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Chapter 5: Chemical Peels

MECHANISM OF ACTION

The application of a wounding agent to induce epidermal and/or dermal sloughing.

INDICATIONS

  • Epidermal defects—ephelides, melasma

  • Epidermal and dermal defects—melasma, lentigines, post-inflammatory hyperpigmentation, actinic keratoses, superficial rhytides, acne vulgaris

  • Dermal defects—deep rhytides, acne scarring, scars

PREOPERATIVE EVALUATION

Peeling agents are selected based on the patient’s lifestyle, defect depth, skin characteristics, and defect location (Tables 5.1–5.3).

TABLE 5.1Clinical Indications and Peel Types
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TABLE 5.1 Clinical Indications and Peel Types

Indication

Peel type

Peel depth/treatment endpoint

Acne vulgaris

Superficial when active

Localized epidermal peeling required; lesional improvement

Ephelides; lentigines

Superficial or medium

Total epidermal peeling required for complete removal; lightening with superficial application

Post-inflammatory inflammation

Superficial or medium

Total epidermal peeling required; lightening with either strength

Melasma

Superficial or medium

Total epidermal peeling required; lightening with either strength; inconsistent response

Superficial rhytides

Superficial

Localized epidermal peeling required; softening

Moderate rhytides

Medium or deep

Total epidermal and papillary dermal peeling required; softening

Deep rhytides

Deep

Total epidermal to reticular dermal peel required; softening

Actinic keratoses

Medium

Total epidermal to papillary dermal peeling required; lesional clearance

Depressed scars

Medium or deep

Lesional edges targeted; total epidermal and partial dermal peeling required; lesional flattening; variable response
TABLE 5.2Wounding Depth of Superficial, Medium-Depth, and Deep-Depth Strength Peels
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TABLE 5.2 Wounding Depth of Superficial, Medium-Depth, and Deep-Depth Strength Peels

Superficial peel

Medium-depth peel

Deep peel

α-Hydroxy acid

Glycolic acid and TCA

Baker’s Gordon phenol, unoccluded

Modified Unna’s resorcinol paste

Jessner’s and TCA

Baker’s Gordon phenol, occluded

Jessner’s

Solid carbon dioxide and TCA

Salicylic acid

50% TCA

Solid carbon dioxide slush

Pyruvic acid

Tretinoin

88% Full-strength phenol

10%–25% TCA; 35% variable
TABLE 5.3Peeling Agent Characteristics
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TABLE 5.3 Peeling Agent Characteristics

Peel type

Color endpoint

Application

Healing time

Safe for

Glycolic acid

Confluent erythema

1–2 coats

1–2 h

All skin types

Jessner

Pale white

Coats are applied singly and endpoint monitored for 3–4 min prior to repeat application

4–5 d; mild epidermal desquamation noted

All skin types

TCA (30% or greater)

Solid white

Single even application; localized applications for lighter white areas may be considered

10–14 d; severe sunburn-like peeling observed

I and II; caution with III and IV

Phenol

Gray white

Single even application; can be conservatively reapplied

10–14 d; superficial burn appearance

I and II

  • Past medical history

    • – Past radiation history—decreased adnexal structures likely

    • – History of oral herpes simplex virus—reactivation may occur

    • – Pregnancy—peels contraindicated with the exception of glycolic acid

    • – History of keloid formation—moderate and deep-depth peels should be avoided

  • Past surgical history

    • – Prior cosmetic procedures—prior face lift, blepharoplasty, carbon dioxide resurfacing, or dermabrasion may affect peel outcome. Increased ...

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