Peels in Men: Special Considerations

Introduction

The low cost and reliable results of chemical peeling have made it a staple procedure in aesthetic medicine. The American Society of Plastic Surgeons ranked chemical peels as the third most popular cosmetic minimally invasive procedure in 2018, with an annual total of 1,384,327 chemical peel procedures performed. Based on estimates by the American Society for Aesthetic Plastic Surgery, consumers spent over $64.5 million on chemical peel procedures in 2017. Men account for only 5.5% and 9.3% of all chemical peel procedures performed in the United States and worldwide, respectively, but the aesthetic market for men is continually growing. The modern aesthetic practitioner understands men’s top cosmetic concerns and can effectively address them using chemical peels as monotherapy or in combination with surgical or minimally invasive procedures.

Intrinsic Gender-Linked Skin Differences Relevant to Chemical Peeling

Basic background information about the different parts of a chemical treatment plan (e.g., pretreatment, preparation, peel technique, etc.) are discussed in detail in the previous chapters. Because chemical peeling can be very operator-dependent and requires careful consideration of many variables, practical knowledge of gender-linked skin differences may increase the likelihood of achieving excellent peeling outcomes. The Obagi Skin Classification assesses skin variables such as color, oiliness, thickness, laxity, and fragility to systematically create a chemical treatment plan. Although the literature on chemical peels in men is scant, an understanding of how intrinsic (cutaneous biology) and extrinsic (psychology/sociology) skin variables differ between genders provides a solid foundation to effectively execute chemical peeling in men. Table 9.1 summarizes male-specific intrinsic and extrinsic skin variables and relevant peeling considerations.

Based on intraethnic group comparative studies of skin tone, men display darker and less reflective complexions, possibly because they have more epidermal melanin and a more highly vascularized superficial dermis. Men’s constitutive and sun-induced facultative pigmentation states are more robust with longer pigment retention than women. Given these inherent features, men may benefit from relatively longer pretreatment and more aggressive photoprotection than their female counterparts within individual geneticoracial skin groups. When evaluating postprocedural erythema, it may be important to consider that chromacity studies, which assess color differences between erythema and normal skin, have demonstrated higher basal values in men because of a relatively more vascularized dermis.

The androgenic stimulation in men causes higher sebum production with resultant pore enlargement and predisposition to acne vulgaris and impaired barrier function. Sebum-induced alterations in intercellular lipid structure and poor corneocyte maturation cause transepidermal water loss that can be further worsened by behavioral tendencies related to excess sebum. Men with excess sebum tend to avoid skin care products because of the perceived fear of exacerbating their already tacky-feeling skin. Because of men’s relatively oilier skin, a longer or more aggressive pretreatment (e.g., more potent retinoid, gel versus cream vehicle) and/or more aggressive degreasing may be warranted. Postprocedure acne flares may also be more likely.

Conversely, men’s significantly higher average number of appendageal structures (e.g., sebaceous glands, dermal blood vessels) may dampen their rate of rhytid development, particularly in the perioral area. Their higher sebaceous gland density may also render lipophilic peels (e.g., salicylic acid [SA], Jessner’s solution) more effective. For example, sebum production, which is critical in the growth of Malassezia restricta and Malassezia globosa , may be improved by these peels, thus preventing flares of seborrheic dermatitis. Facility in performing focal deep peels for sebaceous hyperplasia may also be of value, because men may be more likely to seek treatment for this condition.

The heterogeneity of study design, research instruments, sample size, and genetic background likely played a role in some studies’ conflicting findings regarding gender differences in skin thickness. Although the extent of differences varies by anatomical region, dermal thickness is greater in men, particularly on the forehead and neck, as a result of increased dermal collagen, resulting in part from androgen receptor activation. Similarly, epidermal thickness is greater in men’s cheeks and back than that in women. Thus to achieve the intended depth of peel penetration in men, greater peel application pressure, larger volumes, and higher concentrations of peeling agent are required. The relatively thicker male skin may also entail a need for longer pretreatment to ensure that the peeling agent penetrates evenly.

Although there are no significant differences in skin elasticity between men and women, lower eyelid sagging is significantly more severe in men starting middle age. Indeed, the periorbital area, among all facial features, is of most concern to men and is their top treatment priority. Counseling men about the efficacy of segmental (targeted peeling of a specific cosmetic unit) combination (use of multiple peeling agents) chemical peeling can guide their selection from among the various resurfacing modalities available to address their most common cosmetic concerns.

In general, higher skin perfusion is observed in men than in women. Studies investigating susceptibility of the male skin to persistent erythema is lacking. This complication is thought to result from angiogenic factors stimulating vasodilation and is a sign of a prolonged phase of fibroplasia that may lead to scarring. In theory, the larger number of microvessels in the male face could predispose men to these complications.

Although men may be more likely to tolerate pain from chemical resurfacing, androgen-associated decelerated reepithelialization may extend their expected postprocedural downtime. Furthermore, more robust histamine response is observed in men and older age. Men’s propensity for postprocedural edema should be kept in mind, especially when performing periorbital rejuvenation, during which significant edema may cause the eyes to swell shut, but may be mitigated by aggressive prophylaxis and treatment with antihistamines and systemic corticosteroids.

