I attended a number of interesting courses during this year’s American Academy of Dermatology (AAD) Annual Meeting. I registered for a 2-day self-assessment course in dermatopathology (I admit to being a dermpath geek) and think this may be the best course for sheer knowledge I’ve ever taken. As I snuck from room to room to attend other informative lectures, one of my favorites was by Dr. Gary Monheit, who will be President of the American Society for Dermatologic Surgery (ASDS) next year (disclosure: Dr. Monheit is a friend). During his lecture, Dr. Monheit discussed chemical peels and how they remain an integral part of the cosmetic dermatology practice. Peels, it seems, are this year’s hot topic. He began his talking by asking the audience how many still use chemical peels in this age of lasers and intense pulsed light devices. The answer was remarkable — almost every hand in the room was raised. As he questioned which concentrations of peels we used, fewer hands were raised as the concentration of the peels increased. By the time he got to phenol peels, there were only a couple of attendees admitting to performing them. Dr. Monheit’s review of peels was quite informative, and I thought I would try to share some of it here. Peels act by different mechanisms to remove skin at different layers with different outcomes, risks and downtimes. The main peels utilized by dermatologists remain trichloracetic acid and glycolic, with a few others that occupy niches. Popular Peels Trichloracetic acid (TCA) peels work by coagulating protein. Typical strengths used vary from 15% up to 50% (although when treating acne scars, higher strengths were used with great success). TCA peels may or may not contain dyes to make them blue. These peels are applied to the skin after a thorough cleansing with acetone or other degreasing agent. If this step is omitted, a very uneven peel may result. TCA peels are applied with a 2x2 gauze or a large cotton swab, and care should be taken to apply even amounts to the skin. When I do these peels, I will tend to taper the strength by applying a slightly lower strength to the ears and neck in order to avoid a major transition zone that I find to be the mark of an amateur. TCA peels form a frost that is self-determined. No neutralization is required and once the frost is obtained, the peel has finished. Because the peel can be uncomfortable, we typically use ice water and fans when peeling up to 35% TCA. For higher concentrations, you might consider the use of oral diazepam (Valium) or other drugs. TCA may also be combined with other peels to provide deeper peeling. The most common of these is Jessner’s solution. This solution is applied first because it acts to open up the skin for better penetration by the TCA. This may allow lower concentrations of TCA to penetrate more deeply and evenly. When I do a TCA peel on a patient, I discuss the opportunity to peel other areas, such as the backs of the hands, to make the face and hands match. The second type of peel that is very popular among dermatologists is glycolic acid. This acid is different from TCA in a variety of ways. The most significant difference is that it is a time-dependent peel that needs to be neutralized. Unlike TCA, this product can be left on and will continue to peel. It may be applied in various strengths and is typically applied for a few minutes and then neutralized with either dilute baking soda or water. Higher concentrations may be used to peel to the mid dermal layers. At-Home Peels There is currently a large market for at-home peels. In fact, I constantly have patients asking me about the at-home peels — a force that has driven me to develop home peel systems with a staged series of peel pads. When a patient asks me about products that are available for home use, I recommend them to patients with acne-prone skin or with photodamage, as long as the skin is not sensitive or dry. I instruct patients to start with mild, low-strength acid peels at first and work up from there as needed. And, I recommend that patients use them twice a week, again as long as their skin is not very sensitive or dry. The Benefits of Peels One beneficial aspect of peels is that you can customize them for each type of patient. For instance, a patient who has significant photodamage and can have several days of downtime can be treated with a 35% TCA peel. Another patient who cannot afford to have this type of downtime may be treated with several 20% TCA peels spaced out several weeks or months apart. Peels can also be included with a variety of other procedures performed in a cosmetic dermatology office. Most of my peel patients are interested in low- impact cosmetic procedures and typically receive Botox, Captique, Restylane or other procedures so that the superficial and mid-dermal signs of aging are treated in one or two visits. Avoiding Adverse Effects Some precautions must be used when treating patients with chemical peels. The risks associated with peels increase as the strength of the peels increase. If your patient