Dr Milojevic discusses pigmentation in the Aesthetics Magazine
Practitioners share advice on how to safely and successfully treat hyperpigmentation with chemical peels
Sun exposure, hormonal activity and general ageing can all contribute to the development of hyperpigmentation, which is often a significant concern for aesthetic patients. The darkened patches of skin that appear as a result of increased melanin production can vary in size and appear anywhere on the body,1 although, according to the practitioners interviewed for this article, patients generally request treatment for those on the face.
“My patients are often hugely stressed by hyperpigmentation; often placing more importance on treating it over lines and wrinkles,” says German board-certified dermatologist Dr Stefanie Williams, who runs Eudelo in London, and notes that hyperpigmentation is the most common reason people visit her clinic. Aesthetic nurse prescriber Kelly Saynor, founder of Renew Medical Aesthetics in Cheshire, agrees, saying, “They can become a bit depressed, in the same way as those patients suffering from acne, and feel the need to cover up their skin.”
While lasers are well known as an effective treatment for hyperpigmentation, this article will focus on key considerations when using chemical peels to treat the common aesthetic concern.
Aetiology
Hyperpigmentation is a result of an overproduction of melanocytes, the pigment-producing cells that are located in the basal layer of the epidermis.2,3 According to the practitioners interviewed, there are three main causes for its occurrence. These include:
Sun exposure: “I have found that the most common form of hyperpigmentation is sun damage,” says Saynor, noting that it can affect patients of any age. If skin is over-exposed to sunlight then it can increase pigment production, leading to hyperpigmentation.1 Aesthetic nurse and founder of MBA Clinics, Petrina Nugawela, explains that sun damage tends to be located superficially, so is fairly easy to treat.
Hormonal influences: Most commonly, hyperpigmentation presents itself as melasma as a result of hormonal changes, due to pregnancy or taking contraceptive pills, and can be difficult to treat. As such, it is often referred to as ‘the mask of pregnancy’.1 “If patients are on the contraceptive pill you will have real trouble getting a good result,” says Dr Williams. “It is worth discussing this with the patient to see if they would consider changing their contraception ahead of treatment,” she adds.
Post-inflammatory hyperpigmentation (PIH): Following damage to the epidermis or dermis, inflammation can trigger melanocytes to increase melanin synthesis and transfer the pigment to the surrounding keratinocytes.3 Aesthetic practitioner Dr Xavier Goodarzian, founder of the Xavier G. Clinic in Southampton, says, “PIH is luckily easy to treat with skin lightening topicals and generally clears up well.” Although, it is important to note that the pigmentary changes as a result of PIH can occur with greater frequency and severity in Fitzpatrick skin types IV-VI.4
Consultation
Understanding your patients’ expectations from treatment should be the main priority of any consultation, says Dr Nick Milojevic, aesthetic practitioner and founder of the Milo Clinic in London. Saynor highlights that many of her patients have unsuccessfully tried lots of over-the-counter (OTC) creams and other treatments before presenting to her clinic. “Patients may have over- or under-used products, or just been using the wrongs ones,” she says. As such, Saynor emphasises that practitioners also need to find out how long they’ve had the hyperpigmentation, how they feel about it, what treatments they’re prepared to undergo and how much they’re prepared to spend – “Be tactful and go in with trepidation,” she suggests. Once you’ve established their expectations, the practitioners advise that you then need to carefully outline what can be achieved with chemical peels, the side effects that patients will experience and the complications that could occur.
Saynor adds that ensuring your patient understands that hyperpigmentation can never be completely eradicated is essential. “We can suppress it with the products we put on topically, but it can come back. As long as patients understand that and comply with your pre- and post-procedure advice then they will be happy,” she says.
