Significantly Reduce Redness and Downtime of Chemical Peels

I've been experimenting with a new topical that I'm really excited about using in conjunction with my TCA chemical peels, and I've detailed some of what I've found. 

If you've ever done a chemical peel, you know how erythema (red, hot, and inflamed skin) affects the downtime following a peel. One of the most challenging aspects of chemical peels is the DOWNTIME! I have to hide out in my house for 3-5 days, depending upon the peel. It becomes difficult to schedule around work, family, friends, and other community obligations--especially being a teacher. So anything that reduces the downtime, as long as it also contributes to healing and a positive outcome, is great!

THE RESEARCH

I'd been researching a topical to use for my rosacea. I found Azelex, which contains 20% azelaic acid. I have been using 50% TCA on on some age spots on my forehead, and had used the azelaic acid all over my face, but noticed that those treated spots were barely noticeable and healed very quickly, so I decided to it might be worth a try an an all-over treatment during a chemical peel.

After researching this ingredient, I found that it reduces post-inflammatory redness and hyperpigmentation--and it aids significantly in wound healing. Here's information on the Properties and Mode of Action.

According to the research, "Azelaic acid (AzA) has profound anti-inflammatory, antioxidative effects, and is bactericidal against a range of Gram-negative and Gram-positive microorganisms as well, including antibiotic-resistant bacterial strains. In addition, AzA's antikeratinizing effects are inhibitory toward comedones."

Yes, I know that the word ACID makes you do a double-take, but remember that in chemistry, it simply refers to a molecule or other entity that can donate a proton or accept an electron pair in reactions.

I was concerned though about mixing an "acid" with a chemical peel, so I continued my research and found this study where they combined glycolic acid and AzA. They saw a significant success, so that's what led me to finally try this.

One of my concerns was that a cream to help healing would cause a bad breakout (those antibacterial ointments and some lotions do that to me), but AzA is actually used to reduce acne, and it works great for me in that regard.

Here are a couple pictures so far; I’ll post again in a few days as I move through the healing process:

BEFORE: I have always focused chemical peels around my mouth because that's my problem area. I don't have any lines on my forehead or cheeks. I'll be 52 in February. 

Wearing physical sunscreen and powder

FROST
Yikes, it hurts! I applied 25% TCA in multiple layers (3 layers) with my fan brush for applying peels and let it sit for about 1 minute. Excuse my gaping mouth, but I've learned to apply it with my mouth open so that the solution can get to those tiny lines that are hidden or closed when my mouth is closed. I rinsed with copious amounts of cold water to neutralize. Basically, I just kept rinsing until the pain stopped.

Click on the image to enlarge.

Frost of 25% TCA Chemical Peel in 3 Layers

After rinsing to neutralize the TCA, I immediately applied my copper-peptide lotion, and then I applied 20% azelaic acid that I got as an Rx from my doctor in a medication called Azelex, and that's what I applied on top of the copper-peptide lotion. I left these on overnight since I did the peel at 6pm.

If you can't get an Rx, this serum is a great alternative. It contains Azelaic Acid,  Arbutin, and Hyaluronic Acid. Be careful not to order the one with vitamin C as this can burn if the pH level is too low. You can Contact this seller, and they'll make it without vitamin C and/or add/increase other ingredients since they create each batch as you order it. I think that's a great option--it's fresh and customized.

36 HOURS
Yesterday morning, I cleansed as usual and applied the copper-peptide lotion, Keys Solar Rx with zinc, and the 20% azeliac acid. I had to reapply the copper-peptide lotion several times during the day to keep the area moist, but I just dabbed it on top. Remember to use copper on the face ONLY when peeling and healing; this mineral is too strong for normal, healthy skin.

The pictures below are at 36 hours after the initial TCA application on Saturday evening.

You can see that the area is just starting to peel around the corners of my mouth, but what's really incredible is that the redness is so minimal. It's almost as if I didn't do a peel at all. This really seems to make the downtime tolerable. In fact, I went to the store! I never would have gone out before.

Click on the image to enlarge.


36 hours after 25% TCA peel: copper lotion + zinc sunscreen + azelaic acid

I included a whole-face picture here to show the lack of demarcation between my normal skin color and where I applied the TCA just 36 hours ago. There is so little difference that this is a game changer in downtime.

