Activity Transcript

Pearl Grimes, MD, FAAD: Hello, everybody. I'm Dr Grimes. I'm the director of the Grimes Center for Medical and Aesthetic Dermatology and the founder and director of the Vitiligo and Pigmentation Institute of Southern California. I'm also a clinical professor of dermatology in the Division of Dermatology at UCLA here in Los Angeles. So welcome to this Medscape program titled "The Complete Guide to Chemical Peels, the Why, the What, and the How." And I have to tell you, I love chemical peeling.

And I'm very pleased today to be joined by Dr Heather Woolery-Lloyd. Dr Woolery-Lloyd is the director of the Skin of Color Division at the Dr Phillip Frost Department of Dermatology and Cutaneous Surgery at the University of Miami in Miami, Florida. Welcome, Heather.

Heather Woolery-Lloyd, MD: Thank you. I'm excited to be here. I also absolutely love chemical peels, use them all the time in my practice, so I'm really excited for us to start this discussion.

Dr Grimes: So, Heather, over the next 30 minutes, we're going to be discussing a number of exciting things regarding chemical peels. We're going to talk about the properties of key peeling ingredients, how do we assess patient's skin for optimizing outcomes for chemical peels, and the appropriate peel regimens for patients based on specific skin concerns.

Dr Woolery-Lloyd: Yes, I think that these are really important things to understand for people who are new to chemical peels. And we'll cover all of the things that we need to cover so that if you're very interested in starting chemical peels, you'll have a good base.

Dr Grimes: So then, Heather, in actuality, when we use the terminology chemical peeling, what are we talking about? What is chemical peeling?

Dr Woolery-Lloyd: Well, in the simplest terms, a chemical peel is essentially a wound, right? We're inducing a wound. We're causing exfoliation of the epidermis and sometimes down to the dermis. So we sometimes don't think of it that way, but that's exactly what a chemical peel is. But that wounding has beneficial effects, like we use it for hyperpigmentation. I use a lot of chemical peels for acne. But that exfoliation, that chemoexfoliation is essential to us seeing the results that we need to see with chemical peels. Now, I know that we are basically inducing a wound, but what is the physiologic impact of a chemical peel?

Dr Grimes: So, Heather, if we look at the physiologic impact of chemical peels, what we're actually doing is we're causing denaturation of proteins in both the epidermis and the dermis. So when we denature these proteins, we cause the production of proinflammatory cytokines, chemokines, which are a part of the inflammatory cascade. And given the stimulation of cytokines and chemokines, these are major players in the normal wound healing cascade. So at the end of the day, we want to stimulate regeneration of keratinocytes in the epidermis. We want to stimulate new collagen formation in the dermis, new elastin formation, as well as reorganization of structural scaffolding proteins in dermal connective tissue.

Dr Woolery-Lloyd: Yes, especially in those deeper peels. And that makes me think about skin types, because understanding your patient's skin type, I think, is critical when choosing a chemical peel. So what are the things that help you decide what types of peels you'll use in different skin types?

Dr Grimes: Here at the institute, I peel every single day. And if we look at peels per se, certainly, in your lighter skin, you can do superficial, you can do medium-depth peels, even deep peels, and you have this enormous window of safety. Whereas in your darker skin types, given that propensity to have issues of hyperpigmentation, even hypopigmentation, as you know, because we've worked together, superficial peels are our number 1 go-to. We can do medium depth, but we know when we peel, as we increase the depth of that peeling, certainly, in darker skin types, we're increasing the likelihood that we're going to have complications. So, Heather, how does the depth of penetration impact the skin?

Dr Woolery-Lloyd: Well, I love what you were talking about just now about that depth of peel, because I choose peels based on skin types. Most of my patients are skin types IV through VI. So I am generally doing superficial peels, and superficial peels are really just in the epidermis. They're not going down to the dermis. When we're thinking about the medium-depth peels that you were talking about, we're talking about the full thickness of the epidermis into the papillary dermis.

