Advanced Chemical Peels – notes of interest

Client consultation:
1. DOB so you know approximately how old someone looks (old for their age vs. young for their age).
2. Occupation – lets you determine how their work affects their skin.
3. Referral – often more open to purchasing products, following instructions and offer repeat business.
4. Facial/Peel Experience – determine familiarity with procedures and allows you to modify any previous
experiences.
5. Medical conditions – to determine contraindications for services
6. Pregnancy – ask every woman of childbearing age whether showing or not.

Documentation – Fitzpatrick skin type , Glogau classification (grades 1-4 wrinkling), skin type (dry, oily, acne,
pigment, etc), and skin condition (env. damaged, dehydrated, hyperpigmentation, fine lines and wrinkles,
telangiectasia, eye are issues, moles, birthmarks and warts. (You can document moles by placing a piece of scotch
tape over them and tracing their shape, take the tape off the skin and place in chart. Allows for referral later to
check for changes.

Woods lamp color guide:

White spots –thick corneal layer, scars and dry patches, dead cells, horny layer of skin
White fluorescent – lint, dandruff
White specks – dandruff, hypopigmentation
Blue/White – normal, healthy skin
Purple – thin skin, lacking moisture
Light Violet – dehydrated skin
Pale Grayish Violet – Healthy scalp and hair
Brown – sun damage, pigmentation, freckles
Pink/Coral/Yellow/Orange specks – clogged pores, oil, acne, comedones
Bright Fluorescent – hydrated skin
Deep Purple – overall dark pigment
**If visual hyperpigmentation disappears with woods lamp, the pigment is within the dermal layers and may not be
able to be corrected. You may be able to lighten it, but it will not go away completely.

Client information:
Birth control – can alter natural hormonal levels or be utilized for acne medication
Contact lenses – do they need to be removed?
Acne – any breakouts, patterns or congestion
Elective surgery – show pattern of how dedicated a client is about their skin appearance and commitment to a home
care regimen.
Skin cancer - determines sun exposure patterns
Stress levels – every patient will be different – can effect the clients nervous system and any rosacea conditions
Allergies – fragrances, preservatives, benzoyl peroxide, plant extracts, nuts, chemical sunscreens.
Current care regimen – can determine clients commitment to their skin appearance and the types of products they
are using.
Clients should be on a professional strength AHA home care regimen for 7-14 days prior to beginning a peel
treatment or series! (will get a deeper penetration of the acids)
Clients should be on a professional skin lightening home care product for 14-28 days prior to beginning a peel
treatment or series (for types prone to PIH) –

On AHA/BHA’s:
In the epidermis they work to unglue cells and allow shedding of the keratinocytes at the stratum granulosum layer.
In the dermis they increase the ground substance for collagen remodeling – notice the initial drying then the
plumping of the skin.

Glycolic acid is an AHA that is derived from sugar cane. It comes in varying strengths (40%, 50%, 70%) . It has a
smaller molecular structure that allows easier and deeper penetration. Must be removed by a rinse-off method.
Lactic acid is a slightly larger molecule than glycolic. It is a humectant and part of the natural moisturizing factor of
the stratum corneum layer. It is indicated for skin lightening and can be used on nearly all skin types unless
allergies exist. Great for darker skin types and rosacea patients.

Salicylic acid is a BHA and indicated for reducing bumps associated with acne. Used for oily, acne and ingrown
hairs. Usually in a 20-30% solution. Wors with lipid barrier of the skin and serves as an antibacterial and anti-
inflammatory acid. Often associated with a frosting appearance and skin peeling. Leaves a white residue on the
skin.

Peeling agents:
AHA’s – all come from natural source and cause wounding to skin and force it to heal, must be neutralized
thoroughly to terminate action of otherwise it can over peel.
BHA’s (Salicylic acid) are non-wounding and are a more superficial acid. Salicylic acid can be derived from willow
bark, wintergreen or lab synthesized. Clients allergic to aspirin are not candidates for salicylic.

