Chemical Peels Periprocedural Care

Updated: Jul 26, 2017
  • Author: Gabriella Fabbrocini, MBBS, MD; Chief Editor: Dirk M Elston, MD  more...
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Periprocedural Care

Patient Education and Consent

Patient instructions

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 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.

Elements of informed consent

The patient must be educated concerning the chemical peel process and signed consent is advised if performing a medium or deep peel. The patient has to be questioned about his or her general health status, medications (eg, oral isotretinoin), smoking, previous cosmetic procedures (eg, surgical lifts, fluid silicone injections), recurrent herpetic outbreaks, and keloid formation.

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.

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Preprocedural Planning

Although the technique of chemical peeling is relatively simple, the challenge lies in proper patient and peeling agent selection. In general, the more severe the actinic damage or advanced the aging changes, the more aggressive the treatment should be. Once the patient is appropriately selected to undergo a chemical peel, informed consent, including a thorough discussion of possible complications, is obtained.

Adequate evaluation and photographic documentation of the patient prior to peeling is essential. This includes consideration of the severity of actinic damage, depth and number of rhytides, and need for additional or alternative procedures. The patient with deep rhytides and excessive facial skin laxity is likely to respond better to traditional rhytidectomy. The patient with moderate-to-severe photodamage and medium-to-fine rhytides may be a more optimal candidate for chemical peeling.

Some patients may benefit from both procedures because rhytidectomy addresses skin quantity, whereas peeling addresses skin quality. However, these procedures cannot be recommended as concurrent interventions. In general, for safety purposes, a minimum of 3 months is recommended between the procedures to allow for adequate wound healing.

Fitzpatrick and the Glogau photoaging classifications

A cornerstone of the evaluation of the patient for chemical peeling is the Fitzpatrick and the Glogau photoaging classifications of sun-reactive skin types and a visual grading system used to quantify photodamage.

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.

Medical and drug history

A thorough medical history and review of systems should be completed in concert with the physical examination. Preexisting cardiac, hepatic, and renal disease may influence the treatment decision and choice of peeling agents. History is taken to determine the amount of sun-induced damage, history of hypertrophic scarring or keloid formation. Other items of interest include a history of prior surgeries, dermabrasion, or recent laser therapy.

The use of exogenous estrogens, oral contraceptives, and other photosensitizing medications are known to predispose to unpredictable pigment changes. Therefore, such agents should be avoided several weeks before and after a peel. Medicines such as isotretinoin need to have been stopped for at least 12 months prior to chemical peeling.

If the patient has a history of herpes simplex infection, the physician should provide antiviral prophylaxis several days before and after the peel. This helps minimize chances of unwanted viral reactivation as the re-epithelialization process occurs. Some authors, in fact, advocate prophylaxis in all patients. Toward this end, it is also advisable to allow any existing lesion to heal completely before proceeding with a chemical peel.

Patient selection and compliance

The ideal candidate has minimal sag or severe skin excess but many fine lines and rhytides. Patients with fair complexions are better suited to peels primarily because of possible postinflammatory hyperpigmentation in other skin colors. These long-term concerns can largely be circumvented with proper pretreatment and posttreatment using bleaching agents. The hypopigmentation commonly observed after deep chemical and laser peels generally occurs in whites and can be avoided with a more superficial peel or by peeling adjacent areas lightly to blend the areas. If a deep peel is necessary, discussing the likely probability of hypopigmentation with the patient is best to ensure that when it occurs it is an acceptable result.

Patients must also be aware that cooperation and compliance with the postpeel regimen is required to ensure normal wound healing and to avoid complications. Patients likely to be noncompliant or unable to avoid sun exposure because of occupation are unsuitable candidates. In general, men are considered less optimal candidates because of thicker, oilier skin that risks uneven penetration of the peeling agent. Men are also less likely to be willing to use camouflage makeup in the event of pigmentary disturbances. Patients with a decreased number of epithelial appendages from prior radiation treatment or current isotretinoin (Accutane) use are also poor candidates because healing will proceed more slowly and scarring is more likely.

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Equipment

Various chemical peeling agents are used for superficial, medium-depth, or deep peels.

Trichloroacetic acid

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% concentrations are used for papillary dermal peeling. TCA is most commonly used for medium-depth peels, especially to treat pigmentation disorders and early facial rhytides. A combination of TCA 3.75% and lactic acid 15% can be used in patients with periorbital hyperpigmentation. Patients with skin types II, III, or IV can be successfully treated with this chemical peeling every week for a series of 4 treatments.

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 endpoint is frosting for TCA peels, which are neutralized with either 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 endpoint 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 is 20-30% and can be purchased in easy-to-use kits.

Beta-lipohydroxy acid

A newly introduced agent, beta-lipohydroxy acid, is a salicylic acid derivative and has properties that could possibly expand the clinical use of peels. [11, 12]

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 acid

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 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.

Combination peels

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.

Baker-Gordon solution (phenol)

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.

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.

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Patient Preparation

Preconditioning the skin is a useful adjunct to improving overall results. Trans-retinoic acid (Retin-A, Renova), an exfoliative agent, is believed to facilitate uniform penetration of the peeling agent and promote more rapid re-epithelialization. This may be applied nightly or every other night for several weeks prior to peeling, depending on the degree of skin irritation caused and patient tolerance. This promotes a thinning of the stratum corneum with shedding of keratinocytes while fibroblasts are stimulated.

