Philoderm Professional Peeling

2003

The Skin
Structure of the skin - Epidermis - Dermis - Subdermis

The Skin
- Stratum Corneum
- Stratum Spinosum - Stratum Basale

The Skin
- Vascular system
- Fibroblasten - Collagen fibres and supportive connective tissue

The Skin
Structure of the skin - Epidermis - Dermis - Subdermis

Chemical peel

-is an application of a chemical agent that causes

controlled destruction of the outer layers of the skin.

The concept of treatment is to damage the skin deeply enough to cause exfoliation of the layers while being superficial enough to allow regeneration from the appendageal structures and papillary dermis. More patients are candidates for superficial peels than for deeper peels. Because of pigmentation side effects, deep chemical peels are usually not recommended for oliveskinned or dark-skinned patients.
Superficial peels penetrate through the epidermis and to upper regions of the papillary dermis

2004

Peeling Depth and Skin Problems

General Regeneration Treatments Atrophic skin UV damaged skin Impurities, cellulite, striae, keloid scars Scars
Stratum Corneam Stratum Granulosum Stratum Spinosum Stratum Basale

Critical Depth

POPULAR SUPERFICIAL PEELING AGENTS

Glycolic acid 50% and 70%
Trichloroacetic acid (TCA) 15%,20%,25%, and 35% Jessners'solution Resorcin Retinoic acid

2004

INDICATIONS FOR SUPERFICIAL PEELS

Actinic keratoses Acne scarring

Wrinkles
Melasma Lentigines Acne Skin rejuvenation Seborrheic keratoses, flat

Verrucae planae
Freckles Postinflammatory hyperpigmentation

Hypertrophic scars
Tattoos

2004

HISTOLOGY OF PEELS
The initial reaction is epidermal coagulation. There is a cellular and connective tissue destruction in the papillary dermis. Later, a thin crust forms composed of keratin, necrotic keratinocytes, and a proteinaceous precipitate. Investigators have noted epidermal regeneration between days 2 and 7. After 2 weeks, the epidermis is completely healed, and the rete ridges will have been partially reformed. Studies found dermal thickening with a fibroblastic proliferation and new collagen deposition in the papillary dermis.

Actinic fine-wrinkled skin is the type of skin in which superficial peels may be most beneficial. Also trough repeted superficial peels we can obtain a reduction in the melanosis of the epidermis. 2004

Clinical Test Results

Before Peeling

After Peeling

REVITA Biomedical Supply GmbH

Alpha Hydroxy Acids

AHAs are a class of compounds that are
derived from various types of foods such as fruits and therefore are sometimes called fruit acids. For instance, glycolic acid comes from sugar cane, lactic acid comes from sour milk, malic acid comes from apples, tartaric acid comes from grapes, and citric comes from citrus fruits. As mentioned earlier, sour milk and old wine were probably used for the benefits on the AHAs. Glycolic acid is a small two-carbon molecule and is the smallest AHA. Glycolic acid has been used on various skin lesions associated with excessive corneocyte cohesion, especially ichthyoses. It is thought that AHAs decrease corneocyte cohesions by interfering with ionic bonding. We can treat other epidermal lesions successfully, including seborrheic keratoses, verrucae vulgaris, acne, and actinic keratoses. Additionally we can minimize the wrinkles using glycolic acid.

2004

Glycolic Acid
One

speculated mechanism of glycolic acid influence on wrinkles and hyper-pigmentation is by stimulating the collagen production and by decreasing melanin production. Another speculation is that glycolic acid works on wrinkles by increasing the synthesis of glycosaminoglycans and other intercellular ground substances. Glycolic acid acts on fibroblasts cells and subsequently stimulate the production of collagen. This mechanism is in contrast to other peeling agents, including TCA and phenol, which are acknowledged to damage the skin, which then causes a thickened zone of papillary collagen. Crusting and sloughing of the skin is not always the desired effect. In a mini -pig study, one effect of peels 7 and 21 days after peeling suggests that 15% glycolic acid can show as much new papillary collagen deposition as 25% TCA or 25% phenol after 21 days. When glycolic acid is left on the skin for 15 min, a study demonstrates that 50% and 70% glycolic acid cause a depth of necrosis between the depths caused by 35% and 50% TCA. At shorter exposures, 50% and 70% glycolic acid will cause less depth of damage than 25% TCA.

TRICHLOROACETIC ACID
TCA is a versatile peeling agent that is effective for light peels in concentrations of 10% to 35%. TCA was first mentioned by Samuel Ayres as an alternative to phenol and can be modified to be used superficially or deeply without causing the systemic toxicity found with phenol.

