History of Chemexfoliation
Since the days of ancient Egypt, people have been using chemexfoliation methods, also known as chemical peeling, to rejuvenate skin. The original chemexfoliant was lactic acid, an active ingredient of sour milk that was used topically by the nobles as part of an ancient skin rejuvenation regimen. In the Middle Ages, old wine with tartaric acid as its active ingredient was used for the same purpose. Today, these historical chemexfoliants are known to contain alpha hydroxy acids, which are the active ingredients responsible for the skin exfoliation.
Chemical peelings represent accelerated exfoliation or skin damage induced by caustic agents that cause controlled damage, followed by the release of cytokines and inflammatory mediators, resulting in thickening of the epidermis, deposition of collagen, reorganization of structural elements, and increases in dermal volume. This process decreases solar elastosis and replaces and reorients the new dermal connective tissue. The result is an improved clinical appearance of the skin, with fewer rhytides and decreased pigmentary dyschromia.
Modern day chemical peeling originally was promoted by dermatologists, such as P.G. Unna, who first described the properties of salicylic acid, resorcinol, phenol, and trichloroacetic acid (TCA). Slowly, the early practitioners of chemical peels began to develop other peeling agents for varying depths of penetration. In the 1960s, Baker and Gordon developed a deep peeling agent, which was able to smooth deeper furrows, especially around the mouth. From the 1980s to the present, an explosion has occurred in the mass of research on this subject, with the elucidation of many different types of peels, each for a specific range of problems.
The most common agents used for chemical peels are salicylic acid, glycolic acid, 30% salicylic acid in ethanol, 60% pyruvic acid in ethanol, resorcinol, and 10-50% resorcin paste, depending on the problem being addressed. For medium-depth peeling, the most common agents include 60% pyruvic acid applied for 3-5 minutes, 35-50% TCA, 35% TCA augmented with carbon dioxide, Jessner solution plus 35% TCA, and 70% glycolic acid plus 35% TCA. For deep chemical peels, agents include 88% phenol and Baker-Gordon phenol formula.
Men also request chemical peeling. This 56-year-old man is in the process of a salicylic acid peel.
Same patient as in Media File 3 following a successful chemical peeling.
Stages of Wound Healing After Chemexfoliation
Coagulation and inflammation
The healing process after a chemical peel must be as rapid as possible to avoid infections that may deepen the wounds, extending the peel from superficial to deep, with increased risks of scaring. Deep peels may be prophylactically treated with antimicrobials, but superficial and medium-deep peels are simply kept moist with the application of petrolatum-based products. After reepithelialization, and when skin appearance is back to normal, a regimen of alpha hydroxy acids, retinoic acid, bleaching creams, moisturizers, and sunscreens should be restarted. Sun exposure must be avoided for 6 weeks after the peel to minimize the risks of postinflammatory hyperpigmentation.
Production of controlled chemical burns of the epidermis and/or dermis results in exfoliation. The first phases of this process must be understood well to control the depth of penetration of chemical peelings. Phases are as follows:
- The development of diffuse homogeneous erythema indicates epidermal penetration.
- The development of white frost indicates coagulative necrosis of the papillary dermis.
- The development of gray-white frost indicates coagulative necrosis of the reticular dermis.
Reepithelialization
Preventing scab formation is important for faster and more even healing. Biosynthetic occlusive dressings can be used to hasten the healing process for deep peels.
Granulation tissue
Granulation tissue usually appears the second day and consists of fibroblasts, inflammatory cells, fibronectin, glycosaminoglycans, and collagen. Reepithelialization occurs subsequent to this process.
Angiogenesis
This process begins with endothelial cell migration to the wound site and is essential for wound healing. The erythema following a chemical peel primarily is caused by the new capillary growth in the area.
Collagen remodeling
Collagen remodeling is the main reason that chemical peels are able to reduce wrinkles. The process of remodeling involves a reorientation of the collagen in a parallel fashion and begins as collagen is formed following the peel. Deposition of glycosaminoglycans in the dermis correlates with the efficacy of the peeling procedure.