And then when we're thinking about deep peels, which I actually don't do in my practice because I do tend to have skin types IV through VI and deep peels will be very risky in that skin type; we're looking at the full thickness of the epidermis, papillary dermis, and midreticular dermis. So in my practice, I am doing a lot of superficial peels, and they're extremely effective. I use them all the time, but you do just have to pick your peels appropriately for the patient and their concerns.

Dr Grimes: I agree with you. Here at the institute, I do more superficial peels. However, given the spectrum of individuals that we care for, I do some medium depth. I don't do deep peels. So here, let's take a deeper dive into the specific peeling agents.

For superficial peels, sometimes we can divide them into superficial very light, superficial light. So what are the agents in the superficial light that really just penetrate to the level of the stratum spinosum? These include your alpha hydroxy acid peels, salicylic acid peels, which are amazing for acne by the way. The concentrations are usually 20 to 30%. This also includes your Jessner's solution. Again, glycolic acid, 20, 70%. And these peels can penetrate through the entire epidermis, even to the layer of the papillary dermis.

So for your medium-depth peels, that's TCA, 35 to 40%, the combination of Jessner's peels with TCA, 35%, a 70% glycolic in combination with a TCA peel, solid CO₂ in combination with TCA, and then 88% phenol peel. These penetrate to the level of the upper reticular dermis, and deep peels are your unoccluded or your occluded Baker's phenol peel or TCA greater than 50%, and that penetrates to your midreticular dermis.

Dr Woolery-Lloyd: And when we're getting a little bit deeper into the skin, of course, frosting is something that we see, right?

Dr Grimes: When you have frosting, frosting is indicative of denaturation of proteins. So the level of frosting is indicative of the level of injury. Level 1 frosting is more erythema. It can be very faint, and I think it's okay to get a little bit of frosting in darker skin. You can do a 10% TCA peel and have minimal frosting, and those patients do really well. Level 2, more of a white frost. Level 3, we see that more with your deeper peels, your medium-deep peels, and that is indicative of significant injury, which, again, it's okay if you're treating photodamage, coarse lines, fine lines.

But again, a significant frosting in darker skin, I think. If they have significant frosting, there is a 100% likelihood that you are going to have significant postinflammatory hyperpigmentation that you then spend months eradicating.

Dr Woolery-Lloyd: Yes. Yes, I agree. So whenever I am doing a peel, if I feel like I'm seeing the earliest sign of frost, I'm extra careful in my skin types IV through VI. And the only thing I'll also mention is that perifollicular frosting is sometimes seen in our acne patients, and that's okay. That's the only type of frosting that I am not uncomfortable with in my darker-skinned patients. But when you see that deep-white frost is when you really have to be concerned in your darker-skinned patients.

Dr Grimes: I think when you see significant frosting . . . I think I'm going to take this opportunity to just mention here, Heather, that we can take a superficial peel, and if that patient is retinized and they use their tretinoin the night before or even 2 nights, we can have a superficial peel that then becomes a medium-depth peel with significant frosting. And I can only say been there, done that, and I've certainly experienced that complication.

But I think when we see it, the key is to recognize it and treat it aggressively with a high-potency topical corticosteroid so that you decrease the likelihood of any long-term postinflammatory hyperpigmentation.

Dr Woolery-Lloyd: I must say, I have to agree with you, and I learned from you. I learned chemical peels from you over 20 years ago. So I do use that little clinical pearl there when I do see a frost, which is using a topical steroid to help minimize that risk of hyperpigmentation in our darkly pigmented patients. So now I want to talk a little bit about indications for chemical peels, because we both do lots of chemical peels in our practice, but we do them for many different indications. That's why we both love peels because we really have a wide range of things we can do peels for. So what type of indications do you choose peels for?

