Chemical peels in skin of color effective with post-treatment compliance

Skin that produces a lot of melanin has an increased reaction to influences such as sun exposure and heat, as well as anything else that can potentially irritate the skin, such as a chemical peel. Chemical

peels are as safe and effective in darker-skinned people as in their light-skinned counterparts, but underestimating the potential for adverse events such as post-peel hyperpigmentation can be short-sighted, says Texas dermatologist Vivian Bucay, M.D.

"Generally speaking, the darker skin types tend to have more of a tendency to react to anything that would irritate the skin — anywhere from a mosquito bite to a topical numbing agent to a burn on the stove to a chemical peel," says Dr. Bucay. When a dark-skinned patient presents and either requests or is a candidate for a chemical peel, she analyzes the patient's goals and carefully reviews the medical history. "We need to know if this is somebody who is getting a chemical peel for acne or for melasma or for something else, and I also look to see if they have any history of sensitivity to irritants or a history of eczema or rosacea," Dr. Bucay says.

Armed with this information, Dr. Bucay chooses the appropriate agents accordingly. "For a dark-skinned patient who is seeking a chemical peel for melasma or acne, I would use a product containing salicylic acid, because it does not induce a lot of inflammation and is very good for redistributing pigment granules, but would also take care of acne breakouts," she says. Glycolic acid, she points out, would be too irritating to somebody of darker skin type with sensitive skin and could result in a postinflammatory hyperpigmentation.

SUPERFICIAL TREATMENT New Jersey dermatologist Jeanine Downie, M.D., also stresses the importance of choosing a more superficial peel. "In a situation like this, you should definitely go with a lighter, more superficial peel in the 20 percent, 25 percent or 30 percent range," she says, adding that it's a good idea to "avoid medium-depth peels (in this patient population) until you have significant experience and really know what you're doing."

When performed correctly, chemical peels offer patients of color striking benefits, according to Dr. Downie. "In my African- American patients, if I do the peel close to the lower lid rim of their eyes and they see that their dark circles are fading, they are very appreciative," she says. "African Americans tend to age with patchy dyspigmentation, and my patients of color really enjoy the overall enhancement of their skin tone."

Regarding hyperpigmentation, "People with skin of color are often coming into the office to get help with their hyperpigmentation problems, so you certainly don't want to add to that," Dr. Downie says. Post-peel hyperpigmentation does not happen frequently, she notes, but when it does, it can be troublesome for the patient and the physician. "If the patient's skin is overly sensitive, if you leave the peel on too long or it doesn't get rinsed off (thoroughly), the result can be the induction or worsening of hyperpigmentation," she says.

Post-peel hyperpigmentation is possible in anyone, but is more obvious in skin of color. "If a physician does not have a lot of experience performing chemical peels in patients of color, they should feel comfortable referring the patient elsewhere," Dr. Downie says.

PRETREATMENT OPTIONS Dr. Bucay suggests that inhibiting pigment production before the procedure can reduce a possible inflammatory response to the chemical peel. Starting patients on hydroquinone and/or topical vitamin C six weeks before the chemical peel would be ideal, she says, stressing that even if the patient pre-loads for two weeks prior to the peel, there could be benefits.

Of course, the most important factor in the process is consistent sunblock use. "The patient must wear sunblock from the moment they leave the office, because all it takes is one sun exposure, especially after a peel, and they will pigment quickly," Dr. Downie says. Dr. Bucay says she prefers a physical as opposed to chemical sunblock, such as a micronized preparation of transparent zinc oxide or titanium dioxide. "A physical sunblock reflects the light and is less likely to cause irritation of the skin afterward," she says.

Poor candidates for chemical peels, especially in darker-skinned patients, are those who are not consistent in their use of sunblock and those who have a tendency to pick their skin. "They're going to tell you their skin isn't any better, but it's not because of your treatment plan, it's because they're not committed to the post-peel instructions," Dr. Downie says. "The bottom line is that most people are good peel candidates if they need a deeper level of exfoliation and if they follow our instructions."

In the case of a chemical peel gone wrong, Dr. Downie recommends several options for repairing the post-peel hyperpigmentation: Re-peel the patient with a lighter peel, advise the patient to wear sunscreen and reapply it more frequently, or suggest a gentle fade cream. Among the available prescription fade creams, Dr. Downie says she likes EpiQuin Micro (hydroquinone USP 4 percent, SkinMedica) and Tri-Luma (fluocinolone acetonide 0.01 percent, hydroquinone 4 percent, tretinoin 0.05 percent, Galderma).