Skin resurfacing using chemical peels and lasers of different modalities are popular and effective methods of rejuvenating skin, as well as treating some skin complaints. Allie Anderson speaks to practitioners about how they should be used in aesthetic clinics
They say youth is wasted on the young, and this is perhaps particularly true in relation to the skin. Until the age of around 30, most people are relatively carefree when it comes to looking after their skin, since, to a great extent, the skin appears to look after itself. The process of skin cell renewal is reliable and consistent, and crucially – it’s relatively rapid.1 With age and poor treatment of the skin, however – be it sun exposure, smoking, or lack of an adequate skincare regime – successful skin cell renewal becomes more challenging.1
During skin cell renewal, firstly, the outermost layers of the epidermis (the stratum corneum) are shed naturally through a process called desquamation.
New cells are then formed beneath that gradually make their way towards the surface, in a process called keratinisation,1 meaning that damaged skin is renewed regularly. Second, fibroblasts in the dermis deposit wellstructured and plentiful collagen fibres, which keep theskin plump and elastic.2 As a result, the face retains the characteristics of youthful skin, despite behaviours that will, in time, degrade its health. As we age, however, these youth-prolonging mechanisms become less effective. The matrix that holds the stratum corneum together becomes denser, enabling the cells to build up, and consequently making desquamation more difficult and keratinisation slower.1 Moreover, collagen synthesis begins to decline during our 20s and 30s, and the collagen that is produced is increasingly fragmented and degraded thereafter, causing the skin to weaken and lose elasticity.2 Although taking care of the skin from a young age will go some way to staving off the tell-tale signs of facial ageing, they are inevitable. But for those wishing to turn back the clock, an effective method of rejuvenation is skin resurfacing, the goal of which is to bring new skin to the surface by mechanical or chemical removal of the topmost layer. Perhaps paradoxically, resurfacing entails controlled injury to the skin in order to improve its appearance. This can be performed by peeling or the application of lasers: a third option – dermabrasion – is not discussed herein.
In a peeling treatment, chemicals are applied to the skin so that the epidermis peels away, revealing fresh skin beneath. As well as proving effective in combatting and reversing visible signs of skin ageing – such as fine lines and wrinkles; dull, rough skin; enlarged pores; uneven tone; and areas of pigmentation – peels can be used to treat acne and resulting scarring, rosacea and pigmentation disorders such as melasma and chloasma.3 Peel solutions are categorised in part by how deeply they penetrate into the skin, ranging from superficial (or micro/light), medium and deep peels, with results typically improving as penetration depth increases.4
These commonly contain either alpha-hydroxy acid (AHA), such as glycolic acid; or beta-hydroxy acid (BHA), such as salycilic acid, at various concentrations.5
The procedure tends to be more or less standard, regardless of the type of peel. First, the face is fully cleansed, often with an acetoneor alcohol-based solution to degrease the skin. A barrier gel may also be applied to the more delicate areas, such as the nasolabial folds. The practitioner applies the peel and, with many types of peels, determines how long it is left on by observing the patient’s response and monitoring changes in the skin’s appearance. “We’re looking for flushing, redness, and frosting of the skin, where it goes very pale,” explains Nivern, “at which point we would immediately neutralise and wash off the peel.” However, not all peel treatments have a visible endpoint that indicates that it has reached optimum success. Procter’s glycolic system involves the peel being left on the treatment area for a set time of 10 minutes (assuming it is tolerated), before neutralising the acid with warm water sponges. After this, and depending on the specific protocol, a combination of serums, moisturisers and – most notably – a high-SPF (30 to 50+) sun cream is applied. Practitioners interviewed concurred that strict, continued use of sun protection and lifelong UV avoidance is the most important factor in the success of any resurfacing treatment, and in preventing and minimising complications.14
Occasional side effects and complications are possible, as outlined below:
|Potential side effects/complications3|
MEDIUM AND DEEP PEELS
The practitioner’s expertise is an important factor in preventing complications: they should identify patients who may be more at risk (those with PIH and keloid scars and people who are deemed potentially uncooperative), and select a peel depth that balances desired results with possible adverse events for each patient.3 Contraindications include isotretinoin, used to treat severe acne; guidelines suggest waiting six months after discontinuing the medication before undergoing chemical peeling.15 Notwithstanding, anecdotal evidence shows overwhelmingly that superficial and medium-depth peels are, for the most part, safe and relatively free of complications, hence their popularity. “Chemical peels are an important part of my treatment armamentarium, and I feel comfortable with this procedure because it has a long history,” comments Dr Landau. Research supports this view, suggesting that dermatological uses date back as far as the 1870s.16 Dr Landau adds, “Patients understand the idea of renewing the skin by peeling off the old layers and the clinical results are impressive.”
