SkinCareScience Advanced Chemical Peels: Trichloroacetic Acid (TCA) & Jessner Light Part I
1 Advanced Chemical Peel Manual Introduction This course is designed to give you a solid starting point, a foundation to build on, into the more advanced chemical peels and allow you the opportunity to learn and experience each in a safe and fun environment. This course is not the ending to your education and is only the starting point. Your client s genetic make up and skin is unique to t hem. It will at times challenge you with areas of concern and complications that you will not have experienced or studied. To insure you are offering the safest treatments and home protocols, you must always continue to seek a deeper understanding of potential areas of concern and the most widely excepted and safest methods to treat those potential unexpected events. As you know, you can not prepare for every single event but with continued education and stud,y along with following the Slow and steady wins the post peel complication race phylosophy, you will insure that to the best of your ability, you are providing the safest environment for your client s skin care needs. Welcome Advanced Chemical Peels Always remember we are here for you and in the future if you have a question or are looking for a specific answer, please do not hesitate to ask or inquire, as we are here to help not only during this course but throughout your career. Lets begin...
2 Advanced Chemical Peel Manual Advanced Peel Introduction The first and primary understanding of chemical peels has always been how they work and perform. The three widely accepted stages for chemical peels are - Destruction (eliminating or reducing corneocyte adhesion and / or corneocyte cells or both) Elimination (skin cell exfoliation) Regeneration (new skin cell formation) and then finally...accomplishing these with a controlled or expected amount of inflammation and discomfort. Contraindication [ what to watch for to insure client safety - before / during / after peel ] Each chemical peeling agent has some different contraindications but for the most part the list is static and can be applied to all peel types regardless of the type, percentage or ph. What is most important is to talk with your client and look for indications that might warn you of potential problems that could arise either pre peel or more importantly post peel. A great rule of thumb that you might want to employ when considering the procedure of any chemical peel - you should not peel any client who shows visible signs of facial lesions and or personal stress. A thorough client evaluation is a must when considering any client for a chemical peel. no matter the strength but a base level of common sense is always the first rule to go by. Neutralization [some peels require while others do not - coat dependent DO NOT / time dependent DO ] With advanced peels, such as TCA, Jessner and also Salicylic Acid, neutralization is less important but lower grade peels such as Glycolic or Lactic Acid, its importance should be noted. Peel neutralization is a key concept in time dependent peels which should also be noted here as sometimes using a neutralizer is needed in an emergency with some coat dependent peels as well (TCA). Coat dependent peels normally and in almost all cases do not require a neutralizing step. There is the rare case when a TCA acid is applied and its depth of penetration has reach an undesirable depth and neutralization can be used to stop its further penetration. In most cases only the most experience practitioners are able to accomplish this task so please keep it safe and follow, Slow and steady wins the post peel complication race as once a TCA has penetrated too deep, neutralization is not possible. With that said, it is important to note that the neutralization process is exothermic, which means in this case, Serene s AHA Post Peel Neutralizer when applied will react with the acid and create heat to the application area and possibly surrounding areas. This is a normal chemical reaction and happens when the sodium bicarbonate and the acid mix to form a salt which is the exact moment the peel is no longer an acid and its acidic action can no longer work on the adhesion points or corneocytes themselves in a destructive manner. Please always inform your clients of this action prior to using this product so they feel comfortable and understand what is happening to their skin. With that said, not every client will experience this sensation so not to be alarmed when it happens but be ready just in case and notify your client of its potential. Chemical peels are not all created equal and are described in one of three ways as to how they react. They are: Caustic - able to burn or corrode organic tissue by chemical action. [ i.e. trichloroacetic acid (TCA) ] Metabolic - working on the cells themselves [ i.e. AHA s, retinoic acid ]