General Peeling Concepts
The process of performing a chemical peel
An evaluation of the patient by the clinician is necessary to determine the appropriate treatment based on the dermal defect. When evaluating the patient before the peel, an extensive history should be taken. If it is determined that a chemical peel is warranted, the appropriate agent is selected based on the patient's Fitzpatrick skin type and Glogau photoaging group, as well as other variables that may affect peel penetration. Evaluation of the skin should also refer to skin thickness and oiliness. Sebaceous skin usually requires priming with topical retinoids or/and alpha hydroxy acids and thorough skin defatting before the procedure to assure even penetration of the peeling solution.
The patient must be educated concerning the chemical peel process and give signed consent is advised if performing a medium or deep peel. The patient has to be questioned about their general health status, medications (eg, oral isotretinoin), smoking, previous cosmetic procedures (eg, surgical lifts, fluid silicone injections), recurrent herpetic outbreaks, and keloid formation.
The skin should be defatted properly with acetone. Delicate areas that need to be protected should have petroleum jelly applied, including the lips, inside the nose, and optionally in the nasolabial fold, medial canthus, and lateral canthus. The correct peeling agent then is applied for the appropriate amount of time. When performing a combination peel, pouring one agent at a time is advisable because of the ease in which the agents may be confused when poured into similar cups. Then, the peeled area should be neutralized, and the patient should be sent home with proper instructions along with advice to call should any complications arise. Skin preparation with bleaching creams and early reintroduction of these products in the immediate postpeel period are crucial to avoid postinflammatory hyperpigmentation in dark phenotypes.
The defatting process is important for the even penetration of the peeling agent. This patient is a Fitzpatrick type II, Glogau type I, using alcohol and acetone mixture to defat the skin.
This 45-year-old woman has just completed her salicylic acid peel and will neutralize the peel with cold water.
Indications for chemical peel
Pigmentary disorders
- Melasma
- Postinflammatory hyperpigmentation
- Freckles
- Lentigines
- Facial melanoses
Acne
- Superficial acne scars
- Postacne pigmentation
- Comedonal acne
- Acne excoriée
- Acne vulgaris - Mild to moderately severe acne
- Photoaging
- Fine superficial wrinkling
- Dilated pores
- Superficial scars
Epidermal growths
Upper epidermal defects, such as melasma, can be treated with superficial peels, while deeper defects, such as deep wrinkles, may require a deep peeling agent. Medium-depth (superficial dermis) defects, such as mild dermatoheliosis, require a medium-depth peel. Deep perioral rhytides may require a deep peel, such as the Baker Gordon solution.Available clinical guideline summaries include the following:
- British Association of Dermatologists - Guidelines for the management of actinic keratoses1
- American Academy of Dermatology -Guidelines of care for acne vulgaris management2
Relative contraindications are determined by the skin type of the patient and the defect being treated. To optimize the procedure, some classifications are very useful, such as the Fitzpatrick and the Glogau photoaging classifications.
Fitzpatrick skin typing is graded from 1-6, with the first 3 skin types being white skin with progressively more active responses to tanning. Type 4 is light-brown skin, and type 5 is dark brown skin. Type 6 skin never tans and is essentially black skin with an equivalent sun protective factor (SPF) of 8. Fitzpatrick skin types 5 and 6 are usually not ideal candidates for medium and deep peels. The best candidates are the light skin types, 1, 2, and 3, which are at less risk of complications such as pigment dyschromia and scarring. Although skin types 5 and 6 are not ideal for peels, they can be peeled using superficial agents such as salicylic acid or glycolic acid.
The Glogau photoaging classification is a visual grading system used to quantify photodamage. Patients with photoaging type I are not good candidates for deep peeling because the peel may be more damaging than beneficial, while a superficial peel would be more efficacious. Patients with type IV photodamage may benefit from deep peeling, while a superficial peel may not make much of a difference. Patients with skin types II and III ordinarily benefit from superficial or medium-depth peels, depending on the exact circumstances of the patient. Other variables also should be considered, including the Fitzpatrick skin type, when determining which peeling agent to use.
In type I, the patient, usually is in the second or third decade of life, shows mild early photoaging that consists of mild pigmentary changes, does not have keratoses, and has minimal wrinkles. The patient requires minimal or no makeup.
In type II, the patient has wrinkles that appear when he or she makes facial gestures or other dynamic facial muscle activity (ie, "wrinkles in motion"). Early-to-moderate photoaging is recognized by early senile lentigines, keratoses that are palpable but not visible, and the emergence of parallel smile lines. The patient is usually in the third or fourth decade of life. Female patients usually wear some foundation.
