Peels
Light Skin Peels
If bleaching creams aren't sufficient, light skin peeling is commonly used in the treatment of blotchy pigmentation. These peels are also used to treat acne, dry skin and fine wrinkling.
Bleaching creams
Bleaching creams work to even out skin complexion by subtly inhibiting the production of melanin over an entire area. Melanin is the body's natural chemical that gives skin its colour. Many bleaching creams also exfoliate pigmented cells on the outer skin layers. In this way they act as an extremely mild peel, further contributing to a more even complexion. The better bleaching creams will also have an in-built sunscreen. The regular use of sunscreens is of key importance; exposure to sunlight is a major cause of melanin synthesis, which in turn, serves to aggravate an uneven complexion.
Light peels
Skin Peels are useful for improving the condition of the skin generally, and for producing a healthy, more youthful complexion.
There are a number of light skin peels available in the clinic that may be applicable to your skin type. A single peel or a series of peels may be used, depending on your skin condition.
PCA Peels. These contain several agents including AHAs, non-AHA compounds and bleaching agents such as kojic acid or hydroquinone, and are particularly useful to those for whom pigmentation changes is their main problem. Coats of peeling agent are painted onto the skin and washed off at variable times. Some slight flakiness or peeling may occur for several days following the peel, but this does not always happen and does not mean that the peel has not worked.
Rap Peels. These contain tretinoin or retinoic acid, which has been found useful in the treatment of sun damaged, photo-aged skin and acne prone skin. The peels tend to even out skin colour, increase the skin thickness and reduce the number of sunspots and facial blemishes over time. They have been shown to stimulate new collagen formation and new blood vessel production.
The skin will start to peel approximately 2 days after the peel is applied. The peeling may be quite significant or slight with some flakiness possibly occurring for several days following the peel.
TCA Peels. TCA peels of less than 25% are occasionally used for troublesome colour abnormalities where PCA or AHA peels have been unsuccessful.
Lightening Peel. The lightening peel is designed to treat epidermal hyperpigmentation such as melasma. It is performed in the clinic every 3-4 weeks. It combines the tyrosinase-inhibiting effects of phytoquinone with the keratolytic properties of alpha and beta hydroxy acids.
Clarifying Peel. The clarifying peel is designed to treat acne and is performed in the clinic every 3-4 weeks. It contains a combination of antibiotics, keratolytics and anti-inflammatories.
MicroPeel. The MicroPeel is designed for weekly home use by patients. It can also be used in the clinic as a mild, gentle peel for patients who have very sensitive skin and who may be concerned about chemical peeling.
The procedure
The peeling agent is painted onto the skin in layers, and washed off at variable times. It is common to feel a mild stinging sensation for a few minutes following application. No make-up should be worn for the rest of the day. Some slight flakiness may occur for several days following the peel but this does not always happen and does not mean that the peel has not 'worked'.
Medium-Strength Skin Peels
Chemical peeling refers to the use of peeling agents significantly stronger than AHAs in order to induce a more profound resurfacing of the skin.
Medium-strength skin peels are most commonly done with tricholoroacetic acid (TCA) and may be combined with pre-peeling measures such as Jessner's or glycolic acid.
These contemporary peels are designed to produce similar results to the older and deeper peels but with fewer complications. Deep peels using phenol acid are no longer commonly performed as C02 and Erbium laser resurfacing have become the treatments of choice.
Medium-strength peeling such as TCA peels are used to treat:
- Pigmentation abnormalities such as freckling, sunspots and age spots;
- Moderately wrinkled skin;
- More severely sun-damaged skin, especially where skin cancers are recurrent. Medium peels reduce the risk of future skin cancers in people prone to recurrences.
The procedure
Chemical peels are usually performed as a day procedure in our rooms or in a hospital under a light general anaesthetic. A pre-peeling agent may be used to prepare the face, helping to produce a more even peel. The peeling agent is then applied to the face until a smooth application is attained.
The healing process
Following the peel the face will appear sunburnt and the skin will flake. Some swelling may occur in the first few days. The skin will heal by about day 7 and will appear pink and fresh. Normal colour returns to the skin by week 3-6. It is important to avoid sun exposure during the healing phase.
Sundry Procedures
Minor and adjunct procedures that are also used in the practice
Fine wire diathermy
This treatment works by passing a small electric charge down a hair-like needle into an unwanted spot, causing the spot to shrivel and disappear. It does so over the following few days to weeks depending on the body part treated and the amount of current used. It should not be confused with the rather gross diathermy delivery systems of the past. Correctly used, this is a most elegant technique and one that gives uniformly good results.
Fine wire diathermy may be used in many situations. These include the treatment of dilated blood vessels on the face and any fine vessels on the upper limbs or trunk. It has a major role in the treatment of minor skin blemishes such as small skin tags, milia, syringomas, seborrhoeic warts and sunspots. In this role, it is similar to a CO2 laser in its effects (see page 00). It is also used effectively as part of a hair removal technique called epilation (see page 00).
The healing process
Wounds and scabbing. After the procedure with non-insulated needles, a scab forms after an initial sore. This wound is usually inconsequential, but if a larger area has been treated then a significant sore may be seen and this may need a night-time topical antibiotic or antiseptic ointment (preferably greasy) for seven to ten days on the face or longer if elsewhere.