Dr Grimes: You know, we both, I think, peel for pigmentary disorders. We peel for melasma. We peel for postinflammatory hyperpigmentation. You can also use peeling for lentigines. We peel for inflammatory disorders such as acne vulgaris and rosacea. Peels work great for pseudofolliculitis barbae and keratosis pilaris, then we get into scarring where we may need a deeper peel, acne scars, traumatic scars, scars induced from surgical procedures.

And we couldn't have this conversation without emphasizing the role of chemical peels for aging, for fine lines, coarse lines, textural changes. I love chemical peels for oily skin, because they can be phenomenal in changing the texture of oily skin, and certainly medium-depth peels, even deeper peels are great for precancerous lesions, actinic keratoses.

Dr Woolery-Lloyd: Yes, I agree with you. I do a lot of chemical peels in my practice, melasma, postinflammatory hyperpigmentation (PIH), and textural changes. I agree with you. Those oily-skinned patients, after a series of peels, their skin does change. The texture is smoother and the prominent pores are less obvious. It doesn't change the size of the pores, but definitely makes it less obvious, makes the skin smoother. So I agree with you. Those are the things I use peels most for in my practice.

Dr Grimes: So then, Heather, so I've given you the broad, the global list of indications. So now, if we look at indications based on superficial, medium, and deep, how would you then categorize?

Dr Woolery-Lloyd: So if I was looking at a superficial peel, the types of things I would be treating with superficial peels are mild photoaging, of course, acne vulgaris, we use salicylic acid peels primarily for that, 20 or 30%, mild acne scarring. So I definitely have used peels for my patients who have textural changes from their acne. Not deep ice-pick scars, but just textual changes from having lots of inflammatory acne, and I've seen great results with the series of peels. Of course, pigmentary disorders like we discussed, melasma, lentigines, very superficial pigment.

Now, when you're looking at the medium-depth peels, which I do less of those, but those you would consider for patients with mild to moderate photoaging, actinic keratosis, fine lines, solar lentigines, things that if the melasma is a little bit more resistant and you feel comfortable with the medium-depth peel, you could consider it. But you definitely have to have a comfort level because melasma is, we all know, one of the most challenging things we treat in dermatology. And medium-depth peels have even been used for seborrheic keratosis.

And then deep peels, which I don't do so much in my practice, but have been used with great results for severe photoaging, so very deep rhytids, pigmentary disorders, some premalignant tumors, and for scars. But in my practice, I tend to stick to the superficial peels because of my patient population.

Dr Grimes: Well, I agree. I probably, Heather, do more superficial peels, but as I said, I probably am doing more medium-depth peels, but I am very selective in who I choose for medium-depth peels. And again, I think the take-home message that I would give to our listeners, superficial is always safe. And given that often capricious nature of your darker-skinned individuals, particularly your individuals with skin types V and VI, you must know your boundaries, and it's always safe to be in the superficial range. Whereas if you have lighter skin, you have a much broader window of safety and you can use more medium-depth peels. And I truly think that deep peels should only be done by the people who are skilled in the arena of chemical peeling.

Dr Woolery-Lloyd: I agree. Now, when patients come in to your practice, how do you assess those patients that you think... So you find a patient, good candidate for a chemical peel, what are your steps when you assess that patient and choosing what's the right peel for them, and how do you discuss chemical peels with them and choose the right patient?

Dr Grimes: So great question. So, Heather, when we have a new patient or even a regular patient who decides they want a chemical peel, we really take our time and we do a detailed assessment.

So once we established all the things that we need in that clinical exam and we do a physical exam, we choose, we decide what the depth of peeling should be based on the diagnosis. Is the condition that we're treating, is it amenable to a superficial or a medium-depth or a deep peel? So we decide on the depth of peel needed, what the peel will be. Will we do a proprietary peel? Will we do a Jessner's peel? Will we do a TCA? And I think that's a function of the skill set of the treating physician.