TCA has been used many years because of its spectrum of uses at a wide range of concentrations. For specific, thick keratotic lesions, it has been noted that by using 25% TCA as a light peeling agent every 2 weeks, a deeper peel effect can be achieved without the risk of scarring. One early investigator studied 25% to 50% TCA, finding that it produced a histologic reaction similar to pure phenol. A progression of deeper effects was found with increasing concentrations, resulting in an increased new collagen formation as the number of peels were increased. Severe photodamage can be improved with TCA peels.
To maintain the stability of TCA maximally, several recommendations have been made. Dark glass bottles are more stable than plastic bottles, which will degrade over time. Refrigerated samples kept their concentration better than room-temperature samples. It is suggested that one not continuously use a cotton applicator in the bottle nor leave the bottle open for extended lengths of time as evaporation of the TCA solution will probably occur. Also, crystals of TCA may form along the sides of the bottle. A small sample should be poured out of the stock bottle before use and new stock solution should be made every 6 months.

2004

TECHNIQUE
Planning the Peel: Considerations Before the Procedure assess possible factors or exposures that may affect the outcome of the peel

1.
2. 3. 4.

Severity of the skin preparation

Cleaning agent to prepare the skin Type of peeling agent Concentration of the peel

5.
6. 7. 8.

Time in contact with the peeling agent

Amount of peeling agent applied Degree of rubbing Reapplication requirements

9.

Extent of neutralization

Pretreatment to increase the efficacy of the peel. In our practice , patients are given 10% or 15 % glycolic acid to apply daily for 2 weeks prior to a peel.

SKIN PREPARATION
The patient is instructed to clean off any makeup or sunscreen. This is followed by a skin preparation with chlorhexidine, acetone, or Jessners' solution. The purpose of the preparation is to remove debris and a variable amount, of stratum corneum evenly, depending on the preparatory material and the extent of scrubbing which can enhance the peel effect. Jessners' solution removes most of the stratum corneum. Acetone is thought to remove some of the stratum corneum, and chlorhexidine probably only removes surface debris and oils. Often, two cleanings are performed to remove surface oils, makeup, and debris evenly. Degreasing is important because even small amounts of oils from the skin will cause increased surface tension and allow less penetration of the peeling agent. Many factors in the skin can cause irregular peeling effects if not cleaned evenly. If erythema occurs on sensitive skin after cleaning with acetone, lower concentration peels or shorter application of the peels in these specific areas is recommended. Some dermatologists will gently scrub with alcohol and acetone until the dark film (probably keratin debris) appearing on the gauze disappears. A study showed that skin preparation with acetone scrubbing will cause a much deeper peel than gentle cleaning with a chlorhexidine solution.

Applying the AHA Peel

The glycolic acid is applied with a fan-shaped brush or a cotton tip. . A simple tray is set up to do the peel. The fan brush ideally coats the skin surface with an even amount of the glycolic acid gel while minimizing trauma to the skin. Additionally, the brush allows application of the peel in very close proximity to the eyes with no problems. The glycolic acid is carefully applied to one cosmetic unit at a time to ensure even coverage. One hand is used to stretch out furrows and creases, while the other hand applies the glycolic acid, ensuring coverage in the area. Often, with a cotton applicator or the same brush, more of the glycolic acid will be firmly rubbed into furrows or finely creased areas, such as the nasolabial folds or perioral creases, to enhance the effect in that area. Some keratotic areas will not respond as well and require firm rubbing to react properly. Because the 50% and 70% glycolic acid is a gel like substance, some of the peeling agent may collect more on certain areas slightly; however, unlike TCA, glycolic acid does not react more in areas with more peeling agent on it. The areas around the eyes have to be treated separately, by using a semimoist cotton applicator, to ensure that the peeling agent does not get into the eyes. The patient is instructed to keep the eyes closed to minimize tearing. Tears are wiped dry to avoid capillary movement of the chemical agent into the eye. The application is within a few millimeters from the eyelid ciliary margin. All types of peels should be feathered below the jaw and into the hairline to minimize a line of demarcation. The glycolic acid is left on the skin for a set amount of time measured with a stopwatch. A timer is set at the time of initial contact of the glycolic acid. The skin is then neutralized very carefully with a water-soaked gauze and a buffered neutralizer. Caution should be taken when sodium bicarbonate is used for neutralization because the glycolic acid and sodium bicarbonate form an entropic reaction which creates heat. This heat could intensify or damage the peeled skin. The patient is then told to rinse the skin under cool running water. Occasionally, a patient will complain of stinging of the eyes, even if no glycolic acid has actually entered them, but it will resolve after the peel has been neutralized. A water-soaked gauze can be used to wipe the eyes gently, or a squeeze bottle with water can be kept at hand to rinse the eyes if needed. Patients with moderate to severe erythema are given a mild corticosteroid cream to apply twice daily to affected areas for 2 days.
Superficial chemical peels need to be repeated to have maximal benefit. The initial application is usually 50% solution and is left on for a carefully timed 3 min. If the patient has repeated peels every 2 to 4 weeks, the time is increased by 30 s or the concentration of the glycolic acid is increased to 70%. If the patient has very sensitive skin, the peel may be started at 2 to 2.5 min. Eventually, some patients will tolerate peels lasting for up to 10 min, especially if they have severe chronic sun damage. For acne, it appears that the peeling agent will penetrate the pores and plugs more readily than the epidermis. When glycolic acid is used to treat acne, it is usually left on only 1 to 2 min.