Then, you can move on to tailoring treatment to your patient’s individual requirements. “The best thing to do is to make sure you understand where the pigment has come from,” says Dr Goodarzian, advising that practitioners should ask for a past medical history, as well as a family history to try to establish an accurate skin type. In addition, he advises practitioners to ask patients what products they currently use on their skin and what treatments they may have undergone in the past. “I would then recommend using something like a Wood’s lamp or an imaging device to look at deeper pigmentation under the skin, to understand and demonstrate to the patient the type and extent of their hyperpigmentation.”
Dr Williams agrees, adding, “The first thing I do is diagnose what type of pigmentation it is by thoroughly examining the skin and doing a digital face scan, with a Wood’s lamp where we can look under the skin, as well as on the surface. Once we have a diagnosis we then look at how the patient would be treated.”
Treatment
The practitioners agree that having a thorough understanding of the different Fitzpatrick skin types and how they react to chemical peels is an essential part of your treatment approach.
As mentioned above, while using chemical peels on Caucasian skin is generally considered safe, treating darker skin types carries an increased risk of developing PIH.4 Nugawela explains that approximately 80% of her patients are Asian. She says, “If you are treating darker skin, you have to be able to make an assessment on skin colour and texture. You cannot always go with the basic instructions on a piece of paper, you need to be able to make that visual judgement for yourself and never take a risk with a patient.”
She continues, “With higher Fitzpatrick skin types, you have to be so careful and treat every patient as an individual. You could have 10 people in front of you who have the same colour skin tone, but they all react differently.” Nugawela advises that practitioners should apply a very thin layer of product to begin, and carefully watch how the skin reacts. “You don’t leave the patient; you don’t take your eyes off them,” she emphasises.
Superficial and medium-depth peels are used to treat hyperpigmentation, while deep peels are generally reserved for lines and wrinkles. Careful skin priming and the appropriate selection of peel is essential for successful treatment. However, it is important to note that the peeling solution alone does not necessarily determine the depth of the peel. Depth can be determined by a number of factors including the concentration of the solution, the pH, the availability of free acid, the length of time applied to the skin, the condition of the skin, and the method of application.5
Skin preparation
Prior to treatment with chemical peels, practitioners advise priming the skin with topical de-pigmenting agents, which act as an adjunctive to treatment and can enhance the effect of the peeling agent.4 This also allows practitioners to identify any potential sensitivity to ingredients that may be used later with the peel. The ingredients included in such de-pigmenting agents usually contain a combination of ingredients such as hydroquinone, azelaic acid, kojic acid, licorice extract and retinoids, amongst others, which work to lighten the skin and create an even-toned appearance.6
In addition, Dr Williams recommends that patients use an antioxidant serum and an SPF. Her product of choice is Kligman’s Formula, a prescription-only formulation, which she describes as the ‘gold standard of anti-pigment treatment’. For Dr Milojevic, the Obagi Nu Derm System is his topical product of choice prior to a chemical peel. He recommends that patients use it every morning and night for three months, and visit their practitioner once or twice during this time to check the skin’s progress. “If the patient is examined thoroughly by a practitioner and appropriate dosages are prescribed for home use, then results can be hugely successful,” he says. Dr Goodarzian, on the other hand, has had particular success with Dermamelan, which aims to pause the skin’s melanin production to reduce the appearance of skin blemishes caused by excessive melanin.7 Once a treatment approach has been decided, Dr Goodarzian explains that he creates a skincare programme for each of his patients. “I specifically write down a programme with one to four steps for the morning and night. I try not to make it too complicated as people generally don’t want to spend too long putting creams on their face,” he says, adding, “However, for treating hyperpigmentation, the routine does tend to be a little more complicated so I do try to ensure that patients understand the importance of following it precisely.”
Dr Goodarzian emphasises the importance of using sun protection in each of his programmes and recommends that patients use an SPF 30 or above every day. The practitioners agree that getting patients to comply with staying out of the sun and using protection on a daily basis, regardless of the weather, is one of hardest issues to combat. Dr Williams says, “Patients underestimate the importance of sunscreen; one day of sun can essentially undo three months’ worth of treatment.”