I'm a big believer in priming the skin. Particularly for darker skin types, everyone's on a lightener or hydroquinone prior to peeling, sunscreens. If you want a deeper peel, you can certainly put that patient on a retinoid, but if you do not want a deeper peel, then you should control the use of the retinoid or discontinue it.

So priming, you bring that patient back, then we prep them for the peel, we clean their face, the peel is applied, you achieve the desired outcome, postpeel protocol, bland cleanser, moisturizer, sunscreen. And my typical protocol is, usually, they pretty much healed up in anywhere from 2 days to 5 days postpeeling, and then they can go back on their regular maintenance regimen. What about you, Heather? What's your protocol?

Dr Woolery-Lloyd: As I said, I learned everything from you, so I really do the same exact protocol. I do like my patients to be on, I want to say, a standard skincare routine, meaning that I don't want them to do any major changes, so change the retinoid the week before, or I like to have a level playing field. So I agree with you. My patients, I'm stopping the retinoid at least 3 to 7 days before the peel. I do the same thing when I meet the patient's set expectations. Patients often say, "Can't you just peel this all off in 1 visit?" Most of the time, I'm doing superficial peels, so I explain it's going to be a series of 3 to 5, but ideally 5 peels, several weeks apart, maybe every 4 to 6 weeks.

So I really set realistic expectations for the patient so they know what to expect. I also tell patients, "The first visit, you might not notice a peeling of the skin with a superficial peel," because you'll get that callback, "My skin didn't peel." Well, on the first peel, you might not peel, but on the second, third, fourth, and fifth, you will. So those are the things that I talk about in that visit so that we've set really realistic expectations and people know what to expect.

Dr Grimes: Heather, that is such a key comment and that is... Well, both your comments. Establishing realistic expectations on the part of the patient. I think that is so key in achieving the desired outcomes and having happy patients.

And I think that I've learned, right now, it becomes a part of the conversation so that patients understand you do not have to peel to get the effects of a chemical peel, even with the second peel.

Dr Woolery-Lloyd: Yes. And that you don't have to visually peel to . . . They are actually peeling, but they're just not seeing it visually because it's not as deep. I think that's the key.

Dr Grimes: So what about, Heather, are there more sensitive areas on the face that we need to address?

Dr Woolery-Lloyd: Yes. So everyone has their kind of peel protocol, what they do for patients. But many times, in our practice, we'll put a little petrolatum on sensitive areas. So the sensitive areas are around the eyes, so at the angle of the eyes there, in the alar crease, sometimes around the mouth. I do avoid peeling anywhere close to the eyes. If the peel gets into that alar crease, it can really sting, so I stay away from those areas and very close to the mouth.

The other thing that's a very key point is the upper lip, because many women are using . . . They might wax. They might thread. They might be doing all of these procedures at home to remove the upper lip hair, and of course, that's removing some of their epidermis. And you might get a deeper peel on the upper lip if the patient is doing hair removal procedures at home. So always ask about that. And if they are doing that, I would avoid it for that peel, because if the person waxed their upper lip 2 days before the peel, you'll definitely get a deep peel if you use the peeling agent in that area. So always ask about hair removal.

So what else can you tell us about that patient assessment?

Dr Grimes: Certainly, we want to look at skin type. Is the individual a skin type . . . Do they have lighter skin? Skin types I, II, III, Fitzpatrick skin type. Or are we dealing with skin of color? Individuals who have darker skin, your IVs through VIs.

I like to look at texture. Many patients want a smoother texture. Are the pores enlarged? I look at pigmentation. Do I peel when there's no pigmentation to achieve a smoother texture? Very often, I do want to peel to improve dark areas, dark areas associated with melasma, or blotchy areas associated with postinflammatory hyperpigmentation. Certainly, we want to look at fine lines, coarse lines, because that will definitely be factorial, if you look at Glogau's photoaging scale that we sometimes use.

