Chemical peels: Procedures and complications

Author: Suzan Obagi, MD

Section Editor: Jeffrey S Dover, MD, FRCPC
Deputy Editor: Abena O Ofori, MD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.

Literature review current through: Dec 2019. | This topic last updated: Jun 27, 2019.

INTRODUCTION

Chemical peels are skin resurfacing procedures that can improve skin quality,
texture, and appearance. A chemical peel involves the application of a caustic
substance to the skin to induce controlled skin injury (table 1). Subsequent wound-
healing processes can lead to improvements in hyperpigmentation, rhytides, acne
scars, actinic keratoses, and other features (table 2).

In-depth knowledge of chemical peel techniques is essential for optimizing

treatment outcomes and minimizing risk for adverse effects. Practical guidance
for pretreatment, treatment, and post-treatment management is provided here.
Information on the properties of specific peeling agents, contraindications to
chemical peels, and the pretreatment assessment of candidates for chemical
peels is provided separately. (See "Chemical peels: Principles, peeling agents, and
pretreatment assessment".)

BASIC CONCEPTS

Chemical peels are relatively fast procedures that are most often performed on
the head and neck. Treatment may be administered to a focal area of skin or an
entire region (eg, cosmetic unit or entire face (figure 1)). The wide variety of
chemical peel agents, formulas, and techniques allows for the selection of an
appropriate procedure for a specific indication.

The depth of skin injury a chemical peel induces is the major determinant of effect
(table 2). Light chemical peels (also known as superficial chemical peels) cause
injury limited to the epidermis and are primarily used for cutaneous
hyperpigmentation and mild improvements in skin texture. Medium-depth peels
injure the epidermis and papillary dermis, allowing for improvement of features
such as hyperpigmentation, actinic keratoses, superficial acne scars, and shallow
wrinkles. In deep peels, injury extends from the epidermis into the reticular dermis,
contributing to improvement in deeper acne scars and wrinkles. Both the specific
peeling agent selected and application technique can influence the depth of
peeling. (See "Chemical peels: Principles, peeling agents, and pretreatment
assessment", section on 'Peel types' and "Chemical peels: Principles, peeling
agents, and pretreatment assessment", section on 'Common peeling agents'.)

Prior to treatment, patients should be carefully assessed for an appropriate

indication and risk factors for adverse outcomes, such as dyspigmentation,
infection, and scarring. In particular, compared with the face, other body sites (eg,
neck, chest, dorsal hands) have increased risk for scarring following chemical
peels. In general, these sites should be limited to light chemical peels, avoiding
medium-depth and deep peels. (See "Chemical peels: Principles, peeling agents,
and pretreatment assessment", section on 'Precautions and contraindications' and
"Chemical peels: Principles, peeling agents, and pretreatment assessment",
section on 'Patient assessment'.)

PREPARATION

Once a patient is deemed an appropriate candidate for a chemical peel and

carefully counseled regarding the procedure, expected outcomes, and potential
adverse effects, the need for preparatory interventions should be assessed,
including skin preparation, antiviral prophylaxis, and performance of a test spot.
The need for these interventions is influenced by the type of chemical peel and
patient characteristics. (See "Chemical peels: Principles, peeling agents, and
pretreatment assessment".)

Skin preparation — Skin preparation regimens aim to promote even penetration of

the peeling agent, optimize wound healing, and regulate melanocyte activity to
minimize peel-induced hyperpigmentation. Skin preparation is considered most
important for medium-depth and deep peels because of greater risk for adverse
effects compared with more superficial peels. (See 'Complications' below.)

Although many clinicians, including ourselves, use skin preparation for all
chemical peels, the value of skin preparation has been questioned. A retrospective
study that assessed complications following 473 light chemical peels in patients
with skin phototypes III to VI found similar rates of complications between
patients given preparatory treatment (eg, hydroquinone, topical retinoids, alpha-
hydroxy acids) and patients who did not receive this treatment (table 3) [1]. (See
'Dyspigmentation' below.)

