesthetician is working under the physician, they would be governed by the medical board and covered under the physician’s malpractice insurance. It is recommended that these clinicians review the state laws that govern the medical practices and medical spas in their state with their employers.
The state of California has made recent headlines because the State Board of Cosmetology has teamed up with the California Medical Board to make unannounced visits to medical spas, imposing heavy fines on spas operating outside of state code and laws.
In most states, aestheticians are regulated and licensed by the State Board of Cosmetology. Other common agencies that regulate aesthetics are: the Departments of Health; Occupational Licensing; Consumer and Regulatory Affairs; Occupational and Professional Licensing; Business and Professional Regulations; Commerce; Department of Health and Human Services Regulation and Licensure.
The number of hours required to apply for licensure varies from state to state. In Florida, you can become a licensed facial specialist after completing a 260-hour program (and passing the examination). Florida also offers a paramedical aesthetician program where you can receive additional certification after completion of a 1,200 total-hours program. Connecticut does not offer licensure but many schools in the state offer 600-hour programs, enabling graduates to apply for licensure in the neighboring states of Massachusetts, Rhode Island, and New York. Most states require programs with an average of 600 to 750 hours with Alabama requiring the highest number of hours at 1,500.
Washington State, Virginia, and Utah are among the states offering two-tier aesthetic licenses: basic and master aesthetician. California and Oregon are among the states currently going through the legislative process to add the master aesthetician licensure. In addition to licensure, Colorado requires a 24-hour course on chemical exfoliation prior to an aesthetician peeling clients. It is important to note that while many institutes offer medical aesthetician training, there is no medical aesthetician licensure.
There are other important points to consider. Ask yourself: In applying acids, what acids does your insurance carrier cover? Are you limited to a specific percentage of peeling agent(s) by your insurance carrier or by your state? Are you prohibited from using any specific ingredients by your state regulations? Do you know the applicable state laws governing aestheticians working in medical spas?
Good Preparation Equals Successful Outcome
When selecting the appropriate “professional exfoliation” for your client, consider the desired results, sensitivities to ingredients, and your scope of practice. Set realistic expectations before treating the skin and follow up within 48 hours of the treatment to address any potential concerns. An informed clinician exudes confidence, gaining client trust and compliance to create
Director of Sales and Educational Programs for Vitality Institute Medical Products, Brenda Linday, L.E., L.E.I. has over 12 years of experience in the medical aesthetic industry. She is an industry author and has trained hundreds of skin health professionals worldwide on safe and effective chemical peeling techniques, while instilling the importance of credibility, valuing lasting client relationships, and showing skin care professionals how corrective and preventative skin care can truly improve a client’s life.