Prior to the peel, the patient should thoroughly cleanse the face with nonresidue soap on the evening before and morning of the procedure. The patient is instructed not to apply makeup or moisturizers in the interim. The skin is cleansed immediately prior to the procedure to remove any remaining traces of makeup or oils. Either acetone or isopropyl alcohol may be used for this purpose. This step is essential to prevent uneven penetration of the peeling agent.

The patient may take 1-2 ibuprofen tablets (400 mg) 1 hour prior to the procedure.

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Monitoring & Follow-up

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.

Postoperative care is aimed at providing an ideal environment for moist wound healing. Initially, a generous amount of bland ointment (eg, white petrolatum, A&D ointment) is applied to the entire treated area. Patients are instructed to reapply the ointment throughout the day, any time the face feels tight or dry. As the outer layers begin to shed, the patient is allowed to shower and gently wash the face with nonresidue soap using fingertips only. After showering, the face should be patted dry and a new coating of ointment applied. Instruct patients to not pick at the face during the recovery period.

Rejuvenation regimen

Patients may treat the skin after a peel with agents such as tretinoin, hydroquinone, or an alpha-hydroxy acid. These may help the skin heal faster. Some practitioners use topical agents that contain platelet products or growth factors. While these products have been reported to improve wound healing in other clinical situations, no randomized controlled clinical trials presently support their use in this setting. Further research is ongoing in this area.

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.

In the early stages of wound healing, re-examine the patient within 48 hours and again every several days. Instruct patients to refrain from trans-retinoic acid, sunscreen, or makeup until the face is healed to the satisfaction of the treating physician. [13]

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.

In all these events, clotting factors are activated, as are monophages and lymphocytes. Inflammatory mediators are activated, such as C5a, leukotriene B4, and kallikrein.

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.

Prolonged erythema

Patients usually do not report erythema because it generally subsides in 30-90 days, but sometimes erythema continues. Patients at increased risk are those taking oral contraceptive pills, exogenous estrogens, or other photosensitizing medications.

Prolonged erythema is usually not permanent, and topical hydrocortisone can be used to speed the healing process, as can a short course of systemic steroids. Other treatment options for hyperpigmentation include trans-retinoic acid, glycolic acid, or hydroquinone. Accompanying pruritus may be treated with oral antihistamines.

Acne

Some patients develop acne after a chemical peel. This usually occurs between days 3 and 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.

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Complication Prevention

Complications are not observed with superficial peels, nor are great benefits. In patients prone to hyperpigmentation, pretreatment and posttreatment with a bleaching agent are necessary. Sun exposure must be avoided, especially in these individuals. Deep peeling is a risk. Avoiding the ever-present risk of scarring is of paramount importance, but this is difficult when a marked result is desired and when little control over many of the variables of depth is possible. Conscientious attention to every detail of the peel and experience with the procedure are necessary. Hypopigmentation in white persons after a deep peel is almost universal and should be an accepted sequela of the procedure.

Many more complications and scars are recorded from trichloroacetic acid (TCA) peeling than from phenol peeling, perhaps because of the care with which phenol peels must be performed and the implied safety of TCA. Deep peels can be performed readily with TCA; take care not to peel too deeply. Other complications of infection, severe postoperative pain, and either too deep or too superficial a peel for the particular situation can be minimized with experience and vigilance.

Complications are more likely with darker skin types and certain peeling agents (eg, TCA). [14]

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 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.

Following chemical peeling, the skin is typically sensitive to the sun, which also may be a source of hyperpigmentation. Instruct patients to use sunscreen daily for 6-12 months following a chemical peel. Patients should also be educated in the appropriate application of camouflaging makeup.

Hypopigmentation is the result of melanocyte destruction or inhibition. Melanocytes originate from neural crest cells and do not possess the ability to regenerate or divide. Hypopigmentation is encountered most frequently when phenol is used as the peeling agent, which has led many to abandon phenol in favor of other agents. Hypopigmentation is more noticeable on darkly pigmented patients. Hypopigmentation may be difficult to assess until erythema has subsided, at which point the condition unfortunately becomes permanent. The line of demarcation between treated and untreated skin is usually the most noticeable. Prior to the peel, with the patient in the sitting position, note the position of the skin draping over the mandibular border. The peel may be feathered at this line of natural shadowing to create a transition zone. This may be performed by using a less concentrated formulation or by applying less of the agent in these regions. Camouflage makeup may help conceal this and other pigmentary disturbances.

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.

Delayed healing may lead to hypertrophic scarring, a devastating complication that requires close follow-up and aggressive early treatment. Topical or intralesional steroids, silicone sheeting, pressure application, and scar massage may improve outcomes. Scar excision or dermabrasion may be necessary in some cases of unsatisfactory results.

Infection

By using bacitracin for the medium and deep peels and cleaning the face with a povidone wash, the risk of infection is decreased.

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.

Infectious complications are unusual but also demand vigilance and aggressive therapy with oral and topical antibiotics. Pseudomonas infections are treated by washing the face with equal parts water and distilled vinegar.

Toxic shock syndrome has been reported after a chemical peel. [15]

Herpes exacerbations are treated with oral and topical acyclovir until resolution. Most of these lesions respond rapidly and completely to this treatment and rarely cause scarring. 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.

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