Chemical Peels

Chemical Peels

Frankie G. Rholdon, MD

Chemical peeling (chemoexfoliation) is the application of a chemical agent to the skin to cause controlled destruction of portions of the epidermis and possibly dermis. This results in exfoliation and removal of superficial lesions, as well as regeneration and remodeling of epidermal and dermal tissues. Chemical peeling to improve aesthetics has evolved throughout history, beginning with the ancient Egyptians using animal oils, salt, alabaster, and sour milk. The active ingredient in sour milk is lactic acid, an alpha hydroxy acid, which is still used in chemical peeling today. Dermatologists have been utilizing modern peeling techniques since the late 1800s. Large advances came with P.G. Unna’s descriptions of salicylic acid (SA), resorcinol, phenol, and trichloroacetic acid (TCA) in 1882. Deep chemical peeling was refined in the 1960s and 1970s by Drs Thomas Baker and Harold Gordon using a saponated formula of phenol and croton oil. Medium-depth chemical peeling was pioneered by Drs Harold Brody, Gary Monheit, and William Coleman in the 1980s.1 These peeling techniques have
been optimized, and many commercially available proprietary formulations are now available. Dermatologists performed 434,000 chemical peel procedures in 2017,2 compared to 425,000 in 2016.3 Society’s desire for a more youthful appearance is driving an increase in the demand for chemical peeling.

The goal of chemical peeling is to remove a uniform thickness of skin to eliminate damaged or unwanted cells and to stimulate rejuvenation through wound healing. Caustic agents used in chemical peeling cause exfoliation through keratocoagulation, denaturation of proteins, and/or disruption of intercellular adhesion. Removal of the epidermis improves pigmentation and texture and destroys unwanted epidermal growths. The wounding also causes the release of pro-inflammatory cytokines and chemokines, activating the inflammatory cascade. This targeted inflammation stimulates neocollagenesis and neoelastinogenesis, reorganization of dermal connective tissue, and regeneration of keratinocytes. This results in epidermal and dermal thickening which can improve the clinical appearance of rhytides and acne scarring. The depth of tissue injury correlates with the amount of tissue remodeling and therefore chemical peels are traditionally categorized by depth of wounding into superficial, medium, and deep chemical peels (Table 5.1).

Superficial chemical peels involve injury to varying levels of the epidermis. Medium-depth peels penetrate the full thickness of epidermis and into the papillary dermis. Deep chemical peels wound into the reticular dermis. The depth of a chemical peel can be influenced by several factors including the type of chemical used, chemical concentration, mode of application, number of applications, and amount of time the chemical is active on the skin. The depth of injury directly correlates with healing time, risk of complication, and cosmetic outcome.

preoperative (table 5.2)PREOPERATIVE (TABLE 5.2)


Proper patient counseling is essential in both outcome and patient satisfaction (Table 5.4). Patient goals and expectations should be communicated and aligned with the chosen procedure. The provider should ensure that the patient understands the expected outcome and limitations of the treatment. Detailed information regarding the preparation required prior to the procedure, as well as the procedure technique,

expected discomfort, anticipated downtime, aftercare protocol, and potential complications, must be reviewed with the patient in detail. The patient should understand normal healing and be educated on potential adverse events to enable early identification and intervention in the case of complications. After the patient is educated and given the opportunity to ask questions, written documentation of informed consent is obtained.

Photographic Documentation

The treatment area should be photographed prior to the chemical peel procedure. Ensure that the area is clean and free of makeup. Distractions should be minimized; therefore, it is recommended to use a headband to position hair away from the face and to remove jewelry. Photos should be standardized using consistent positioning and lighting. The photographs are part of the medical record, require Health Insurance Portability and Accountability Act (HIPAA)-compliant storage, and should be used for patient care as part of the medical record. If identifiable photographs are to be used for publications or advertising, written patient consent is necessary.

operative (table 5.5)OPERATIVE (TABLE 5.5)

Prior to beginning the chemical peel, all necessary supplies (Table 5.6) should be present and readily accessible. Care should be taken to ensure that the correct chemical peeling agent and concentration were selected and labeled accurately. The patients should wash their face with a gentle skin cleanser and position hair away from the treatment area using a headband or cap. For facial peeling, position the patient reclined at 30° to 45° angle with eyes closed. Alcohol and/or acetone on a gauze are used to clean and degrease the treatment area. A fan can be helpful to protect the patient from the noxious fumes.

To avoid accidental spillage, the peeling solution should never be passed over the patient. Special care is taken to avoid drips or spills near the eye area, and the patient’s eyes should remain closed for the procedure. An eyewash bottle of normal saline should be present in the procedure room at all times in case of accidental exposure. It is optional to protect vulnerable areas with the application of white petrolatum. The medial canthus and nasojugal folds can pool peeling solution resulting in deeper than desired wounding. The medial and lateral canthi can also be protected with petrolatum to prevent tears from
interacting with the peeling solution. This can result in premature neutralization of peeling solution or “wicking” of peeling solution into the eyes. Clean gauze or cotton-tipped applicators should also be used to prevent complications from tearing.

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Jun 9, 2022 | Posted by in Aesthetic plastic surgery | Comments Off on Chemical Peels
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