Superficial peels
For patients suffering from mild hyperpigmentation, or for those who do not want the discomfort and downtime associated with a deeper peel, there are a number of types of superficial peels that can be used with reliable results.
Alpha hydroxy acids (AHAs) and beta-hydroxy acids (BHAs) are applied as the peeling agents for superficial peels, as they work to penetrate the epidermis, break the bond between the keratinocytes and allow for faster exfoliation of those skin cells. The most common AHAs are glycolic acid and lactic acid, although they can use a number of different formulations including citric acid, phytic acid and kojic acid.
Dr Goodarzian explains that while the AHAs main role is to exfoliate the skin, their secondary role is to lighten the skin by having an influence on the physiology of the melanocytes’ pigment production.9 According to Dr Goodarzian, patients usually need a minimum course of four AHA-based peels, although it can be up to eight, spaced two weeks apart for effective results. His current products of choice include the Neostrata peeling range, which he says offers different percentages of glycolic acid, as well as citric acid and mandelic acid packaged separately so that you can mix with the glycolic acid as needed. “They’ve been around a long time and have got brilliant data in regards to efficacy,” he says. At each clinic session, Dr Goodarzian advises that practitioners should check that the skin is healing properly and is progressing at the rate it should be. With superficial peeling there is minimal downtime, he says, noting, “Patients won’t need to take time off work, even if they’ve had six peels.”
Salicylic acid is the most frequently used beta hydroxyl acid (BHA). It is different to AHAs as it is lipophilic, whereas AHAs are water-soluble, which is why salicylic acid is often chosen to treat oily and acne prone skins.8 Nugawela says that she uses mainly glycolic and salicylic acid-based superficial peels and highlights that she has had successful results with both the Jan Marini glycolic acid portfolio for its high safety record and the salicylic acid-based Obagi Blue Peel RADIANCE, which she says is a bit stronger than a glycolic acid-based peel but does not stress the skin. “I love Obagi Blue RADIANCE as patients feel like they’re having something done as there is a little burning sensation but it doesn’t irritate the skin,” she says. In addition, she notes that the fact that the peel changes colour (from a blue to white frosting on the skin) is a really good indication for how well the product is working and when to stop application.
While superficial peels are effective at treating the outer layers of the skin, particularly for sun damage, and taking a more gradual approach to skin improvement with minimal downtime, some patients may require a deeper treatment and request quicker results. As such, a medium-depth peel may be appropriate.
Medium-depth peels
“Medium-depth peels have a better chance of being able to suppress and reset the skin,” says Saynor, although she does note that sometimes it will get worse before it gets better. Medium-depth peels are most commonly performed with trichloroacetic (TCA) acid and Jessner’s solution, in various combinations and concentrations.10 and typically result in a patient’s skin peeling for a week following treatment, so it is essential that they are prepared for the downtime. Dr Goodarzian says, “TCA can look weird but you can still go out – it just looks like you’ve got cling film on your face. Patients will start peeling after about two to three days, and on day three, four and five it looks really obvious that the patient has had something done, so most patients prefer to stay at home.” Dr Williams uses peels from a range of different brands, including NeoStrata, Sesderma, Image Skincare and the SkinTech Easy Peel. “I’m not saying these are the only good ones,” she says, adding, “Practitioners should look at the clinical trials and evidence behind products before deciding on a peel brand – also, you can’t compare peels directly, even if they have the same concentration of active ingredient on paper.”
For Saynor, her product of choice is The Perfect Peel, a product distributed by her company Medica Forte. The peel is made up of glutathione, vitamins and minerals, and five different types of acids, all at low percentages, that work together aiming to reduce pigmentation, correct wrinkles, exfoliate the skin and reduce inflammation.11 Saynor says, “It allows the practitioner to bridge the gap between the old and new style peels.”
