Indications:
- Photoaging
- Hyperpigmentation
- Wrinkles and fine lines
- Passive acne & Scars
- Melasma
- Dilated pores
- Skin type of IV, V, VI on Fitzpatrick scale.
- Freckles
- Facial melanoses
- lentigines
Contraindications:
- Psoriasis
- Eczema
- Active infection and inflammation of the skin including active acne.
- Type I, II, III skin on Fitzpatrick scale.
- Atopic dermatitis
- Active bacterial and fungal infection anywhere in the body.
- Tendency to produce keloids and hypertrophied scar.
- Recently waxed or shaved the affected area.
- Present history of radiation therapy
STEP 1: Assessment of Patient
- Detailed case history of the patient should be taken including the patient’s occupation to evaluate the level of sun exposure, the patient’s subjective area of skin concern, specific past & family history, surgical history, and any medicinal and cosmetic allergies must be taken into consideration before proceeding for peeling.
- Detailed physical examination should include analyzing the skin type ( oily, dry, or mixed), and look for the presence of preexisting inflammation, infection, keloid, or hypertrophic scar. Immunocompromising conditions and smoking may delay healing in deep peels. This is not relevant in superficial peels.
STEP 2: Selection Of Peels
- Superficial peels act on the epidermal layer only. It can be used in all skin types.
- Epidermal regeneration takes place in 3-5 days. The procedure can be repeated once in 7-10 days.
Superficial peels are :
- Glycolic acid (10-15%)
- Salicylic acid ( 10-20%)
- TCA ( 10-15%)
- Yellow peel ( bridal peel
- Mandelic acid
Indications for superficial peel :
- Mild and noninflammatory acne
- Superficial scar with negligible depth
- Shallow hyperpigmentation
- Grade 1 sun tanning
- Very fine wrinkles
- Medium peels act on the epidermis and upper part of the dermis
- Skin regeneration takes place in one week
- The procedure can be repeated once in 15-20 days
Medium peels are:
- Glycolic acid (30-35%)
- Salicylic acid ( 30-40%)
- TCA ( 20-35 %)
- Lactic acid ( mainly for removing the pigmentation of extremities)
- Azelaic peel ( mainly for sensitive and acne-prone skin)
Indications for medium peel:
- Moderate acne in the inactive form
- Moderate wrinkles
- Deep hyperpigmentation
- Scar with medium depth
- Considerably dull face due to photoaging
- Deep peels act on the deeper layer of the dermis.
- Skin regeneration takes place in 10-15 days.
- The procedure can be repeated once a month.
Deep peels are :
- Nomelan peel
- Phenol peel
- TCA ( 50-55%)
Indications for deep peels :
- Severe deep-rooted acne
- Melasma
- Deeper scar
- Moderate wrinkles.
- Tanning leads to considerable blackening of the skin.
Note to remember: Two superficial peels, one superficial and one medium peel, and two medium peels can be combined together. Deep peels can not be combined with other peels.
- Do not mix the peels of different manufacturers. If the patient is allergic to milk and milk products – Avoid lactic peel.
- If the patient is allergic to strawberries or synthetic sweeteners – Avoid Glycolic peel
- If the patient has severe sensitivity to aspirin – Avoid Salicylic peel. Lactic acid can be used in such conditions.
STEP 3: Counseling and pre-peel Instructions
- Proper counseling and instruction prior to peeling is very important and it should include,
- The explanation that patients should have realistic expectations, is very important for the media-hyped patient who may have unrealistic expectations.
- Explain the number of sessions required to meet desired results.
- Explanation about the nature of treatment and its expected outcome. It is advisable to downplay the degree of improvement expected.
- Inform the patient about the time taken for recovery of normal skin and the importance of a maintenance regime.
- Retinol in any form should be avoided 24-48 hours before undergoing peeling.
STEP 4: Pre-peeling Safety Precautions
- The procedure room should be sterilized 15-20 min before the procedure. All required equipment should be cleaned with trillium.
- Physicians and supporting staff should wear gloves and face masks to avoid contamination of peels and equipment.
- The label on the bottle must be checked before applying the peel.
- A 10 ml syringe filled with normal saline or distilled water should be kept for irrigation in case of accidental spillage in the eyes.
- The patient is asked to wash the face with face wash to remove makeup if any.
- The head of the patient should be kept at an elevation of 45 degrees to avoid accidental spillage.
- The hair is pulled back with a hair band.
- The face is cleaned with cleansing milk by using a 2”x2” gauze piece or cotton.
STEP 5: Peeling Procedure
- The required amount of peeling agent is poured into a small glass bowl or beaker.
- The neutralizing agent is also kept ready. Neutralization is done with 10-15% of sodium bicarbonate solution. In case neutralizing agents are not available, then ice packs can be used.
- Cold water should not be an alternative as it only dilutes the peel but can not neutralize it.
- Sensitive areas like the inner canthus of the eyes and nasolabial folds are protected with Vaseline.
- The peeling agent is applied with the help of a soft brush or cotton-tipped applicator.
- Peeling application should begin from the forehead, then the right cheek, nose, left cheek, and chin in that order. The perioral, upper, and lower eyelids are treated last.
- For glycolic acid peel, the peel is neutralized usually after 3 minutes, but if a grayish white appearance or blisters on the skin is noticed, then the peel must be immediately neutralized irrespective of the duration.
- When the salicylic peel is applied, it crystallizes and shows the frosting. It should be neutralized after frosting is seen. Usually, it takes 3-5 minutes to show the frosting. However, if the patient feels intolerable burning, it should be neutralized irrespective of desired time and frosting.
- For TCA peels, neutralization is done after frosting.
- Yellow peels or tretinoin peels are left on the skin for 4-5 hours and then washed away.
- Neutralization should be done in reverse order of the application. That is eyelids should be neutralized first.
STEP 6: Post-Procedure Care
- Patients are advised not to wash their face with soap or any other cleanser for 24 hours.
- Make the patient aware that the degree of peeling is different in different individuals.
- It may take up to 3-5 days for complete peeling with mild erythema and edema. Advised the patient not manually pull or peel the skin, as it may cause soreness of the skin.
- Advised the patient to apply sunscreen every time he/she steps out of the house.
- If burning persists, then he/she may apply calamine lotion or aloe vera gel for soothing. In severe persistent burning analgesics may be prescribed.
- Give the follow-up date to the patient depending upon the type of peel.
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