Australasian Journal of Dermatology (2018) 59, 171–181
12715
REVIEW ARTICLE
Chemical peels: A review of current practice
Alicia A O’Connor,1 Patricia M Lowe,1,2 Stephen Shumack2,3 and Adrian C Lim2,3
1
Department of Dermatology, Royal Prince Alfred Hospital, 2Sydney Medical School, University of Sydney, and
3
Department of Dermatology, Royal North Shore Hospital, Sydney, New South Wales, Australia
ABSTRACT
Chemical peels belong to a group of cutaneous
resurfacing procedures that are used in the treat-
ment of photoageing, inflammatory dermatoses, epi-
dermal proliferations, pigmentary disorders and
scarring. This review describes best current practice,
highlights recent advances in chemical peel technol-
ogy and discusses the recommended uses for differ-
ent peel types. It also presents the results of a survey
of the chemical peeling practices of 30 Australian
dermatologists.
Key words: acne vulgaris, chemabrasion, facial
rejuvenation, photoageing and pigmentary disor-
ders.
INTRODUCTION
Over the centuries numerous techniques have been
employed to reverse the ravages of age and the effects of
cutaneous disease.1 Among these methods, chemical peel-
ing has withstood the test of time with superficial peels
in particular remaining a popular tool in the dermatology
therapeutic armamentarium (Table 1). Chemical peels
consist of the application of one or more chemical abla-
tive agents to the skin’s surface in order to induce kera-
tolysis or keratocoagulation.1,2 This process causes the
controlled destruction of all or part of the epidermis or
dermis, resulting in the subsequent exfoliation of these
layers.2–4 After wounding, regeneration and remodelling
Correspondence: Dr Alicia A O’Connor, Department of Derma-
tology, Royal Prince Alfred Hospital, Gloucester House Level 3,
Missenden Road, Camperdown, NSW 2050, Australia. Email: alici-
aann.oconnor@health.nsw.gov.au
Alicia A O’Connor, MBBS. Patricia M Lowe, FACD. Stephen
Shumack, FACD. Adrian C Lim, FACD.
Conflict of interest: none.
Submitted 24 April 2017; accepted 16 July 2017.
© 2017 The Australasian College of Dermatologists
doi: 10.1111/ajd.
of the epidermis and dermis ensues, leading to the
improved appearance and texture of the treated skin.5
Dermatologists frequently use chemical peels to treat an
array of cutaneous conditions, including acne vulgaris,
actinic or solar keratoses, melasma and scarring. This
technique has also been used to rejuvenate the skin of the
face, neck, trunk and hand. Peeling agents may be divided
into superficial, medium-depth and deep subtypes based
on the depth of their penetration (Fig. 1). They may be
used alone or in combination with other cosmetic proce-
dures for cutaneous aesthetic enhancement.
Synonyms for chemical peels include chemabrasion,
chemexfoliation, chemical exfoliation, chemical face lift-
ing, chemosurgery, dermapeeling, facial rejuvenation
and surface surgery.1,6 In this article we review the his-
tory, classification, mechanism of action, indications,
contraindications, complications and general principles
of chemical peels. Furthermore, we examine recent
advances and future directions in this field. Finally, we
present the results of a survey of the chemical peeling
practices of 30 Australian dermatologists.
CLASSIFICATION OF CHEMICAL PEELS
Chemical peels are classified according to their depth of
penetration of the skin into superficial, medium-depth
and deep subtypes (Table 2). The depth of penetration is
determined by the concentration, pH and type of peeling
agent used.28,29 Anatomical location, epidermal integrity,
adnexal structure density and skin thickness also influ-
ence the depth of the peel.28 Other important considera-
tions include cutaneous priming, application technique,
occlusion and contact time.1,28,30
Superficial peels target the epidermis and the epider-
mal-dermal interface causing partial or complete necro-
sis.28,31,32 They exfoliate the skin from the stratum
corneum down to the papillary dermis at a depth of
60 lm.4 Superficial chemical peels work by causing
decreased corneocyte adhesion, epidermolysis and
increased dermal collagen deposition.31–34 This results in
Abbreviations:
AHA alpha hydroxy acid
BTX-A botulinum toxin-A injection
TCA trichloroacetic acid
172 AA O’Connor et al.