Regimen — Skin preparation regimens vary among clinicians but typically begin

a few weeks to a few months prior to the chemical peel. Because risk for peel-
induced hyperpigmentation increases with increasing baseline skin pigmentation,
our practice is to begin skin preparation 6 weeks prior to the chemical peel for
patients with skin phototypes I or II and 12 weeks prior to the chemical peel for
skin phototypes III to VI (table 3).

Preparatory interventions typically include strict sun protection measures, a

topical retinoid, and topical hydroquinone. Hydroquinone is used to combat
hyperpigmentation and may be eliminated from the regimen for patients with skin
phototype I due to the low risk for chemical peel-induced hyperpigmentation in this
population (table 3). Alpha-hydroxy acids may also be utilized in skin preparation
regimens.
● Sun protection – Unprotected sun exposure and tanning of the skin in the
treatment area may increase risk for hyperpigmentation after a chemical peel
and should be avoided prior to the peel. We instruct patients to avoid
unprotected sun exposure and tanning for at least six to eight weeks prior to
the chemical peel. Patients should apply a broad-spectrum sunscreen with a
sun protection factor of 30 or higher to the treatment area daily. We typically
suggest use of inorganic sunscreens (zinc dioxide and/or titanium dioxide as
active ingredient[s]). During periods of sun exposure, sunscreen should be
reapplied frequently. (See "Selection of sunscreen and sun-protective
measures", section on 'Selection of sunscreen products' and "Selection of
sunscreen and sun-protective measures", section on 'Proper use of
sunscreens'.)

● Topical retinoids – Topical retinoids thin and smoothen the stratum corneum,
facilitating improved and even penetration of peeling agents and
hydroquinone. Retinoids also have other effects that may augment the results
of chemical peels, including promotion of collagen and elastin synthesis,
restoration of normal epidermal thickness and maturation, and improvement
of solar elastosis. Faster wound healing after skin resurfacing has been
demonstrated in patients pretreated with tretinoin [2].

Tretinoin (0.05 to 0.1% cream) is commonly used in skin preparation regimens.

Tretinoin is applied once daily at night. Retinaldehyde 0.1% is a less irritating
alternative for patients who cannot tolerate tretinoin. (See "Treatment of acne
vulgaris", section on 'Topical retinoids'.)

● Hydroquinone – Hydroquinone is an inhibitor of tyrosinase, a key enzyme in

melanogenesis. Pretreatment with hydroquinone is intended to reduce risk for
peel-induced hyperpigmentation and support improvement in disorders
presenting with hyperpigmentation, such as melasma. Hydroquinone 4% is
typically applied twice daily. (See "Postinflammatory hyperpigmentation",
section on 'Topical hydroquinone'.)
 ● Alpha-hydroxy acids and polyhydroxy acids – Topical alpha-hydroxy acids (eg,
6 to 8% glycolic acid) and polyhydroxy acids (eg, lactobionic acid,
gluconolactone) may be added to the skin preparation regimen. We typically
incorporate them for patients with acne or severe dyschromias and prescribe
once-daily application. These agents exfoliate the stratum corneum, enhancing
the penetration of tretinoin and hydroquinone, and may accelerate resolution
of acne comedones.

Patients should be given clear instructions to ensure proper implementation of the

skin preparation regimen. For patients undergoing facial chemical peels, the entire
face is typically treated. Care should be taken to include areas that are easily
missed, such as the lower eyelids, hairline, jawline, and preauricular areas.

Of note, topical retinoids often induce skin irritation, particularly near the medial
and lateral commissures of the eyes, oral commissures, upper eyelids, neck, and
chest. Avoidance of application of retinoids near the commissures of the eyes and
mouth may facilitate tolerance of topical retinoids. Less frequent (ie, once to twice
weekly rather than daily) application of topical retinoids is suggested for the
eyelids, neck, and chest. If skin irritation occurs, the topical retinoid can be
stopped for one to two days and restarted upon improvement.

Infection prophylaxis — Infection prophylaxis typically consists of protection from

reactivation of herpes simplex virus (HSV) infection.

