Case Study: Treating Acne

By Dr Jasmeet Baxi / 10 Jun 2016

Dr Jasmeet Baxi details how she successfully managed a patient’s acne using chemical peels and topical skincare

 As an aesthetic clinician, I have been treating and assessing patients with both acne and acne scarring for the past five years. In February 2015, I met a 23-year-old woman (Patient A) who has been suffering with acne for several years. Her skin tone on a Fitzpatrick scale was II.1

During the initial consultation it became obvious that she had tried several over-the-counter preparations with no resolve. She was rather frustrated with her skin and noted that this was affecting her psychologically. As a result she had developed low self-esteem and was keen to have her skin treated to help resolve the acne and improve her confidence. A full medical history was taken which clarified that she had no past medical problems, no allergies and was not taking any current medication to note. Upon review of her skin, it was evident that she was suffering from mild to moderate acne vulgaris with some inflammation. The acne vulgaris was mainly localised to her cheeks and there was also some on her chin. There were evident inflammatory papules, with a few pustules in places. There was also evidence of some scarring left over from previous acne lesions.

Treatment: first peel

Prior to treatment Patient A was using a face wash system she had bought online, which contained small amounts of salicylic acid as its main active ingredient to help resolve acne. However, she felt this was not really helping. Following a review of her skin and discussing the results with her, it was evident that she was keen to try using topical treatments such as chemical peels first, which she had heard could help, rather than taking any form of oral medication. Following this discussion, and given that studies regarding acne and chemical peels have indicated that a course of four to six peels can result in an approximate 45-50% reduction in acne lesions present,2-4 I decided to initially treat Patient A with one chemical peel and determine if she would require further treatments following this.

Figure 1: Patient A before treatment

Based on the patient’s skin type, and also upon reviewing the mild to moderate acne present, a medium depth chemical peel was used that contained a combination of acids. Due to the severity of Patient A’s skin (Figure 1), a series of superficial peels would be needed to achieve the same result as a couple of medium depth peels. It was therefore more efficient to offer two medium depth peels. The peel used was The Perfect Peel, which is a 5-acid blended peel with glutathione, vitamins and minerals. This peel was chosen due to the fact that it was not only easy to apply and use, but also provided Patient A with a mix of acids to help treat the skin for both the erythema, acne and elements of uneven skin tone and texture. The main ingredients included:5

  • Trichloroacetic acid
  • Salicylic acid
  • Retinoic acid
  • Glutathione
  • Kojic acid
  • Phenol
  • Vitamin C
  • Minerals
Figure 2: After one medium depth chemical peel 

The peel was applied to a cleansed face and Patient A was given an aftercare advice leaflet that  stated, amongst other points, that the patient should not touch, rub, wash or apply makeup to the treated area for the first day. It also gave instructions on how to appropriately use the products included in the post-peel aftercare home kit and advised that patients should always wear sunscreen of at least SPF 30 from the third day post peel. Patient A was contacted regularly during the week following treatment as the skin peeled. During the peeling process, no complications occurred. A week after the treatment, I reviewed her skin (Figure 2). 

Skincare

Studies have suggested that the effect of chemical peels generally tends to last for one to two months and results are reported as ‘fair’ to ‘good’.3-8 As such, during Patient A’s review, we also discussed the possibility of a good skincare regimen to try and enhance the effects of the peel that had just been applied.

A week after treatment I started Patient A on the Obagi Nu-Derm skincare routine, as it provided good but gentle exfoliation of the skin and also provided products to help not only brighten the skin, but also promote skin cell rejuvenation and prevent hyperpigmention. Thus creating a brighter, lighter and even toned complexion. It is not necessary to use these particular products. Similar products from other skincare ranges can also be used in a similar way post peel to help treat acne and acne scarring. Patient A was using the following:9

Morning

  • Face wash – 2% salicylic acid based
  • Toner
  • Vitamin C serum – 15%
  • Clear – a topical treatment that contains
  • 4% hydroquinone to correct slight pigmentation and improve overall skin tone
  • • Exfoderm – a topical treatment that contains a plant acid (3% phytic acid), which removes old skin cells while promoting new skin cells for a lighter, brighter complexion
  • • Hydrating moisturiser
  • • Sun protection cream SPF 50

Evening

  • Face wash – 2% salicylic acid based
  • Toner
  • Clear – a topical treatment which contains 4% hydroquinone to correct slight pigmentation and improve overall skin tone
  • Blender – a topical treatment that contains 4% hydroquinone to target hyperpigmented (discolored) areas
  • Hydrating moisturiser
  • Obagi Tretinoin 0.25% cream

These products were started a week post treatment and continued for eight weeks. Patient A was compliant with the products and found them quite easy to use.

Figure 3: Eight weeks after first peel 

I reviewed Patient A again in the clinic eight weeks after the first chemical peel (Figure 3). There was a reduction in the erythema and inflammation of the skin and also in the number of breakouts that had occurred. The skin had improved and she was also noticing that people were complimenting her on the overall appearance of her skin, which was also improving her self-esteem and confidence. The skincare products were stopped for a week prior to the next chemical peel treatment except for the cleanser, hydrating moisturiser and sun protection cream.



Treatment: second peel

Figure 4: One week after the second medium depth chemical peel

The same 5-acid blend chemical peel was then applied as previously and I monitored Patient A’s skin’s progression closely. During the peeling of the second peel there were no complications and the skin peeled over the course of a week after it had been applied. Once the peeling had resolved, Patient A was again reviewed a week later in the clinic.

A week after the second peel (Figure 4), I provided Patient A with a protocol to re-introduce the products she had been using to her skincare routine. I reviewed her skin again six weeks later and was pleased to learn that her skin had continued to remain breakout-free and was no longer as red and inflamed as it once was. However, she still had some acne scarring left on the cheeks, and we discussed the possibility of doing a further chemical peel to help with this. Due to financial reasons, this suggestion has currently been postponed. She continued with the current skincare routine for up to six months and then reduced it gradually to:


Morning

  • Face wash – 2% salicylic acid based
  • Toner
  • Vitamin C serum – 15%
  • Hydrating moisturiser
  • Sun protection cream SPF 50
  • Evening
  • Face wash – 2% salicylic acid based
  • Toner
  • Hydrating moisturiser

Evening

  • Face wash – 2% salicylic acid based
  • Toner
  • Hydrating moisturiser

Moving forward

I have arranged follow-up consultations with Patient A several times over the course of the past 12 months and am delighted that her skin is much better; the acne vulgaris has improved immensely (Figure 5). She has the odd spot but nothing as bad as it once was. Currently, Patient A’s skin is acne free but she still has a few scars left from previous acne vulgaris episodes, which we will aim to treat later this year using a combination of microneedling sessions with a dermaroller and a course of microinjections of hyaluronic acid, alongside regular treatment reviews.

The best part of the treatment process has been the level of confidence and improved self-esteem that treating Patient A’s acne has created. It is extremely rewarding to be able to improve a patient’s lifestyle as well as their skin concerns.

Acne and acne scarring are very common problems faced by many patients who present to aesthetic clinics. Helping a patient improve their overall skin tone, texture and complexion will improve and enhance other treatments within that area. Chemical peels are not only used to treat acne but can also be used for antiageing and skin rejuvenation. As such, I believe peels are a good treatment to offer aesthetic patients either for the purpose of acne or as a basic add-on to their current treatments. Clinicians who would like to add peeling to their treatment list should only do so once they have attended a chemical peels course and received the appropriate training for the peel or set of peels they wish to use.

Figure 5: 12 months since the first treatment


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