Table 1 History of chemical peels

Year Source Comment

1500 BC Ebers papyrus Ancient Egyptians used alabaster, animal oils, salt, honey & sour milk for cutaneous aesthetic
enhancement7–9
1871 Tilbury Fox 20% Phenol to lighten skin8,10
1874 von Hebra Iodine tinctures, croton oil, mustard seed, cantharides, sulphuric acid, acetic acid, nitric acid,
hydrochloric acid, borax, alkalis & corrosive sublimate for disorders of increased pigment8,11
1881 Piffard Croton oil to induce inflammation8
1882 Gerson Unna Described properties of phenol, resorcinol, salicylic acid & TCA10
1892 Saalfeld Phenol for ephelides8
1903 & 1952 Mackee Phenol for acne scars
Histological changes with phenol peeling12
1941 Eller Salicylic acid, resorcinol, acetone, formaldehyde solution, beta naphthol, phenol, glacial acetic
acid, sulphur, mercurial salts, & solid CO2 for pitted scars & pigmentation13
1945 Monash Diluted TCA to treat acne scars, molluscum contagiosum, xanthelasma palpebrarum, tinea
versicolor & lichenified eczema14
1946 Urkov Salicylic acid, resorcinol, lactic acid and ethyl alcohol solution under tape occlusion for
superficial peeling; deep exfoliation with cantharides tincture & phenol15
1950 Jessner Alcohol-based solution of lactic acid, salicylic acid & resorcinol for superficial peeling8
1960 Ayres Diluted TCA superior to pure phenol for extensive superficial peeling16
1960 Brown, Kaplan, & Brown Histological changes, technique & complications of phenol peeling17
1962 Litton Phenol, glycerin, distilled water & croton oil solution for facial rejuvenation18
1960s Baker & Gordon Phenol-based formula containing Septisol, distilled water & croton oil for facial
rejuvenation19–22
1984 Van Scott & Yu Alpha hydroxy acids for hyperkeratinisation disorders23
1986 Brody & Hailey TCA 35% + solid CO2 for medium-depth peeling24
1989 Monheit Jessner’s solution + TCA 35% for medium-depth peeling25
Late 1980s L’Oreal Recherche C8-lipohydroxy acid26
1994 Coleman III & Futrell Glycolic acid 70% + TCA 35% for medium-depth peeling27

CO2, carbon dioxide; TCA, trichloroacetic acid.

Figure 1 Depth of chemical peel penetration.

the thinning of the stratum corneum, increased epidermal
thickness and a more even distribution of melanin.32,35
Superficial peels are suitable for all Fitzpatrick skin photo-
types and may be used on extra-facial sites such as the
upper limbs, neck and chest.3,28 Serial application is often
required. Examples of superficial peeling agents include
10–30% salicylic acid, 20–70% glycolic acid, Jessner solu-
tion, solid carbon dioxide slush and <20% trichloroacetic
acid (TCA).
Medium-depth peels penetrate the papillary dermis to
the upper reticular dermis at a depth of 450 lm.4,5,34 They
cause extensive protein precipitation, resulting in
coagulative necrosis of cells in these layers.34 This pro-
duces oedema and homogenisation of the papillary der-
mis.36 Medium-depth peels are typically performed as a
one-off procedure.5,37 Desquamation occurs over 5 days
and patients can return to work after 1 week.6 TCA 35–
50% is a commonly used medium-depth peeling agent.34
TCA 35% may also be combined with glycolic acid 70%,
Jessner solution or solid carbon dioxide to form a combi-
nation medium-depth peel.34
Deep peels penetrate to the mid-reticular dermis at a
depth of 600 lm.3,31 They denature epidermal keratin and
dermal proteins, causing complete epidermolysis and mid-

© 2017 The Australasian College of Dermatologists

 Chemical peels 173

Table 2 Classification of chemical peels

Depth of penetration Peeling agent Conditions

Superficial Stratum corneum to
papillary dermis 60 lm
Medium Papillary dermis to upper
reticular dermis 450 lm
Deep Mid-reticular dermis to 600 lm
Alpha-hydroxy acids (glycolic acid 20–70%,
lactic acid, malic acid, pyruvic acid,
tartaric acid); beta hydroxy acids (salicylic
acid 10–30%), carbon dioxide snow,
Jessner solution, lipohydroxy acid,
resorcinol, retinoic acid, TCA <20%,
Unna paste, 5-fluorouracil
TCA 35–50%, TCA 35% + solid CO2,
TCA 35% + glycolic acid 70%, TCA 35% +
solid CO2, TCA 35% + Jessner solution
Baker–Gordon, TCA >50%
Mild photoageing (actinic keratoses, fine
lines, roughness, solar lentigines, yellow
stains), acne vulgaris, mild acne scarring,
pigmentary disorders (melasma, mild
dyschromia, post-inflammatory
hyperpigmentation)
Mild-to-moderate photoageing, actinic
keratoses, fine lines, rhytides, solar
lentigines, pigmentary disorders, (melasma,
mild to moderate dyschromia) seborrhoeic
keratosis, superficial atrophic scars
Severe photoageing (advanced rhytides),
pigmentary disorders, premalignant skin
tumours, scars

CO2, carbon dioxide; TCA, trichloroacetic acid.