Click on the image to enlarge.
36 hours after 25% TCA application: copper lotion + zinc sunscreen + azelaic acid

48 HOURS:
There's still no significant redness, although I am starting to peel on the same schedule I usually experience. The area is a little pink, but I don't see the leathery, red or brown, irritated skin that I usually have at this point. There's no question that it would still be impossible to have an event scheduled this evening, but it's easier to not look like I've been using a blow torch on my face.

I tried to take a close-up picture to show more detail. Click on the image to enlarge.

48 hours after 25% TCA application: copper lotion + zinc sunscreen + azelaic acid

60 HOURS:
I woke up this morning and took this picture, so I'm really dry and afraid to move much before moisturizing in fear of cracking the skin. Still no significant redness or leathery look, but I'm continuing to peel. I expect much will peel today. Click on the image to enlarge.

60 hours after 25% TCA application - just woke up

66 hours after 25% TCA: copper lotion + zinc ss + AzA
This peeling should be done--or most of it--by 6pm, which is the end of day 3 or 72 hours after initial application, and I really didn't look hideous until last night/this morning. Looks like there's a 24-hour period of downtime for the peeling, which trims off at least a full day. Because there doesn't seem to be any major redness, I can still run errands and do other activities that won't require me to look presentable. I'm so excited to find a topical that makes downtime more tolerable. This truly changes the way I can perform TCA peels.

If you're interested in other ways to reduce downtime, look at this post on how to reduce swelling and inflammation


Use Caution when Combining some Supplements, Foods, and Medications with Chemical Peels

Those of us plagued with acne, even mild, have great results with chemical peels. Others choose oral prescription medications to control acne, and one common medication is Accutane, roaccutane, or isotretinoin.  Even doses as low as 10mg per day show incredible results for many people, but do NOT combine isotretinoin and chemical peels! Also, females taking isotretinoin are required in the United States to take two forms of birth control since this medication causes birth defects.

Even a low dose of only 10mg per day does not mix well with any type of chemical peel. The recommendations are to wait a minimum of 90 days after the final dose of isotretinoin before performing a light chemical peel, although six months is probably safer.

These photos show the results of combining 10mg per day of isotretinoin with a 70% glycolic acid peel:
 
10mg/day isotretinoin + 70% glycolic acid peel


The hyperpigmentation will require other treatments, such as corrective laser or chemical peels, although some fading can be achieved with a mild glycolic acid peel used 2-3 times per week in conjunction with a good physical sunscreen.

Typically, if a medication or supplement will cause increased sensitivity to UV rays, that's a red flag that it shouldn't be mixed with a chemical peel; however, I would ask my prescribing healthcare provider about doing a peel while taking medication. I never like to leave these details to anyone else, so I'd verify anything someone tells me--or thoroughly investigate it myself. 

Even some sunscreens increase UV sensitivity, so I would investigate other items I consumed and/or applied before a chemical peel. I would investigate medications, supplements, product ingredients, or even certain foods. 

Here's a list of items known to increase UV sensitivity, so I'd investigate further if I were considering a chemical peel:

  • Acne treatments: Creams and astringents with benzoyl peroxide. Prescription drugs including Accutane, doxycycline (an antibiotic), and Soriatane.
  • Antihistamines: Benadryl and other products with diphenhydramine.
  • Antibiotics: Tetracyclines, including Sumycin, Tetracyn, and Vibramycin (doxycycline). Sulfa drugs including Bactrim and Septra. Quinolones, including Cipro and Levaquin.
  • Antifungals: Griseofulvin, including Grifulvin V, Fulvicin P/G, and Gris-PEG.
  • Anti-inflammatories: Prescription and over-the-counter nonsteroidal anti-inflammatory pain relievers, including Celebrex, naproxen (Aleve), and ibuprofen (Motrin, Advil).
  • Chemotherapy drugs: Imatinib and dasatinib.
  • Cosmetic treatments: Microdermabrasion, chemical peels, laser treatments, exfoliating facial scrubs.
  • Diabetes: Sulfonylureas including Diabinese (chlorpropamide) and glyburide (Micronase, DiaBeta, Glynase).
  • Diuretics: Hydrochlorothiazide (HCTZ), used to treat high blood pressure. Lasix (furosemide). Combination drugs with HCTZ include Dyazide, Hyzaar, Maxide and Zestoretic.
  • Foods: Celery, citrus fruits (such as lime peel), dill, fennel, parsley, parsnips, and artificial sweeteners.
  • Heart medicines: Amiodarone (Cordarone), nifedipine (Procardia), quinidine (Quinaglute and Quinidex), and diltiazem (Cardize, Dilacor, and Tiazac).
  • Herbal remedies: Dong quai, St. John’s wort.
  • Perfumes: Lavendar, cedar, bergamot oil, sandalwood, rose bengal, musk, 6-methylcoumarine.
  • Psychiatric: Tricyclic antidepressants such as Norpramin and Tofranil; the antipsychotic medication chlorpromazine (Thorazine).
  • Skin care products: Check ingredients for alpha-hydroxy acids (AHAs), beta-hydroxy acids (BHAs), salicyclic acid, glycolic acids, Retin-A, and hydrocortisone.
  • Sunscreen: Benzophenones, dibenzoylmethane, oxybenzone, cyclohexanol, salicylates, cinnamate, and PABA (para-aminobenzoic acid).