Applying the TCA Peel

Preparation of the skin is the same to remove oils and excess keratin debris. TCA is also applied evenly with several cotton applicators or cotton balls. The same basic pattern of starting on the forehead, proceeding down one cheek, and proceeding around the face to the other cheek is recommended. TCA can be reapplied into furrows in a similar manner as glycolic acid. In addition, keratotic lesions can be re-treated with a cotton applicator and TCA since keratoses can be more resistant to frosting. Unlike glycolic acid, TCA elicits erythema very quickly, and frosting appears within 1 to 2 min. It is important not to let the TCA drip or collect in a pool to prevent overreaction in areas. The discomfort from TCA can be more severe than that from glycolic acid, and having patients fan their skin will cause some relief. If the discomfort is too great, the peel can be stopped for several minutes before proceeding so that the patient can rest. As mentioned, reapplication may deepen the peeling effect. Some physicians may apply TCA once evenly, and others may apply it until frosting is achieved. Usually, neutralization is performed with water or a 5% bicarbonate solution. Neutralization for superficial peels of TCA should be done immediately within 60 to 90 sec or soon after frosting appears, although the skin itself may neutralize the peel; therefore, many peel specialists do not neutralize. Probably, neutralization after frosting is not very helpful because the TCA reaction has already reached its end point. After skin preparation, TCA is applied into all the peel areas Usually, the first application should be light and the agent should not be reapplied to any areas. Without reapplication of the TCA, the skin is allowed to frost or blanch. The area is then neutralized immediately after blanching, although neutralization may have a limited effect at this time. Often, it is easier to section the face into anatomic units to apply the TCA, and then neutralize before moving on to the next facial area. The most important difference between applying TCA or glycolic acid is that glycolic acid reactivity is very dependent on the length of time that the glycolic acid stays on the skin. The amount of glycolic acid applied is not as critical as with TCA peels. On the other hand, TCA is very dependent on the concentration, on the amount of TCA used, and on the application pressure. If a lower concentration of TCA is continuously applied several times or reapplied after a frost appears, the peel will be deeper and be equivalent to a higher concentration. The time of neutralization makes a difference in the peel reaction only if the peel is neutralized from 1 to 2 min before frosting occurs.

POSTPEEL
Patients are warned about crusting and erythema for 3 to 7 days after any peel. Discomfort usually occurs only during the procedure and is a combination of stinging and pruritis. No oral analgesia or oral steroids are usually required after the peel procedure. As mentioned, mild cortisone cream can be given if the inflammation and erythema are uncomfortable. Later, after 30 to 60 min, makeup can be used to cover the treated areas. In our practice we advise our patients to restrain in using any make-up for 2-3 days. The face can be rinsed, but the patient is told not to scrub. A non cleansing soap lotion can be provided. For crusting, an antibiotic ointment is applied, and the crust is not to be mechanically removed. Patients are advised not to apply AHAs or topical retinoic acid for at least 4 to 5 days after the peel to avoid deepening the reaction of the peel. Protection from sun exposure is strongly recommended for at least 2 weeks, especially when pigmentation problems are treated. A written sheet informing patients of discomfort, crusting, and erythema is important with instructions on general care of the skin.