dermal injury.6,31,35 Deep chemical peels are single-ses-
sion rather than serial procedures. Wound healing occurs
in four distinct phases including inflammation, coagula-
tion, re-epithelisation and fibroplasia.38 Re-epithelisation
occurs after 10–14 days, with the patient being able to
return to work in 2–3 weeks.35,39 Erythema may persist up
to 3 months.6 Examples of deep-peeling agents include
concentrations of TCA greater than 50% and Baker–Gor-
don formula.31
SUPERFICIAL PEELING AGENTS
Alpha hydroxy acids
Alpha hydroxy acids (AHA) constitute a family of carboxylic
acids with a hydroxyl group attached at the alpha position
of the carboxyl group.26 They are derived from fruit such
as apples (malic acid), grapes (tartaric acid), lemons and
oranges (citric acid), sugar cane (glycolic acid) and milk
(lactic acid).30 At lower concentrations, AHA causes
decreased corneocyte adhesion.33,40 At higher concentra-
tions it promotes epidermolysis.33,40 AHA requires neutrali-
sation to terminate its action. This is achieved with water,
sodium bicarbonate, sodium hydroxide or ammonium salt
solutions.30,41 AHA do not induce a frosting pattern. Glyco-
lic acid is the most common AHA peeling agent.41 It is
available as an esterified, buffered, partially neutralised or
free acid solution.41 Glycolic acid has a pKa of 3.83 and is
soluble in water. pKa is an important concept in chemical
peeling. It is the pH at which half of the solution is in a free
acid form.42 A low pKa value indicates a greater availability
of free acid and hence a stronger peel.42
Beta hydroxy acids
Salicylic acid
Salicylic acid (also known as ortho-hydroxybenzoic acid) is
a naturally occurring beta hydroxy acid that is derived from
the sweet birch, wintergreen leaves and willow tree
bark.5,30 It has a pKa of 2.97 and is poorly soluble in
water.28,43 Salicylic acid differs from AHA by the presence
of a hydroxyl group at the second carbon atom position. It
destroys intercellular lipids that are covalently linked to the
cornified envelope surrounding cornified keratinocytes.28
This results in the desquamation of the stratum corneum
and the activation of basal keratinocytes and fibroblasts.28
Salicylic acid has mild analgesic, antimicrobial, keratolytic
and comedogenic anti-inflammatory effects.28,30 For super-
ficial chemical peeling, salicylic acid is used in concentra-
tions of 10–30% in a hydroethanolic or polyethylene glycol
base.28 It is applied to the skin for 3–5 min, causing a fleet-
ing burning sensation before its analgesic properties pre-
vail.5,28 Evaporation of the hydroethanolic base leaves a
white precipitate often mistaken for frosting.28 It is impor-
tant to note that salicylic acid peels do not induce a frosting
pattern or require neutralisation.28 They also have a theo-
retical risk of salicylism if they are applied to large surface
areas at one time.5,28 Salicylic acid peels are favoured for
use in comedonal and inflammatory acne, as well as for
oily skin.28
Lipohydroxy acid
C8-lipohydroxy acid (also known as capryloyl salicylic
acid, 2-hydroxy-5-octanoyl benzoic acid or b-lipohydroxy
acid) is a lipophilic derivative of salicylic acid.32 It consists
of an 8-carbon acyl fatty chain that is attached to the fifth
carbon of the benzene ring.26 Lipohydroxy acid targets
corneodesmosome protein structures to separate corneo-
cytes uniformly.31,32 Its increased lipophilicity means it has
a more targeted mechanism of action in the epidermis and
sebaceous follicle and a greater keratolytic effect than sali-
cylic acid.31 Lipohydroxy acid is used in concentrations of
5–10% and does not require neutralisation.31 It also has
antimicrobial, anti-inflammatory and non-comedogenic
properties.31
Jessner solution
Jessner solution consists of salicylic acid (14 g), resorcinol
(14 g), lactic acid 85% (14 g) and ethanol (100 mL q.s.).33 It