Herpes simplex virus — Reactivation of HSV infection and spread of the

infection throughout the treated area is a risk of medium-depth and deep facial
resurfacing procedures and may result in scarring [3]. Given the high prevalence of
HSV infection, antiviral prophylaxis is indicated for all patients undergoing
medium-depth or deep chemical peels that involve treatment of the perioral area.
Antiviral prophylaxis is not typically necessary for light peels.

Regimens for prophylactic antiviral therapy vary. We typically begin prophylaxis

with valacyclovir the day prior to the procedure and continue for 7 days after
medium-depth peels and for 14 days after deeper peels, with the intent of
continuing treatment until reepithelialization is complete. Typical dosing for
valacyclovir in this setting is 500 mg twice daily [4].

Higher doses of valacyclovir (eg, 1 g twice per day) are utilized by some clinicians,
including the author, for HSV prophylaxis in patients with multiple HSV recurrences
per year, in an attempt to augment suppression given the potentially devastating
consequences of HSV reactivation after a chemical peel. However, the superiority
of this approach is unproven.

Some clinicians administer prophylactic treatment for herpes zoster to patients

with a history of herpes zoster in the treatment area based upon concern for
trauma-induced recurrence. However, recurrence of herpes zoster is less common
than recurrence of HSV infection, and recurrence of herpes zoster in association
with chemical peels has not been reported. (See "Epidemiology, clinical
manifestations, and diagnosis of herpes zoster".)

Other infections — Prophylactic therapy for bacterial or Candida infections is not

required. Some clinicians, including the author, prescribe daily application of
mupirocin to the nares, beginning one week prior to the chemical peel to one week
after the chemical peel, in an attempt to minimize risk for Staphylococcus aureus
infection. However, benefit of this approach is unproven.

PROCEDURE

Before application — Important initial interventions for all types of chemical peels

include assembly of all necessary supplies, thorough skin cleansing, and provision
of measures to optimize patient comfort. Additional interventions are necessary
for the safe performance of phenol peels. (See 'Special precautions for phenol
peels' below.)
 Set up — Light and medium-depth peels are typically performed in the office
setting. Deep chemical peels with phenol should be performed in a setting where
cardiac monitoring, intravenous fluid administration, and perioperative advanced
cardiac life support can be performed. (See 'Special precautions for phenol peels'
below.)

Prior to application of the peeling agent, all materials necessary for the peel
should be assembled in the treatment room in a location where they are
immediately accessible to the clinician. Typical supplies include:

● Acetone or 70% alcohol for skin cleansing

● Applicator (eg, cotton-tipped swab, gauze, brush)

● Peeling agent (typically poured into a glass receptacle)

● Neutralizing agent for glycolic acid peels

● Appropriate liquid to flush eyes in the event of accidental entry of the peeling
agent

Saline solution is appropriate for flushing the eyes for most chemical peels. We
typically keep a 20 mL syringe of normal saline available. Mineral oil should be
used to flush the eyes after entry of a phenol-containing peel solution. Water may
increase penetration of phenol.

The patient should be positioned in a manner that allows the clinician easy access
and full visibility of the entire treatment area. A surgical cap or band is used to
keep hair off of the treatment area. Patients' contact lenses should be removed.

Skin cleansing — Proper cleansing of the skin promotes even penetration of the

peeling agent and is crucial for optimizing outcomes of chemical peels. The goal
is to remove all traces of oil or debris.

First, the patient should wash the skin with a gentle skin cleanser to remove
makeup and lotions. Next, the clinician degreases the skin with either acetone or
70% alcohol. Use of acetone is preferred prior to phenol peels. A typical
degreasing technique involves rubbing a 4x4 inch gauze moistened with the
degreasing agent over the entire treatment area.

Comfort measures — Discomfort during light chemical peels is usually limited

to a transient, mild burning sensation during application that is generally well
tolerated. A small electric fan or forced-air cooling unit is helpful for reducing
discomfort. Anesthesia is not typically necessary.