Extrinsic Gender-Linked Skin Differences Relevant to Chemical Peeling

As previously alluded to, men may be more likely to avoid healthy skin care practices. Higher prevalence of smoking (tobacco and nicotine-containing electronic cigarettes) and ultraviolet (UV) light exposure are also observed in men and contribute significantly to skin aging. Patients who fail to modify these behaviors should be thoroughly counseled on their higher risks for suboptimal peeling outcomes and worse complications and hence are generally not candidates for chemical peeling.

Tobacco exposure–related mechanisms of skin aging include vasoconstriction, increased oxidative damage, inhibition of fibroblastic activity, and upregulation of matrix metalloproteinases. Given the higher prevalence of daily smoking in men (25%) than women (5%) and smoking’s association with disastrous resurfacing complications, tobacco exposure assessment and smoking cessation are crucial in chemical peeling. This caution extends to the use of nicotine-containing vaping solution or electronic cigarettes.

Outdoor occupations overwhelmingly comprise men. To make matters worse, men, including those with personal history of skin cancer, are less likely to practice sun-protective behaviors. On a cellular level, such a nonchalant approach can compound UV damage because of male skin’s reduced antioxidant capacity and increased tendency for UV-induced immunosuppression. These behaviors place men at a higher risk for postinflammatory hyperpigmentation (PIH) after a peel. Apart from UV-exposure behavior modification, aggressive and/or prolonged skin conditioning may be necessary to prevent pigmentary complications. Moreover, chemical peeling can be of unique benefit to those seeking cosmetic resurfacing but who also have medical conditions such as actinic keratoses or history of keratinocyte carcinoma. Trichloroacetic acid medium-depth peels can be used to prevent and reduce the incidence of these UV-induced disorders.

Peeling practitioners should also be familiar with current research on men’s preferences regarding skin care products. Men’s adherence to various aspects of a chemical treatment plan may be augmented by catering to some extent to their preferences toward particular skin care products (e.g., blue/green-tinged cleansers, emollients in “lighter” vehicles). Familiarity with new and existing skin care products that conform to men’s preferences but also fulfill their necessary role in the chemical peeling process may improve peeling outcomes by virtue of improving patient experience and treatment adherence.

Peel Considerations in Sexual-Minority Men

About 3.9% of men in the United States identify as a sexual minority (gay, bisexual, or transgender). The literature specifically addressing chemical peel considerations in sexual-minority men appear even more sparse than that in heterosexual men. This section aims to synthesize known epidemiological, behavioral, and physiological data pertaining to sexual-minority men that are relevant to chemical peeling procedures ( Table 9.2 ).

Homosexual men engage in riskier UV-exposure behaviors, with rates of indoor tanning reported up to six times more than that observed in heterosexual men. Additional counseling on photoprotection may be necessary for peel candidates who are light skinned but whose perceived ideal skin tones are darker, as these individuals are more likely to engage in indoor and outdoor tanning. UV-exposure behavior modification among sexual-minority men whose cultures value lighter skin may be much less of a challenge, although this remains to be investigated. Although they have a higher prevalence of skin cancer than their heterosexual counterparts, photoprotection counseling in sexual-minority men may be most effectively relayed by emphasizing wrinkle and skin aging prevention. Knowing that homosexual men are more likely to consider noninvasive and invasive cosmetic procedures, those who present to the clinic with expressed interest in chemical peels should be explicitly forewarned that inadequate photoprotection can jeopardize their candidacy and/or the outcomes of their chemical peeling procedure.

Up to 94% of transgender men undergoing cross-sex hormone treatment with testosterone develop acne vulgaris on their face, chest, and back, with symptoms peaking 4 to 6 months after testosterone initiation. Although the majority improve in severity after 12 months and respond adequately to standard acne management, some cases may be severe and/or persistent. Face or body peeling using serial SA and other peels should be considered, because they can offer immediate and reliable improvement of comedonal and inflammatory acne. Severe cases may require treatment with isotretinoin, which requires nuanced comprehension of the complexities surrounding contraception and pregnancy testing in this population. Superficial peels such as SA or Jessner’s solution (JS) may still be safely performed in patients concomitantly on isotretinoin and may serve as an effective adjunctive treatment.

A higher prevalence of anabolic androgenic steroid (AAS) use is reported among sexual-minority men compared with their heterosexual counterparts. These behaviors may start early in life, because AAS misuse among sexual-minority adolescent boys is three to four times higher than in heterosexual boys, especially among Black and Hispanic males. Although addressing misuse of AAS in these populations is well beyond the scope of this chapter, similar peeling recommendations as discussed in transgendered men applies to this group and may improve self-esteem in this population known to have a pervasive unhealthy body image. The potential role of chemical peels in acne management in cisgender and transgender men undergoing testosterone therapy is an area in need of research.

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