© 2017 The Australasian College of Dermatologists

174 AA O’Connor et al.

is a clear, amber-coloured solution that needs to be kept in
a brown bottle to prevent photo-oxidation.28,30 Jessner solu-
tion is generally applied in two to three coats before mild
erythema and delicate, patchy frosting develops.28,40 It does
not require neutralisation.40 Patients may experience a
burning sensation with this peeling agent.28 It can be used
as a preparatory peel to enhance the penetration of another
peeling agent such as TCA.
Pyruvic acid
Also known as acetyl formic acid, pyruvic acid is an a-keto
acid that differs from AHA by having a carbonyl group in
the position of a carboxyl group.42 It is a potent peeling
agent with a pKa of 2.39 and is soluble in water and etha-
nol. Pyruvic acid is physiologically converted to lactic acid
and is used in concentrations of 40–70%.28,42 It causes
ablation of the stratum corneum and dermo-epidermal
separation resulting in decreased epidermal thickness.42
Over a long term it induces increased collagen, elastic
fibre and glycoprotein deposition in the papillary dermis.28
Pyruvic acid causes intense pain on application and its
vapour is pungent and irritating.28,44
Resorcinol
Resorcinol is a phenol derivative. It has a pKa of 9.32 and
is soluble in water, ether and alcohol.28,30 Resorcinol stim-
ulates prostaglandin E2 formation and disrupts the hydro-
gen bonds of keratin.30,45 This accounts for its keratolytic
and bactericidal properties. Resorcinol is used at concen-
trations of 10–50% for chemical peeling and induces a
frosting pattern.28 It is used in the treatment of acne, acne
scars, hidradenitis suppurativa nodules and melasma.45
Adverse effects associated with resorcinol include allergic
and irritant contact dermatitis, myxoedema and ochronosis
from prolonged use, and methaemoglobinaemia.44
TCA peeling is performed with concentrations of 10–30%,
which induces a level 1 frosting pattern (Table 3).28 Med-
ium-depth peeling is performed with TCA 35–50%, which
causes a level 2 pattern. Higher TCA concentrations
(>50%) cause a level 3 frosting pattern and should be used
with caution due to the risk they present of post-inflamma-
tory hyperpigmentation and scarring.28,40 Several cosmetic
procedures use high-concentration TCA in a localised
manner. Atrophic acne and varicella scars may be treated
with 70–100% TCA via a targeted toothpick application as
part of the chemical reconstruction of skin scars tech-
nique.47,48 Xanthelasma palpebrarum may also be treated
with a focal application of 50–100% TCA.49,50
DEEP-PEELING AGENTS
Phenol
Phenol (C6H5OH, also known as carbolic acid or hydroxy-
benzene) is an aromatic hydrocarbon with a pKa of 9.99.43
It is derived from coal tar and in its pure state exists as a
crystal.1,46,51 For chemical peeling, liquefied phenol USP, a
solution containing phenol 88% and water 12%, is
used.1,40,51
The physical effects of phenol vary according to its con-
centration and the surface area to which it is applied.6 At
concentrations of above 80% phenol causes rapid and irre-
versible denaturation and coagulation of epidermal keratin
and proteins.40 This action results in the formation of a bar-
rier that prevents the penetration of the peeling agent into
the deep dermis.6 Conversely, when phenol is diluted to
50% it functions as a keratolytic agent.6 It disrupts sulphur
bridges and allows phenol to penetrate further into the der-
mis, causing greater destruction and systemic absorption.6

MEDIUM-DEPTH PEELING AGENTS

TCA
TCA is a tricholorinated carbonic acid that exists in a
hygroscopic and deliquescent crystal form.28,30,43 It has a
pKa of 0.26 and is hydrophilic.42 TCA precipitates epider-
mal proteins and causes destruction of the upper dermis.30
It is dissolved w/v in distilled water to create the desired
concentration for chemical peeling.30 This solution is clear
and colourless, and is best stored in an amber-coloured
glass bottle for up to 6 months. TCA cannot be neutralised
and has not been associated with allergic reactions or sys-
temic toxicity.28,40 It may be used alone or as part of a
combination peel. Common pairings include solid carbon
dioxide and TCA 35% (Brody peel), Jessner solution and
TCA 35% (Monheit peel), and glycolic acid 70% and TCA
35% (Coleman peel).
An important concept relevant to TCA is that of frosting.
Frosting refers to the whitening of the skin due to protein Figure 2 Frosting pattern on upper lip of a middle-aged woman
coagulation (Fig. 2).46 It is an unreliable but widely used treated with a local combination peel of alpha hydroxy acid 70%
guide of keratocoagulation and peel depth.33 Superficial and trichloroacetic acid 40%.

