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Chemical Peels

Author: Gabriella Fabbrocini, MBBS, Tenured Researcher in Cutaneous and Venereal Diseases, Department of Systemic Pathologies, Division of Dermatology and Venereology, Università degli Studi di Napoli Federico II, Italy
Contributor Information and Disclosures

Updated: Nov 6, 2009

Introduction

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.

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.

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.

General 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 images below depict a patient during and after a salicylic acid peel.

Indications

Pigmentary disorders

• Melasma
• Postinflammatory hyperpigmentation
• Freckles
• Lentigines
• Facial melanoses

• Superficial acne scars
• Postacne pigmentation
• Comedonal acne
• Acne excoriée
• Acne vulgaris - Mild to moderately severe acne

• Photoaging
• Fine superficial wrinkling
• Dilated pores
• Superficial scars

• Seborrheic keratoses
• Actinic keratoses
• Warts
• Milia
• Sebaceous hyperplasia
• Dermatosis papulosa nigra

Contraindications

Relative contraindications

• 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.

• 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

• Degree of photoaging damage
  • 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.

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