Chemical Peels Technique

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

Approach Considerations

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. [16] Several superficial peels are not equal in result to one deeper peel.

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

Men also request chemical peeling. This 56-year-ol Men also request chemical peeling. This 56-year-old man is in the process of a salicylic acid peel.
Same patient as shown above following a successful Same patient as shown above following a successful chemical peeling.
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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.

Most patients can tolerate a monthly superficial peel, while medium-depth peels can be performed at 6-month intervals if necessary.

Patient and equipment set-up

The peeling agent should be removed from its reservoir and put into a glass bowl. 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.

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 passed, 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).

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 (see image below). Three parts alcohol with 1 part acetone works well.

The defatting process is important for the even pe 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.

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 (see image below). 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.

This 45-year-old woman has just completed her sali This 45-year-old woman has just completed her salicylic acid peel and will neutralize the peel with cold water.
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Superficial Skin Peel

Superficial chemical peels are typically accomplished with use of alpha-hydroxy acids (AHAs). This group of chemicals is largely comprised of naturally occurring fruit acids, including glycolic, lactic, citric, tartaric, and malic acid. Arguably the most popular physician grade AHA used is glycolic acid, which is derived from sugar cane. Most formulations include concentrations of 50% glycolic acid or higher. After application, subsequent exfoliation occurs over several days. Over-the-counter AHA products contain 3-10% glycolic acid or one of the many other milder fruit acids. These formulations cause gradual exfoliation over several weeks and actually may be used as a pre-peel primer to potentiate the effects of a higher concentration peel. Unlike other peeling agents, penetration of glycolic acid is time dependent; thus, the agent is applied for a specific amount of time and then neutralized.

Many commercially available peels have applicators and are thickened with glycerin or similar substances so that they do not run. Avoid pooling of peeling solutions to ensure an even application. Only a thin coat is necessary, but it must be even.

The systematic application of glycolic acid with a sponge typically proceeds from one facial region to another, dividing the face into 6-8 regions and treating each in succession. The length of time that glycolic acid is left on the skin relates to concentration, with increasing concentrations achieving the desired results in less time.

Following application of glycolic acid, an initial erythema may become frankly red, often accompanied by edema. White patches subsequently develop, indicating epidermolysis with separation of the epidermis from the underlying dermis. Development of a frost indicates deeper depth of destruction into the dermis and is not desirable, as this is meant to be a relatively superficial peeling agent.

Removal of the glycolic acid is achieved by washing the face with water or neutralizing it with an alkaline solution such as sodium bicarbonate. Exfoliation typically occurs over several days, and re-epithelialization is complete within 7-10 days.

Multiple glycolic acid treatments may be required to achieve the desired results and should be spaced several weeks apart. Glycolic acid peels produce the least profound results but also are associated with the lowest frequency of complications.

Another agent used for superficial peeling is Jessner solution. [6] This solution is composed of 14 g of resorcinol, 14 g of salicylic acid, and 14 mL of 85% lactic acid mixed in enough 95% ethanol to bring the quantity to 100 mL. Jessner solution is usually applied with either cotton-tip applicators or sponge gauze. The Jessner solution is applied evenly with one or more coats to achieve a light but uniform frost. In some cases, 2-4 coats are necessary to achieve the desired level of resurfacing. The frosting achieved with Jessner solution typically results in the subjective feeling of heat with a mild discomfort that is easily controlled with a fan. After several minutes, a mild erythema appears with only faint evidence of scattered frosting over the skin surface.

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Medium-Depth Peel

Medium depth peels are usually performed with trichloroacetic acid (TCA) in concentrations ranging from 20-35%. [17, 18] Depth of penetration is increased as concentration increases, with formulations of 50% having a well-documented ability to penetrate into the reticular dermis. Such concentrations are not recommended because of the extremely high risk of scarring associated with this depth of penetration. Currently, 35% TCA is considered the high end of a medium-depth peel formulation.

TCA works as a keratocoagulant that produces a frost or whitening of the skin, which is dependent on the concentration used. Vigorous rubbing of the agent, as compared with blotting, yields a deeper penetration. This technique is not time dependent, and the agent does not require neutralization.