© 2017 The Australasian College of Dermatologists

 Chemical peels
Table 3 Frosting reaction patterns
Frosting
intensity Depth of peel Clinical findings
I Superficial Blotchy/speckled white frost; mild
erythema
II Medium Even white frost; background
erythema
III Deep Solid white frost; no background
erythema
Lipophilic phenol is rapidly absorbed via the skin into the
systemic circulation.51 Serious adverse effects include car-
diac arrhythmias, renal failure and hepatotoxicity, making
it a potentially dangerous agent in inexperienced hands.40
Baker–Gordon formula
The Baker–Gordon formula contains 88% phenol (USP;
3 mL), croton oil (3 guttae), hexachlorophene (Septisol)
soap (Vestal Laboratories, St Louis, MO, USA; 8 guttae),
and distilled water (2 mL).6 Croton oil is a vesicant derived
from the seed of the Croton tiglium plant that promotes
deeper penetration and absorption of phenol.6,46,51 Hex-
achlorophene is a liquid soap that increases surface ten-
sion, acts as an emulsifier and retards phenol
penetration.6,51 It balances the irritant and macerative
effects of phenol and croton oil.6,46
Variants
Several other formulas have been described for deep
chemical peeling. They consist of phenol of varying con-
centrations together with other ingredients such as croton
oil, water, distilled water, hexachlorophene, olive oil and
glycerine. Examples of these peels include Litton, Brown,
and Venner-Kellson formulas.
GENERAL PRINCIPLES
Chemical peel consultation
History
The pre-procedure consultation should begin with an
assessment of the patient’s motivation for chemical peeling
as well as their expectations of treatment. Any history of car-
diac, hepatic or renal disease, diabetes mellitus, immuno-
suppression or nutritional deficiency should be elicited, as
patients with these comorbidities are at increased risk of
toxicity, delayed wound healing and infection.5,7,51,52 Previ-
ous resurfacing procedures, Herpes simplex infection, post-
inflammatory hyperpigmentation, photosensitivity and
abnormal (hypertrophic and keloid) scarring should be
noted, as these factors increase the risk of post-peeling com-
plications.53 Having undergone prior radiation and X-ray
therapy also requires evaluation as these treatments may
reduce the density of adnexal structures, delaying re-epithe-
lisation and increasing the risk of scarring with dermal
peels.2–5 Likewise, recent facial surgery with significant
175
undermining, large flap repairs and rhytidectomy should be
identified as these procedures may alter cutaneous blood
supply, impairing wound healing. Finally, concomitant der-
matological conditions that may worsen with chemical peel-
ing should be noted. These include eczema, psoriasis,
vitiligo, rosacea and seborrhoeic dermatitis.3,5,31,53
All current and past medications require review. The
use of isotretinoin in the previous 6–12 months increases
the risk of delayed re-epithelialisation and scarring with
medium-depth and deep chemical peels.3,4,30 Similarly, the
use of photosensitising drugs, hormonal agents and oral
contraceptives increases the risk of post-peel hyperpig-
mentation.5,52,55
The occupation, lifestyle and hobbies of the patient
require exploration. The amount of UV light exposure
should be quantified and photoprotection maximised.4,52
The patient’s smoking status should also be determined
and cessation for at least 1 week before and 6 months after
each procedure is recommended.4,52 Lastly, women of
childbearing potential should be asked about possible
pregnancy and where relevant, their breastfeeding status
clarified.
Examination
The physical examination should begin with assessment of
skin colour using the Fitzpatrick skin phototype scale.2,5
Skin colour is used to predict the pigmentary response to
chemical peeling and to guide the selection of patients for
test-spot testing.2,5 The degree of photoageing should also
be assessed with a standardised tool such as the Glogau
classification.2 The patient is then examined for the pres-
ence of intact pilosebaceous units, sebaceous gland activ-
ity, skin thickness and health, laxity of periorbital skin,
pre-existing inflammation and hypertrophic or keloid scar-
ring.2,4,5
Photographic documentation
Baseline photography is highly recommended. Pho-
tographs may be used to guide peel selection and for
before-and-after comparisons. The use of polarised light to
highlight pigment and capillaries is adjunctive to standard
lighting.
Informed consent
A detailed consent discussion should be undertaken by the
treating clinician and appropriately documented in the
medical record. This process may be facilitated by pho-
tographs and videos of the peeling procedure, the provi-
sion of written information and the use of a dedicated
consent form.56
Patient selection
Superficial chemical peels are suitable for all Fitzpatrick
skin phototypes.30 The ideal candidate for medium-depth
and deep chemical peeling has a composite of blue eyes,
© 2017 The Australasian College of Dermatologists
176 AA O’Connor et al.
fair complexion and female sex.6,7,57 Dry skin, superficial
fine rhytides and minimal gross redundancy are other
desirable characteristics.7,27 Care should be taken when
treating patients with Fitzpatrick III–VI phototypes as they
are at greater risk of pigmentary dyschromias and scar-
ring.6,38 Chemical peeling in male patients should also
proceed with a degree of caution.58 Men have thicker,
coarser and more oleaginous skin, making the penetration
of the peeling agent less predictable.6 Moreover, they are
less likely to employ cosmetic camouflage techniques dur-
ing the post-treatment phase.6,58
Test-spot testing
The role of test-spot testing in chemical peeling remains
controversial and thus is infrequently performed.59 Test-
spot testing involves the application of the medium-depth
or deep-peeling agent to a small area of skin in an incon-
spicuous area or at the edge of the treatment field.6,60
Common areas for test-spot testing include the lateral tem-
ple, anterior hairline and pre-auricular region.60 The
advantages of test-spot testing include the more accurate
predication of peel efficacy, healing time, pigmentary
response and post-peel complications.59,60 It also facilitates
the proper selection of candidates, alleviates their anxiety
and discourages impulsivity.60 The disadvantages of this
technique include a delay of treatment, misrepresentative
results and the persistence of the test-spot until the defini-
tive procedure takes place.59,60
Pre-peel care
Priming is a term that encompasses all pretreatment and
preparation activities that are performed on the skin prior
to chemical peeling.5,42 The goal of these activities is to
thin the stratum corneum, enhance the penetration of the
active agent and accelerate healing.5,42 These activities
enhance patient compliance, detect intolerances and
reduce the risk of complications such as post-inflammatory
hyperpigmentation and scarring.5,28,42 They also allow the
clinician to identify patients who are non-adherent with
treatment regimens, making them less suitable candidates
for chemical peeling.28
Pretreatment
Pretreatment of the skin should begin at least 2–4 weeks
before the chemical peel and ceased 3–5 days prior.5,31,42
Patients should be instructed to limit their UV exposure
and apply a broad-spectrum sunscreen with a sun protec-
tion factor of 50+ that blocks both UVA and UVB each
morning.5,42 Photoprotective activities are important as
they prevent sunburn, diminish tanning and reduce mela-
nocyte activity.52 Sunscreen should ideally be instituted
3 months prior to the procedure and continued indefinitely
thereafter.
Tretinoin 0.025–0.05% cream should be applied nocte
for a minimum of 2 weeks (preferabley longer to avoid
pre-peel irritant dermatitis) before the chemical
© 2017 The Australasian College of Dermatologists
peel.29,40,52 Tretinoin (all-trans retinoic acid) causes
decreased epidermal adhesion resulting in thinning of the
stratum corneum.40 This enables the peeling agent to
penetrate the skin more rapidly and deeply.40 Tretinoin
also enhances epithelial differentiation and accelerates
epithelial proliferation, hastening re-epithelialisation.42 It
may be restarted after the procedure once healing is
complete.40
Hydroquinone 2–4% cream is a phenolic compound used
to treat dyschromias29 and in the post-peel setting it
reduces the risk of post-inflammatory hyperpigmenta-
tion.29,40 In post-inflammatory hyperpigmentation-suscepti-
ble individuals hydroquinone is inititated at least 2 weeks
before a chemical peel and re-introduced 1–2 weeks post-
peel. Hydroquinone reversibly inhibits the enzyme tyrosi-
nase and selectively damages melanocytes and melano-
somes via the formation of free radicals.61 Adverse effects
of this bleaching agent include allergic and irritant contact
dermatitis as well as ochronosis.40 Other topical agents
that may be used in the pretreatment phase include glyco-
lic acid 5–10%, salicyclic acid 5–10%, kojic acid 1–4%,
azelaic acid and topical corticosteroids.
Patients should be instructed to avoid waxing, electroly-
sis and dermabrasion for a minimum of 3–4 weeks prior to
chemical peeling.52 Individuals with a history of recurrent
herpes simplex virus infection should be commenced on
systemic antiviral treatment prior to medium-depth and
deep chemical peeling.5
Preparation
The day prior to peeling the patient should wash their skin
with non-residue soap and refrain from using moisturisers
and make-up. On the day of the procedure the patient
should wash their skin with a non-residue cleanser and
wear no jewellery or contact lenses.43 Prior to chemical
peeling the skin should be degreased with acetone, tri-
closan or isopropyl alcohol to remove residual cosmetics,
oils, loose keratin, and other debris.1,28,30,54
PEELING TECHNIQUE
Location, personnel and equipment
Chemical peeling should be undertaken in a dedicated
procedural room with appropriate lighting, adequate venti-
lation and access to resuscitation equipment.6 An assistant
should be present to position the patient, manage equip-
ment and to blot tears from the medial canthal regions to
prevent the backtracking of the peel agent into the eye.
Under no circumstances should the patient be left alone
during the procedure.
At a site separate to the patient, the peeling agent should
be checked and poured into a small, clearly labelled glass
receptacle or prepared according to the product specifica-
tion. The clinician should remove any crystals that have
formed in the solution as these may increase the concentra-
tion of the solution that is applied. The peeling agent should
be securely stored and never passed across the patient in
case of inadvertent spillage. Neutralising agents and eye
 Chemical peels 177