In type III, the patient has wrinkles not dependent on facial movement (ie, "wrinkles at rest"). Advanced photoaging is recognized by obvious dyschromia, telangiectasias, visible keratoses, and wrinkles at rest. The patient is usually aged 50 years or older, and female patients almost always wear heavy foundation.
In type IV, the patient has only wrinkles, and nearly no smooth skin. Severe photoaging is characterized by yellow-gray coloration of the skin, prior history of skin malignancies, and skin that is thoroughly wrinkled. The patient is usually in the sixth or seventh decade of life. In addition, the patient cannot wear makeup because it cakes and cracks in the wrinkles.
Absolute contraindications
- Active bacterial, viral, fungal, or herpetic infection
- Open wounds
- History of drugs with photosensitizing potential
- Preexisting inflammatory dermatoses (eg, psoriasis, atopic dermatitis)
- Uncooperative patient (patient is careless about sun exposure or application of medicine)
- Patient with unrealistic expectations
- For medium-depth and deep peels, history of abnormal scarring, keloids, atrophic skin, or isotretinoin use in the last 6 months
Patients with either severely damaged skin or excellent skin may not be good candidates for chemical peels. Sun-damaged skin shows epidermal changes, elastosis, and collagen distortion in the midreticular dermis. To eradicate photodamage, deep peels are required. More superficial peels, even when performed in repetitive fashion, do not reach the affected histological level and therefore have a minimal effect on photodamaged skin.
Smoking
Patients must understand the necessity for smoking cessation. The dynamic action of puffing can worsen perioral rhytides, and the chemicals in the smoke can cause enzymatic reactions that weaken the skin and cause further wrinkling around the mouth and eyes.
Prior cosmetic surgery
Waiting several months following surgery that involves the face is recommended. Give the skin time to heal prior to subjecting it to chemexfoliation. Compliance with prepeel and postpeel treatment must be assured. The patient must be motivated enough to adhere to a daily regimen for a few weeks before and after the procedure
General health
With phenol peels, the patient should be in good general health because phenols can cause arrhythmias. Phenol is directly toxic to myocardium. Cardiac arrhythmias have been recorded in up to 23% of patients when a full-face peel was performed in less than 30 minutes. These arrhythmias have included tachycardia, premature ventricular beats, bigeminy, atrial tachycardia, and ventricular tachycardia. Adequate patient management reduces this complication rate to less than 7%.
Good kidney and liver function are necessary for adequate excretion and detoxification. A screening blood chemistry that includes blood urea nitrogen, creatinine, and liver function is wise. ECG monitoring is necessary during the peeling process. No hepatorenal or central nervous system toxicities have been reported in the literature with properly performed chemical peels.
Mental health
Patients who are mentally unstable may be overly self-conscious and may not be prepared for their aesthetic appearance immediately following the peel.
Medications
A thorough medical and drug history is very important. Medical conditions such as cardiac, hepatic, or renal disease may influence treatment decisions and the choice of peeling agents. Exogenous estrogens, oral contraceptives, and other medications may be photosensitizing and predispose patients to pigmentation complications after chemical peeling and worsening the skin discoloration that the chemical peel was intended to eradicate. Patients taking blood thinners, such as warfarin, should avoid deep peels because of the possibility of blood oozing from the peel site. Patients taking aspirin usually do not have complications, but, if the medication is not necessary, advise them to stop taking it 1 week prior to a deep peel.
Herpes
A history of herpes simplex requires antiviral prophylaxis from the immediate prepeel period until reepithelialization is complete. Acyclovir (400 mg) should be started 2 days prior to the peel and continued for 5 days after the peel to reduce the risk of recurrent herpes infection. Some dermatologists advise prophylaxis in all patients to avoid the risks of a herpetic outbreak. Any existing lesion must heal completely before undergoing a chemical peel.
History of scarring
Patients need to be asked if they have a history of hypertrophic scarring. Many people who have hypertrophic scarring can develop keloids. This usually is found in patients with Fitzpatrick skin types 5 and 6 but can develop in patients with skin types 1, 2, 3, and 4. Medium and deep peels penetrate into the superficial and deep dermis, which may stimulate keloidal development in patients who are inclined to develop keloids. Weak superficial peels can be considered in patients with skin types 4 and 5 because the penetration is only into the epidermis. Patients with a history of scarring are not candidates for major skin resurfacing, such as laser or medium/deep peels.