Glycolic –AHA – deepest penetrating acid (due to short carbon chain (2)), unclogs pores, improves texture,
rejuvenates basal cell turnover, exhausts melanocyte activity, keratolytic.
Lactic - (3 carbon chain), origin- sour milk and tomato juice, very skin friendly, eliminates germs, toxins and dead
cells, skin lightener (will not excited melanocytes – great for hyperpigmentation in FP IV-VI), keratolytic
Malic – (4 carbon chain) origin – apples, natural pH adjuster, used in home facials, keratolytic.
Tartaric – (5 carbon chain), origin – sour grapes, contains antioxidant properties, keratolytic.
Citric – (6 carbon chain), origin – oranges, lemons, pineapple, natural skin lightener, very superficial, pH > 5.0=skin
healing properties, keratolytic.
Mandelic – (8 carbon chain), origin – bitter almonds, contains lower natural pH than glycolic, penetrates without
wounding properties of gycolics, keratolytic
Salicylic – BHA- origin – sweet birch bark, willow, wintergreen, Aspirin derivative, antiseptic (drying to the skin),
analgesic, keratolytic.
Jessners – man made solution of 14% salicylic, 14% lactic and 14% resorcinol. Retards sebaceous activity, highly
keratolytic, anti-microbial, can cause heart palpitations, self neutralizing, not removed from the face. (Jessners
Lite is 7%/7%/7% with pH of 2.0. Can apply up to 4 layers.)
TCA Orange peel is 12% TCA and 2% salicylic acid. Vaseline is a good product to use with TCA to keep skin
moist during peeling phase.
**Lesser carbon molecules = deeper penetration. pH of agent also determines depth of peel (lower pH= deeper
penetration.)
** superficial peels can be repeated every 7 days.

Glycolic/Lactic Acid – both AHA’s. Glycolic has smaller molecule, is keratolytic, stimulates fibroblasts and has
anti-inflammatory effects. Lactic is a larger molecule doesn’t over excited melanocytes and useful in treating skin
types IV-VI. Works well to apply this solution first then other’s to allow for deeper penetration.

Salicylic Acid – frequently used in topical acne preparations due to comedolytic effects. Facilitates penetration of
other topical agents, can alter underlying dermal tissue without directly wounding the tissue, anti-microbial. 20-
30% can be used safely on darker patients.
Indications: Acne Vulgaris, Acne Roseacea, Melasma, PIH, Freckles, Photodamage, rough skin
Suggested acne treatment: 1 layer of salicylic, wait one minute, then apply glycolic/lactic combo. If see hot
spot, remove acids in that spot and apply acids to other areas.

Jessner’s Solution – has been around for more than 100 years as a therapeutic agent to treat hyperkeratotic epidermal
lesions. Is combination of Salicylic and lactic acid and resorcinol. Typically induces wounding to the level of
papillary dermis, enhances penetration of other agents. Will cause darkening of treated skin, this is normal, it will
peel off and lighten. Wait 5-7 minutes between layers. Works great using retinol cream with 2 drops retinoid
applied to skin after “heat” of peel has calmed down. Enhances peeling effects of the Jessners. Follow with oil-free
sunscreen as sunscreens with oil may re-increase the heat of the peel.
Indications: Acne, Melasma, PIH, Lentigines, Freckles, photodamage
 Contraindications: extreme caution with Fitz 5&6, pregnancy, dermatitis or infection, allergy to aspirin.
Resorcinol - related to phenol both structurally and chemically, soluble in water, ether and alcohol, bacterial agent,
keratolytic.
Indications: acne is active phase, post-acneic disorders (PIH, erythema, shallow scars), epidermal melasma,
mild photoaging, freckles.
Contraindications: skin type 5 & 6, pregnancy, allergic reaction to resorcinol, herpes simplex in active
phase.

TCA – first use in 1882!!! Is a chemical cauterant and causes protein denaturization resulting in readily observed
white frost. Peeling preparation is very important to avoid post-peel complications. Concentration 10-20% = very
light superficial peel, 25-35% = light superficial peel and use of TCA >35% can cause unpredictable results
including scarring. A medium depth peel should be achieved with maximum of 35% TCA and another peeling
agent such as Jessners solution (to help TCA penetrate deeper). Not recommended on skin type 3-6.
Indications: AK’s, mild-moderate photoaging, melasma/yperpigmentation, acne/acne scarring.