has a history of cold sores, peels may precipitate an outbreak and prophylaxis should be used. Pre-treatment with a retinoid will help to condition the skin for a peel (and also make it more sensitive to the peeling agent) and many dermatologists will utilize this regimen prior to a peel. Perhaps the most important thing to discuss with a potential peel patient is the downtime associated with a peel. For a low- strength glycolic peel, there is typically no down time. For anything upward of a 25% TCA peel, warn the patient to expect 3 to 5 days of peeling that may be unsightly. Some dermatologists will use intramuscular triamcinolone (Aristocort, Kenalog, Triacet) to shorten this window. Another strategy is to employ several low-strength (20% TCA) peels spaced out over the span of a week. One other aspect of post-peel patient care that we find helpful is to give patients a small bag prepared with products that are needed, such as mild moisturizers, mild cleansers and a business card so people can call with questions. Getting Started For dermatologists starting a cosmetic practice, I would recommend spending some time with one of the peel experts, such as Dr. Monheit or Dr. Harold Brody, as well as reading one of the excellent books on the subject. Start by peeling lightly — use 20% TCA. Make sure that your consent and post-operative care sheets are in place before you treat your first patient. Peels offer a great way to rejuvenate the epidermal and upper dermal layers. There are some great textbooks about them and the talks at the ASDS and AAD are great starting points for those of you who have not yet incorporated them into your practice.
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Back to Basics: Peeling
I attended a number of interesting courses during this year’s American Academy of Dermatology (AAD) Annual Meeting. I registered for a 2-day self-assessment course in dermatopathology (I admit to being a dermpath geek) and think this may be the best course for sheer knowledge I’ve ever taken. As I snuck from room to room to attend other informative lectures, one of my favorites was by Dr. Gary Monheit, who will be President of the American Society for Dermatologic Surgery (ASDS) next year (disclosure: Dr. Monheit is a friend). During his lecture, Dr. Monheit discussed chemical peels and how they remain an integral part of the cosmetic dermatology practice. Peels, it seems, are this year’s hot topic. He began his talking by asking the audience how many still use chemical peels in this age of lasers and intense pulsed light devices. The answer was remarkable — almost every hand in the room was raised. As he questioned which concentrations of peels we used, fewer hands were raised as the concentration of the peels increased. By the time he got to phenol peels, there were only a couple of attendees admitting to performing them. Dr. Monheit’s review of peels was quite informative, and I thought I would try to share some of it here. Peels act by different mechanisms to remove skin at different layers with different outcomes, risks and downtimes. The main peels utilized by dermatologists remain trichloracetic acid and glycolic, with a few others that occupy niches. Popular Peels Trichloracetic acid (TCA) peels work by coagulating protein. Typical strengths used vary from 15% up to 50% (although when treating acne scars, higher strengths were used with great success). TCA peels may or may not contain dyes to make them blue. These peels are applied to the skin after a thorough cleansing with acetone or other degreasing agent. If this step is omitted, a very uneven peel may result. TCA peels are applied with a 2x2 gauze or a large cotton swab, and care should be taken to apply even amounts to the skin. When I do these peels, I will tend to taper the strength by applying a slightly lower strength to the ears and neck in order to avoid a major transition zone that I find to be the mark of an amateur. TCA peels form a frost that is self-determined. No neutralization is required and once the frost is obtained, the peel has finished. Because the peel can be uncomfortable, we typically use ice water and fans when peeling up to 35% TCA. For higher concentrations, you might consider the use of oral diazepam (Valium) or other drugs. TCA may also be combined with other peels to provide deeper peeling. The most common of these is Jessner’s solution. This solution is applied first because it acts to open up the skin for better penetration by the TCA. This may allow lower concentrations of TCA to penetrate more deeply and evenly. When I do a TCA peel on a patient, I discuss the opportunity to peel other areas, such as the backs of the hands, to make the face and hands match. The second type of peel that is very popular among dermatologists is glycolic acid. This acid is different from TCA in a variety of ways. The most significant difference is that it is a time-dependent peel that needs to be neutralized. Unlike TCA, this product can be left on and will continue to peel. It may be applied in