Expectations
A discussion between the physician and patient is necessary prior to a chemical peel, especially a deep peel. Examples of before-and-after results should be shown, and the possibility of complications must be explained to the patient.
Follicle unit density
Previous use of isotretinoin must be noted. Patients should wait until 6 months after the last dose of isotretinoin to reduce the risk of scarring. Patients who have had recent radiation treatment need to have a skin biopsy performed to ascertain the existence of hair follicle units, because these follicle units are where the reepithelialization occurs.
Factors Affecting Peel Depth
Chemical peels are divided into 3 categories depending on the depth of the wound created by the peel. Superficial peels penetrate the epidermis only, medium-depth peels damage the entire epidermis and papillary dermis, and deep peels create a wound to the level of the midreticular dermis. The depth of the peel is dictated by a number of factors, including the chemicals applied and their concentration, mode of application, and skin type and its condition. In general, the depth of the peel determines the patient's inconvenience during and after the procedure, the healing time, the rate of the potential adverse effects, and the results.
Patient history
History is taken to determine the amount of sun-induced damage, history of hypertrophic scarring or keloid formation, and a general medical history. Items of interest include a history of prior surgeries, dermabrasion, or recent laser therapy. In addition, medicines, such as isotretinoin, need to have been stopped for at least 6 months prior to chemical peeling.
Peeling agent concentration
Peeling agent concentration can vary, even though the label indicates the same concentration. The different methods used to determine the concentration of an acid can produce some variation. From strongest to weakest, these methods are dilutions of a saturated solution, the weight-to-weight method, the weight-to-volume method, and grams of acid crystal mixed to 100 mL of water.
Free acid availability
Molecules found in chemical peels are either alcohols that contain a carboxyl (-COOH) and hydroxyl (-OH) groups or regular acids. It has been suggested that according to their chemical properties, substances used in chemical peels are classified as metabolic, caustic, and toxic.
The pH of the agent, or free acid available (pKa), is another measurement. The pKa of the solution is the pH at which half is in acid form; therefore, a lower pKa means that more free acid is available. Many products advertise the acid percentage; however, pKa is a more accurate determinant of strength.
Application of peeling agent
The clinician can vary the number of coats depending on the depth of peel desired. The peel frost, or facial whitening indicating depth of epidermal damage, can aid in the determination of this number.
Frequency that patient receives a peel
Most patients can tolerate a monthly superficial peel, while medium-depth peels can be performed at 6-month intervals if necessary.
Method of application
The peeling agent should be removed from its reservoir and put into a glass bowl. Cotton-tipped applicators may be used individually or put together to deliver more of the agent. Alternatively, 4 X 4-inch gauze may be folded into squares to apply the peeling agent. The gauze has the advantage of directing tactile pressure on the skin surface as the peel is performed. Neutralizing agents are put in metal bowls to distinguish them from the peeling agents. One bowl contains a 1% sodium bicarbonate solution and the other contains cool water. The patient should be resting comfortably in the supine position. The acid should not form pools in the facial folds nor drip from the face. The more acid the clinician applies, the deeper the peel.
Hair is removed from the face with a hair bonnet. The lips are coated with an occlusive ointment preparation, and cotton is put in each ear opening during the peel. If only the face is being peeled, the neck and shoulders are draped with towels. Eyewear is optional and often interferes with the area to be peeled; however, patients must understand that they should keep their eyes closed during the procedure. This is usually not an issue.
Contact time
The duration the peeling agent is in contact with the skin also helps determine the depth of the peel. After the appropriate time has past, neutralization is performed. Some chemical peels, such as salicylic acid and trichloroacetic acid, do not require a neutralization step because the skin neutralizes the acid. Glycolic acid peels must be neutralized. Always wash the patient's face with water following the peel.
Density of adnexal structures
Recent radiation treatment can affect the density of adnexal structures. The reepithelialization process partially occurs from the adnexal structures; therefore, some clinicians advise that a punch biopsy be performed to verify their existence.
