Chemical Peeling

Definition:
o The application of acidic or basic abrasive chemical substances that can
destroy selective levels of the epidermis or dermis
o All ablative resurfacing procedures injure the skin, in a controlled fashion,
to a specific depth and thereby promote the growth of new skin with
improved surface characteristics
o The three fundamental methods used to create this controlled injury are
❖ Chemical resurfacing (chemical peeling)
❖ Mechanical resurfacing (motorized dermabrasion)
❖ Laser resurfacing
o Can be classified as superficial, medium-depth or deep, according to their
level of injury
o The third most commonly employed cosmetic procedure, after injectable
neurotoxins and soft tissue fillers

Main Indications:
1. Actinically damaged skin and rhytides
❖ Mild photoaging: superficial peel in conjunction with topical
medications or cosmeceuticals (e.g. retinoids, glycolic acids,
antioxidants, vitamin C, vitamin E)
❖ Moderate photoaging: medium-depth chemical peel as well as long-
term medical therapy to include a retinoid and/or an α-hydroxy acid
(AHA)
❖ Severe photoaging: medium or deep peel and correction of deep
furrows with injectable neurotoxins and soft tissue fillers
2. Scarring
3. Multiple pre-neoplastic or neoplastic epidermal lesions (e.g. actinic
keratosis, lentigines)
❖ Those originating in the epidermis, such as actinic keratoses or
lentigines, are more amenable to treatment than those with a
dermal extension or origin
4. Acne, rhinophyma
5. Pigmentary dyschromias

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 ❖ Such as melasma respond favorably to superficial chemical peeling or
microdermabrasion, especially when accompanied by appropriate
cosmeceutical products and sunscreens
6. Demarcation lines secondary to other resurfacing procedures

Contraindications:
1. Poor physician–patient relationship
2. Lack of psychological stability and mental preparedness
3. Unrealistic expectations
4. Poor general health and nutritional status
5. Active infection or open wounds such as HSV, excoriations, or open acne
cysts
6. Patients with certain cutaneous disorders such as rosacea, seborrheic
dermatitis, atopic dermatitis, psoriasis or vitiligo
❖ may be at increased risk for postoperative complications, including
disease exacerbation, prolonged erythema, contact dermatitis, or
even delayed healing
7. History of abnormal scar formation or delayed wound healing (Relative
contraindication)
8. Fitzpatrick skin types IV, V and VI (Relative contraindication to medium and
deep peels)
❖ Are at greater risk for hyperpigmentation or hypopigmentation after
medium-depth or deep resurfacing
❖ Test spots are definitely recommended for individuals with skin types
III–VI

Preoperative and intraoperative:

o Careful history and physical examination are important
❖ To assess the skin problems which prompted his or her presentation
❖ To identify any factors that may contribute to intraoperative or
postoperative difficulties (eg. Skin type, active wounds, history of
abnormal scar etc…)
o Patient must fully understand the potential benefits, limitations and risks of
the procedure, and an informed consent must be signed
o A test spot (e.g. along the lateral hair line) may be useful in some patients
❖ To assess their suitability for resurfacing

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 ❖ May be particularly helpful when there is a great deal of concern
about the chances of postoperative pigmentary dyschromias
o In patients with photoaging, it is recommended that botulinum toxin
injections be administered as an adjunctive therapy at least 3 days prior to
medium-depth or deep chemical peels to improve dynamic wrinkles
o Patients who undergo medium-depth or deep resurfacing should be treated
prophylactically with an antiviral agent
❖ Regardless of whether there is a history of HSV infections
❖ Acyclovir (400 mg three times daily beginning on the day of the
procedure)
o Use of preoperative topical tretinoin
❖ To reduce areas of hyperkeratosis and decrease the thickness of the
stratum corneum
❖ Allows for greater penetration of the peel solution
❖ Resulting in a more homogeneous peel and a deeper peel
o Patients with skin type III or higher may benefit from twice-daily application
of 2% to 4% topical hydroquinone
❖ During the preoperative and postoperative (post-healing) periods
❖ Even if there is no history of pigmentary abnormalities

Postoperative:
o Adhere to strict photoprotective measures
o On the day of the procedure, the patient washes his or her face with a
gentle cleanser and preferably avoids the application of any cosmetics
o The presence of persistent postoperative erythema may indicate continued
collagen remodeling and may serve as a warning that a similar resurfacing
procedure performed prematurely could produce scarring
o After superficial chemical peel:
▪ Cause minimal downtime and necessitate little postoperative care
▪ Usually produce mild erythema and desquamation that last from 1 to
4 days depending on the wounding agent and the techniques used
▪ Regular washing with a mild cleanser and the use of routine
moisturizers and sunscreens are generally sufficient during the
healing period
o After medium-depth chemical peel

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 ▪ There is initially a brawny, dusky erythema which is followed by the
formation of a brownish crust that begins to separate from the skin
surface between days 4 and 8 postoperatively
▪ The underlying, newly formed epithelium is brightly erythematous
but fades to a pink color that resembles a sunburn
▪ By postoperative day 7 to 10, re-epithelialization has occurred and
the erythema can be camouflaged with cosmetics
o The patient is instructed to soak the areas four times daily with warm
compresses and to apply an emollient after each soak and during the
intervening periods as necessary. Occlusive emollients, such as petrolatum,
Aquaphor® or Eucerin® Creme, speed the process of re-epithelialization and
lessen the tendency for delayed healing. These emollients are also helpful
in wound debridement and in the prevention of crust formation and
infection
o Milia formation, which commonly occurs 3 to 4 weeks after deep chemical
peeling is easily managed with needle extraction