Medium-depth and deep chemical peels can be painful and typically require
greater intervention. Oral analgesia with a nonsteroidal anti-inflammatory drug
(NSAID), administration of an oral or intramuscular sedative, and use of a
refrigerated forced-air cooling unit may be sufficient for medium-depth peels.
Opioid analgesics may also be utilized. Intravenous sedation is an option for
select patients requiring a greater degree of anesthesia, usually for patients
receiving full-face phenol peels.

Topical anesthetics can hydrate the skin and accelerate penetration of peeling
agents. Therefore, use of topical anesthetics should be approached with caution
and reserved for clinicians experienced with chemical peels.

Special precautions for phenol peels — Systemic absorption of phenol can

result in cardiac arrhythmias. Therefore, cardiac monitoring (continuous
electrocardiography, blood pressure, and pulse oximetry) is indicated during
phenol peels that involve peeling of more than a single cosmetic unit or more than
1% total body surface area (figure 1) [5]. Patients with hepatic or renal
insufficiency have increased risk for toxicity. (See "Chemical peels: Principles,
peeling agents, and pretreatment assessment", section on 'Precautions and
contraindications'.)

In addition, intravenous hydration should be administered prior to and during the

procedure to minimize the concentration of phenol in serum. If only one cosmetic
unit is being treated, having the patient drink 1 liter of water during the procedure
can be sufficient [5].

Permanent hypopigmentation is a potential complication of phenol peels that is

most likely to occur in individuals with skin phototypes IV to VI (table 3). Although
select phenol formulations have been utilized successfully on skin phototypes IV
and V, deep chemical peeling in this population should be reserved for clinicians
with expertise in chemical peeling, and patients should be advised of the potential
for this complication. (See 'Dyspigmentation' below.)

Application — Application of chemical peels is typically performed quickly with a

cotton-tipped swab or gauze. A specialized sable or goat hair brush is an option
for light chemical peels; brushes can speed application and reduce waste of the
peel solution [6].

Sequence — Chemical peels may be applied to focal areas of skin (eg, a single

scar or cosmetic unit) or to an entire region (eg, face). In some patients,
achievement of the desired effect may require application of different peels in
different cosmetic units (ie, segmental peeling). For example, deep perioral
wrinkles may require a deep peel while a light chemical peel is sufficient for
improving mild photodamage elsewhere [6].

A predetermined sequence of application helps to ensure timely application of the

peeling agent, avoidance of missed areas, and prevention of unintentional repeat
application. A carefully planned sequence also allows for the shortest duration of
application on the most sensitive areas of skin when the entire face is treated.

Typically, the application sequence for light and medium-depth facial peels begins
with the forehead and temples, proceeds to the cheeks and chin, then concludes
with perioral and periocular skin. The agent is feathered at the margins of the
hairline, rim of the jaw, and brow to minimize the development of lines of
demarcation after healing [7].
To reduce the risk of phenol toxicity during deep chemical peels, phenol is usually
only applied to one small area of skin at a time. The face is subdivided into
sections that are treated at 15-minute intervals, such as the forehead, one cheek,
the alternate cheek, nose and perioral area, and the periorbital region. The
applicator swab should only be slightly moist. More solution can be applied to the
deeper wrinkles and scars to achieve deeper peeling in those areas. The phenol
solution should be swirled periodically to prevent separation of the components
between applications.

Precautions — Periocular skin should be treated carefully to minimize risk for

entry of the peeling agent into the eye. The applicator should only be slightly
moist, and a safety margin of untreated skin should be left near the eyelid margin.
Care should be taken to ensure that excess peel solution is not left on or around
the eyelids, and any tears should be dried immediately.

Treatment endpoints — The peeling agent utilized and the desired depth of peeling
determine the amount of time a chemical peel agent should remain on the skin.
The major factors used to identify treatment endpoints include time and the
physical appearance of the skin.

Time — A time endpoint is commonly employed for light peels and is

particularly critical for glycolic acid peels. Glycolic acid solution is applied quickly
(within 15 to 20 seconds). Once the desired contact time is reached, glycolic acid
must be neutralized with copious amounts of 5% sodium bicarbonate or water.
The concentration of glycolic acid and contact times are slowly increased with
subsequent treatments. We often begin with 50% glycolic acid applied for 30
seconds from the moment application of glycolic acid begins. We slowly increase
the contact time with each subsequent peel up to a maximum of two minutes for
patients undergoing a series of peels.