Occlusion
Products available, such as biosynthetic occlusive dressings, may decrease pain and speed healing. Examples include hydrogel membrane products, such as Vigilon (Hermal Labs, Delmar, NY); polyurethane membranes, such as Meshed Omiderm (Doak Dermatologics, Fairfield, NJ); and silicone membrane Silon II (BomMed Inc, Bethlehem, Pa).
Rejuvenation regimen
Patients may treat the skin before and after a peel with agents such as tretinoin, hydroquinone, or an alpha hydroxy acid. These may help the skin heal faster and may allow the chemical peel agent to achieve better penetration.
Ointments
Petroleum jelly and other occlusive ointments may, to a minor degree, act as an occlusive barrier.
Defatting
The skin should be cleaned, and excess fat should be removed with agents such as acetone, rubbing alcohol, Septisol, or a combination of these agents. Three parts alcohol with 1 part acetone works well. A thorough defatting of the skin is necessary for proper penetration of the peeling agent because most agents are not lipid soluble.
Application
The patient should sit in a comfortable position, wear a disposable hair cap, and be instructed to keep the eyes closed during the procedure. A zinc oxide past should be applied at the lip and eyelid commissures.
The peeling agent can be applied with 4 X 4-inch gauze, cotton swabs, or the foam applicator that comes with the peel kit. Popsicle sticks are good applicators for the paste form. Apply the peeling agent in cosmetic units, beginning with the forehead and finishing with the chin. Feather the peeling agent into the hairline and the shadow of the mandible. Reapplication of the peeling agent may be necessary if the frost is uneven or is not white enough.
Frost
The change in coloration of the skin to a whitish tint is called frost. This represents the end stage of the chemical peel and shows that keratin agglutination has occurred. Depending on the agent used, the white tint may vary from a brighter white in a superficial peel to a grayish white in a deep peel.
Neutralization
Neutralization of the chemical peeling agent is an important step once the clinician has achieved the proper depth of the peel, which is determined by either the frost or how much time has elapsed. Neutralization can be achieved by applying cold water or wet, cool towels to the face following the frost. This soothes the sharp tingling discomfort caused by the peeling agent. Other neutralizing agents that can be used include bicarbonate spray or soapless cleanser. Peeling agents for which this neutralization step is less important include salicylic acid, Jessner solution, and phenol.
Instruction and Consent
A detailed consent form listing details about the procedure and possible complications should be signed by the patient. The consent form should specifically state the limitations of the procedure and should clearly mention if more procedures are needed for proper results. The patient should be provided with adequate opportunity to seek information through brochures, presentations, and personal discussions. The need for postoperative medical therapy should be emphasized.
Following the peel, the patient must follow the instructions given by the physician to prevent complications. If possible, the patient should stay out of the sun; when unavoidable, the patient should apply a strong sunscreen and wear a hat. An ointment, such as petroleum jelly or bacitracin, should be applied to the involved skin.
The patient should be made aware that the skin will exfoliate and may look cosmetically unattractive for a period of time depending on the depth of the peel. For superficial peels, a follow-up appointment can be scheduled at the time of the next peel. For deeper peels, patients should be seen 2-3 times the week following the peel to provide for early intervention if problems develop.
The patient should be instructed to remain vigilant for signs of infection. If the patient has a history of cold sores, treating the patient with acyclovir (400 mg PO bid) or an equivalent drug is advisable, beginning 2 days prior to the peel and continuing for 7 days after the peel.
Chemical Peeling Agents
Superficial peeling agents
Trichloroacetic acid3,4
Trichloroacetic acid (TCA) can be used to create a superficial, medium, or deep peel. Apart from variables such as patient skin type, adequacy of skin priming, layers of acid applied, and technique of application, the most important factor affecting the depth of the peel is the concentration of TCA used. Concentrations of 10-25% are used for intraepidermal peels, whereas 30-40% are used for papillary dermal peeling. TCA is most commonly used for medium-depth peels, especially to treat pigmentation disorders and early facial rhytides.
TCA (10-35%) has been used for many years and is safe to use at lower concentrations. At higher concentrations, such as 50% and greater, TCA has a tendency to scar and is less manageable than other agents used for superficial peels. TCA is found in several proprietary peels at varying concentrations, and some kits have instructions and buffering agents so the peel can be diluted as deemed necessary. The end point is frosting for TCA peels, which are neutralized either with a neutralizing agent or cold water, starting from the eyelids and then proceeding to the entire face.