various strengths and is typically applied for a few minutes and then neutralized with either dilute baking soda or water. Higher concentrations may be used to peel to the mid dermal layers. At-Home Peels There is currently a large market for at-home peels. In fact, I constantly have patients asking me about the at-home peels — a force that has driven me to develop home peel systems with a staged series of peel pads. When a patient asks me about products that are available for home use, I recommend them to patients with acne-prone skin or with photodamage, as long as the skin is not sensitive or dry. I instruct patients to start with mild, low-strength acid peels at first and work up from there as needed. And, I recommend that patients use them twice a week, again as long as their skin is not very sensitive or dry. The Benefits of Peels One beneficial aspect of peels is that you can customize them for each type of patient. For instance, a patient who has significant photodamage and can have several days of downtime can be treated with a 35% TCA peel. Another patient who cannot afford to have this type of downtime may be treated with several 20% TCA peels spaced out several weeks or months apart. Peels can also be included with a variety of other procedures performed in a cosmetic dermatology office. Most of my peel patients are interested in low- impact cosmetic procedures and typically receive Botox, Captique, Restylane or other procedures so that the superficial and mid-dermal signs of aging are treated in one or two visits. Avoiding Adverse Effects Some precautions must be used when treating patients with chemical peels. The risks associated with peels increase as the strength of the peels increase. If your patient has a history of cold sores, peels may precipitate an outbreak and prophylaxis should be used. Pre-treatment with a retinoid will help to condition the skin for a peel (and also make it more sensitive to the peeling agent) and many dermatologists will utilize this regimen prior to a peel. Perhaps the most important thing to discuss with a potential peel patient is the downtime associated with a peel. For a low- strength glycolic peel, there is typically no down time. For anything upward of a 25% TCA peel, warn the patient to expect 3 to 5 days of peeling that may be unsightly. Some dermatologists will use intramuscular triamcinolone (Aristocort, Kenalog, Triacet) to shorten this window. Another strategy is to employ several low-strength (20% TCA) peels spaced out over the span of a week. One other aspect of post-peel patient care that we find helpful is to give patients a small bag prepared with products that are needed, such as mild moisturizers, mild cleansers and a business card so people can call with questions. Getting Started For dermatologists starting a cosmetic practice, I would recommend spending some time with one of the peel experts, such as Dr. Monheit or Dr. Harold Brody, as well as reading one of the excellent books on the subject. Start by peeling lightly — use 20% TCA. Make sure that your consent and post-operative care sheets are in place before you treat your first patient. Peels offer a great way to rejuvenate the epidermal and upper dermal layers. There are some great textbooks about them and the talks at the ASDS and AAD are great starting points for those of you who have not yet incorporated them into your practice.
I attended a number of interesting courses during this year’s American Academy of Dermatology (AAD) Annual Meeting. I registered for a 2-day self-assessment course in dermatopathology (I admit to being a dermpath geek) and think this may be the best course for sheer knowledge I’ve ever taken. As I snuck from room to room to attend other informative lectures, one of my favorites was by Dr. Gary Monheit, who will be President of the American Society for Dermatologic Surgery (ASDS) next year (disclosure: Dr. Monheit is a friend). During his lecture, Dr. Monheit discussed chemical peels and how they remain an integral part of the cosmetic dermatology practice. Peels, it seems, are this year’s hot topic. He began his talking by asking the audience how many still use chemical peels in this age of lasers and intense pulsed light devices. The answer was remarkable — almost every hand in the room was raised. As he questioned which concentrations of peels we used, fewer hands were raised as the concentration of the peels increased. By the time he got to phenol peels, there were only a couple of attendees admitting to performing them. Dr. Monheit’s review of peels was quite informative, and I thought I would try to share some of it here. Peels act by different mechanisms to remove skin at different layers with different outcomes, risks and downtimes. The main peels utilized by dermatologists remain trichloracetic acid and glycolic, with a few others that occupy niches. Popular Peels Trichloracetic acid (TCA) peels work by coagulating protein. Typical strengths used vary from 15% up to 50% (although when treating acne scars, higher strengths were used