INDICATIONS FOR CHEMICAL PEELS

Actinic keratoses Wrinkles

Melasma
Lentigines Acne Skin rejuvenation Seborrheic keratoses, flat Acne scarring Verrucae planae

Freckles
Postinflammatory Hyperpigmentation Hypertrophic scars Tattoos

WRINKLES
The improvement of photoaged skin by chemical peels involves new collagen deposition either on top of or in place of the upper papillary zone of elastotic damaged deposits. Medium and deep peels are thought to function histologically like dermabrasions by causing a similar scar formation in the upper papillary dermis. Superficial peels may achieve satisfactory results by repeatedly stimulating the skin and stimulating new collagen growth, without causing the deeper wound healing of deep chemical peels. For wrinkles, the glycolic acid or TCA peel penetration is enhanced by using stronger skin preparations and increasing the strength of the peel. Repeated 70% glycolic acid (Fig. 1) and 25% TCA can be used; however, glycolic acid and TCA will need to be pretreated with another chemical agent. Jessners' solution is used with regular peeling agents (TCA or glycolic acid) as combination peels to increase significantly the depth of peel penetration

Figure 1 (a) Deep creases on an elderly woman. (b) After two months of peels, the creases were beginning to smooth

ACTINIC KERATOSES
Chemical peels can be used to treat actinic keratoses that are not excessively hyperkeratotic. The result can be beneficial by decreasing the formation of skin cancers and also in clearing a number of actinic keratoses to even the blotchy appearance of the skin. 70% glycolic acid causes increased epidermolysis and discohesiveness of the cells, thus thinning actinic keratoses. Patients will actually have resolution of most of their actinic keratoses. If some of the thicker actinic keratoses do not resolve, the lesions are always thinner, thus making them easier to treat with 5Fluorouracil or other modalities. The advantage of pretreating a patient with chemical peels before 5Fluoraouracil is the decreased discomfort and time required for application of the 5-Fluorouracil. TCA at 30% or 35% has also been found to be effective to treat actinic keratoses. TCA will work better in removing lentigines and wrinkles than in removing actinic keratoses. Another variation for actinic keratoses treatment is 5-Fluorouracil for only 2 weeks to bring out many previously subclinical lesions, followed by a peel of glycolic acid or TCA localized to the remaining inflamed lesions. Using repeated peels at this point may prevent or retard the appearance of further actinic keratoses.

Figure 2(a) Actinic keratoses on an elderly woman. (b) After 8 peels, the keratoses were thinner and some disappered

ACNE
Although acne is not usually treated with superficial peels, the peeling agent may effectively reduce comedones and pustules. Glycolic acid has been reported to penetrate into open and closed comedones very readily. TCA is used successfully as an acne exfoliant for active acne lesions and improving acne scarring. The use of glycolic acid or TCA for acne and acne scarring should be at a more superficial depth and should produce less reaction than other glycolic acid peels. Thus, 50% glycolic acid can be applied for only 1 to 2 min over the entire face. Often, no redness is seen at the time of neutralizing the,glycolic acid. After one or two of these light peels, the acne can be the same or look worse; new comedones come to the surface after several peels. After three to five peels repeated every 3 weeks, a majority of comedones and pustules are gone. If the 15% glycolic acid is used thereafter, the peel effect may be maintained for at least 6 months. TCA at concentrations of 25% is applied for 30 to 45 s and thoroughly neutralized right away. After a number of these very light peels, acne scars and acne are also thought to be improved; however, the actual improvement has not been subjected to well-controlled comparison studies. These peeling agents can be more potent keratolytic and comedolytic acne treatments than retinoic acid for certain acne cases. For acne, superficial, not deep, peels are recommended. For acne scarring, superficial and deeper peels can be very beneficial. Deeper peeling high concentrations of TCA will restructure sufficient amounts of collagen in the dermis to smooth layers of scarring. Even repeated glycolic acid 70% chemical peels will improve scarring if the peel is allowed to penetrate into the dermis.

Melasma
Patients can apply a cream 10% glycolic acid and are applied twice a day before and after a series of peels Fifty percent glycolic acid chemical peels or 25% TCA peels are used, although TCA peels may cause sometimes problems. Crusting should be minimized because of the risk of hyperpigmentation on darker skin. A regimen of four to five peel treatments is recommended to the patient before very clear improvements are clinically made. It is recommended to repeat the peel every 3 to 4 weeks. A sunscreen with maximum UVA and UVB coverage is strongly recommended to the patient to prevent further darkening. The mechanism by which glycolic acid and TCA works on hyperpigmentation is not known. Glycolic acid, as with other AHAs, is closely related chemically to ascorbic acid. There are studies suggesting that ascorbic acid has a direct effect on melanocytes by inhibiting melanocyte activity.