List provided by WebMD. Photo from
"Severe hyperpigmentation and scarring following glycolic acid peel treatment in combination with low-dose isotretinoin" by Peter Arne Gerber,corresponding author Gabriela Kukova, Edwin Bölke, Bernhard Homey, and Evelyn Diedrichson.


Chemical Peels with Rosacea? Yes.

Do you have adult acne? I thought I did too.

I discovered a few years ago, when I started getting acne in my 40s, that it wasn’t acne at all. It was rosacea, type 2, referred to in the medical world as P&P or papulopustular rosacea. Sounds pretty, eh? "Most people classify rosacea into four types," says Sandra Marchese Johnson, MD. “Papulopustular rosacea or inflammatory rosacea’s key symptom is chronic red [patches] on the face, as well as an outbreak of red bumps and pimples. These bumps, known as pustules and papules, are different from actual acne and require a different treatment." [1]

This is a picture with a rosacea flare on my face: red, inflamed bumps that look like pimples somewhat, rough, tight skin. This is not an easy picture to post, but I think it's important for people to understand that rosacea skin SHOULD be treated with peeling agents. It's really the only thing I've found that keeps my skin clear, and I've used metro gel, azeliac acid, steroids, antibiotics, and more. 




Here's my skin now: click both to enlarge.


My keys to successful chemical peels with rosacea are …

1.      Dr. Steven Wallace in Manhattan says, “get the rosacea under control before doing anything else,” [2] and I totally agree. Find triggers and avoid them! This is a time-consuming process, but well worth it. I won’t bore you with how to do that, but post a comment if you’re interested and I’ll reply on the method that worked for me.

2. Use a gentle chemical peel agent on a regular basis, such as 5% glycolic acid in combination with 2% salicylic acid; alternate these on an interval that works with skin type and problems. BHA is also a great anti-inflammatory agent, so this will help! I use one of these every night, although I substitute the glycolic acid with retin-a about 3 times a week.

3. Do not proceed with a scheduled chemical peel if flaring; wait until flare is completely gone. My medium chemical peel of choice is TCA at about 25%, and I try to do this at least three times a year.

4. Stop the daily exfoliants 3-10 days before the scheduled chemical peel, depending upon skin condition

5. Clean up diet, which will help flares and contribute to better skin overall

6. Get a copper-based healing moisturizer to use post-peel only; don’t use this regularly because too much copper is bad for the skin but great for healing

7. Find a good zinc-based sunscreen to use every day, not just after the peels

I've linked the products I've found to work best with my skin.

[1] http://www.webmd.com/skin-problems-and-treatments/rosacea-symptoms
[2]  http://www.realself.com/question/mild-rosacea-chemical-peel-before-after-ipl-photofacial

Should I use an AHA or BHA?


Combination 

Glycolic acid, an AHA, is a good choice for combination skin. Glycolic acid has the smallest molecule of all the AHAs, so it is able to penetrate without encouraging more sebum production. This acid is derived from fruit sugars. AHAs are water soluable, so they also work well for areas that are not as oily. 

For a mild nightly cream that is inexpensive and highly rated, I really like Reviva's 10% cream. Lots of people rave about this. I've also found this at Ulta on sale occasionally.

For a bi-weekly or monthly peel, I like Skin Obsession's 40% Glycolic Acid Peel. This peel really works well, but it stings and itches A LOT. I use this about once a month.