with great success). TCA peels may or may not contain dyes to make them blue. These peels are applied to the skin after a thorough cleansing with acetone or other degreasing agent. If this step is omitted, a very uneven peel may result. TCA peels are applied with a 2x2 gauze or a large cotton swab, and care should be taken to apply even amounts to the skin. When I do these peels, I will tend to taper the strength by applying a slightly lower strength to the ears and neck in order to avoid a major transition zone that I find to be the mark of an amateur. TCA peels form a frost that is self-determined. No neutralization is required and once the frost is obtained, the peel has finished. Because the peel can be uncomfortable, we typically use ice water and fans when peeling up to 35% TCA. For higher concentrations, you might consider the use of oral diazepam (Valium) or other drugs. TCA may also be combined with other peels to provide deeper peeling. The most common of these is Jessner’s solution. This solution is applied first because it acts to open up the skin for better penetration by the TCA. This may allow lower concentrations of TCA to penetrate more deeply and evenly. When I do a TCA peel on a patient, I discuss the opportunity to peel other areas, such as the backs of the hands, to make the face and hands match. The second type of peel that is very popular among dermatologists is glycolic acid. This acid is different from TCA in a variety of ways. The most significant difference is that it is a time-dependent peel that needs to be neutralized. Unlike TCA, this product can be left on and will continue to peel. It may be applied in various strengths and is typically applied for a few minutes and then neutralized with either dilute baking soda or water. Higher concentrations may be used to peel to the mid dermal layers. At-Home Peels There is currently a large market for at-home peels. In fact, I constantly have patients asking me about the at-home peels — a force that has driven me to develop home peel systems with a staged series of peel pads. When a patient asks me about products that are available for home use, I recommend them to patients with acne-prone skin or with photodamage, as long as the skin is not sensitive or dry. I instruct patients to start with mild, low-strength acid peels at first and work up from there as needed. And, I recommend that patients use them twice a week, again as long as their skin is not very sensitive or dry. The Benefits of Peels One beneficial aspect of peels is that you can customize them for each type of patient. For instance, a patient who has significant photodamage and can have several days of downtime can be treated with a 35% TCA peel. Another patient who cannot afford to have this type of downtime may be treated with several 20% TCA peels spaced out several weeks or months apart. Peels can also be included with a variety of other procedures performed in a cosmetic dermatology office. Most of my peel patients are interested in low- impact cosmetic procedures and typically receive Botox, Captique, Restylane or other procedures so that the superficial and mid-dermal signs of aging are treated in one or two visits. Avoiding Adverse Effects Some precautions must be used when treating patients with chemical peels. The risks associated with peels increase as the strength of the peels increase. If your patient has a history of cold sores, peels may precipitate an outbreak and prophylaxis should be used. Pre-treatment with a retinoid will help to condition the skin for a peel (and also make it more sensitive to the peeling agent) and many dermatologists will utilize this regimen prior to a peel. Perhaps the most important thing to discuss with a potential peel patient is the downtime associated with a peel. For a low- strength glycolic peel, there is typically no down time. For anything upward of a 25% TCA peel, warn the patient to expect 3 to 5 days of peeling that may be unsightly. Some dermatologists will use intramuscular triamcinolone (Aristocort, Kenalog, Triacet) to shorten this window. Another strategy is to employ several low-strength (20% TCA) peels spaced out over the span of a week. One other aspect of post-peel patient care that we find helpful is to give patients a small bag prepared with products that are needed, such as mild moisturizers, mild cleansers and a business card so people can call with questions. Getting Started For dermatologists starting a cosmetic practice, I would recommend spending some time with one of the peel experts, such as Dr. Monheit or Dr. Harold Brody, as well as reading one of the excellent books on the subject. Start by peeling lightly — use 20% TCA. Make sure that your consent and post-operative care sheets are in place before you treat your first patient. Peels offer a great way to rejuvenate the epidermal and upper dermal layers. There are some great textbooks about them and the talks at the ASDS and AAD are great starting points for those of you who have not yet incorporated them into your practice.