3 Advanced Chemical Peel Manual Toxicity [ i.e. salicylic acid - phenol derivative, resorcinol ] How peels work - Lets review glycolic acid Glycolic Acid - will reduce sulphate and phosphate groups (includes desmosomes) from the surface of corneocytes which induces exfoliation. Glycolic acid at higher percentages ( > 30% ) is mainly destructive in nature and since it has a very low acidity they cannot induce coagulation of skin proteins and are not self neutralizing. Glycolic acid requires a neutralizer to stop its action. AHAs at low percentages act in a metabolic [relating to or deriving from the metabolism of a living organism.] way by interfering with specific enzymes who s role is to keep corneocytes together. The reduction of these groups of enzymes leads to a breaking away of the cells from each other. At higher percentages and lower ph [30-70%] the effect is based on its acidity and the results are more destructive. With said, we can generalize and say that lower percentages are gentler and work within the boundaries of the skin while higher percentages and a lower ph destroy everything in its path. AHA s are the most common acids used in cosmetic application Glycolic acid - Sugar Cane Lactic Acid - Sour Milk or bilberries Malic Acid - Apples Citric Acid - Citrus Fruits [lemons, oranges, limes, pineapples] Tartic Acid - Grape Extract Epidermal Effects - AHA s diminish cellular cohesion between corneocytes at the lowest levels of the stratum corneum Dermal Effects - With topical application have been proven to increase collagen production and increased skin thickness without detectable inflammation. AHA s most common side effects Mild irritation Redness Skin flaking The largest warning a client who is using an AHA should be given is increased photosensitivity or sun exposure. The stratum corneum is a large part of our protection from the sun and when AHAs are applied, this thinning of the stratum corneum increases the skin s sensitivity to the suns rays. What is critical is that although sun screen should be given to all clients using glycolic acid products, it is important to let them know that sun screen is not an excuse to go into the sun. Sun avoidance is the key and will promote healther skin and better results over time while on a skin regeneration cycle. Beta Hydroxy Acid [ Salicylic Acid - Latin willow tree ] Salicylic acid is converted by treating sodium phenolate [ this is the reason salicylic acid and phenol are closely related ] with carbon dioxide at high pressure and temperature. Acidification of this product with sulfuric acid gives salicylic acid. It can also be prepared by the hydrolysis [ the chemical breakdown of a compound due to reaction with water.. ] of Aspirin
4 Advanced Chemical Peel Manual [ acetylsalicylic acid ] or Oil of Wintergreen [ methyl salicylate ] with a strong acid or base. Two major benefits to salicylic acid: Anti-inflammatory and Anesthetic These two benefits result in a decrease in the amount of erythema [ redness ] and discomfort which is generally associated with chemical peels. Salicylic acid works as both: Keratolytic - Keratolytic therapy is treatment to remove warts and other lesions in which the epidermis produces excess skin. In this therapy, acid medicine, such as salicylic acid is put on the lesion. Keratolytic therapy thins the skin on and around the lesion. It causes the outer layer of the skin to loosen and shed. Comedolytic - Breaks up comedones and open clogged pores. WARNING: Using Salicylic acid in very large quantities or on very large areas, such as a full back peel with salicylic acid should not be done and can result in a condition known as: Salicylism: a toxic condition produced by the excessive intake of salicylic acid or salicylates and marked by ringing in the ears, nausea, and vomiting. Treatment includes the following: Activated charcoal and or Alkaline diuresis with extra KCl. If you suspect salicylic acid poisoning you should refer your client to a medical center immediately. Salicylic acid should be avoided for women who are breast feeding or pregnant. Opt for glycolic acid or TCA. Trichloroacetic Acid (TCA) The general toxicity when taken in low doses is almost nonexistent and its molecular structure is very close to glycolic acid. Like glycolic acid, TCA does not have a general toxicity, even in high concentrations when applied to the skin. TCA s ability to peel deep comes from its combination with aqueous solutions. The big difference is that it is rapidly neutralized as it progresses through the layers of the skin, leading to protein coagulation or White Frost or Blanch as it is sometimes called within the medical field. TCA is considered to be the most aggressive acid [ lowest pk value of all the acids used for peeling ] and the depth of penetration is directly linked to its low ph. Serene s TCA peels have a ph of 1.0. IMPORTANT: The application of a TCA peels requires that you apply more coats to some areas then you do to others. The diagram to the right shows the areas where you might have to apply more liquid to achieve the same depth of peel. This is not to be followed 100% for every client but is only a guideline and each client should be treated individually and with caution. TCA has the ability to penetrate deeper without warning and should always be on your mind and something to watch for.