Salicylic acid (20 to 30%) and Jessner's peel solutions are often left on the skin for
six minutes. Slightly deeper penetration of the epidermis can be achieved through
application of more solution to the skin or application of firm pressure as the
solution is rubbed into the skin. After six minutes, the skin is wiped with a wet
washcloth to remove the peel solution. However, the action of salicylic acid and
Jessner's solution on the skin is self-limited, and application of a neutralizing
agent is not necessary to conclude the peel.  

Physical — The appearance of skin after application, assessed by the level of

frosting, identifies the treatment endpoint for medium-depth and deep chemical
peels. Epidermal sliding is another helpful clinical endpoint for medium-depth
trichloroacetic acid (TCA) peels.

Frosting describes a whitened appearance of the skin. The degree of frosting

correlates with the depth of penetration of the chemical peel:

● Level 1 frost – A light, nonorganized, nonhomogenous frost with associated

erythema. Frosting should be absent or no greater than level 1 at the endpoint
of a light chemical peel. In addition, because of fewer adnexal structures to
support reepithelialization on the neck and chest compared with facial skin, a
level 1 frost is the suggested endpoint for neck and chest chemical peels.

● Level 2 frost – A solid, organized, more homogenous frost. The superficial

vascular plexus in the papillary dermis remains intact, indicated by associated
erythema (pink sign). A level 2 frost is the standard endpoint for a medium-
depth chemical peel.

● Level 3 frost – A solid, organized frost with loss of the pink sign. Loss of the
pink sign results from vasospasm of capillary loops in the papillary dermis. A
level 3 frost indicates that the peel has crossed the full thickness of the
papillary dermis but has not penetrated the reticular dermis.

Further penetration of the peeling agent into the midreticular dermis will result in a
"grayish" frost. This appearance correlates with increased risk for
hypopigmentation and scarring.
The pink sign may be difficult to appreciate in patients with highly pigmented skin.
The epidermal sliding sign is useful for identifying the treatment endpoint for
medium-depth peels in these patients. The "epidermal sliding sign" is an
exaggerated wrinkling of the skin that occurs when papillary dermal edema forms
and disrupts the anchoring fibrils between the epidermis and dermis. This allows
the epidermis to be more freely movable, resulting in exaggerated wrinkling when
the skin is pinched. Epidermal sliding is a transient sign that will disappear when
the peel coagulates the epidermal proteins with dermal proteins, indicating that
the peel depth has reached the superficial reticular dermis.

Achievement of the desired degree of frosting (and, accordingly, the depth of a

chemical peel) is modulated through the type and concentration of the peeling
agent(s) and, for medium-depth peels with TCA, is frequently adjusted further with
the number of applications. At least two to three minutes should pass after an
application to allow the TCA to penetrate before determining the degree of frost
insufficient and applying more TCA. Commonly, medium-depth peels involve
achievement of a level 1 frost with a superficial peeling agent (eg, glycolic acid,
Jessner's solution) followed by achievement of a level 2 frost with one or more
applications of 35% TCA. Applying pressure and rubbing the TCA solution into the
skin during application can also augment the depth of penetration.

The rapid appearance of a solid, organized, white frost is expected for phenol
chemical peels.

POSTPROCEDURE COURSE AND CARE

The recovery time following a chemical peel rises with increasing depth of the
peel. Careful skin care (gentle cleansing, regular use of emollients, sun protection,
and avoidance of rubbing or picking the skin) is performed during the recovery
period to support wound healing and minimize risk for complications.
Close adherence to postprocedure skin care is most important for medium-depth
and deep chemical peels given the greater degree of skin injury compared with
light peels. Patients should receive written instructions to assist with correct
performance of wound care recommendations.