We want to look at scarring. Certainly, some patients will have acne scars. These superficial acne scars may be amenable to superficial or medium-depth peels. So, again, detailed history, detailed cutaneous examination, a key part, a key component of patient assessments in choosing the optimal peel for any given patient.

Dr Woolery-Lloyd: Patients who have herpes simplex virus (HSV) or cold sores are something I definitely specifically ask about. Interestingly, sometimes patients will walk in with an active cold sore. Absolutely I will not peel patients who have active cold sores. I have them go home, and this happens. If you peel, if you do enough cosmetic procedures, this will definitely happen.

So pay attention. Don't assume it's a pimple and say it was. . . . I always ask, "What is that?" If it's not obvious that it's an active cold sore, just to make sure, because we have to be careful with those patients when we're assessing those patients. And I'll do some prophylactic valacyclovir if they have a history of frequent or active cold sores or HSV infection. So that's 1 other thing that I look out for in those patients. Anything else you want to add?

Dr Grimes: I think the take-home message here is you just have to emphasize to patients, "Look, peeling is peeling. You can't rub it off or scrub it off. You have to let the peeling cycle ensue on it, the natural course, but you cannot scrub off your peel, because if you induce additional damage, you increase the likelihood of postinflammatory hyperpigmentation or hypopigmentation and even scarring related to your chemical peel."

Dr Woolery-Lloyd: Yes. Yes. You have to be very careful. I had a patient who, before the peel, was manipulating an area maybe where there was a pimple. And so, that person peeled much more deeply in that area. So really, I always talk about having a level playing field before we start the peel so we can have more predictable results, and I kind of explain that to patients too.

Dr Grimes: So, Heather, as we talk about tools, I think it's so important to emphasize the importance of photography.

Dr Woolery-Lloyd: Yes.

Dr Grimes: I do not do any peels or, for that matter, any cosmetic procedures without baseline photos, because patients forget what their skin was like at baseline and they don't always appreciate the changes. So I think if I were to leave you with any take-home message, if you're going to do a peel, you got to have baseline photos before and after. I think it's so important. And we have a research center and there's another tool that we use for studies, but I think eventually it'll become more mainstream, and that is colorimetry.

It's a tool that we use to give us an objective measure of the intensity of pigmentation. So it's not mainstream, but I think that will come in the future and we'll be able to correlate the intensity of pigmentation with colorimetry devices. I think we'll be able to establish a correlation with skin type.

Dr Woolery-Lloyd: Yes, I agree, and I think photography is key. We also photograph all of our patients, because it really gives the visual, especially with superficial peels, where you really do need a series and the results can be a little more subtle, the patient doesn't remember, but when you see the pictures, it's very obvious. So that's a really important clinical pearl.

Dr Grimes: Yeah. So, Heather, what about potential side effects of chemical peels? What do you think? What's your experience?

Dr Woolery-Lloyd: One of the biggest ones that we want to avoid, I just mentioned, which is in patients who have HSV, recurrent HSV. So that is a potential side effect that I am very hyperaware of. And so, I do ask about cold sore history and pay close attention if there's anything on the face that looks like it could be a cold sore and ask about that. But the other common side effects that we see, so with superficial peels, obviously, if you get a frost, as Pearl mentioned, even though it's superficial, you can still get frosts if the patient is using a retinoid or if you don't have that even playing field that I keep talking about.

And so, you can see postinflammatory hyperpigmentation right after the peels. Some peels, people have a little bit of redness, that usually resolves. Some patients report burning, a little bit of stinging. Again, during the peel, that's okay. But if it's extraordinary, so they've had 3 or 4 peels and the patient says, "I'm really, really burning today," I use that as a sign to maybe slow down and remove the peel because it gives me the indication that it might be going a little bit deeper than expected.

With medium type of side effects that we see, again, you can have deeper postinflammatory pigment. Usually, it resolves. I mean, in my experience, it does resolve. It can take months, and it does require a little bit of handholding, but it can resolve. Rarely, you can have bacterial or fungal infections, but that's not common. And then with very deep peels, you can have scarring. I don't do those in my clinical practice. But definitely, if you're going down to the level of the deeper dermis, deeper layers of the dermis, there's obviously going to be a risk of scarring if you're doing those types of peels.

