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neutralisation is performed at this site. It is recommended to begin with a low concentration of the acid (20–30%), and to increase its concentration and application time during the subsequent sessions. The treatment schedule includes a monthly peeling session with topical glycolic acid, and home-care products range from 8–15% concentrations.

Salicylic acid peels Salicylic acid is a beta-hydroxyl acid. It is well known in dermatology owing to its keratolytic properties. Its exfoliative activity on the epidermis is almost devoid of associated inflammation; therefore, this agent can be safely used on skin types that are prone to develop post- inflammatory hyperpigmentation (PIH)6

. Salicylic acid

peels are preferred by some practitioners over other superficial peels in cases of acne and PIH7

. The formulations of salicylic acid used for the peeling

are 20% or 30% in ethanol, or 50% in ointment. The treatment regimen includes six peels 2–4 weeks

Superficial peels Superficial peels are used to refresh the skin, to improve its texture and tone, and to assist in treating active acne and superficial dyschromia4

. Serial procedures are

usually required to achieve these goals and a combination with home-care products is recommended. Owing to their superficial action, these peels are usually appropriate for all skin phototypes5

. A single treatment with a superficial agent may induce

gentle and visible skin exfoliation, but this will not occur in every patient and is not a necessary phase for the achievement of the full beneficial effect of the peel. However, some patients feel disappointed after a peeling procedure with no peel. Light chemical peel solutions include 70% glycolic

acid, Jessner’s solution (resorcinol, lactic acid, and salicylic acid in ethanol), trichloroacetic acid (TCA) 10–15%, salicylic acid 20–30%, and combination peels. The ideal candidate for a superficial peel is someone with mild skin damage and dyschromia, who is seeking minimal recovery time and is willing to go through a serial treatment regimen to achieve the desired results. Superficial peels do not affect wrinkles or deep pigmentations.

Figure 2 A patient (A) before and (B) 2 months after one medium depth peel treatment

apart. After cleansing and defatting of the skin, the solution is applied using a cotton-tipped applicator or gauze sponge. The patient will usually experience a burning sensation. A white precipitate of the salicylic acid appears after 1 minute and this should not be confused with a real frosting (Figure 1). The solution can be washed or left on the face for longer periods. Salicylism or salicylic acid intoxication is a rare

complication of salicylic acid applied to large areas of the body, and is not related to the peeling of small areas, such as the facial skin8

. A single treatment with a superficial agent may induce

gentle skin exfoliation, but this will not occur in every patient and is not a necessary phase

for the achievement of the full effect of the peel.

Alpha-hydroxy acid peels Glycolic acid has the smallest molecular weight of all alpha-hydroxy acids (AHAs), penetrates the skin easily, and is therefore the most common AHA used. Glycolic acid peels are commercially available as free acids, partially neutralised (higher pH), buffered or esterified solutions. The application of the solution is performed after defatting of the skin using q-tips, gauze pads or brash. The skin is covered with a thin layer of the product, and neutralisation is performed once the skin achieves uniform erythema. If frosting is observed in any particular area before full-face erythema appears, then immediate

46 ❚ November/December 2012 |

Combination superficial peels Combination peels aim to achieve a synergistic interaction of their components, with regard to either efficacy or safety. Despite the scarcity of evidence to support their superiority, combination peels are considered to be a current trend in chemical peeling.

Medium depth peels The main clinical indications for medium depth peels include dyschromia (mainly solar lentigines), multiple solar keratosis, and textural changes of the skin. Wrinkles and acne scars can be improved only slightly, and deeper treatment modalities are usually required to provide a more significant improvement in these cases.

Trichloroacetic peels TCA can be used in different concentrations. A 10–20% TCA peel is used for superficial peels, while 35% is used as a medium depth peel. Concentrations higher than 35% are not recommended as the results are less predictable and the potential for scarring is higher. In order to increase the depth and efficacy of the TCA peel, without increasing the concentration of the acid, it has been suggested to combine this chemical with Jessner’s solution (Monheit method)9

, 70% glycolic acid (Coleman method), or solid CO2 (Brody method).

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