irrigation solutions such as water, saline or glycerine must
be readily available. Local occupational health and safety
practices and infection control guidelines must be followed.
This includes wearing gloves throughout the procedure.
Patient
The patient undergoing facial chemical peeling should be
positioned supine with their head elevated on a pillow at
45° and a towel placed around their neck. Their eyes should
remain closed for the procedure and appropriate eye shield-
ing provided where appropriate. A surgical cap or hair band
is used to keep the hair off the treatment site. Petrolatum or
zinc oxide paste may be applied to the lateral canthi, nasal
alar grooves, nasolabial folds, lips and oral commissures to
prevent pooling of the peeling agent in these areas.
Pain control and anxiety management is an important
aspect of patient care. This may be achieved by physical
agents (e.g., cool packs and fans), oral agents (e.g., parac-
etamol, non-steroidal anti-inflammatory agents and anxi-
olytics), regional nerve blocks and general anaesthesia.43
Superficial peels generally do not require anaesthesia,
whereas phenol peeling often requires sedation, regional
or general anaesthesia.6
spatula is used to apply gels. Chemical peeling should start
on areas of thicker skin. The forehead, cheeks, nose and
chin are treated first, followed by the perioral and perior-
bital skin (Fig. 3). The peeling agent should be applied in
an upward direction with firm even strokes and extended
beyond the vermillion border and into the oral commis-
sures.4,7 Care should be taken to avoid overlapping brush
strokes and skipping areas. A feathering technique should
be employed at the edge of the treatment field to avoid
sharp demarcation lines.4 In areas of deep wrinkling the
clinician should stretch the skin to prevent pooling of the
peeling agent.
Post-procedure care
Good post-peel care ensures prompt recovery of the skin
and prevents unwanted complications. The patients should
be given written information on what to expect over the
ensuing days and instructions on how they should care for
their skin. They should be instructed to wash their face
with a non-soap cleanser and to avoid rubbing, scrubbing,
scratching or picking their skin. A bland emollient should
be applied regularly to the skin until peeling is complete.