Combination use of TCA and other peeling agents has been demonstrated to provide more effective skin resurfacing in some cases. For instance, application of Jessner solution immediately prior to use of 35% TCA has been shown to disrupt the epidermal skin barrier and promote deeper, more uniform penetration of the TCA. Similarly, Coleman has reported improved results with application of 70% glycolic acid prior to a 35% TCA peel.

The systematic application of TCA with a sponge also involves treating the face in a succession of 6-8 regions. TCA application is associated with an intense burning that usually resolves within 30 minutes. Administer appropriate analgesia prior to the procedure and consider regional nerve blockade with lidocaine. Patient comfort may also be improved by having a fan to cool the face and by applying sponges soaked in iced saline prior to moving from one facial region to another.

During the procedure, if the frosting is not uniform or complete, reapplication may be performed until frosting of a desired plateau is reached. Once completed, exfoliation proceeds for several days, and re-epithelialization is complete within 10-14 days.

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Deep Skin Peel

The standard-depth deep chemical resurfacing procedure is a phenol peel. Phenol peels may be performed with various formulations, such as pure phenol (which is really 88%) or phenol mixed with soap, water, croton oil, and sometimes olive oil. These formulas have such names as Baker-Gordon, Venner-Kellson, Maschek-Truppman, and Grade. The classic Baker-Gordon formula is composed of 3 mL of United States Pharmacopeia (USP) phenol, 2 mL of tap water, 8 gtt of liquid soap, and 3 gtt of croton oil.

Phenol causes keratolysis and keratocoagulation. In contrast to other agents, increasing the concentration of phenol actually decreases the penetration up to a point. This is because the ensuing destruction forms a barrier to further penetration of the chemical. Pure phenol does not penetrate as deeply as the various formulations. Occlusion with a waterproof mask is reported to deepen the level of the peel, which increases the time required to fully re-epithelialize and increases posttreatment erythema. Following the peel, many physicians now apply a thick layer of petroleum jelly or other equivalent agent. Predictable but less profound results are produced, and penetration is less. Similar to trichloroacetic acid (TCA), the time spent applying the agent and the amount of sponge strokes used are proportional to the depth of penetration. The addition of croton oil to the various formulations as a skin irritant also allows deeper penetration.

Although phenol produces the most remarkable resolution of actinic damage and wrinkling among the various chemotherapeutic agents, it also possesses some of the more significant morbidities. Many have abandoned phenol in favor of other agents or laser resurfacing. [19] Marked hypopigmentation may result following the use of phenol and is correlated with the depth of penetration, use of the Baker-Gordon formula, and addition of croton oil. Hypopigmentation may occur in all skin types, noticeably lightening the skin of patients with darker skin and making lighter-skinned patients appear waxy or pale. A clear line of demarcation may be present between treated and untreated skin. [18]

Phenol causes an intense burning upon application that may last 4-6 hours, which is much longer than the discomfort associated with other peeling agents. Administer appropriate analgesia prior to the procedure and consider regional nerve blockade with lidocaine. Patients also must be provided with sufficient oral analgesics and anxiolytics for use at home following the peel.

The toxicity of phenol may be significant. Phenol is absorbed through the skin, metabolized by the liver, and subsequently excreted by the kidneys. Some practitioners preload the patient with fluids to facilitate renal clearance. Overdoses may injure the liver and kidney and may lead to myocardial irritability, including arrhythmias. For this reason, monitor patients with telemetry during the procedure and in the immediate recovery period. The face is again divided into 6-8 regions, but 20 minutes must be allowed to elapse between treating subsequent regions. This allows for some degree of ongoing metabolism and helps avoid a toxic systemic dose.

The length of time of peeling usually is similar to that for superficial peels, but because of the depth of peel, redness may be present afterward for 6-8 weeks.

Follow-up care is frequent, with visits every 2-3 days until re-epithelialization is complete, and then every week until the redness is gone.

Avoid steroids so as not to interfere with the maturation and thickening process of the new skin.

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