Pain is not expected after light or medium-depth chemical peels. After deep
chemical peels, discomfort characterized by a burning sensation is common for
the first 24 hours. Patients who develop unexpected pain, purulence, or any type of
exudate after a chemical peel should be evaluated immediately for infectious
complications. Patients who develop findings suspicious for herpes labialis after
medium-depth or deep peels should also be promptly examined. (See 'Infection'
below and "Epidemiology, clinical manifestations, and diagnosis of herpes simplex
virus type 1 infection", section on 'Oral infections'.)

Light peels — The recovery time following a light chemical peel is three to four
days. The skin is mildly erythematous for one to two days and will exhibit slight
desquamation for three to four days.

We typically provide patients with the following instructions for skin care during
the healing period:

● Wash twice per day with a gentle cleanser and apply a light, noncomedogenic
moisturizer

● Apply a noncomedogenic, mineral-based sunscreen every morning on top of

the moisturizer

● Avoid rubbing or picking flaking skin

● Avoid direct sun exposure to minimize risk for sunburn and hyperpigmentation

Patients can resume their regular skin care regimens once the skin has healed.

Medium-depth peels and deep peels — The time between the chemical peel and
complete reepithelialization after medium-depth and deep chemical peels is 7 to 8
days and 8 to 10 days, respectively. Skin edema is usually prominent and may
continue to worsen during the first two days. The skin then develops a darkened,
mask-like appearance, which is followed by desquamation and subsequent
reepithelialization. Desquamation in deep peel areas may reveal skin with a moist
appearance and a layer of yellowish exudate.

Skin erythema is common and expected after reepithelialization. Erythema

typically resolves completely within one month for medium-depth peels and two to
three months for deep peels [8].  

We typically provide patients with the following instructions for skin care during
the healing period:

● Apply a clean, moldable ice pack (eg, small plastic bag of frozen peas) to the
eyes and cheeks for 10 minutes each hour during the first one to two days,
while awake, to minimize swelling.

● Gently wash the face in the morning and before bedtime with fingers. Do not
rub. Do not use a washcloth. Gently pat the skin with a towel to dry the skin
after washing. Gently apply a bland ointment emollient after washing. The
emollient should be patted, not rubbed, onto the skin.

● At noon and in the late afternoon, perform an astringent soak using gauze
soaked in aluminum acetate solution. Wet the gauze and lay it on the skin for
approximately 10 minutes. Do not rinse the solution from the skin.

● Avoid picking or rubbing the skin.

Wound dressings may or may not be used.

Patients can restart their regular skin care regimen once reepithelialization is
complete. Sun exposure should be avoided for one month. Exercise should be
avoided until the skin has fully reepithelialized (six to eight days).
COMPLICATIONS

Complications, such as ocular injury, infection, dyspigmentation, prolonged

erythema, and scarring, can occur and require prompt recognition and treatment
[8].

Irritant contact dermatitis may also occur as a result of products applied after the
chemical peel. Irritant contact dermatitis is managed with the elimination of any
potentially irritating skin care products. A low-potency corticosteroid can be
applied when needed.

Ocular injury — Entry of chemical peeling agents in the eye can result in corneal
injury. The eye should be rinsed immediately. Saline solution can be used to rinse
the eye for most chemical peels. Mineral oil should be used to rinse the eye
following entry of phenol peeling solutions because water may increase
penetration of phenol. A prompt ophthalmologic evaluation is indicated following
ocular exposure to a chemical peel agent.

Infection — Viral, bacterial, or fungal infections can follow chemical peels.

Regression of healing, pain, purulent drainage, and ulceration require an evaluation
for infection.

Bacterial infections due to S. aureus, Pseudomonas aeruginosa, or other bacteria

may occur as early as 24 hours after the chemical peel. Potential manifestations
include honey-colored crusting, pustules, erythematous papules, pain, or swelling.
The diagnosis is confirmed via culture. Treatment involves oral antibiotic therapy.

Herpes simplex virus infection presents with moderately painful, small ulcerations
that may rapidly spread within the treatment area. Signs of infection often appear
two to three days after the chemical peel [6]. Infection may be confirmed with
polymerase chain reaction, direct fluorescent antibody, or viral culture. Oral
antiviral therapy is indicated. (See 'Infection' above and "Epidemiology, clinical
manifestations, and diagnosis of herpes simplex virus type 1 infection", section on
'Oral infections'.)