Indications and contraindications

Indications and contraindications for chemical peels are
listed in Table 4.

Application
The application technique varies according to the peeling
agent used. Liquid products may be applied with a brush,
cotton tip applicator or cotton or gauze swab. A wooden

Table 4 Indications and contraindications for chemical peels

Indications
Aesthetic conditions
Dilated pores, photoageing, superficial fine rhytides,
superficial scars
Epidermal proliferations and tumour
Actinic keratoses, dermatosis papulosa nigra, milia, seborrhoeic
keratoses, sebaceous hyperplasia, warts
Inflammatory dermatoses
Acne cosmetica, acne excorie e, acne vulgaris, comedonal
acne, pseudofolliculitis barbae
Pigmentary disorders
Ephelides, lentigines, melasma, post inflammatory
pigmentation
Contraindications
Absolute
Active infection (bacterial, viral or fungal), history of allergy to
peeling ingredient, isotretinoin therapy within the previous
6 months (for medium-depth and deep chemical peels),
open wounds, pregnancy
Relative
Inflammatory dermatosis (e.g. rosacea, atopic dermatitis, and
psoriasis), radiation exposure, recent facial rejuvenation
surgery
Figure 3 Aesthetic units of the face.

© 2017 The Australasian College of Dermatologists

178 AA O’Connor et al.
If crusting develops a topical antibacterial agent may be
prescribed. Make-up may be applied after re-epithelisation
has taken place. Sun avoidance and daily application of
sunscreen should also be encouraged.
COMPLICATIONS
Chemical peels are a relatively safe procedure provided they
are performed under the supervision of an experienced clin-
ician. Appropriate patient and peel selection, counselling,
priming and aftercare minimises the risk of complications.53
Despite such measures, adverse effects can occur following
chemical peeling and vary according to peel depth. They are
divided into minor and major subgroups.
Minor
Minor complications may occur within minutes to hours of
the procedure. These include irritation, burning, erythema,
pruritus, oedema and blistering.11,52,62 Minor complications
also occur in a delayed fashion appearing over days to
weeks. These include the development of acneiform erup-
tions, infection (bacterial, fungal and viral), persistent ery-
thema, demarcation lines and milia. Pigmentary changes
(hyperpigmentation and hypopigmentation), textural
changes, scarring (atrophic, hypertrophic and keloid) and
the increased pigmentation of naevi may also occur.2,53
Major
Although they are rare, major local and systemic complica-
tions of chemical peeling include allergic reactions, laryn-
geal oedema, toxic shock syndrome, cardiotoxicity,
salicylism, acute kidney injury, lower lid ectropion, corneal
damage, significant scarring and dyspigmentation.63
COMBINATION TECHNIQUES
Chemical peels are often combined with other cosmetic
procedures for cutaneous resurfacing. This synergistic
approach to facial rejuvenation provides a fast, cost-effec-
tive and less invasive alternative to surgery.64
Microdermabrasion
Chemical peeling may be combined with microdermabra-
sion for the treatment of photoageing, moderately deep
rhytides and acne scars. Microdermabrasion involves the
mechanical exfoliation of skin by the application of
microcrystals.65 A specialised closed-circuit device con-
taining a vacuum propels aluminium oxide, sodium
bicarbonate or salt crystals of varying velocities against
the skin.65 This action abrades the stratum
corneum allowing for increased penetration of the chem-
ical peel.
Microneedling
Microneedling (also known as percutaneous collagen
induction or collagen induction therapy) involves the
© 2017 The Australasian College of Dermatologists
penetration of the stratum corneum into the papillary der-
mis with needles. This results in the formation of
microchannels and a demarcation current that stimulates
the release of growth factors that are involved in neocolla-
genesis and neoangioenesis. It may be combined with gly-
colic acid to manage acne scars.66
Botulinum toxin-A injections (BTX-A)
BTX-A injections may be combined with chemical peeling
techniques for facial rejuvenation. The relaxation of the
facial muscles responsible for dynamic rhytides allows for
superior collagen remodelling and cutaneous healing.64
This combination technique carries a theoretical risk of
excessive toxin dispersion in the setting of marked inflam-
mation. The timing of BTX-A injections should thus be
carefully considered when using aggressive peels. In the
authors’ experience, BTX-A injections may be performed
at the same time as a superficial peel, but are best per-
formed a week before medium-depth and deep chemical
peels.
Dermal fillers
Soft tissue augmentation with hyaluronic acid may also be
combined with superficial chemical peeling. However,
non-hyaluronic fillers in conjunction with concurrent med-
ium or deep chemical peels carries a theoretical risk of
biofilm formation and should be discouraged.
Ablative laser resurfacing
Individuals with mixed photoageing such as combination
complexion and volume issues may benefit from the
sequential application of ablative laser and medium-depth
chemical peeling in one session to different areas. For
example, TCA 35% is applied to the skin first, followed by
fractionated carbon dioxide laser to treat periorbital and
perioral rhytides.42
CURRENT PRACTICE
Over a 4-week period (19 November to 18 December 2016)
we conducted an online survey to understand better the
chemical peeling practices of Australian Dermatologists. A
17-question electronic survey constructed using Sur-
veyMonkey (San Mateo, CA, USA) was emailed to the 52
dermatologists listed on the Australasian College of Der-
matologists website as performing chemical peels
(Table S1). The response rate was 60% (31/52), of which
30/31 respondents performed chemical peels. Of these
respondents 60% were male, 77% were aged between 35
and 54 years and 43% had 10–19 years of clinical practice
as dermatologists.
Most respondents (40%) in our survey prescribed chemi-
cal peels on a weekly basis. The most common depth of
chemical peel performed was ‘very superficial’ (73%). In
contrast, only three (10%) respondents reported perform-
ing deep chemical peels. Boutique or pamper peels were
 Chemical peels 179

