20 February 2020
A chemical peel is a medical procedure that uses chemicals to improve the appearance of the skin on your face, hands and neck. These chemicals gently remove the top layer of dead skin cells and grime on the skin, allowing newer skin to reach the surface. This newer, generated skin generally looks younger and feels smoother with less wrinkles.
In Singapore, chemical peels are commonly used to treat acne and signs of aging such as pigmentation and wrinkles.
1. Lighter pigmentation
2. Lighter pimple/acne scars
3. Removal of comedones (blackheads and whiteheads)
4. Smoother skin texture
5. More even skin complexion
6. Brighter skin
7. Improvement in acne
8. Improvement in fine lines and wrinkles
As its name suggests, chemical peels make use of chemicals to cause controlled peeling of the skin, to remove the top layer of dead and dull skin, pigmentation, comedones and dirt. The chemical peel also causes collagen remodelling in the skin on top of allowing the newer skin underneath to reach the surface.
Different types of chemicals have different properties and one of the easiest way to classify chemical peels is according the depth of the skin that the chemical peel penetrates- superficial, medium and deep1. Of course, other factors such as the concentration of the chemical and duration that the chemical peel is left on the skin will also determine the depth of the peel.
Superficial; medium and deep chemical peels and the depth of the skin that they act on.
Superficial chemical peels (“light peel”) e.g. AHA, BHA, Jessner’s solution
Superficial chemical peels exfoliate the epidermal layers of the skin without going beyond the basal layer of the skin
Medium depth chemical peels e.g. 35-50% TCA
Medium depth chemical peels reach the upper layer of the dermis (down to the papillary dermis)
Deep chemical peels e.g. >50% TCA
Deep chemical peels reach all the way down to the reticular dermis.
Generally speaking, the deeper the chemical peel reacts, the greater the skin resurfacing effects of the chemical peel. This means that a deeper chemical peel will be able to treat more severe conditions and conditions that affect the deeper part of the skin (e.g. pigmentation or wrinkles that extend deeper in older patients) by virtue of the chemical being able to penetrate a greater depth in the skin. Deeper chemical peels are also capable of producing more remarkable results with each session with greater collagen formation in the skin too.
If deeper peels are more effective, why does it remain unpopular?
Samantha from Sex and the City after a chemical peel; it was very likely that a deep chemical peel was performed. Superficial and medium depth chemical peels do not cause redness of this severity.
The disadvantages of deeper chemical peels have resulted in deep chemical peel remaining as an unpopular choice in Singapore. With deep chemical peels, the risks of complications are higher and the recovery time required is longer. For example, superficial chemical peels cause very fine peeling which is almost imperceptible. Patients can resume their daily routine, skincare and makeup after a superficial chemical peel. There is no obvious redness or downtime required2. In contrast, a deep chemical peel usually requires general anaesthesia (because of the severe discomfort) and the immediate end result is akin to a burn (albeit a controlled one) with obvious redness, raw skin blistering and peeling3. The healing time can take as long as 2-3 months for the skin colour to normalise and the risk of complications such as worsening pigmentation (hyperpigmentation), scarring, hypopigmentation and skin infections are significant3.
Due to these reasons, superficial chemical peels remain the most popular choice of chemical peels in Singapore.
Why do I prefer to do superficial or medium depth chemical peels?
Besides the high risk of complications and recovery time required for deep chemical peels; my preference and that of most of my patients’ is for a superficial chemical peel because they are capable of achieving obvious improvement in pigmentation, acne, dull skin…etc. This is especially true when I combine modalities of treatment, for example, the Q-switched laser with chemical peels to achieve synergistic results without causing downtime or inconvenience for my patients.
For the chemical peels that I perform, I prefer to use single-use pads that come sealed individually for sterility. In this picture, I am using 35% acid; at this concentration, the chemical peel should only be performed by doctors.
In Singapore, chemical peels should only be performed by doctors with the requisite qualifications. You may have heard of beauty salons touting chemical peels performed by therapists; these therapists do not have training that is regulated by Singapore’s Ministry of Health and they should not be performing chemical peels especially since chemical peels can also result in complications.
Step 1: Cleaning
The face is first cleaned to remove makeup, dirt and sweat that would impede the penetration of the chemical peel.
Step 2: Application of the chemical peel
Applying the acid using soaked cotton pads to the face
The chemical peel is applied to the skin either using soaked cotton pads or a brush. A clock timer is started to time the chemical peel. The doctor continues to monitor your skin for any changes.
Step 3: Neutralisation of the chemical peel
Terminating the chemical peel by applying the neutraliser cream.
Once the skin has reacted and reached its end point, the chemical peel is terminated. The endpoint is a change in the skin which tells the doctor that it is time to end the chemical peel before the chemical peel becomes deeper than intended. The depth of a chemical peel also determined by the duration of time that it is left on the skin; on top of the type of chemical and concentration used.
Different types of chemical peels cause different types of endpoints. For some types of chemical peels, it is erythema (redness) of the skin; for some, it is frosting on the skin. The doctor performing your chemical peel will determine when and what is the appropriate endpoint for your skin condition.
The chemical peel is terminated by neutralising the peel with the application of neutralising cream or gel to the skin.
Done! Skincare and sunscreen and you are good to go!