Candida infection typically presents as erythematous, pruritic papules several days

after the chemical peel. A potassium hydroxide preparation is useful for rapid
identification of Candida infection. Treatment with an oral antifungal with activity
against Candida is indicated.

Dyspigmentation — Risk for chemical peel-induced postinflammatory

hyperpigmentation (PIH) increases with increasing skin pigmentation and is most
likely to occur in individuals with skin phototypes III to VI. PIH often becomes
evident three to four weeks after the procedure. PIH is generally transient but often
takes three to six months to resolve. Implementation of treatments for PIH, such
as strict sun protection, topical hydroquinone, and light chemical peels, may
accelerate improvement. (See "Postinflammatory hyperpigmentation", section on
'Treatment'.)

Permanent hypopigmentation can occur as an adverse event of deep chemical

peels or in association with complications, such as infection or scarring. This
differs from the lightening of skin color that can occur as a normal consequence
of chemical peeling, as epidermal melanin is removed during peeling [8].

Prolonged erythema — Prolonged erythema usually occurs in the setting of deep

chemical peels and is thought to result from the action of angiogenic factors
during the healing process [8,9]. Other associations include infection, delayed
healing, recent use of topical or oral retinoids, alcohol consumption, contact
dermatitis, and preexisting skin conditions associated with facial erythema (eg,
rosacea) [8].

Postpeel erythema often improves spontaneously, and with the exception of

patients with areas of intense erythema, treatment is usually reserved for
erythema that persists beyond the expected period (eg, remaining two months
after a medium-depth chemical peel or three to four months after a deep peel).
The best approach to treatment has not been established. Our approach consists
of judicious use of a midpotency topical corticosteroid (triamcinolone acetonide
0.1% cream or ointment) for one or two days of each week. Patients for whom
erythema causes significant psychologic distress can be treated with a low-
fluence pulsed dye laser to accelerate resolution.

Intense erythema — Intense erythema is different from prolonged erythema,

manifesting with focal areas of extreme redness that can be a harbinger of
scarring. These areas are prone to develop along bony prominences (orbital rim,
jawline, zygoma) and can be asymptomatic or pruritic.

In the absence of treatment, areas of intense erythema may progress to a

hypertrophic scar or keloid. We closely monitor the patient for scar development
and treat with triamcinolone acetonide 0.1% cream or ointment applied one to two
days per week plus pulsed dye laser therapy. Pulsed dye laser sessions can be
repeated weekly, biweekly, or monthly depending on the patient's response to
treatment and the severity of the erythema.

Scarring — Scarring is an uncommon adverse effect that is most likely to occur in

the setting of deep peels, particularly in the setting of treatment of the neck, chest,
or dorsal hands and factors contributing to delayed or poor wound healing [8].

Hypertrophic scars or keloids that develop following chemical peels are managed
similarly to scars secondary to other events. Examples of therapeutic options
include high-potency topical corticosteroids, intralesional corticosteroid injections,
intralesional 5-fluorouracil, and pulsed dye laser therapy. (See "Keloids and
hypertrophic scars", section on 'Management'.)

ASSESSMENT OF EFFECT

Light chemical peels generally induce subtle improvements, and performance of a

series of at least several light peels is usually necessary to achieve a more
noticeable effect. Mild, incremental improvements in features such as skin texture
and dyspigmentation may be visible soon after each peel, whereas features such
as comedonal acne may require several peels before the appearance of a clinically
relevant effect. (See "Light-based, adjunctive, and other therapies for acne
vulgaris", section on 'Office-based superficial chemical peels'.)

Cosmetic benefits of medium-depth and deep chemical peels involve effects on

cutaneous collagen, and clinical improvement can occur over several months as
collagen remodeling continues. Repeating medium-depth peels is generally not
indicated for at least three months. Repetition of a deep chemical peel is typically
avoided for at least one year.