Following any type of peel, Saynor emphasises that patients should aim to keep their skin hydrated, with the use of a cosmeceutical hydrating product that has active ingredients, rather than an OTC moisturiser, to further enhance the results of the treatment.
Side effects and potential complications
As expected, the main concern with undergoing a chemical peel treatment for patients is the peeling itself. “Following a superficial peel, there may be faint flaking after a couple of days, but very often not even that,” says Dr Williams.
Medium-depth peels, on the other hand, are associated with much longer downtime, with skin peeling for, on average, up to three weeks. In addition, the practitioners interviewed all say that patients are very often tempted to pick at the peeling skin, which can have serious implications. “If you’re picking at scabs, greatly increases the risk of scarring and can potentially also create an entry point for bacteria so, in theory, you have a higher risk of infection,” explains Dr Williams, although she notes that she has never seen this in practice.
Dr Goodarzian adds that infection is either bacterial or viral and the practitioner should treat accordingly. “You would normally see red patches or, in a worst-case scenario, pus-filled spots with a bacterial infection,” he says, noting that these are easily treatable with antibiotics. However, a viral infection could result in herpes simplex virus (HSV). “You should always ask patients if they have any cold sores and cover them with HSV treatment prior to the peel,” he says, adding, “If you don’t there is a risk that they do get herpes and it can spread across their entire face, which can lead to severe scarring and pigmentation problems.”
Dr Goodarzian notes that there is sometimes a misunderstanding that superficial peels can’t cause scarring. This is very wrong, he says, explaining that it is possible to get scarring as a result of a superficial peel if the skin has been too well prepared, is overly sensitive or if product has been left on for too long. “Even with a 50% glycolic acid peel it is absolutely possible to get scarring so it’s important to stick to the protocols,” he says, adding, “Don’t leave the peel on for too long and if you do start to see a negative reaction then neutralise and remove the peel immediately.”
Dr Goodarzian advises that practitioners should start using peels with a low percentage before working their way up. “I would recommend you stick to somewhere between 15-20% and layer it up, which will drastically reduce the risk of scarring,” he says. Although rare and not something seen by the practitioners interviewed, they explain that some patients can suffer an allergic reaction to a chemical peel. As such, it is important to monitor the skin closely through both the preparation phase and the peeling phase, and remove the product used immediately if an adverse reaction begins to occur. Finally, Dr Goodarzian says, “A good consent form is really important, as well as good aftercare instructions that people take home, read and really understand what they need to be doing. In addition, having a system where patients can call you or the clinic if there are any issues is hugely valuable.”
Education is key
While chemical peels offer promising results and improvements to the appearance of hyperpigmentation, they do not come without their risks. Having thorough training in their application, as well as a high level of understanding of treating different skin types and how to manage complications is hugely important to safe and successful results. Dr Goodarzian says, “Please make sure you get training; don’t just think you can buy something off the internet and slap it on. Educate yourself; read about it. The two textbooks I recommend are The Textbook of Chemical Peels by Dr Philippe Deprez and Obagi Skin Health Restoration and Rejuvenation by Dr Zein Obagi. If you read these books as background, they will really help you with the basics of peels.”
Saynor adds, “The skin responds differently from person to person, so make sure you do your homework, listen to your peers, attend as many courses as you can and really understand your patients’ skin.” In addition she says, “Don’t think you can get into peeling overnight – everyone will get that patient who doesn’t respond as you think they will, so it is imperative that you armour yourself with knowledge so that you are able to look at the skin, assess it correctly and treat it appropriately.” Dr Williams concludes by emphasising the importance of also educating patients on the damage that can be caused by the sun, and how to make the most of their treatment. She says, “In most cases, we can’t switch off the internal reasons why you have a predisposition to hyperpigmentation, however we can change patients’ attitude to the sun, which goes a long way.”
Disclosure: Kelly Saynor is the owner of Medica Forte, the distributor of the Perfect Peel.