Dr Grimes: Heather, here at the institute, I think probably, for me, the number 1 side effect of superficial peels, I mean, they're the acute and then the chronic. The acute ones resolve.

Dr Woolery-Lloyd: Right.

Dr Grimes: Chronic postinflammatory hyperpigmentation. When we get into medium depth, I think postinflammatory hyper- and hypopigmentation, scarring, and certainly with the deep peels, scarring, phenol, cardiotoxicity. There's just a spectrum of peeling. And again, I don't think deep peels are to be done by the inexperienced. So, again, I will make the statement, know your peels, understand your concentrations, and know your boundaries. And I love the comment that you made early on, and that is, if you're just beginning to peel, start with 1 peeling agent, know that peeling agent, and then expand your repertoire of peels that you want to incorporate in your portfolio of agents that you offer your patients.

Dr Woolery-Lloyd: Yes, I agree. I think that learning 1 peel is key if you're just starting out. If you start and you do 5 different peels, 5 different days, you'll never get a good sense of what to expect. And a key part of doing peels well is knowing exactly what to expect with a given peel. So I do want to bring up 1 more key point when it comes to frosting, that side effect of frosting that we see in our patients. Tell me a little bit about frosting, the true frost, vs the frost that people sometimes describe with salicylic acid peels. Can you clarify that for our listeners today?

Dr Grimes: Absolutely. So true frosting, as we've already discussed, refers to denaturation of proteins. And true frosting, given the depth of frosting, can be associated with peel complications. In particular, postinflammatory hyperpigmentation, or given the depth of frosting, it could even cause hypopigmentation. But with salicylic acid peeling, we can get precipitation of salicylic acid, which looks like a frost, but in actuality, it's simply the salicylic acid precipitate on the skin, which is really . . . it's not associated with any complication whatsoever.

Dr Woolery-Lloyd: That's right. And the key I always say is, if you can wipe it away, so if it looks like a frost, but when you put on your next layer, that white goes away. That's not the frost. That was just a salicylic acid precipitant and not actually true denaturation of protein at the level of the dermis. So that's a key. And if you have perifollicular frosting with acne, that's okay and expected.

Dr Grimes: So, Heather, we've covered so much in this session, the whys, the hows, and the whats. So what are your take-home messages?

Dr Woolery-Lloyd: Well, I would say the biggest take-home message is to set realistic expectations. I think a lot of patients think that we do 1 peel and everything is taken care of. And I think that that can be the case with some deeper peels, but most patients are doing superficial and medium-depth peels. And in general, those work best in a series. So set realistic expectation, picking the right patient, and, as we mentioned earlier, get used to 1 peel.

If you don't have any experience with chemical peels and you're interested in getting started, pick a peel that you feel comfortable with, ideally a superficial peel, and do many, many, many of those procedures so you know what to expect before you move on to the next peeling agent, because the biggest predictor of good outcomes with chemical peels is knowing what to expect and knowing when to intervene if the peel is going a little bit deeper than you'd like it to go.

Dr Grimes: So my take-home message is, I'm going to go back to the very beginning. I love chemical peels. Why do I love chemical peels? I think they have a tremendous efficacy and safety profile. I think priming is essential to achieve optimal outcomes.

And again, you have to know the peeling agent. You have to know the concentration. You have to know the drug. You have to know the pH of your peeling agent. So knowing your peeling agent and knowing your boundaries, knowing your skin type, knowing your indication to achieve desired outcomes. Those are the things Heather and I have covered in this Medscape session on Chemical Peels, the Why, the What, and the How. Thank you, Heather. This was so much fun.

Dr Woolery-Lloyd: Thank you.

This transcript has not been copyedited.