Phenol – Indications: dyschromia, wrinkles, premalignant lesions, acne scars. Pretreatment: darker skin types
should be treated with HQ 4 weeks prior to tx. In light/thick skin pt’s topical retin-a used daily for 3-6 weeks prior
to procedure may create better and more even penetration of peeling solution in sebaceous and hyperkeratotic skin.
Performed under full cardiopulmonary monitoring with IV hydration and sedation. Complications: cardiac
arrhythmias, hypopigmentation, scarring.

Pre-Treatment is a critical component in the peeling process.

In Fitz 1-3: 7-14 days of glycolic wash, retinol, hydration, sun protection. Type 3 –best to pre-treat with
HQ s well.
In Fitz 4-6: 3-4 weeks glycolic wash, hydroquinone use, d/c retinoid 1-2 weeks prior, hydration, sun
protection.

There are ways to manipulate products and application to allow yourself a more aggressive peel and stay within the
boundaries of your licensure. Here are some ways to enhance in-clinic treatments

Client Cleanser Mask (if any) Degreaser Applicator Pressure

1st time client Emollient/cream Enzyme Astringent Cotton Soft
cleanser
Novice Detergent AHA such as Alcohol 2x2 or Medium
(salicylic) or Image Total Glycolic
Image Total Resurfacing Applicator
Facial Cleanser mask
Advanced Detergent (same Salicylic such as AHA/BHA 5% Rough gauze Hard with
as above) Image or greater pressure (or even
Medicated Acne scrubbing in
Mask areas with less
frosting)

One option:
Cleanser => degrease => resurfacing solution (ex: glycolic or lactic) => Total Resurfacing Mask => resurfacing
solution (what you want to drive in deep for conditions of interest) => Vital C Enzyme Mask => remove all =>
Serum (Image MAX Ageless – has lower pH than Total Antiaging Serum w/o AHA’s – MAX corrects DNA
damage, tightens skin and increases cell life) => Oil Free Sunscreen (sunscreens with oils can trap in heat from acid
such as Jessners and can be too occlusive.

Post-Treatment Care: The initial 72 hours is the most critical. Clients should adhere to the following:
1. Avoid direct sun and heat. This includes day to day activities such as gardening, cooking over a hot stove
or oven for a long period of time, sitting next to fireplace, etc (Heat causes PIH and delayed blistering of
tx’s skin)
 2. Discontinue use of any AHA products. May continue regular skin care regimen after 72 hours or when
their skin is no longer peeling and flaking.
3. Use hydrating and reparative products. Products rich in soothing and healing ingredients are best and
encourage healthy new cell growth. Antioxidants, Vitamins A, C and E and growth factors work very well.
4. Use sunscreen. Suncare products should be applied no less than 30 to 90 minutes. Sunscreen must be worn
at all times, including indoors.
5. No scratching or peeling, limit exercise the first week (exercise can cause delayed blistering due to
increased body heat), drink plenty of water and have realistic expectations of the healing process.
Suggestions:
Image Post-Treatment Kit contains all Vital C products which have no AHA/BHA’s. Use until peeling is
completed.
Vital C Enzyme Mask – helps breakdown and digest peeling skin. Begin use when peeling begins. Speeds peeling
process and hydrates, can be worn overnight. Do not use with steam (breaks enzymes down).

Typical post-treatment care duration:

Glycolic peel – 3-4 days of post care
TCA peel – 4-7 days of post care
Combo peels/Dual modalities – 4-7 days of post care.

Orange TCA peel:

(12% TCA, 2% salicylic and 0.4% Retinol)
Cleanse => Prep => apply 3 layers (read skin) => apply on dry skin => use fan => apply in sweeping motion with
even pressure => apply retinol to seal and do not remove for at least 5 hours or sleep in overnight => post care.

Managing client relationship:

While client is changing or getting ready, set aside appropriate products from retail area and write up home
prescription for the client.
1. make sure client has realistic expectations – ex: sun damage took a long time to get there, will take a long
time to improve it.
2. Understand current products that you client is using and add products as necessary, recommending products
as the client runs out.
3. Make sure client understands that you are not able to maximize treatment results if the client insists on
using their own homecare products.
4. Review homecare directions and give client a copy
5. Never tell the client to throw away products they have at home or discontinue use of them. Instead, ask if
they are seeing results with their current products.
6. Encourage and book next appointment or series as you leave the client nd make sure to thank them for our
business.
7. Build rapport with clients by following up within 1-2 days post-treatment and answer any questions they
may have regarding home care.