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Types of Peels:
1) Superficial chemical peel:
✓ Very Light peels:
1. low-potency formulations of glycolic acid
2. 10–20% trichloroacetic acid (TCA)
3. 20% salicylic acid
4. Jessner’s solution
5. Tretinoin
❖ injury is usually limited to the stratum corneum and only creates
exfoliation
✓ Light peels:
1. 50–70% glycolic acid
2. 25–30% TCA
3. 30% salicylic acid
4. Jessner’s solution (greater number of coats than or very light peels)
❖ injure the entire epidermis down to the basal layer, stimulating the
regeneration of a fresh new epithelium
2) Medium depth peel:
1. 35% TCA in combination with Jessner’s solution (Safer than 50% TCA)
2. 70% glycolic acid in combination with Jessner’s solution
❖ Controlled damage through the epidermis and papillary dermis, with
variable extension to the upper reticular dermis
❖ Postoperatively, over a period of 3 months, there is increased
collagen production with expansion of the papillary dermis and the
development of a mid-dermal band of thicker collagen fibers. These
changes correlate with continued clinical improvement in texture,
fine lines, and color
❖ Useful for the improvement of mild to moderate photoaging
❖ Blend the effects of other resurfacing procedures with the
surrounding skin
❖ Epidermal lesions such as actinic keratoses, pigmentary dyschromias,
and mild acne scarring
3) Deep chemical peels:
1. TCA in concentrations >50% (not recommended for deep chemical
peeling because of the risk of scarring and other complications)
2. Phenol (preferred formulation for deep chemical peels)

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 ❖ create an injury through the papillary dermis and into the superficial
reticular dermis, which may extend into the mid-reticular dermis
NB:
✓ The “TCA CROSS” technique is a newer innovative approach to deep icepick
and fibrotic acne scars method of exfoliation, it is the use of 90% TCA as a
full-thickness destructive tool.

NB:
➢ Glycolic:
▪ Alpha-hydroxy acids (AHAs)
▪ Time of application is critical for glycolic acid, as it must be rinsed
off with water or neutralized with 5% sodium bicarbonate after 2
to 4 minutes
▪ The only peeling agent that is time-dependent, requiring
neutralization to end its action.
➢ TCA:
▪ Produces erythema and a very light frost within 15 to 45 seconds
▪ Depth of penetration of the peeling solution is related to the
number of coats applied
➢ Jessner’s:
▪ The clinical endpoint of treatment is erythema with blotchy
frosting (when used prior to application of TCA in medium-depth
peels) or a more uniform frosting (when used alone for superficial
peels)
▪ Resorcinol 14g + Salicylic acid 14g + 85% lactic acid 14g + 95%
ethanol
➢ Salicylic acid:
▪ A preferred therapy for comedonal acne and inflammatory
rosacea as it is lipophilic and concentrates within the
pilosebaceous apparatus
▪ Produces less inflammation (lower risk of postinflammatory
hyperpigmentation), as a result, it is the preferred peeling agent
for removing the excess pigmentation in melasma and
postinflammatory hyperpigmentation

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Complications:
1. Erythema
o Is seen following most chemical peels and the redness usually fades
over the course of a week
o Persistent erythema is uncommon and is more likely to be seen in
patients with rosacea or if the patient has been on topical tretinoin
before and after the peel, but is never permanent
o Localized persistent redness may be a sign of an impending scar
2. Infection
o Reactivation of dormant herpes simplex infection can occur,
prophylactic antiviral needed for medium depth peels
o Infection is not common following a chemical peel but can occur as
an early postoperative complication due to overgrowth of skin flora
o The risk of infection increases with the depth of the peel as deep
peels will result in extensive crust formation, which is prone to
bacterial colonization
3. Chemical burns
o If it occurs, burns tends to be localized and heal with post-
inflammatory hyperpigmentation
4. Premature peeling
o Can occur with medium and deep peels
o It may occur accidentally or intentionally
o The necrotic layer acts as a superficial dressing while the deeper
layer heals
o If the protective necrotic layer is removed, the underlying fragile
healing skin may not re-epithelialize, which could lead to persistent
erythema, post-peel pigmentation or even scarring
5. Milia
o Likely to be due to the occlusive effects of the ointment used after
treatment
o Tend to occur approximately 3 weeks after peeling, commonly in the
periorbital area
6. Acneform eruptions
o May occasionally appear during the healing phase post peel
7. Allergic contact dermatitis (rare)
8. Systemic toxicity

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 o Resorcinol, salicylic acid and phenol applied on the skin may be
absorbed systemically to cause toxicity
o Salicylic acid toxicity (salicylism) can occur when large areas of the
face, chest, arms and legs are treated simultaneously
9. Post‐inflammatory hyperpigmentation
o Not uncommon complication if there is unprotected sun exposure
after chemical peeling
o More frequent in patients with skin of colour
o Usually seen 1–4 weeks after treatment
o High-risk individuals should be primed with topical hydroquinone
prior to the procedure and require fastidious sun protection and sun
avoidance after the peel
10.Post‐inflammatory hypopigmentation
o Due to melanocyte destruction in hair follicles and reticular dermis
o Phenol peels are known to cause hypopigmentation
11.Scarring
o The most concerning complication
o Deeply penetrating peeling agents are a risk factor
o Most scars are a result of a secondary event, such as infection or a
premature repeat procedure

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