Jessner solution
Jessner peel solution is a combination of salicylic acid 14%, lactic acid 14%, and resorcinol 14% in alcohol. This agent is easy to use, with no timing necessary. Apply the agent, wait for a light frost, and then neutralize with water. The solution is applied to the skin with a soft applicator in patients with thin, sensitive skin or is rubbed in with gauze squares in patients with thick sebaceous skin. The depth of the peel depends on the number of coats of solution applied. A very superficial Jessner peel results in faint erythema, which may be associated with a light powdery-looking whitening of the skin surface.
Salicylic acid
Salicylic acid has been used for several decades and is found in medications such as Whitfield's ointment at 4% and Trans-Ver-Sal at 17% concentrations. Adverse effects, usually only found with high-dose oral ingestion, include headache, nausea, and ringing of the ears, each of which may be resolved with a few glasses of water and rest. These have never been reported with a peel procedure. For salicylic acid peels, the end point is the pseudofrost formed when the salicylic acid crystalizes. This type of agent is very safe, and patients generally tolerate the procedure well.
Salicylic acid is lipid soluble; therefore, it is a good peeling agent for comedonal acne. The salicylic acid is able to penetrate the comedones better than other acids. The anti-inflammatory and anesthetic effects of the salicylate result in a decrease in the amount of erythema and discomfort that generally is associated with chemical peels. The most common concentration used today is 20-30% and can be purchased in easy-to-use kits.
A newly introduced agent, beta-lipohydroxy acid, is a salicylic acid derivative and has properties that could possibly expand the clinical use of peels.5,6
Carbon dioxide
Carbon dioxide peels use a solid block of carbon dioxide ice dipped in an acetone-alcohol mixture, which is then applied to the skin for 5-15 seconds, depending upon the desired depth. Carbon dioxide is easier to use, and the depth of the peel can be controlled more easily than with liquid nitrogen; carbon dioxide is at -78°C, while liquid nitrogen is at -196°C.
Alpha hydroxy acid7,3
Alpha hydroxy acid peels include lactic acid, glycolic acid, tartaric acid, and malic acid that are synthesized chemically for use in peels. Various concentrations can be purchased, with 10-70% concentration used for facial peels, most commonly 50% or 70%. Alpha hydroxy acids are weak acids that induce their rejuvenation activity by either metabolic or caustic effect. At low concentration (<30%), they reduce sulfate and phosphate groups from the surface of corneocytes. By decreasing corneocyte cohesion, they induce exfoliation of the epidermis. At higher concentration, their effect is mainly destructive. Because of the low acidity of alpha hydroxy acids, they do not induce enough coagulation of the skin proteins and therefore cannot neutralize themselves and must to be neutralized using water or a weak buffer.
Pyruvic acid
Pyruvic acid is used in superficial peeling and if difficulty is encountered controlling peel depth. A product currently is being developed that uses ethyl pyruvate and has a higher pH and greater buffering ability than other related products.
Medium-depth peels8
Three combination peels currently being used are carbon dioxide and TCA 35%, Jessner solution and TCA 35%, and glycolic and TCA 35%. These peels are as effective as the other medium-depth peels, with less chance of scarring and pigment dyschromia. An endless number of combinations are possible, more than can be covered in this overview.
TCA 50% is seldom used because of a higher risk of scarring and the availability of the combination peels.
Full-strength phenol (88%) is a very caustic agent that causes immediate keratin agglutination, preventing further penetration of the agent deeper into the dermis. Again, the increased risk of scarring and pigment dyschromia makes this agent less attractive to the practitioner. If diluted and mixed with other complementary chemicals, this agent can be used effectively as a deep peeling agent.
Deep peels9
Baker-Gordon peel produces the most dramatic results and is the most effective peeling agent currently used. The phenol produces a new zone of collagen that is thicker than that produced by laser. This solution is very effective in smoothing wrinkles related to aging and sun damage.
