Dr. Jaishree Sharad shares tried and true peel regimens from 23 years of practice with skin of color patients in Mumbai, India.
Jaishree Sharad, MD, Cosmetic Dermatologist, Skinfinitii Aesthetic Skin and Laser Clinic, Mumbai, India
“The first thing we need to know about doing peels in skin of color is we always restrict ourselves to superficial and medium depth. We never do deep peels in dark skin. Our skin types are usually 3, 4, and 5,” said Dr. Jaishree Sharad, who presented “Superficial and Medium-depth Peels, What You Need to Know” at the 2022 ASDS Annual Meeting in Denver, Colorado.
Priming the skin is essential—from educating darker skin patients about the importance of daily sunscreen to recommending a topical regimen, said Dr. Sharad.
“We use vitamin C and certain bleaching agents, like a 2% hydroquinone, Licorice, arbutin, Kojic acid, and sometimes an AHA (alpha hydroxy acid) as well, or even a retinol is usually prescribed for about 2 to 3 weeks before the peel session. I do not prescribe 4% hydroquinone.”
It’s also important to diagnose the condition and understand the underlying pathology before deciding on the best peel for the patient, said Dr. Sharad.
Combining TCA and Glycolic for the ‘Sequential Peel’
“My favorite peels for a lot of pigmentation—post acne pigmentation or forehead melanosis—is a combination of 35% glycolic acid and 15% trichloroacetic acid. This is called a sequential peel.”
Dr. Sharad said she starts with cleansing the face. The “degreasing” is done in three steps with chlorohexidine, acetone, and then alcohol.
“Then you apply the glycolic peel, which is a timed peel usually set for 5 to 7 minutes. Just use cotton pads and apply it sequentially on the entire face. Leave it on, then take the 15% trichloroacetic acid and apply that just on the dark spots.”
The key is to wait for a little bit of frost to appear—do not wait for clouding, she said. Clouding could lead to scarring and post inflammatory hyperpigmentation. Neutralize the peel with water or ice water the minute you see a little frosting, said Dr. Sharad.
“Although trichloroacetic acid is a self-neutralizing peel, yet we’ve seen in dark skin if you leave it for a longer time, it can seep in and cause PIH (post-inflammatory hyperpigmentation).”
Dr. Sharad said she repeats the peel every 2 to 3 weeks, depending on the skin type.
“Make sure to watch out for red spots, flaking, and dryness, and avoid peeling the patient during those times or skip those lesions. Also remember never to apply the peel in the corners of the nose and corners of the mouth. Do not go too close to the undereye, because you may cause irritation and PIH.”
The most common complication is PIH, so choosing the concentration of the peel is important, said Dr. Sharad.
Another Favorite: Retinol Peels
“We also use retinol peels, namely a 1% tretinoin, which is left on the skin for about 8 hours. So, after degreasing the face, you apply this yellow paste (it’s also called the yellow peel) on the entire face. Do not forget the neck. Same protocol while applying the other peels, do not forget to feather the peel onto the neck so there is no line of demarcation.”
After about 8 hours with the retinol peel, Dr. Sharad tells patients to wash their faces.
“There is a significant amount of peeling which occurs from day 3 to day 7. The patient must avoid sun exposure. Post-peel care is important, so using a broad-spectrum sunscreen, avoiding any kind of scrubs or exfoliating agents, for at least 10 days post peel.”
Be aware of pickers and try to determine which patients might be pickers during the consultation. It’s important to counsel these patients about the importance of not picking or peeling their skin after the peels because that can cause PIH, said Dr. Sharad.
“I give my patients instructions post peel. I do not like to start them on any creams and just ask them to use petroleum jelly for about 2 or 3 days if they feel too dry. But a sunscreen is a must. After a week to 10 days, they can resume whatever creams they were using for the next 10 to 15 days before the next peel.”
Other Peeling Options
Dr. Sharad also does salicylic acid peels, using 20% salicylic acid for acne and PIH due to acne.
Mandelic acid peels are also an option, she said.
“Mandelic acid is an AHA but has larger molecules, so it is less irritating. For people with more sensitive or thinner skin, I would rather do a Mandelic acid peel. Or if I knew that this person probably will not be compliant and will be out in the sun, I would not opt for a higher percentage glycolic acid. Yes, the number of treatment sessions would be more than for glycolic acid, but at least we don’t risk side effects.”
These are among the many options for safely peeling skin of color, according to Dr. Sharad.
“It’s about safety. It’s all about priming the skin, proper post care and understanding the pathology, and you will not make a mistake with these treatments.”