A superficial chemical peel is generally very safe with no downtime when performed safely by an experienced doctor. With superficial chemical peels, there may be initial redness and skin sensitivity, but this is temporary and it disappears in a day or two. With medium depth chemical peels, there is also the risk of post inflammatory hyperpigmentation or worsening of pigmentation if sunprotection is not adhered to. There is also a risk of skin infection with medium depth chemical peels.
I have been performing chemical peels on myself (perks of being a doctor) and my patients for years now and I feel that for common skin conditions such as comedones (i.e. blackheads and whiteheads), pigmentation, dull skin, acne and uneven skin tone are concerned, chemical peels are extremely helpful.
Chemical peels may have earned a bad reputation in the past because of the severe complications that have resulted with deep chemical peels; but the trend for most doctors in Singapore is to move towards safer treatment options (i.e. superficial chemical peels) that are also effective.
If you have blackheads and whiteheads, chemical peels are a very effective way of having them removed without requiring painful extractions or your face steamed. These comedones need to be removed; but I have seen a disproportionate number of patients who end up with scars and even larger pores after extractions by their beauticians. I do my own chemical peels monthly to treat my own blackheads and whiteheads and I can attest to the safety and efficacy of chemical peels.
I also get a chemical peel and Q-switch monthly to treat my pigmentation and for general maintenance. By gently peeling off the top layer of the skin, skin is renewed for brighter skin and lighter pigmentation. I have a pigmentation condition called melasma that developed soon after my pregnancy and by treating Q-switch laser and chemical peels combined, I have managed to erase all my pigmentation so I can go makeup free every day, even at work.
For women who may be pregnant or breastfeeding, chemical peels are still a safe option but please be sure to check with your doctor on his/her choice of chemicals- some chemicals have not been proven to be safe for pregnant or breastfeeding mothers. My practice is to stick to chemicals that are safe for pregnant or breastfeeding mothers.
What should I expect after a chemical peel?
After a superficial chemical peel, there may be temporary redness and discomfort, which lasts for 1-2 days at the most. There may also be very transient skin sensitivity, especially to acids or exfoliating skincare. You can resume your skincare and makeup after a superficial chemical peel.
Do I need special skincare after a chemical peel?
For a superficial chemical peel, a simple facial wash; moisturiser and a broad-spectrum sunscreen is all that is required. You can resume makeup on the same day of the superficial chemical peel too.
How often can I have a chemical peel
My practice is to have a 4-week interval between each chemical peel.
Our skin’s natural cycle of production and replacement takes 28 days. The outermost layer of our skin is made up of dead skin cells called the epidermis. The cells in the epidermis are constantly removed by flaking or rubbing off. The cells in the epidermis are constantly replaced by newer skin cells that are formed deeper in the skin, which gradually move towards the topmost layer of the skin.
By allowing sufficient time for your skin’s natural cycle of production and replacement, there is no chance of thinning the skin.
Do chemical peels thin the skin?
Chemical peels, when performed at the correct intervals do not thin the skin. On the contrary, chemical peels have an added benefit of enhancing collagen formation in the skin, which adds a slight increase in the skin thickness microscopically.
However, when chemical peels are performed too frequently, before the skin has had enough time to replace itself, then there is a risk of causing thinning and redness of your skin.
Is there anything that I need to avoid with a chemical peel?
After a chemical peel, minimise your sun exposure to prevent worsening of pigmentation. Acids such as AHA and BHA in skincare can also be more irritating so avoidance of acids in skincare is advised.
Harsh, physical scrubs and astringent skincare should also be avoided in the first few days after a chemical peel to minimise skin irritation.
Can;laser treatments be treated with chemical peels?
Flat, dark acne marks or pimples marks can be treated with chemical peels to lighten them. When combined with Q-switched laser, there is faster removal of these marks.
Depressed acne scars, however, do not benefit greatly from chemical peels. Fractional CO2 laser is still regarded as the gold standard for resurfacing depressed acne scars. TCA cross peels (a deep chemical peel where 100% TCA is used) were used to treat these depressed acne scars but due to the high rate of complications and side effects of deep chemical peels; TCA cross peels are less commonly done now and fractional CO2 laser is now the standard of care for most types of depressed acne scars.
My review and personal experience with Fractional CO2 laser in How to Get Rid of Large Pores: Myths and Truths
Am I suitable for a chemical peel?
Unless you have an ongoing skin infection or eczema flare or isotretinoin therapy for the last 6 months. If you have a history of autoimmune skin conditions such as psoriasis and atopic dermatitis you may experience protracted healing and prolonged erythema.
If I have dark skin, can I still have a chemical peel?
There has been concern that patients with darker skin have a higher risk of complications such as increase in pigmentation (post inflammatory hyperpigmentation) or complete loss of pigmentation (hypopigmentation). This concern applies mainly to deep peels. In fact, patients who belong to ethnic groups with darker complexions respond well to superficial chemical peels2.
Patients with darker skin complexions respond well to superficial chemical peels. When treating patients with darker complexions, I usually use a lower concentration of chemicals when doing superficial chemical peels and this has been effective in treating a variety of conditions such as pigmentation and acne without incurring any downtime or complications for patients.REFERENCES 1. Chemical peels. Monheit GD, Chastain MA. Facial Plast Surg Clin North Am. 2001; 9: 239–255. 2. Chemical peels. Jackson. Facial Plast Surg 2014;30:26– 34. 3. Deep-depth chemical peeling. Maloney BP and McCollough EG. Facial Plast Surg. 1995 Jan;11(1):30-8.