PEELING PARTICULARS Chemical peeling plays an integral role in the provision of remedial skin care and medical aesthetics, writes Karen Ellithorne.  With an extensive range of active ingredients available, peels can offer versatile yet adaptable treatment for a wide variety of skin conditions namely: • Skin ageing, skin laxity and loss of volume • Fine lines and wrinkles • Hyperpigmentation and irregular tone • Acne and acne scarring • Open pores and coarse texture • Congested and sluggish skin • Rosacea Defining the different levels Superficial Peeling  These are generally achieved when working with mild AHA’s and BHA’s which act on the skin surface (Stratum Corneum) by gently breaking down the adhesion of the keratinocytes and dissolving the protein bond which binds them together. This will bring about a gentle exfoliation. You will very seldom experience any form of frosting on the skin when working at this level. Medium depth  Medium Depth peels can be achieved when working with AHA’s and BHA’s but at a stronger concentration and therefore will work at mid epidermal level ( Stratum Granulosum). The exfoliation effect will move up through the layers of the skin towards the surface, resulting in flaking of the epidermis and a thinning effect on the Stratum Corneum. When preforming a treatment at this level you may experience a rosy frost on the skin which indicates partial de- epithelialization. Deep Chemical Peels Using a higher concentrate of peeling agents will cause a detachment of the keratinocytes and consequent epidermolysis, whereby the entire epidermis will sheath away from the dermis to be renewed and regenerated. With these types of peels the skin will frost completely white and this will indicate that the peel has reached the papillary dermis.  These types of peels are doctor only peels and an occlusive dressing would need to be applied to the skin during the healing period. The different chemical peeling ingredients Alpha hydroxy acids or AHA’s are acids that are derived from fruits, nuts, milk or sugars. They are hydrophilic (attracted to water) and break down the bonds between cells (desmosomes) to allow for easier removal of dead skin cells. Below are the more common AHA’s that are found in formulations. • Glycolic acid is derived from sugar cane juice and fruit. It is degreasing and is effective for controlling sebum production and also good for treating photo ageing on the skin. • Malic acid is derived from apples and is hydrating, soothing and increases tissue respiration. • Tartaric acid is found in grapes is a strong antioxidant. • Mandelic acid is derived from hydrolysis of bitter almonds and is mostly used to help control pigment and photo ageing. • Citric acid is found in citrus fruits and corn. It has a strong anti-aging, brightening action. • Lactic acid is derived from sour yogurt and has an antimicrobial and hydrating action.  It also able to inhibits pigment and adjusts ph. Alpha hydroxy acids are commonly used in skin care to brighten the skin by increasing exfoliation. Citric and lactic acids are beneficial in that they are both biocompatible and have multiple benefits. BHA (beta hydroxy acids), the most common of which is salicylic acid, is derived from willow tree bark, wintergreen oil or sweet birch. Because salicylic acid is lipophilic (attracted to oil) and keratolytic, it is able to penetrate the oils in the skin and clear out follicles of excess debris and skin cells, making it especially effective in the treatment of acne skin conditions. PHA (poly hydroxy acids) function the same as AHA, but cause less irritation due to their larger molecular size. They are especially beneficial in treating sensitive skin types that may not be able to tolerate AHA. They provide anti-inflammatory and antioxidant benefits as well as assist with exfoliation. Some common PHA’s are: • Lactobionic acid is derived from lactose found in cow’s milk, it is humectant, antioxidant and soothing ingredient. • Galactose is a sugar utilized in glycosaminoglycan and collagen synthesis, and cell migration, which may enhance wound healing. • Gluconic acid is a naturally occurring ingredient in cells, also known as gluconolactone in skin care products. It is an antioxidant and anti-inflammatory, while possessing AHA properties. There are two more peeling ingredients that can be found in peeling products that are not part of the fruit acid family, they are as follows: • Trichloroacetic acid (TCA) which is generally used to treat moderate photo ageing, wrinkles, pigmentation acne scarring and very useful in the recovery of skin texture and general skin tone. This particular acid is a layer dependent ingredient and not time dependent unlike the AHAs • Phenol is one of the strongest chemical solutions available and produces a deep skin peel. The effects of a phenol chemical peel are long lasting, and in some cases can still be apparent up to twenty years later, Phenol peels are used to treat thickened, wrinkled sun damaged skins. Why are PH levels in peels important? The skin is made up of mainly protein, water and other minor chemicals? Proteins are very complex chains of amino acids and they are very sensitive to the level of pH surrounding them. When the skin's proteins come into contact with an acid product with a low pH, coagulation will occur. The acid destroys the existing bonds that hold the keratinocytes together so they can be exfoliated be replaced by fresher younger skin tissues. The lower the pH - the stronger the peel and the more coagulation will take place. This is a non-reversible reaction where the proteins bonds in the skin are destroyed. Frosting is what you see when this process takes place. What is Buffering? Buffering is when the natural pH level of an ingredient or product is altered. It can be used to either increase or decrease a pH level when mixing chemicals. Buffered and non-buffered products can carry the same percentage of an active ingredient, but the strength of the ingredient will vary greatly. The reaction of a peel is slower and the coagulation will be less if a peel is buffered.  Why would one patient peel more than another? This amount of visible exfoliation on the skin would depend on the current state of the skin in combination with atmospheric conditions and the fact that the skin does not peel, is not an indication of the fact that the peel is not working. You will find that not all patients will have the same treatment experience.  If you live in a humid area like Natal your patients will experience less peeling than if you live in Gauteng where it is drier. You will also notice that patients that do not have regular treatment will have more visible peeling than a patient who comes in regularly for treatment. Also if a customer suffers from hyperkeratinisation, they may require three to four treatments before they start to experience peeling due to the dead skin build up on the surface. Chemical peeling is a great way to introduce aesthetics into you practice as they are cost effective treatments to offer  and can be used across the board on most skin types. Peels are less risky than purchasing machinery and equipment and you will still have very pleasing results and happy patients.