The use of chemical peels to treat the aging face is well established and poses minimal risk when performed by educated practitioners. In addition to improving the texture of the skin and reducing hyperpigmentation and mild wrinkling, peels are also useful in the treatment of acne, rosacea, and melasma. In 1999, chemical peels were so popular that they were found to be the most common cosmetic procedure performed in the United States.1 In 2006, chemical peels were second only to Botox among the top five minimally invasive cosmetic procedures performed by board-certified members of the American Society of Plastic Surgeons, with 1.1 million procedures performed.2 The introduction of lasers in skin rejuvenation may have some impact on the frequency of chemical peel treatments. Although the claims of what chemical peels can do have been frequently overstated, there is actually an abundance of research on the utility of these products, which are used in physicians’ offices and salons worldwide.
Chemical peels are categorized based on the depth of the procedure: superficial, medium or deep. Superficial peels induce necrosis of all or parts of the epidermis, from the stratum granulosum to the basal cell layer (Figs. 20-1 and 20-2). Medium-depth peels create necrosis of the epidermis and part or all of the papillary dermis in the treatment area. The necrosis extends into the reticular dermis following deep peels.3 Currently, superficial peels are the most frequently performed peels, as intense pulsed light, laser resurfacing and dermabrasion have essentially supplanted medium and deeper-depth peels. Superficial- and medium-depth peels do not significantly ameliorate deep wrinkles or sagging skin, but can improve the color and texture of the skin thereby yielding a more youthful appearance. This chapter will focus on and differentiate between the most frequently used in-office types of superficial and medium-depth peels, including mechanisms of action, side effects and results obtained with the various acids used in peels. Many of the ingredients in these peels are also found in home products; therefore, some skin care products will be mentioned in this chapter as well.
A hematoxylin and eosin (H&E) stain of untreated normal bovine skin.
A hematoxylin and eosin (H&E) stain of bovine skin treated with a superficial chemical peel (two coats of the Pigment Peel Plus). This biopsy demonstrates a split in the spinous layer of the epidermis.
Although a wide variety of agents have been shown to be effective for superficial peeling, alpha hydroxy acids (AHAs), beta hydroxy acid (BHA), Jessner’s solution, modified Jessner’s solution, resorcinol, and trichloroacetic acid (TCA) are the most commonly used in-office peel compounds. All of these compounds produce effects on the skin by inducing desquamation with resultant hastening ...