5 Advanced Chemical Peel Manual Choosing the Correct Peel Evaluation of Client 1. Question your clients history of herpes simplex virus infection, HIV, Keloid formation 2. Nicotine use 3. Oral isotretinoin [ Accutane ] 4. History of plastic surgery [ face-lift or brow lift ] 5. Previous X-ray therapy of the skin What do all these contraindications have in common? They all delay wound healing, delay re epithelialization and increase risk of infection which leads to an increased risk of post peel complications and or scarring. IMPORTANT: A proper client evaluation must be performed on all clients regardless of peel used. Peel Indications Very light peel indications Superficial skin retexturization Acne vulgaris: comedolytic Light peel indications Actinic keratoses [ Rough, scaly patch on your skin that develops from years of exposure to the sun. ] Solar lentigines [ Dark (hyperpigmented) lesion caused by natural or artificial ultraviolet (UV) light. ] Acne vulgaris Melasma Epidermal growths: thin seborrheic keratoses [brown, black or light tan growth / waxy, scaly, slightly elevated. ] Medium peel indications Actinic keratoses Rhytides [ Skin wrinkle ] Melasma Seborrheic keratoses [ noncancerous benign skin growth ] Solar lentigines [ blemishes on the skin associated with aging and exposure to ultraviolet radiation from the sun. ] Skin retexturization Deep chemical peel indications Deep rhytides Acne scarring Skin laxity improvement
6 Advanced Chemical Peel Manual Priming the Skin for Chemical Peels The foundation of an effective chemical peel is in the skin preparation. This begins in the weeks leading up to the peel, and also on the day of the peel. Skin priming can be divided into two phases: 1. Pre Peel Treatment 2.. Peel Preparation These two phases are different and are determined by timing and the products used. The Pre Peel Treatment phase consists of topical products applied to the treatment area in the days or weeks prior to the procedure. The Peel Preparation phase consists of the products used just prior to peel application. Goal: Thin the epidermal barrier, enhance uniform penetration, accelerate healing and reduce the potential for post peel complications, most importantly to reduce the possibility of post inflammatory hyper pigmentation. Pretreatment Pre treating the skin 2-4 weeks prior to peel procedure is the gold standard and what you should always strive to accomplish. This time period will allow you the opportunity and your client to understand the importance of proper skin care and realise that a well planned and executed regimen will enhance and improve the entire chemical peel process. It goes without saying that 2-4 weeks is a long time and although this is a a best practice standard you should always do your best to get as close to this as possible. Remember the old saying, Shoot for the moon and even if you fail, you will still land among the stars. With that said, if you shoot for 2-4 weeks, maybe you will only get at the minimum 2 or maybe even 1 week, but that would certainly be better then 2 days or worst yet no days at all. Another asset of the pretreatment phase is the ability to prepare the client mentally for the procedure. With an at home care regimen that will enforce the habits necessary for a safer and more effective healing post procedure, you and your client will almost be guaranteed the best possible outcome. Products Used During the Pretreatment Phase 1. AHAs 2. Hydroquinone Preparation Goal: uniformity of depth, ease of application, reduced client pain and discomfort and enhanced healing. Products which make up this phase: 1. Serene AHA 3 Facial Cleanser or Facial Cleanser Sensitive Skin 2. Serene s Bio Film Cleanser Other factors that influence this phase and be determining factors on depth and uniformity of peel application: 1. Amount of product used 2. Time spent and force of application
7 Advanced Chemical Peel Manual Conclusion Chemical peeling is a constant learning process; please see this material as only a starting point to your knowledge and education. Most importantly, start slow, work with clients you know and practice from a safe place of lower percentages and easy to work with skin types. As you learn, gain experience and work with experienced clients, gradually increase to stronger deeper peels and more difficult conditions. This slow and steady approach will allow you to learn and experience pre and post peel issues while eliminating most of the complictions experienced by those who rush in and use a deeper is better approach. Reference material is available upon request. If at a later date you have specific questions not covered in this material please see your class educator for further education. The Esthetic Institute