performed by 27% of respondents. Dermatology nurses Table 5 Adverse effects of chemical peels (from a survey of Aus-
(73%), dermatologists (47%) and dermal therapists (27%) tralian dermatologists)
most commonly performed the chemical peel.
% (n)
In total, 77% of our respondents reported combining
chemical peels with other treatments. These included Acne/folliculitis 37 (10)
Allergic reactions 11 (3)
BTX-A injections (52%), dermal fillers (39%) and radiofre-
Delayed healing 22 (6)
quency procedures (22%). Nine (39%) respondents Demarcation lines 19 (5)
reported combining chemical peels with treatments other Hyperpigmentation 67 (18)
than those listed in the survey, which included AHA, topi- Hypopigmentation 30 (8)
cal retinoids, oral acne therapy, intense pulse light, Infection (bacterial, viral or candidal) 26 (5)
cryotherapy, daylight photodynamic therapy and shave Laryngeal oedema 4 (1)
excision. Only 20% of respondents reported performing a Milia 22 (6)
Miliaria 11 (3)
test-spot test as part of their clinical practice. Reasons cited
Ocular complications 4 (1)
included routine practice, darker skin type, patient ethnic- Oedema 37 (10)
ity (e.g., Asian), previous adverse outcome (e.g., post- Excessive pain and burning 33 (9)
inflammatory hyperpigmentation or dyspigmentation) or Excessive superficial crusting 22 (6)
prior to the performance of a deep chemical peel. Persistent erythema 52 (14)
The most common age range of patients on whom Pruritus 30 (8)
Scarring 11 (3)
chemical peeling was performed on was 30–41 years
Telangiectasia 15 (4)
(33%). Altogether 70% respondents reported performing Textural changes 19 (5)
chemical peels on both men and women, 30% on women Toxicity 4 (1)
alone and none exclusively on men. Fitzpatrick phototype I Other 19 (5)
and II (93 and 97%, respectively) were the most common
27 of 30 dermatologists responded: more than one answer was
skin types selected for chemical peeling. Common areas
allowed.
for chemical peeling included the face (100%), chest
(40%) and neck (37%).
The most common indications for chemical peeling were There is also an increasing trend for superficial peels to
photoageing (87%), comedonal acne (67%), lentigines be used as maintenance therapy after intense pulsed light
(60%) and melasma (60%). Two respondents listed and fractional resurfacing procedures. This offers patients
xanthelasma and acne rosacea as other indications for the opportunity to engage with trained nurses and thera-
chemical peeling. Adverse outcomes with chemical peeling pists to develop a maintenance skin care programme with
were reported by 27 (90%) respondents (Table 5). The at-home cosmeceuticals in conjunction with periodic in-
most commonly encountered adverse effects included clinic peels.
hyperpigmentation (67%), persistent erythema (52%),
oedema (37%) and acne or folliculitis (37%). Five (19%)
respondents indicated other adverse effects. These CONCLUSION
included a lack of efficacy, desquamation and death (one Chemical peels remain a rapid, safe and cost-effective tech-
respondent). Despite a follow-up email sent to all respon- nique for cutaneous rejuvenation, particularly in our ageing,
dents, further details of the latter serious adverse event photodamaged population. They are also a useful treatment
could not be elucidated. option for certain dermatological conditions such as acne
vulgaris, melasma, actinic keratoses and scarring.31 Success-
RECENT ADVANCES AND FUTURE ful chemical peeling is reliant on the proper selection of
DIRECTIONS patients and peels. This comprehensive review provides
clinicians with the theoretical and practical knowledge
Boutique or pamper peels (e.g., Valeant Pharmaceuticals, essential for the expert application of chemical peels.
Irvine, CA; Rationale, Rationale Skincare Melbourne, Victo-
ria, Australia; Aspect Dr, Advanced Skin Technology,
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© 2017 The Australasian College of Dermatologists