SkinCareScience. Advanced Chemical Peels Trichloroacetic Acid & Jessner Light

SkinCareScience Advanced Chemical Peels Trichloroacetic Acid & Jessner Light!1

Trichloroacetic (TCA) Acid Peels Percentage of peel and the number of coats is the key to success! Information related to TCA chemical peels is filled with an abundance of good information as well as a vast array of misinformation. In fact, the internet, although amazing and detailed, is the main culprit since it allows for anybody (experienced and non experienced) to post or populate a searchable website with advice or education that may not be entirely true or worse yet may fall short in giving the whole story. If your new to chemical peels, then the TCA Peel is one you have most certainly heard horror stories about and probably are not at all interested in ever performing. Or maybe, your a very experienced skin care professional but have only required glycolic or salicylic acid to meet the needs of your clients. The use of TCA peels being something you would like to offer one day but like new skin care professionals, you are also nervous about what you have heard. The pictures and stories that populate the web and continued education facilities often tell a very scary story but once you understand the basics (behind what is actually happening to the skin when TCA is applied), the results that are shown and described by these pictures and stories begin to sound a lot like user carelessness and inexperience rather then an out of control chemical acid. The diagram and peel depth descriptions below will illustrate and explain what is happening and how you can have a better understanding of the TCA peel. Penetration Depth Depth of Peel Stratum Disjunctum ( Upper 3-5 layers) Stratum Compactum (Lower 3 layers) Stratum Granulosum Two of the most important aspects of trichloroacetic (TCA) acid 1st coat of 10% might only penetrate to this point. 2nd coat of 10% might increase to this point Stratum Spinosum 3rd coat of 10% might increase to this point and is equal to one coat of 30% concentration Stratum Germinatum Stratum Basale (basal cells) Epidermis and Dermis connecting zone Papillary Dermis Upper Reticular Dermis Reticular Dermis Deeper Reticular Dermis 4th coat of 10% might increase to this point and is now equal to one coat of a 40% concentration. Serious complications can happen at this depth and applying more coats can only increase penetrtation and potential for post peel complications. Up to the Reticular Dermis is the maximum level that should be used with a TCA peel and in most if not all cases should be handled only by a licenced physician or under its guidance. It is now hopefully very clear just how easy a TCA peel can be to apply and also abuse. Critical points to remember: Hypodermis ( Subcutaneous) Skin type and condition Desired client results Percentage of TCA Pre-determined coats Knowledge of frosting Knowledge of Pink Sign 1. Trichloroacetic acid is neutralized by the coagulation of proteins. Better said, when trichloroacetic comes into contact with a cellular protein its chemical composition changes and it stops being an acid, thus its penetration and acidic action on the skin stops. Even simpler said, when there is no more trichloroacetic because its total volume (percentage) has been neutralized by same volume of available skin cell proteins, it stops penetrating. 2. Trichloroacetic is coat dependent and not time dependent. This point cannot be stressed enough as this is critical for proper results. As trichloroacetic acid is applied to the skin its percentage will dictate how much protein it will coagulate (destroy). Obviously 10% TCA vs 30% TCA would travel deeper since it contains a higher volume of trichloroacetic thus has more trichloroacetic to destroy more proteins deeper within the skin. Trichloroacetic works basically on a percentage of acid volume to the percentage volume of proteins. The higher the % volume, the deeper it goes. With trichloroacetic acid being a coat dependent acid, this means that 10% volume can be made equal to a 20% solution with an additional coat applied. With that said, can you imagine what would happen if an inexperienced user applied 2 coats of 30% Trichloroacetic or 3 coats at 20%? Now that you know that trichloroacetic is coat dependent, would you ever use a single coat of 60% Trichloroacetic on a person s skin? I would think not. Within the medical field, it has been documented and clinically proven that the use of trichloroacetic at over 35% (with multiple coats) should not be used and results in post peel complications with undesirable consequences. Within the Serene Professional Skin Care line, 30% is the highest percentage offered with the lowest at 5%. The reason such a low amount is offered with incremental increases of 5% up to 30% is because of the importance of offering the professional the ability to have as much control over the peel as possible. Through this approach, post peel complications are reduced and a higher level of consistent results is achieved. For complete details and continued education see the Serene Professional Manual section: Trichloroacetic Acid (TCA) Peel Protocol 1!1

