Chemical Peels

 Updated 3/2017-- photos and all links removed as many are no longer active and it's easier than checking each one.

Chemical peels have been around for many years. Even with the continued improvement of lasers, there will most likely always be a place for chemical peels. If the right peel is used for the skin problem, the results can be spectacular. If not done properly, they can (like lasers) create new problems (scarring, hypopigmentation, etc).

Chemical peels are classified into three categories based on the depth of the burn created by the peel.
Superficial

• includes Jessner's peels, salicylic acid peels, gylcolic acid peels, and light trichloroacetic acid (TCA) peels
• uses include acne treatment, rosacea, and fine lines
• minimal discomfort, no recovery time, may be repeated weekly
• may have mild skin irritation (2 days), temporary flaking, redness or dryness (up to 5 days)
• Use of cosmetics and moisturizers during the time of the peel generally is avoided if at all possible

Medium

• includes 30-50% TCA peels, and Jessner's combined with TCA peels
• used for melasma, pigment disorders of the skin such as lentigos, deeper wrinkles, and acne scars
• there is mild to moderate discomfort with these peels
• recovery time may be up to two weeks to heal completely
• there is usually some crusting, swelling, and redness

Deep

• includes phenol peels, 75% and higher TCA peels
• used to reduce severe wrinkling, aging and scarring
• severe pain should be expected
• takes two weeks or more to heal
• severe swelling (5-7 days), crusting, and redness (up to 6-8 weeks)

The risk of complication is greater with the deeper peels, but the benefits are increased also. Risks include infection (more so with the deep peel), scarring, pigmentation problems, unsatisfactory results (ie patient expected the results of the deep peel but only wanted to go the superficial or medium route), and possible unevenness (acid solution not applied evenly).

In patients prone to hyperpigmentation, pretreatment and posttreatment with a bleaching agent are necessary. Sun exposure after the procedure should (must) be avoided, especially in these individuals who are prone to hyperpigmentation. Hypopigmentation in white persons after a deep peel is almost universal and should be an accepted sequela of the procedure.

Pre-peel

Preconditioning the skin is a useful adjunct in order to improve results. Use of an exfoliative agent like transretinoic acid (Retin-A, Renova) is believed to facilitate uniform penetration of the peeling agent and promote more rapid re-epithelialization. The transretinoic acid should be applied nightly or every other night for several weeks prior to peeling, depending on the degree of skin irritation caused and patient tolerance.

Patients with a history of hyperpigmentation may also beneifit from pre-and post-treatment with hydroquinone.

Patients with a history of cold sores should receive acyclovir (400 mg PO bid), beginning 2 days prior to the peel and continuing 7 days after the peel.

Patients with a decreased number of epithelial appendages from prior radiation treatment or current isotretinoin (Accutane) use are poor candidates because healing will proceed more slowly and scarring is more likely. Recent use of Accutane is considered a contraindication to medium or deep peels. Wait at least 12 months after stopping Accutane to allow some regeneration of epithelial appendages prior to peeling.

Following the peel, it is important that the patient follow instructions given by the physician to prevent complications (especially with the medium to deep peels).

• The patient should stay out of the sun. When unavoidable, the patient should apply a strong sunscreen (SPF 45 or greater) and wear a hat. An ointment, such as petroleum jelly or Aquaphor, should be applied to the involved skin.
• Remind the patient that the skin will exfoliate and may look cosmetically unattractive for a period of time depending on the depth of the peel.
• For superficial peels, a follow-up appointment can be scheduled at the time of the next peel. For deeper peels, patients should be seen 2-3 times the first week following the peel to provide for early intervention if problems (ie infection) develop.

REFERENCES
Skin Resurfacing, Chemical Peels; Gregory Caputy MD, PhD; eMedicine Article, March 28, 2008
Chemical Peels; Raymond T Kuwahara MD; eMedicine Article, Jan 19, 2007
Skin Resurfacing: Chemical Peels; Don R Revis Jr MD and Michael B Seagle MD; eMedicine Article, Oct 27, 2005