Makeup and sunscreen are usually permissible after the procedure.
Sun avoidance. It is important to protect this treated area from the sun whilst the spot is healing. Otherwise the spot may preferentially tan and stay that way for weeks.
Side-effects
Scarring and other side effects are very unusual.
Hearing aid and pacemaker malfunction. Caution is usually advised for people who use these devices as some of the older diathermy units have been known to stop them from working. The newer diathermy machines, which we use, don't really have this problem and most modern pacemakers also protect the patient from this rather nasty situation.
Cautery
Hot cautery is similar to diathermy except instead of electricity this technique uses straight heat to remove lesions. A wire loop is heated to red hot and, usually with local anaesthetic, the spot is cooked and left to fall off over time. This is an effective technique for treatment of brown spots on hands or anything that is entirely growing on the surface of the skin.
Another very good use for the hot cautery is in the treatment of skin cysts. With this type of spot the cautery tip is inserted into the cyst centre and the contents of the cyst melted. The lining also comes away with this technique and the cyst is often able to be delivered through a very small cut which becomes virtually invisible.
Side-effects
White spots may be left behind when hot cautery is used upon darker-complexioned patients. It is considered a less useful procedure for this group.
Liquid nitrogen
This chemical is most natural: it is around us all the time and represents 80% of the air that we breathe. The only difference is that once made into a liquid it has an incredibly low temperature of close to -200ºC. This low temperature allows us to selectively destroy anything that we aim it at. It affects the top layer of skin much more than the second layer, and given that scars are formed from injury to the second layer of skin, this approach can successfully treat large surface spots without scarring if correctly applied.
Liquid nitrogen is a traditional dermatologist's tool and is used widely to remove all sorts of lesions but especially sunspots and seborrhoeic keratoses. It is also particularly good at treating brown age spots on the backs of hands and faces. It is either applied with a swab on a stick dunked into the liquid nitrogen or it is sprayed on or applied with a cold probe.
The healing process
Blistering and scabbing. Whichever delivery method is used, the end result is the same. It produces localised frostbite which readily forms a thick blister that may break or remain intact and slowly evolve into a scab. This scab lifts in a week on the face and longer if applied elsewhere or for a longer time.
Colour resolution. After the healing time, the patch is often transiently red then white and finally in most cases returns to its normal skin colour.
Side-effects
Pain. There is some discomfort with liquid nitrogen application; a peculiar sensation whereby the body can't quite work out if this substance is cold or hot or just painful. The pain, however, is fleeting.
Scarring and changed skin colour. These undesired effects are not common if the procedure is carefully performed.
Skin shaving, snipping
These are two extremely simple but very effective techniques used for skin lesions such as acrochordans, seborrhoeic warts, cherry angiomas and moles.
Skin shaving is a technique in which the skin is inflated a little with local anaesthetic and the razor bowed so that it takes off the spot with a minimum surround of normal skin. The level of control that one can exert using this simple but exquisitely sharp instrument is very fine indeed. The edges of the wound are sometimes further bevelled with fine wire diathermy if necessary and the result, if the removal is kept superficial, is excellent. This technique is particularly effective on the nose and on the concave areas of the face such as the temples, around the nose, eyes and ears.
The snipping procedure is appropriate for any spot that has begun to hang from the skin surface such as a mole or skin tag. It is often done without local anaesthetic as the snip is so swift that it is not felt. This painlessness is also attributed to the extreme sharpness and special design of the scissors.
Spot peeling
This technique uses strong caustic substances such as Trichloacetic acid and Phenol usually in relatively high concentrations. The substance may either be painted on the skin such in treating xanthelasma around the eyelids or it may be applied in point fashion down the centre of either a dilated oil gland (sebaceous hyperplasia) or down a dilated pore or deep ice pick scar.
The healing process
Time. If painted on, the resulting healing will generally follow the same time frame as that seen with the more general chemical cosmetic peeling process.
Scabbing. If point peeling is performed healing will produce a very small sometimes miniscule scabbing.
The painting is usually performed with a cotton swab after cleansing of all skin oils with acetone. The point peel is often done with a sharp instrument such as a toothpick dipped in the peeling solution.
Side-effects and complications
Side-effects are rare.
Scarring is occasionally seen with painting but such a small area is being done that this is not usually visually obvious even if it occurs.
A need for repetition. The main problem with point peeling is that it doesn't always work and it may need to be repeated.
Curettage
This instrument is very versatile despite being mainly used for skin cancer treatment. It has been used for acne cysts and its newer use is in lipoma removal. It gently scrapes away seborrhoeic warts and other surface lesions that have been loosened with glycolic acid or other peeling agents or after fine wire diathermy.
The curette can not be used in areas of loose or very thin skin such as around the eyelid. But correctly used in the treatment of non-cancerous spots, it is a very useful instrument.
Cortisone injections
This very simple technique is useful in the therapy of scars and cysts.
A dilute local mixture of local anaesthetic and cortisone is sufficient treatment for early scars after sugery or acne or other inflammatory cysts. More entrenched or thickened scars may require stronger concentrations of cortisone to settle these down.