LENTIGINES
Lentigines are due to an increase of melanocytes and melanocytic activity at the epidermal basal layer. Some dermatologists now believe that lentigines also have a keratotic component along with the hypermelanization component. These lesions have been called keratoses simplex. Much of the aging that occurs on the hands is a function of the number of these lentigines lesions. Peels can be very effective in the treatment of lentigines. By repeating light peels of glycolic acid or 25% TCA . In our experience, the chemical peel must penetrate through the lentigo lesion to the papillary dermal layer to be effective. On some patients, Jessners' formulation may allow the glycolic acid to penetrate deeply enough to remove the lesions. Deeper peels are also very effective when applied locally to each lesion and are well tolerated on the hands, chest, and back. Jessners' formula is a good pre-peel adjunct to enhance penetration of the peel. It is recommended to the patient to apply 10% glycolic acid or topical retinoic acid before and after the superficial chemical peels when lentigines are treated.

Contra-indications
Absolute: - Active Herpes Simplex Virus - Skin type V and VI - Ehlers-Danlos Syndrome Relative:

- Tendency to keloid formation

- Oral medication Retinoide group - Pregnancy (Fenol) - Unrealistic expectations (for example Roacutane)

Complications
Hyperpigmentation is probably the most common side effect caused by chemical peels. Many believe that color outcome cannot be fully predicted for peels. Mediumpigmented or olive-skinned patients (Asians, Hispanics, Mediterraneans) can have irregular pigmentation. If patients experience persistent hyper-pigmentation 2 weeks after a peel, they can apply glycolic acid 10% with 2% hydroquinone lotion or 4% hydroquinone alone to lighten areas. With TCA, even at 25%, hyper-pigmentation can occur and be persistent. Glycolic acid has not caused permanent hyper-pigmentation in any patient at this time. Theoretically, the skin in a darker person can result in a line of demarcation, which is why the edge of anatomic areas such as under the angle of the jaw, around the eyebrows, and in the hairline should be feathered. Post-peel factors can enhance post-inflammatory hyperpigmentation, including oral contraceptives, pregnancy, prolonged sun exposure, and photosensitizing drugs. One should restrict these factors for 2 to 4 weeks after the peel. Deeper peels need to be watched for 6 weeks to 6 months.Some anatomic areas are more susceptible to hyperpigmentation, including the jaw line and around the mouth.

Complications

Persistent erythema occurs uncommonly with superficial peels. Erythema should not last longer than 2 to 3 months; the majority of cases resolve within 2 to 3 weeks. Mild hydrocortisone ointment is applied for 2 days after the peel for patients with severe erythema. Erythema may be a sensitivity to the peel, with persistent inflammatory reaction. TCA tends to cause more erythema than glycolic acid. Infections have not been a problem with superficial peels. The skin preparation agents and peeling agents themselves are bactericidal, although the crust may harbor and colonize skin and cause infections. The crust resulting from superficial peels is thinner and less adherent. It is recommended that patients use triple antibiotic ointment to wash the face gently. The crust usually washes off in 2 to 3 days. Herpes simplex outbreak has occurred in light-peel patients, and hyper-pigmentation and hyper-trophic scarring also are potential hazards.s Patients should be questioned about history of herpetic outbreaks and incipient causes. Even though patients may not have had herpetic outbreaks for years, they can develop postoperative scarring and herpetic flares due to chemical peels. Susceptible patients are put on acyclovir 200 mg orally three times a day. Hypertrophic scarring is very rare in superficial peels since this type of scarring may be a function of the depth of injury to the skin. Low-dose interlesional steroid shots are recommended. With deeper peels of phenol and TCA, certain facial areas appear to be prone to thick, overhealed scars. The perioral areas and along the length of the jaw are common areas of hypertrophic scarring involvement. Intra-lesional injections are often needed to soften the scars and alleviate the condition. No allergies have been reported for patients treated with TCA or with glycolic acid. Renal hepatic or cardiac toxicities are associated with phenol but appear to be minimized when the peel is delayed between applications to facial segments.

Conclusions
Chemical peels can be safe and effective procedures for treating a variety of skin problems. Newer peels, such as glycolic acid and pyruvic acid, make peeling easier to be performed by more dermatologists and allow for a wider selection of patients to tolerate the procedure. Recently, histologic studies have furthered dermatologists' understanding of chemical peels by comparing different peeling agents. Future studies will encourage the increased use of chemical peels in treating a wider variety of skin conditions.