Trichloroacetic Acid (TCA) Neither Homogeneous or Stable Homogeneous: A solution is said to be homogeneous when the different elements of which it is made up are evenly distributed in the container that holds it. Stability is often one of the biggest concerns regarding skin care. Whether the question is how long will it last after it is manufactured or can it withstand direct sunlight, a products stability is always a concern. We feel product education along with proper buying patterns are more important tools to employ as deterrents to product loss. But none the less, we must always consider every possible solution to protect the quality of our investments. One very important category a skin care professional must look at with regards to this issue is the stability and health of professional exfoliating peels. Most if not all have a shelf life of 18 to 24 months (i.e. glycolic acid), with others needing special attention to sunlight and heat (i.e. jessner). To always be on the safe side and offer your peels the best care, we recommend the following: 1. Keep lids tightly closed 2. Keep in a cool climate 3. Avoid direct sunlight One professional peel that offers a slight modification to these rules is Trichloroacetic Acid (TCA). It is neither homogeneous nor is it stable. The idea that TCA will change over time to a darker color or lose its strength is not our definition of stability. Our topic is how if left motionless, TCA will not remain uniform in its aqueous solution and become more concentrated or dilute in different parts of its container, thus becoming unstable. See diagram below: Fig 1 Fig 2 Fig 3 30% 30% 30% 28% 25% 37% 40% 30% 20% TIME The above illustrations give an example of what can happen when TCA remains motionless between treatments. The TCA molecule is very mobile in an aqueous solution and will move about in a random fashion. This movement, over time, is what causes the solution to have different sections of either higher or lower concentrations. For example, when this might be a problem is when a dropper is used and you think your getting 20% (figure 3) but in fact your actually getting 40% or another possibility is when your method of disbursement is to poor and you get 30%. It is recommended to occasionally give your TCA peels a smooth back and forth motion during the slow seasons or even after long weekends. This practice will insure the highest level of homogeneous. The inhomogeneity of a TCA solution, at least partially, can explain certain complications and horror stories that are associated with this type of professional peel. A key point to remember is to start slow and start low. Higher percentages with a reduced number of peel sessions vs a lower strength peel with an increased number of sessions increases your chances for post peel complications. Slow and steady wins the post peel complication race. 2!2

Trichloroacetic Acid (TCA) Peel Protocol CAUTION: We highly discourage the use of a TCA peel on walk-in clients, it is important to discuss complications and offer a lower level peel such as a 35% 2.5 ph glycolic acid peel. TCA peels are for experienced, and well trained skin care professionals and medical practitioners. Please read completely before performing any TCA peel. Important Points Regarding TCA Peels I. There are Hot Spots where a TCA peel can penetrate deeper for no apparent reason. Start slow with lower strengths and as your experience grows increase to higher percentages. As you decrease the TCA concentration and number of coats these hot spots become less of a problem. Understanding your client s skin as well as how peel strengths react is very important to your success when using TCA acid. II. TCA peels are coat dependent unlike AHA peels which are time dependent. An example would be two coats of 10% TCA can potentially add up to one coat of 20%. This is not an exact science but something to always consider when applying multiple coats of TCA peeling agent. Using lower percentages of TCA actually works in your favor since each coat increases the depth of the peel which gives you time to watch the peels action. With that said, it is important to remember that slow and cautious wins the peel race and watching the development of the white frost as well as the time it takes for it to disappear is critical. Using lower peel strengths and