SUMMARY AND RECOMMENDATIONS

● Chemical peels comprise a group of procedures in which caustic substances
are applied to the skin to induce skin injury. Healing after injury can lead to
improvements in multiple features, such as dyspigmentation, wrinkles, acne
scars, and actinic keratoses (table 2). (See 'Basic concepts' above and
"Chemical peels: Principles, peeling agents, and pretreatment assessment".)

● Chemical peels are divided into light, medium-depth, and deep chemical peels
based upon the depth of skin injury induced in the skin. Injury from light
chemical peels is limited to the epidermis. Medium-depth peels injure the
dermis and papillary dermis, and deep chemical peels involve injury extending
into the reticular dermis. (See 'Basic concepts' above.)

● Skin preparation regimens are commonly initiated prior to chemical peels,

although the value of routine performance of skin preparation has been
debated. Herpes simplex virus infection prophylaxis is indicated for all patients
undergoing medium-depth or deep perioral or full-face chemical peels. (See
'Preparation' above.)
 ● Proper preparation on the day of the chemical peel is crucial for achieving
optimal results, minimizing risk for adverse effects, and optimizing patient
comfort. All necessary materials should be assembled prior to application of
the chemical peel agent, and skin in the treatment area should be adequately
cleansed. Phenol has cardiotoxic effects, and cardiac monitoring is often
necessary for phenol chemical peels. (See 'Before application' above.)

● Application of chemical peel agents should be performed carefully to avoid

excessive application, insufficient application, and entry of chemical peel
agents into the eye. The sequence of application should be planned prior to the
start of treatment. (See 'Application' above.)

● The peeling agent utilized and the desired depth of skin injury determine the
treatment endpoint for a chemical peel. The endpoint for light chemical peels
is often based upon contact time with the skin. Physical signs, such as frosting
and the epidermal sliding sign, are used to guide the endpoints for medium-
depth and deep chemical peels. (See 'Treatment endpoints' above.)

● Gentle skin care is implemented after chemical peels to support healing and
reduce risk for complications. This typically includes gentle cleansing, regular
use of emollients, sun protection, and avoidance of additional trauma to the
skin. (See 'Postprocedure course and care' above.)

● Complications of chemical peels requiring prompt recognition or treatment

include ocular injury, infection, dyspigmentation, prolonged erythema, intense
erythema, and scarring. (See 'Complications' above.)

REFERENCES

1. Vemula S, Maymone MBC, Secemsky EA, et al. Assessing the safety of

superficial chemical peels in darker skin: A retrospective study. J Am Acad
Dermatol 2018; 79:508.
2. Abdelmalek M, Spencer J. Retinoids and wound healing. Dermatol Surg 2006;
32:1219.

3. Rapaport MJ, Kamer F. Exacerbation of facial herpes simplex after phenolic

face peels. J Dermatol Surg Oncol 1984; 10:57.

4. Gilbert S, McBurney E. Use of valacyclovir for herpes simplex virus-1 (HSV-1)

prophylaxis after facial resurfacing: A randomized clinical trial of dosing
regimens. Dermatol Surg 2000; 26:50.

5. Wambier CG, Lee KC, Soon SL, et al. Advanced chemical peels: Phenol-croton
oil peel. J Am Acad Dermatol 2019; 81:327.

6. Lee KC, Wambier CG, Soon SL, et al. Basic chemical peeling: Superficial and
medium-depth peels. J Am Acad Dermatol 2019; 81:313.

7. Soleymani T, Lanoue J, Rahman Z. A Practical Approach to Chemical Peels: A

Review of Fundamentals and Step-by-step Algorithmic Protocol for
Treatment. J Clin Aesthet Dermatol 2018; 11:21.

8. Costa IMC, Damasceno PS, Costa MC, Gomes KGP. Review in peeling
complications. J Cosmet Dermatol 2017; 16:319.

9. Maloney BP, Millman B, Monheit G, McCollough EG. The etiology of prolonged

erythema after chemical peel. Dermatol Surg 1998; 24:337.

Topic 13632 Version 1.0

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