Philoderm Chemical Peelings

Introduction
What is the action of the chemical peeling? Classification of chemical peelings Superficial Medium Deep What is a superficial peeling?

50% AHA CHEMICAL PEELING

50% Glycolic Acid + 10% Kojic Acid + 1% Phytic Acid Mild / purifying peeling Removes the upper layer of the epidermis Strengthens the skin, stimulates collagen synthesis

70% AHA CHEMICAL PEELING

70% Glycolic Acid + Chitosan Medium peeling Removes several layers of the epidermis revealing dermis Strengthens the skin, stimulates collagen synthesis

70% AHA Peeling Gel

Advised indications Ageing signs in consequence of excessive sunlight Fine lines and small wrinkles Dry and tough (leathery) skin Skin which has lost its elasticity and softness Acne scars

25% TCA CHEMICAL PEELING

25% Trichoroacetic Acid Deep peeling to dermis Powerful exfoliating qualities Stimulates collagen synthesis

25% TCA Peeling Gel

Advised indications Seborrhea (extremely greasy skin) Rough lines and slightly deeper wrinkles Skin with acne scars and comedonen Ageing signs in consequence of excessive sunlight Tightening for non-elastic skin Ichtiosis (extremely dry skin)

Philoderm Professional Peeling Treatment

2003

Philoderm Professional Peeling Products

General benefits Highest quality individual ingredients Highly tolerable with minimal side-effects Easy, safe, non-painful technique Unique gel formula Does not drip, better control Economical in use Easy to use Effective Convenient peeling procedure Complete product range

Philoderm solution for:

6. Pre- and post peeling treatment normal skin

Anti-Dark Circle Eye Patches

GinkgoActive Whitening Cream

HiPro Anti-Ageing Sunblock SPF40 MultiCare Anti-Ageing Moisturizer SPF15 IntensPure Gentle Daily Cleanser Philoderm Cosmetic Bag Philoderm Info booklet

Philoderm solution for:

7. Pre- and post peeling treatment sensitive skin IntensPure Gentle Daily Cleanser

Ginkgo Active Whitening Cream

Hipro Anti-Ageing Sunblock SPF40 MultiCare Anti-Ageing Moisturizer SPF15 8% AHA Peel Glycolic Acid Cream Recel lCell Stimulation Complex Philoderm Cosmetic Bag Philoderm Info booklet

Philoderm solution for:

8. Pre- and post peeling treatment acne skin IntensPure Gentle Daily Cleanser GinkgoActive Whitening Cream 15% AHA Peel Glycolic Acid Gel HiPro Anti-Ageing Sunblock SPF 40 Retinol HA Anti-Ageing Moisturizer A-Sence Acne Care Cream MultiCare Anti-Ageing Moisturizer SPF 15 Recell Cell Stimulation Complex Philoderm Cosmetic Bag Philoderm Info booklet

Peeling Preparations
Cleanse skin thoroughly with

Philoderm Gentle Daily Cleanser Remove grease and oils using 70% alcohol or acetone If desired, a plaster or vaseline may be used to protect the eyes, nostrils, and lips

Application of Philoderm Peelings

Always follow the sequence as outlined When applying peel slightly over-lap each area Do not apply too thickly as peel may not be visible during application Regularly use new gauze and cotton buds (for each treatment consistently use the same number) Follow the skin lines

Order of Peel Application

1. 2. 3. 4. 5. 6. The forehead (horizontal direction) The nose (vertical, semi-circular with cotton buds) The cheeks (semi-circular, follow nasal/lip line to, and including jaw line) Below the eyes (horizontal with cotton buds maintaining a distance of 3mm under the lower eye lid) The upper-lip (horizontal/circular in combination with the chin) The chin

Order of Peel Application

1
4 3 2 5 6

Order of Peel Application

Apply from the middle moving in the outwards direction slightly over-lapping the areas with each stroke

Apply from the middle moving in the outwards direction slightly over-lapping the areas with each stroke

On completion of the forehead, apply one stroke over eachyebrow

Followed by both sides of the nose

Next, both cheeks in the direction of the skin lines

Apply to the cheeks, to and including the jaw line

Apply to the area below the eyes extending out to the temples

Neutralization
Depends upon: Purpose of peeling Skin type Peeling material

Neutralization
After 3 to 7 minutes the peeling should be actively neutralized (using water) Thoroughly rinse the skin Apply specific treatment cream (Philoderm MultiCare) Apply GinkoActive Whitening Cream for prevention of pigment changes HiPro provides optimal protection against the sun

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