multiple coats allows you this time. Glogau s Classification of Photoaging Type Visible Indications No Wrinkles Age I Early photoaging: - mild pigmentary changes - no keratoses - minimal wrinkles Minimal or no make-up 20-30 s II Wrinkles in Motion Early to moderate photoaging: - slight lines near eyes and mouth - keratoses palpable but not visible - parallel smile lines beginning to appear lateral to mouth Usually wears some foundation 30-40 s III. One of the most important client characteristics to watch for is what are known as pickers. With a TCA peel you will see actual peeling of the skin and this is what the picker cannot stay away from. Be very mindful of this personality type since you will be blamed for the results that are ruined by your clients obsessive compulsive behavior. IV. Inform clients with deep furrows that they will not improve with a TCA peel. You may apply peeling agent to these areas but dramatic reductions will not be seen. 3!3

Desirable Skin Types The following skin types will receive the best results with the least amount of post peel complications: Fitzpatrick Scale I, II and III. As an additional tool, you may refer above to the Glogaus classification which will give a good basic foundation for the skin types that perform well with TCA peels. Performing the correct peel at the correct percentage on the correct skin type is the single biggest factors in your success with TCA chemical peels. Care should always be taken when choosing your clients. Un-desirable Skin Types Fitzpatrick scale IV, V, VI need special care and attention due to the fact that they are more prone to developing postinflammatory hyperpigmentation. For descriptions of all Fitzpatrick classification scales, see section within this manual: Fitzpatrick Scale - Product Use Protocols - Class Room Study Put on protective gloves before starting any skin care procedure (latex or latex free). Pre Peel Facial Cleanse Using Serene AHA 3 Facial Cleanser (sensitive skin types use Serene Facial Cleanser Sensitive Skin, gently massage cleanser using moistened 2 round cotton pads starting with the décolleté, working up towards the forehead. Every pre-peel cleanse will start with either Serene AHA 3 Facial Cleanser or Facial Cleanser Sensitive Skin. It is best practice to inform your client to arrive on the day of the peel without makeup. Heavy makeup or oily skin may need an extra cleansing. What is important to remember at this step is aggressive cleansing with extra force or pressure is not necessary. Gently clean the surface of the skin as you would that of a babies. Gentle and thorough wins the post peel complication race. With water saturated 4x4 cotton gauze, thoroughly remove cleanser. Pre Peel Preparation Bio Film Facial Cleanser Specifically designed (without glycolic acid) to cleanse the skin of surface contaminants and oily residues, this cleansing process will insure the skin s surface is best prepared for the application of a professional peeling agent. Apply a liberal amount to dry 4 cotton gauze, start on the décolleté and work upwards towards the forehead, finish at the temple. For more sensitive skin types use less product and dilute with water (50/50). Gently wipe peel area and alloy to air dry. Lip and Eye Care Cleanse the eyes using Serene s Facial Cleanser Sensitive Skin. For most peel procedures and skin types, it is best to not cleanse the eye area with products that contain glycolic acid. Cleanse eyes, one at a time, wipe with light pressure and then under the eye from tear duct to corner of eye. Apply a small amount of Serene s Lip and Eye Care (Petroleum Jelly) to the sensitive under eye area and lips. Cleanse lips using same procedure as described for eye area, use three gentle strokes from left to right. Any lipstick or other make-up should be completely removed. Finish with a small amount of Serene s Lip and Eye Care (Petroleum Jelly). Special Note: The areas near the corners of the nose can be classified as sensitive or transitional skin. Care should be taken when applying a chemical peel agent near this area and Serene Lip and Eye Care (Petroleum Jelly) can be used to help protect from peel irritation. 4!4

