The treatment of photoaging is challenging.

Everyone wants an affordable treatment regime that works reasonably easily, quickly and with little or no downtime. For centuries, skin peeling has been one of the mainstays in treating photoaging, but is always associated with pain and significant downtime. The heavier peels gave better results, but with an element of risk from over-peeling. Years ago, almost nobody was using topical vitamin A to prepare the skin for the insult ahead. After extensive research, I came to realize that before any peel, one needed to use the cosmetic versions of vitamin A in preference to tretinoin to help the skin heal faster, remove the risk of hyperpigmentation and promote collagen deposition.

The Problem With Peels

My research into what I call “cool peeling” emerged from the dissatisfaction with very low pH, destructive phenol peels and the somewhat less destructive, intense trichloroacetic acid (TCA) peels. Clinicians then believed that one needed to destroy most of the skin so that it could grow anew from the remnant hair follicles and sweat glands.

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The peel killed every cell in the epidermis and extended to varying depths into the papillary and reticular dermis, resulting in the intense scarring and tightening of the skin’s appearance. The epidermis remained compromised and thinner with loss of the dermal papillae. One had to be very careful not to over-treat any area due to the very real danger of scarring. The peel product was watery and transparent, making it difficult to control even after dyes were added.

A Peel Discovery

Starting in 1994, I worked on creating a safer peel by formulating low concentrations of acid in a thicker gel or cream, so that one can clearly see where it has been applied. The thicker formulations meant the acid remained active on the skin for a much longer time, and I could use low concentrations of TCA or lactic acid and still achieve controlled frosting similar to higher concentrations of watery peels without the risks of “over-peeling”. At that stage, I still believed that some degree of frosting was necessary to get good results. All patients treated with these peels were concurrently using vitamin A-based cosmetics.

However, I soon realized after starting my research project that the 2.5% TCA creams and gels, without ever causing any intense burning and frosting, were achieving significant skin tightening and smoothening, especially if the treatment was repeated at monthly or weekly intervals.

Figure 1(a) shows a patient who had typical photodamage and was put onto a vitamin A based cosmetic and then assigned to skin peeling using a cream with 2.5% TCA. She was terrified that this was going to burn her skin, even though she could not feel any actual stinging. After 3 minutes on her first exposure, she requested that the peel be removed. This was done without neutralizing the skin by simply using a damp swab to wipe off the cream. Her skin was dried and then the vitamin A cosmetic was re-applied. One month later, she returned for a second session, and I left the 2.5% TCA cream on the skin for 15 minutes. The consistency of the cream allowed for the safe application of it to the skin of the upper eyelids. Thereafter she was comfortable leaving the peel on her skin for 20 minutes and by six months I observed changes such as tightening of the upper eyelid, with better results than those after an upper blepharoplasty. The wrinkles on the upper medial eyelid skin were smoother – something we cannot achieve with surgery. This was a conundrum, as I expected the least impressive changes in her because of the very low concentration of TCA. I initially attributed these changes to the vitamin A cosmetics. However, by 1994, I had seven years’ experience with these cosmetics and had never seen such a change before.

The conclusion slowly dawned on me that this process of peeling somehow stimulated the release of growth factors resulting in healthier growth and visible tightening of the skin.

Cell Rehab and Regeneration

This research made me realize we should rehabilitate cells and encourage regeneration rather than torture the cells. “Threaten to kill the cells but don’t.” As my research continued, I explored various levels of acidity and differing lengths of exposure of these acids to human skin. In some cases, fairly harsh levels (by this I mean 7.5% or 10.0% TCA) were used, but the stronger levels were not associated with the best results. What seemed to be more important was the length of time the acid remained active on the skin. With the higher concentrations, patients had mild peeling of the skin between the third and the fifth day post treatment, whereas the low dose the patients only experienced dry skin on about the third day.

Figure 1(a)

In my experience, best practice is a course of six cool peels done at weekly intervals, ideally starting the process in winter and continuing with monthly maintenance treatments. The peel is not recommended during the summer. Recent research concluded that more than 95% of patients felt the changes were impressive, would do the treatments again and would confidently recommend it to their friends.

∗The Cool Peel is a peeling system designed and sold by Environ Skin Care.

Available on St. Thomas @VI Skin Care by Christy; call or text for consultation 340.690.5233;

Des Fernandes, MB.B.Ch., FRCS, is a plastic and reconstructive surgeon. He first described the method for Collagen Induction Therapy and used his research and in-depth knowledge of the beneficial effects of vitamin A on the skin to develop the Environ Skin Care products.





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