This advantage is countered by several disadvantages. The agent may produce premature ventricular contractions or more serious arrhythmia. A long healing time is required, with erythema occasionally lasting as long as 6 months. In addition, the potential for pigmentary changes, scarring, and infection are high with this peel. Despite the problems that may be encountered, a properly administered phenol peel is unmatched by the other peeling agents, and, for perioral wrinkles, the phenol peel even surpasses laser resurfacing. Although dramatic results can be achieved with the phenol peel, the risks and benefits should be weighed carefully before proceeding. Only experienced clinicians should attempt a phenol agent–based peel.
The Baker-Gordon solution is made of phenol 88%, 2 mL distilled water, 8 drops Septisol, and 3 drops croton oil. This formula penetrates into the middle reticular dermis and requires special monitoring devices, such as an ECG monitor and pulse oximeter, because of the potential of the phenol to cause arrhythmias. The Baker-Gordon formula is not often used in current practice because of resurfacing laser technology; however, a deep peel works well on deep perioral rhytides. Deep peels can be occluded or nonoccluded. The occluded method uses zinc oxide tape or another artificial barrier product to prevent evaporation of the phenol from the skin, thus enabling the solution to penetrate deeper.
Two variants of the Baker-Gordon peel are Litton's formula, which replaces Septisol with glycerin, and the Beeson-McCollough formula, which uses aggressive defatting and a heavier application of Baker-Gordon solution.
Complications
Pigmentary change
Pigmentary change is not an uncommon complication, especially with the deeper peeling agents. In some cases, the peeled area remains stark white. Taking proper precautions (as described earlier) can help prevent undesirable pigmentary changes. Usually, patients with lighter complexions have a lower risk of hyperpigmentation, but genetic factors play an important role, and, sometimes, light-skinned patients with "dark genes" hyperpigment unexpectedly. Skin priming using a combination of hydroquinone and tretinoin cream (Kligman formulation) before a superficial or medium-depth peel and early introduction of this preparation after deep peels reduces the rate of this complication.
Scarring
Scarring remains the most dreaded complication of chemical peels. The contributing factors are not well understood. By matching the patient and peeling agent properly, the risk of scarring can be decreased. In addition, to further decrease the risk of scarring, the patient should be advised to refrain from picking at the healing skin. Patients with a history of keloids should not undergo medium or deep peels because of the risk of scarring. Medium and deep peels penetrate to the superficial and reticular dermis and, thus, may stimulate keloids. Weaker superficial peels that only exfoliate the stratum corneum or superficial epidermis can be used.
Infection
By using bacitracin for the medium and deep peels and cleaning the face with a povidone wash, the risk of infection is decreased. Cold sores can be prevented with acyclovir (400 mg PO bid), beginning 2 days prior to the peel and continuing 7 days after the peel. Candidiasis infection also can develop, for which a short course of fluconazole can be used. Cultures need to be taken, and appropriate antibiotics should be administered. Toxic shock syndrome has been reported after a chemical peel.10
Prolonged erythema
Patients usually do not report erythema because it generally subsides in 30-90 days, but sometimes erythema continues. Prolonged erythema is usually not permanent, and topical hydrocortisone can be used to speed the healing process.
Acne
Some patients develop acne after a chemical peel. This usually occurs between days 3-9. Cultures should be taken, and an antibiotic that covers gram-positive bacteria should be prescribed. If it is a true acne occurrence, then the appropriate topical treatment also should be started. If severe enough, isotretinoin may be initiated.
Milia
Small inclusion cysts, sometimes called milia, can appear in the healing process after a chemical peel. These usually appear about 2-3 weeks after reepithelialization and may be aggravated by ointments, owing to occlusion of the sebaceous glands.
Summary
Novices at chemical peeling should educate themselves through dermatology conferences, journals, and hands-on training. After sufficient knowledge is obtained, starting with superficial problems, such as acne, general skin rejuvenation, or melasma, using a superficial peel such as 20% salicylic acid, is recommended.
Chemical peels are not a cure-all, and patient expectations should be realistic. Dynamic wrinkles caused by muscle action or sagging due to old age usually requires an alternative treatment, such as facelift, botulinum toxin (BOTOX®), or collagen injections. The clinician should assess each patient, explain the alternatives, and then decide on a course of action. The correct peeling agent needs to be chosen if chemexfoliation is decided. Proper defatting of the skin is critical for an even peel. Application of the peeling agents must be performed correctly. Postpeel instructions need to be explained carefully. If performed correctly, the chemical peel can give excellent results, with many satisfied patients.