Additional Considerations Before Any Professional Treatment - Client expectations Determine your client s skincare concerns and desired outcome. Consider your client s skin type, past peel treatments, whether this is a first time treatment, and the frequency of treatments to come; these factors will help you choose the appropriate percentage and comfort level. As with all higher strength peels, TCA peels are more advanced then glycolic acid peels and not only is the experience of the professional very important but also that of the client. Professional peeling is a partnership and strong communication and commitment is critical to achieve the highest level of results. It is our recommendation that TCA peels not be a client s first peel, please start with a lower level glycolic acid peel such as 35% 2.5 ph and work your way up from there. Special Note: Higher percentage peels are not the best approach when treating a client for the first time. Not all clients tell the whole story with regards to their peel history. Approach all your clients with a slow and steady wins the skin care race and plan an increasing level of chemical peels with lower to higher percentages/ph, as you progress toward your clients skin care success. Even if your client talks about higher strengths, you do not know the whole truth, use caution. Best practice with new clients is to prepare the skin s surface with a proper at home pre peel regimen for a minimum of two to three weeks. This period is critical to prepare the surface of the skin by reducing the thickness of the stratum corneum which will allow for a more even and successful peel. If this period does not occur and it can limit the success and outcome of the chemical peel procedure. Make sure your client is informed before chemical peel procedure if this period of time is not allocated. Special Note: Never apply a chemical peeling agent without the proper documentation, check list and insurance. Your license depends on it. Application of Serene Professional TCA Peel Three to four weeks prior to TCA chemical peel, client should do the following (will insure even penetration of TCA peel and reduce the potential of post peel complications): Stop use of all exfoliating sponges or buff pads All forms of hair removal should be discontinued Do not use Retin-A (Tretinoin) ten days prior to peel Application of Serene AHA 10 Pre Peel Cream should be applied once nightly to area being chemically peeled For men, shaving should be discontinued 48 hours prior to day of peel Contraindications As with all types of chemical peels, a proper pre peel examination and questionnaire is a must. The following contraindications should be looked for on the day of the peel: Sun burn, skin irritation including dermatitis and/or eczema on or close to the face Waxing or laser treatments within last two weeks (facial and neck area) Open skin or visible herpes simplex or bacterial infection The following should have been noted during initial pre peel consultation: Client should have discontinued the use of Accutane (Isotretinoin) for at least 6-12 months - Accutane inhibits wound healing and can induce abnormal scarring Recent history of cancer treatment to region above chest* Pregnant or breast feeding* Diabetes* Autoimmune Diseases History of sun allergies History of herpes simplex or bacterial infections (pre treatment with oral anti-viral agent may be necessary) 5!5

History of hypertrophic scar formation Surgery within last 8 weeks to area being peeled* * (Consult with physician prior to peel with written consent) Application of Peeling Agent *** NEVER LEAVE YOUR CLIENT DURING A CHEMICAL PEEL PROCEDURE. *** 5 ph 15% Stratum Disjunctum 7 ph 30% Stratum Compactum Stratum Granulosum Stratum Spinosum 70% Stratum Germinatum - Stratum Basale (basal cells) Epidermis/Dermis Connecting Zone Papillary Dermis Upper Reticular Dermis Stratum Corneum Epidermis Put on protective gloves. See previous section Pre Peel Facial Cleanse. Reticular Dermis Deeper Reticular Dermis Dermis Cleanse skin with Serene Bio Film Cleanser using a 2 x 2 gauze. Prep should not take longer then 2-3 minutes and careful attention should be noted on how hard you press as you clean. A firm pressure can increase the depth of peel and needs to be considered when the intention is to apply multiple coats of peeling agent. Pay close attention to how you prep the skin and apply peeling agent: are you wiping in one direction with a firm and uniform pressure or using bidirectional strokes with more aggressive pressure. The skin type and condition along with your experience will be used to determine how this part of the peel procedure will be performed. Apply Serene Lip and Eye Care (Petroleum Jelly) to sensitive areas as you would during a glycolic acid peel. When ready to apply TCA peeling agent, remind client to keep eyes closed and relax. At the beginning of the peel the fan should not be blowing directly at client s face. This could cause the liquid to run and is not desired. Once the peel has been applied, the fan should be placed so the flow of air is over their face for Fig. 1 Layers of the Skin Pink Sign - Exactly what is it? The pink hue or pink sign as it is called is created by the action of the blood vessels within the layers of the skin as the chemical peeling agent enters and traverses through the