Be cautious when performing superficial chemical peels; acne can, ironically, be a side effect. [1] Avoid occlusive moisturizers if possible, which will help.

Acne Prone

Salicylic acid is the only BHA available; it encourages skin exfoliation and penetrates deeper than AHAs, so it's a good option for acne-prone skin. This acid is oil soluble, so it's a great option for oily skin that is plagued by acne. 

Beware with BHA: this can increase sun sensitivity by 50%, which can easily result in hyper-pigmentation. Salicylic acid also seems to cause more irritation. 

When to Use

Do NOT choose a daily moisturizer with BHA since it increases sensitivity to sun. Also, avoid cleansers with BHA because the acid must have time to penetrate the skin, and the cleanser will be rinsed too quickly. This is best used in a night-time moisturizer or serum--or monthly chemical peel. Remember to use sunscreen regularly with BHA. 

Dr. Heather Brannon recommends solutions with BHA at 1-2% and pH of 3-4. [2] This 2% Salicyclic Acid by Refresh Skin Therapy is well rated and is naturally derived.

Glycolic acid, an AHA, is another good choice for mild acne-prone skin. See Combination above for more.

Dry and/or Aging

Lactic acid chemical peel  is better suited to aging and/or dry skin because it encourages sebum production, among many other benefits, such as reducing age spots, freckles, sun spots, hyperpigmentation, and wrinkles. This acid is derived from milk sugars. For peels, I like the Lactic Acid by Perfect Image. It has high ratings at a descent price.

For a daily lactic acid lotion, I like AmLactin 12% Lotion. This is also a great body exfoliation lotion that will help retain moisture while increasing cell turnover.




Gloss Chemical Peel

The Gloss peel is the first generation of “non-wounding” chemical peels designed to retexturize the skin without harming it. This chemical peel is reported to contain restorative acids at levels that work symbiotically to restore a healthy, reflective glow to the complexion with little down time.

Before and After:
This is a "before and after" gloss peel picture from Dr. Steven Hopping's website:


It's difficult to see if she achieved HER desired results with this size and resolution.

Purpose:
This peel seems to be most effective in reducing large pores and retexturizing skin that may not seem smooth. The combination of acids indicates (to me) that it would also help reduce acne, fine lines, and hyperpigmentation or dark spots.

Ingredients:
This peels contains TCA, Salicylic acid, Azelaic acid, and a retinoid (vitamin A). It’s touted as gently exfoliating the skin as it delivers anti-inflammatory, anti-bacterial, and anti-aging benefits to the skin.

It’s a combination of 17% Trichloroacetic acid (TCA),  17% Salicylic acid, Azelaic Acid, and varying amounts of vitamin A, in a phenol-free,  anhydrous gel vehicle that limits ionization of the free acids. This results in limiting the pain and cellular injury associated with conventional TCA aqueous solutions. It also allows a longer contact time of the peel solution with the skin, thus enhancing efficacy.

Prep:
To prepare for this peel, one week before the treatment, avoid electrolysis, waxing, sunless tanning, spray tanning, or UV free tanning, depilatory creams, laser hair removal treatments, cosmetic facials, Botox, Retin-A, Renova, Differin, Tazorac, Avage, retinols, alpha hydroxyl acids, beta hydroxyl acids, benzoyl peroxide, or any other exfoliating products that may be drying or irritating.

Application:
After a 10-minute contact period, the peel solution is wiped from the skin using a solvent containing 1% retinol. The remaining residue is left on the skin an additional period of time before washing it off, adding retinoid benefits to the keratolytic effects of the peel solution.

After the Peel:
Most of these peels include a take-home kit consisting of a gentle, fragrance-free cleanser, emollient physical sunscreen, additional retinoid treatment pads and niacinamide-containing moisturizer.

I’ve read that the normal reaction is redness for 2-5 days but minimal peeling if at all. Results will vary, but generally users will see smoother skin texture, and revived appearance. Remember to use sunscreen every day after a peel since this new skin is especially vulnerable to hyperpigmentation.
It’s recommended to use this peel only two times per year, or at 6-month intervals.

Costs:
I haven’t been able to find this peel combination for purchase to use at home, but for treatment by a professional, I’ve seen it listed from about $200 to $600, depending on location.

If you've seen this available online for purchase, please let me know. I want to try it to post pictures and give a review.