Multimedia
 | Media file 1: The defatting process is important for the even penetration of the peeling agent. This patient is a Fitzpatrick type II, Glogau type I, using alcohol and acetone mixture to defat the skin. |
 | Media file 2: This 45-year-old woman has just completed her salicylic acid peel and will neutralize the peel with cold water. |
 | Media file 3: Men also request chemical peeling. This 56-year-old man is in the process of a salicylic acid peel. |
 | Media file 4: Same patient as in Media File 3 following a successful chemical peeling. |
Keywords
chemical peels, chemexfoliation, peeling agents, chemical abrasion, glycolic acid, trichloroacetic acid, salicylic acid
The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Raymond T. Kuwahara, MD, MBA, and Ron Rasberry, MD, to the development and writing of this article.
More on Chemical Peels |
| References |
References
[Guideline] de Berker D, McGregor JM, Hughes BR. Guidelines for the management of actinic keratoses. Br J Dermatol. Feb 2007;156(2):222-30. [Medline].
[Guideline] Strauss JS, Krowchuk DP, Leyden JJ, et al. Guidelines of care for acne vulgaris management. J Am Acad Dermatol. Apr 2007;56(4):651-63. [Medline].
Duffy DM. Alpha hydroxy acids/trichloroacetic acids risk/benefit, strategies. A photographic review. Dermatol Surg. Feb 1998;24(2):181-9; quiz 190-1. [Medline].
Glogau RG, Matarasso SL. Chemical peels. Trichloroacetic acid and phenol. Dermatol Clin. Apr 1995;13(2):263-76. [Medline].
Berson DS, Cohen JL, Rendon MI, Roberts WE, Starker I, Wang B. Clinical role and application of superficial chemical peels in today's practice. J Drugs Dermatol. Sep 2009;8(9):803-11. [Medline].
Fischer TC, Perosino E, Poli F, Viera MS, Dreno B. Chemical peels in aesthetic dermatology: an update 2009. J Eur Acad Dermatol Venereol. Sep 8 2009;[Medline].
Briden ME. Alpha-hydroxyacid chemical peeling agents: case studies and rationale for safe and effective use. Cutis. Feb 2004;73(2 Suppl):18-24. [Medline].
Halaas YP. Medium depth peels. Facial Plast Surg Clin North Am. Aug 2004;12(3):297-303, v. [Medline].
Landau M. Advances in deep chemical peels. Dermatol Nurs. Dec 2005;17(6):438-41. [Medline].
Holm C, Muhlbauer W. Toxic shock syndrome in plastic surgery patients: case report and review of the literature. Aesthetic Plast Surg. May-Jun 1998;22(3):180-4. [Medline].
A. Tosti, P. E. Grimes, M. P. De Padova. Glicolic Acid. In: Springer-Verlag Berlin Heidelberg. Color Atlas of chemical peels. Germany: 2006:Chapter 2; pages 13-21.
Brody HJ. Chemical Peeling and Resurfacing. 2nd ed. St. Louis, Mo: Mosby-Year Book; 1997.
Landau M. Cardiac complications in deep chemical peels. Dermatol Surg. Feb 2007;33(2):190-3; discussion 193. [Medline].
Monheit GD. Chemical peels. Skin Therapy Lett. Feb 2004;9(2):6-11. [Medline].
Rendon MI. Utilizing combination therapy to optimize melasma outcomes. J Drugs Dermatol. Sep-Oct 2004;3(5 Suppl):S27-34. [Medline].
Resnik SS, Resnik BI. Complications of chemical peeling. Dermatol Clin. Apr 1995;13(2):309-12. [Medline].
Truppman F, Ellenbery J. The major electrocardiographic changes during chemical face peeling. Plast Reconstr Surg. 1979;63:44.
Tse Y, Ostad A, Lee HS, et al. A clinical and histologic evaluation of two medium-depth peels. Glycolic acid versus Jessner's trichloroacetic acid. Dermatol Surg. Sep 1996;22(9):781-6. [Medline].
Further Reading
Keywords
chemical peels, chemexfoliation, peeling agents, chemical abrasion, glycolic acid, trichloroacetic acid, salicylic acid