skin s different layers. Looking at fig. 1 we can see two important layers of the skin: The papillary dermis and the reticular dermis (see arrows). As the chemical peeling agent penetrates the skin it reaches the papillary dermis and opens the blood vessels and blood will flow more then normal. This is an indicator as to how deep you have penetrated. For darker skin types you will need to look at a secondary indicator called Epidermal Sliding to gauge the depth of the peel (see Pict. 1). Continued application of additional coats will result in a closure of blood vessels and will indicate that you have completely entered the papillary dermis and reached the upper reticular dermis, but not penetrated. The disappearance of the pink sign is your key to determining the depth of the peel. What you would also notice at this point if this depth is reached ( pink sign disappearance) is that your light frost has turned into a solid white coating covering the skin of your client. Although recommended for only very experienced professionals, additional coats will penetrate the upper reticular dermis and the white coat will start to take on a grey hue. This is the maximum recommended depth for TCA chemical peel. See Fig 2 for further details. comfort. This air flow will insure a cooling effect for the burn that a chemical peel can induce. Best practice at beginning of peel is to find the best air flow so that the vapor fumes from the TCA peeling agent are blown away but not too much air flow to disrupt client comfort. This procedure helps to crystalize the TCA peeling agent that is still sitting on the surface of the skin and as a result stops the residual burn. CAUTION: In most cases brush application will result in a deeper peel then using a 2 x 2 gauze do to the amount of peeling agent a fan brush is able to soak up. It is recommended that first year students use 2 x2 to apply TCA peels and later progress to a fan brush if that is the desired method of application. We do not recommend fan brush application for TCA peels due to the increased potential of increased amount of peeling agent being applied. Fat Hypodermis (Subcutaneous) 6!6

In glass dish pour approximately 3 ml (2 cc) of Serene professional TCA peeling agent. That is enough to cover one coat when using 2 x 2 medical gauze. Dip the gauze and saturate, do not soak, and follow the same application technique as you would using a fan brush starting with forehead. REMINDER: Pay close attention to the pressure you use when applying the TCA peeling agent. Use firm pressure, with even force and do not use light soft strokes. Light pressure promotes streaking so be mindful of using an even touch and pressure for proper peel application. Special areas such as under the eye can be done with a Q-Tip. Pay close attention to how close you come to the eye (give at least 1/8 of an inch) and be mindful of how thin this under eye area is. When application is complete, set timer and watch for the time it takes for the development of a LIGHT white frost or blanch (frosting represents the coagulation of epidermal and dermal proteins) to appear with a slight pink hue called pink sign. The pink sign as it is called is caused by the TCA peel reaching the papillary dermis and the blood vessels are open and more blood is flowing through. (See Fig. 2) A good even coat applied properly should result in an even frost within approximately 1-2 minutes and fade within 5 (as the proteins in the epidermal layer of the skin coagulate, the white frost transitions from a light unorganized frost to a complete blanket of white). The pink sign along with an organized light white frost is exactly what you want to see within 1-2 minutes and a complete disappearance within 5 minutes. (TCA peel can be very difficult to neutralize unlike a glycolic acid peel so if the frost does not fade after 13-15 minutes the peel has penetrated deeply and scarring or other adverse affects such as delayed wound healing could present themselves). For safety always keep on hand Serene Post Peel Neutralizer in a spray bottle. It contains sodium bicarbonate and this can help neutralize the peel if it is not too late. This technique takes practice so as always, error on the side of caution and use the slow and steady wins the peel race. Choose lower levels and start slow and error on the side of caution. Once you move too quickly and a problem presents itself it could be too late to reverse and with a TCA peel it normally is. Pict. 1 Epidermal Sliding - picture taken from Procedures in Cosmetic Dermatology Tung & Rubin 2nd Edition. Elsevier Saunders publishing The white frost represents the end point of the peel and should be met with cotton compresses saturated will cool water for client comfort. At this point