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

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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 – it’s 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 REJUVENATIONDuring 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 well-structured 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.

PEELSIn 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 patient’s 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

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

Delving beneaththe surface ofpeels and lasers

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

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PEEL DEPTH Potential side effects/complications3

SUPERFICIAL

Transient burning

Irritation

Erythema

Scarring (rare)

Post-inflammatory Hyperpigmentation (PIH) (rare)

Infection (rare)

MEDIUM AND DEEP PEELS

Pigmentary changes

Infection

Allergic reactions

Compromised skin healing

Hypersensitivity

Lines of demarcation between treated and untreated areas

Scarring

Persistent redness

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.

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 medium-depth peels.11 These occur because phenol is a stronger solution and penetrates several layers causing a second-degree burn;

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 it’s 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 PEELSThe procedure tends to be more or less standard, regardless of the type of peel. First, the face is fully cleansed, often with an acetone- or 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 patient’s response and monitoring changes in the skin’s appearance. “We’re 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. Procter’s 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

CONSIDERATIONSOccasional side effects and complications are possible, as outlined below:

Images courtesy of Dr Marina Landau

Before deep peel Two months after deep peel

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

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The practitioner’s 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.”

LASERSThe 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 skin’s 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 patient’s 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

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 LASERSMachines 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 patient’s eyes, the treatment is applied. The skin is lasered one area at a time based on the laser’s 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.

COMPLICATIONSTypes 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

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

Before After

27

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-a-chemical-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): 254–260. <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): 405-40917. 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.

FURTHER READINGDr Firas Al-Niaimi, ‘Laser complications in aesthetic procedures’, Aesthetics, Volume 1/Issue 11, October 2014.

Effective Pigmentation ResolutionThat’s kind on skin

© Ferndale Pharmaceuticals Ltd® 2015. 1Truchuelo M et al, Journal of Cosmetic Dermatology, 2014. 2Cameli N et al, Dermatological Experiences, 2012.

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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.

CONCLUSIONSkin 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 practitioner’s toolbox.