What is the proper protocol for applying Alpha Hydroxy Acid (AHA) peels in facial therapy?

AHA Peel Application Protocol for Clinical Facial Therapy

For clinical AHA (glycolic acid) peels, use concentrations of 30-70% applied for 1-15 minutes depending on desired depth, with treatment repeated every 15 days for 4-6 months, ensuring proper patient screening and neutralization protocols are followed. 1, 2

Pre-Treatment Patient Screening

Absolute Contraindications (Do Not Proceed)

• Isotretinoin therapy within the last 6 months 1, 2
• Active infection or open wounds on treatment area 1, 2
• Lack of psychological stability or unrealistic expectations 1
• Poor general health and nutritional status 1

Relative Contraindications (Proceed with Extreme Caution)

• History of abnormal scar formation or delayed wound healing 1, 2
• History of therapeutic radiation exposure 1
• Active rosacea, seborrheic dermatitis, atopic dermatitis, psoriasis, vitiligo, or retinoid dermatitis 1
• Recent medium-depth or deep resurfacing procedure within 3-12 months 1, 2
• Recent facial surgery involving extensive undermining 1

Pre-Peel Skin Priming (2-4 Weeks Before First Treatment)

• Apply sunscreen daily 3
• Use hydroquinone for pigmentary concerns 3
• Apply tretinoin to condition the skin 3

Concentration and Application Protocol by Depth

Very Superficial Peels

• Concentration: 30-50% glycolic acid 1, 2
• Application time: 1-2 minutes 1, 2
• Indications: Mild photoaging, fine lines, maintenance therapy 4

Superficial Peels

• Concentration: 50-70% glycolic acid 1, 2
• Application time: 2-5 minutes 1, 2
• Indications: Acne, melasma, moderate photoaging, acne scars 5, 4

Medium-Depth Peels

• Concentration: 70% glycolic acid 1, 2
• Application time: 3-15 minutes 1, 2
• Indications: Deeper wrinkles, significant photoaging, actinic keratoses 6, 4

Step-by-Step Application Technique

Preparation

1. Cleanse the skin thoroughly to remove oils and debris 3
2. Degrease with acetone or alcohol if needed for uniform penetration 3
3. Protect periorbital areas, lips, and nostrils with petroleum jelly 3

Application Process

1. Apply glycolic acid solution evenly using gauze or cotton applicator 6, 3
2. Start application from forehead, moving to cheeks, nose, chin, then perioral area 3
3. Apply 1-3 coats depending on desired depth 6, 3
4. Monitor continuously for clinical endpoints 3

Critical Endpoints for Neutralization

• Time-based: Neutralize after predetermined duration (typically 3 minutes for superficial peels) 3
• Erythema: Uniform pinkness indicates appropriate penetration 3
• Epidermolysis: Grayish-white appearance or small blisters require immediate neutralization regardless of time 3
• Patient tolerance: Excessive burning sensation warrants early neutralization 3

Neutralization Protocol

1. Apply 10-15% sodium bicarbonate solution immediately when endpoint is reached 3
2. Start neutralization from eyelids, then entire face 3
3. Alternatively, rinse thoroughly with cold water 3
4. Continue rinsing until all burning sensation subsides 3

Treatment Schedule and Frequency

• Repeat treatments: Every 15 days (biweekly) 1, 2
• Total duration: 4-6 months for optimal results 1, 2
• Alternative schedules: Weekly, fortnightly, or monthly depending on peel depth and patient tolerance 3
• Multiple sessions: 3-4 treatments typically needed for ideal results 6

Post-Treatment Care

Immediate Post-Peel (First 24-48 Hours)

• Apply moisturizers liberally 3
• Use broad-spectrum sunscreen (SPF 30+) during all daylight exposure 1, 7
• Avoid sun exposure and heat 3

Ongoing Maintenance

• Continue daily sunscreen application 3
• Use gentle, non-medicated cleansers 7
• Avoid other keratolytic or photosensitizing agents during healing 7

Expected Adverse Effects to Monitor

• Postinflammatory hyperpigmentation: Primary concern, especially in darker skin types (Fitzpatrick III-VI) 1, 4
• Erosive blisters with potential scarring: Requires immediate intervention if occurs 1
• Transient erythema and burning: Expected, should resolve within hours to days 7, 5
• Dry skin, peeling, scaling, and flaking: Normal healing response 7

Critical Safety Considerations

Skin Type Limitations

• Safe for: Fitzpatrick skin types I-IV 4, 3
• Use extreme caution: Fitzpatrick skin types V-VI (higher risk of postinflammatory hyperpigmentation) 3
• Not recommended: Deep peels for Indian or darker skin types 3

Common Pitfalls to Avoid

• Do not confuse clinical concentrations (30-70%) with home-use formulations (7-15%) - these serve entirely different purposes and home products should never be used for clinical peeling 1, 2
• Never perform peels without proper neutralization agents immediately available 3
• Do not exceed predetermined application times unless clinical endpoints indicate earlier neutralization 3
• Avoid treating patients on isotretinoin within 6 months - this is an absolute contraindication for clinical peels (though not for 7% home-use solutions) 1, 2, 7

Facility and Provider Requirements

• Physician should have completed postgraduate training in dermatology 3
• Training in chemical peeling acquired during residency or through focused workshops 3
• Adequate knowledge of peeling agents, wound healing, technique, and complication management required 3
• Can be performed safely in any clinic/outpatient dermatosurgical facility 3
• Detailed informed consent must be obtained listing procedure details and possible complications 3