your client may if desired rinse with cool water splashes or you may gently continue to apply cool water for cleanup and comfort. The burning sensation subsides and becomes more comfortable depending on the depth of peel over a period of 5-10 minutes and should completely stop after 15-20 minutes. Total procedure time should last 30-40 minutes from start of procedure to client discharge. Special Note: Once peel has completely self neutralized DO NOT occlude (cover) the peel with any Serene Professional Skin Care products. This could reactivate the TCA crystals that are still remaining on the skin and could cause burning and a deeper peel. CAUTION: Any stretching or pulling of the skin during the first 3-5 days post procedure could stretch the epidermis and cause an open crack in the skin and should be avoided. The result of such action could result in scarring and or permanent pigment change. Once peeling starts, all peeling should be allowed to happen naturally. This means no picking 7!7

TCA Depth of Peel As the TCA peel penetrates the stratum cornuem and travels deeper into the epidermis and reaches the very top of the dermis; proteins coagulate (chemically altered) and produce a white frost (blanch). 5 ph 15% Stratum Disjunctum 7 ph 30% Stratum Compactum Stratum Granulosum Stratum Spinosum 70% Stratum Corneum Epidermis.1.2 Note: The layers of the skin are not a straight line so please take note that this is how you get unorganized frosting until the transitions zones between the different layers are completely saturated. This results in the organized full white face mask. Stratum Germinatum - Stratum Basale (Basal Cells) Epidermis/Dermis Connecting Zone Papillary Dermis Upper Reticular Dermis 1 2 3 Once the TCA peeling agent has reached the papillary dermis the blood vessels are open and blood is flowing. This is known as the pink sign and indicates that a papillary dermis peel has been achieved. A thin transparent white frost will also be evident. Reticular Dermis Dermis Pictured below is a normal blood vessel before a TCA chemical peel and what it looks like just before the acid reaches the papillary dermis Deeper Reticular Dermis After the TCA acid reaches the papillary dermis the blood vessels swell and more blood passes through. This is what causes the Pink Sign When the TCA peel has passed through papillary dermis and the top of the reticular dermis has been reached, the pink sign will stop. This is caused by the blood vessels closing within the papillary dermis. This depth of peel will also bring about a uniform white frost. Additional coats of TCA peeling agent will cause the white frost to take on a grey color and the reticular dermis will then have been penetrated. This level is the maximum level recommended for a TCA peel. Extreme caution and experience must be used when peeling to this level. Fat Hypodermis (Subcutaneous) With additional coats, TCA acid will penetrate deeper and will reach the top layer of the reticular dermis. Once this occurs the blood vessels will shrink back and the pink sign will disappear. Fig. 2 Peel Penetration: (.1 = No Frosting /.2 = Slight, Nonuniform Frosting) SEE ARROWS #1 Unorganized white frost with pink sign and epidermal sliding appear. #2 Pink sign and epidermal sliding disappear. #3 White frost turns light gray (deepest point for a TCA peel). The grey bars next to arrows represent the white frost from unorganized white to grey. The color bars do not represent the color one will see, they are for graphical representation only. or harsh scrubbing of the face and avoid direct water flow while showering. Post peel care is equally if not more important then pre peel care since removing pieces of skin before they are ready can cause scarring and or pigment changes. Inform your client that if a raw area is found, to cover the sensitive area with Serene Lip and Eye Care (Petroleum Jelly). This will protect the fresh new skin for proper healing. Complete sun avoidance is critical during this phase of recovery and any sun exposure must be protected with Serene UVA UVB Shield Special Note: The products and equipment you will use for each treatment should always be organized and placed in the same manner for each and every peel. Especially eye flush and other first aid items you feel are necessary. Do not keep inventory of chemical peels near treatment area. Check and double check percentage before each client application. Epidermal Sliding This technique will help you determine the depth of peel on darker skin types but on thicker skin types is not the best approach to use and the pink sign will provide a better and more accurate sign of peel depth. As you might have already guessed, dark thick skin is very difficult to peel with TCA and should be reserved for a later time until more experience has been acquired. 8!8