The core component of laser resurfacing is heat, and most often uses light waves for its creation. When a wavelength of light is applied to the skin, it targets substances in the skin’s molecules called chromophores, which absorb the light and turn it into heat energy. Different light wavelengths penetrate at different depths and target particular chromophores – haemoglobin for vascular lesions,17 melanin for pigmented lesions,18 and water for lines and wrinkles.19 Generally speaking, two types of lasers are used in skin resurfacing: ablative and non-ablative.
Ablative lasers – Ablative lasers cause wounding to the skin and, consequently, removal of its outermost layers, thereby stimulating renewal of collagen-rich skin beneath.
Non-ablative lasers – Non-ablative lasers also work by boosting collagen production, but they bypass the top skin layers and conduct heat deeper in the dermis. Targeting water chromophores, a cellular reaction is triggered that stimulates the production of collagen and elastin, thus firming and plumping the skin.20
Fractional lasers – A more recent development, the fractional laser is commonly used as an intermediate treatment between the former two, working at both the epidermal and dermal layers. The laser beam is divided into thousands of minuscule columns, each intensely targeting a tiny fraction of the skin at a time while leaving surrounding tissue unharmed. This promotes faster healing than the traditional laser procedures, in which the whole area is exposed.21 Consultant dermatologist and medical director of sk:n clinics, Dr Firas Al-Niaimi, offers a combination of full-area, fractional, ablative and non-ablative treatments, using erbium-doped yttrium aluminium garnet (Er:YAG) and carbon dioxide (CO2) as their media. “Depending on the severity of the condition treated, the patient’s age and skin type, and the downtime request, we can choose the most appropriate laser,” he comments. “The fractional non-ablative laser has a shorter downtime, but it will require a number of treatments because the effects are not as dramatic as ablative. But if someone has a severe form of wrinkling or acne scarring, and does not mind downtime, then obviously the ablative resurfacing will be quicker and give better results.”
Radiofrequency lasers – These (non-ablative) lasers use radiofrequency (RF) energy, rather than light energy, to generate the heat required to affect the resurfacing process. Lucy Xu, treatment director at Premier Laser and Skin, explains, “The system we use utilises gold-plated isolated microneedles to deliver RF energy to the deep, middle and upper level dermis and the epidermal layer. This creates controlled thermal damage that generates a tightening effect, and triggers a healing response in the dermis to boost collagen production.”
Machines typically either have a rolling motion, whereby the head is rolled over the skin in a number of passes; a stamping motion, where the hand-piece is moved up and down between adjacent areas of skin to be treated; or a scanning-type mode. The skin is numbed with a topical solution for around 45 minutes: for full resurfacing, which is more painful and requires greater downtime, local anaesthetic is injected. Next, the skin is thoroughly cleansed and when goggles are in place to protect the patient’s eyes, the treatment is applied. The skin is lasered one area at a time based on the laser’s spot size, although, according to Dr Al-Niaimi, best results are achieved by treating the entire face to avoid visible demarcation. “The face is divided into so-called ‘sub-units’. At a minimum, you would treat an entire sub-unit – the whole nose or the whole mouth unit – or, for optimum results, you treat the entire face, but you use a ‘blending’ technique,” he explains. This involves applying a milder form of laser to the rest of the face, feathering the borders with low-pulse energy and density.22 As with peels, post-laser aftercare centres on sun protection. In addition, regular cleansing and moisturising is essential – using occlusive ointments following ablative procedures and lighter moisturisers for non-ablative. “A good antiseptic is the key component of good aftercare to prevent infection,” explains Dr Al-Niaimi. “Patients are able to return to work the day after a RF resurfacing treatment,” adds Xu.
Types of complications include:
The severity of each complication can be classified as minor, intermediate or major and will vary depending on the type of patient and concern treated, as well as the strength of the laser used.22,23
Notwithstanding, most devices and types of laser are deemed safe and effective, balanced against the pain and downtime of the procedure itself. Most complications have been shown to be caused not by device malfunction, but by errors on the part of the practitioner.24 In the hands of experienced and reputable aestheticians, one can expect these complications to be minimal.
Skin resurfacing by application of chemical peels or lasers is a popular choice for patients. Like any aesthetic procedure, especially those that cross over into the realm of medical treatment, it is essential that clinicians fully understand the complexities and potential pitfalls of these options. In capable hands, however, skin resurfacing can be a safe and effective treatment and therefore, a valuable addition to the practitioner’s toolbox.
Dr Firas Al-Niaimi, ‘Laser complications in aesthetic procedures’, Aesthetics, Volume 1/Issue 11, October 2014.