What causes epidermal sliding is a rather complicated subject but to make it simple please refer to Fig. 2 and look at the area between the epidermis and the dermis. You will notice an area called the Epidermis and Dermis Connecting Zone or sometimes known as the Intra-epidermal Plane. What happens when the TCA peel reaches this area is too complicated for this text but basically the anchoring points between the epidermis and the dermis become detached and this allows the epidermal cells to move freely from the cells within the dermis. Think of it like one layer sliding more freely on top of the layer below; a loose slipping action and not a complete detachment. If you look closely at the Pict. 1, you will notice near the finger how the skin has become very tight and wrinkled at the pressure point of the finger. The wrinkling affect is what is referred to as the visible sign of Epidermal Sliding. Epidermal sliding and the pink sign are inter-connected signs which relate to the depth the peel has penetrated. The basic nature of what is happening is as the pink sign appears and epidermal sliding becomes evident, the intra-epidermal plane is reached. If you apply more coats to the skin, the peel will deepen and the papillary dermis will be completely penetrated and at this point the pink sign will disappear as the blood vessels close and epidermal sliding will stop due the anchoring points between the epidermis and dermis becoming connected again. Both the pink sign and epidermal sliding are specific indications that present themselves when a depth has been reached and then disappear as you pass through it. The next indication of TCA peel depth is the color of the blanch which turns a light grey. For thinner skin types you can imagine how pink and tight a TCA peel could make ones skin and the opposite is true for thicker darker skin types (darker skin types do not show pink sign very clear). Although adverse reactions are very possible with a TCA peel, it offers many more indications then a more superficial peel such as glycolic acid as to what depth has been reached. A clear and experienced hand and eye are learned over time and is an acquired skill. With each and every TCA peel you perform, make sure you look for all the signs as the chemical peel penetrates the skin from start to finish. These learned skills are critical to performing deeper peels across the entire fitzpatrick scale. 9!9

Post Peel Care As already noted, there should not be anything applied to the face after the peel. Best Practice: No topical skin care products including makeup should be applied for at least 24 hours after peel and complete sun avoidance for 7-14 days. Once this time period has elapsed the following products should be applied as needed for the next 4-7 days: Product Name Skin Benefit Lotion Hydrating Lotion Moisturizer and anti-oxidant (Vitamin B3) Ceramide Lotion 1% Moisturizer and anti-oxidant (Vitamin B3 and Ceramide 1%) Cream Skin Soothing Cream Hydration and anti-oxidant (Vitamin K 1% and Avocado) Moisturizing Cream Moisturizer (heavy cream) and anti-oxidant (Vitamin B3) Ceramide Cream 1% Moisturizer and anti-oxidant (Vitamin B3 and Ceramide 1%) Ageless Peptide Cream Moisturizer (palmitoyloligopeptide / palmitoyl tetrapeptide-7) Apply petroleum jelly for areas that are very dry or where areas of peeling skin are noticeable. The edges of peeling skin should be covered with Serene s Lip and Eye Care (Petroleum Jelly) until they slough off on their own. Picking or pulling is strictly prohibited. Special Note: Advise your client to avoid all outdoor activities that involve the sun for the next two weeks. Makeup should not be applied for one full day following chemical procedure. The proper use of sunscreen and its benefits should be discussed at this time. Continued sun exposure will remove the benefits you are providing and the results your client is seeking. Home Care Prescription Fill out a complete home care regimen for AM and PM product usage and address any client concerns. Special Note: Always follow through with a phone call to your client at 24 hours post peel and also at 72 hours. Discuss any concerns and reiterate best peel practices. Through this process you will insure the best outcome for your clients skin. Follow-Up Explain the benefits of follow-up treatments for their particular skin concerns and the importance of continual use of home care products in conjunction with the additional products and services you offer. 10!10

Jessner Acid Peels Overview Over peeling is rare Fitzpatrick type IV to VI are contraindicated because of the risk of pigmentary changes. Risk for salicylism is not a concern. Standard skin preparation is mandatory to increase peel penetration and results Resorcinol is a phenol derivative and its power is about 1/40 of phenol. It breaks down the weak hydrogen links of Keratin and acts a proteolytic agent, even at concentrations as low as 5%. At higher concentrations, it can also precipitate skin proteins and become a protein coagulant. Allergy Skin Allergy test is essential to determine client s reaction to resorcinol. Small patch test behind ear should be completed one week prior to a Jessner peel. Best practice is to always perform test before each peel. An allergic reaction will NOT be redness or flaking but will present itself in more severe skin reactions such as blistering or itching. Fitzpatrick type IV to VI - The phenolic compound, resorcinol, may cause some depigmentation problems in skin types V and VI. Photographic documentation prior to peel is mandatory. Best practice is to start with lower concentrations or coats and and perform in stages in stead of going for it all in one deep peel. WARNING: Do not peel large areas of the body with Serene Jessner 7% Light. An example would be the entire back or face, neck and chest. Small areas at a time are best practice and a good rule of thumb is to be well hydrated before a Jessner peel. Cleansing and Degreasing Skin Use Serene Bio Film Pre Cleanser Care should be taken to not use excessive force as this can cause skin irritation and increase depth of penetration and increase post peel complications. Applying Jessner Solution The pain associated with a Jessner Strong (14%) peel is that of a 15% TCA peel. The Jessner solution should be applied in coats allowing for each coat to dry before additional coats are applied. The number of coats like a TCA peel determines peel depth. The force of application also determines penetration depth so care must be taken with the amount of pressure used. Having clear knowledge of your clients skin type and thickness is critical to a successful Jessner peel. With that said, thin skin vs thick skin should be handled with light and hard pressure respectfully. A Jessner peel takes time to perform properly and rushing will only create the possibility of post peel problems. Jessner Levels Level I (1 Coat) An even coat is applied to the area to be treated. Always use disposable applicators between coats if more then one coat is being applied. The first coat usually causes erythema (redness) and occasionally some pinpoint frosting. Some pseudofrosting can usually be seen after the ethanol has evaporated; this is caused by the ingredients of the solution, especially the salicylic acid, precipitating on the skin. Unlike genuine frosting, which is protein coagulation, pseudo-frosting can be brushed off easily. Use small fan to cool treatment area to reduce burning sensation and to rid any unpleasant fumes. If you stop at level I, only a very slight drying of the skin will be observed. If you continue to Level II the skin should be allowed to dry for 4-6 minutes between coats. 11!11

Jessner Acid Peels (cont.) Level II (2-3 Coats) The second coat will trigger a more intense burning and a cloudy white frost, as well as mild discomfort. The discomfort could last as long as a half hour. At this stage the client s skin will feel tight with increased visual dryness. The top layers of the epidermis are now dry and will appear transparent but will stay stuck to the underlying cells. Flaking occurs within 4-5 days. Some areas may turn a brownish color where the Jessner s solution has penetrated deeper then others. After three coats, the stratum corneum separates from the skin, there is no blistering or epidermal necrosis, and the dermis is not directly affected. Level III (3 - More Coats) Applying further coats deepens the affects of the peel. The erythema (redness) becomes established and the frosting tends to spread over a wider area, sometimes over the whole treatment area. Flaking is more pronounced, and the skin is brownish and peels in longer flakes. This process can last up to 10 days. Down time is common at this depth, even if there is rarely any scabbing. Post-peel Care The skin feels tight and dry, but it should not be hydrated. Do not use moisturizers. After flaking has finished, the patient can wear make-up and should use effective sun protection. Make sure there is no picking or pulling at flaking skin as this can cause damage to the underlying healing skin. Caution Pigmentation issues are a real concern with Jessner exfoliating peels. Clients with pigmentation problems before an exfoliating peel will normally have a higher risk of post peel pigmentation issues. Special care needs to be made for clients on birth control, hormone therapy or clients who find it difficult remain out of the sun and use sun protection. 12!12