Chemical Peels

Chapter 44. Chemical Peels

Olubimpe A. Ayeni, MD, MPH, FRCSC;
Samuel J. Lin, MD, FACS; Thomas A. Mustoe, MD

INDICATIONS

Chemical peels involve the application of a caustic solution to the skin to produce a controlled, partial thickness chemical burn and subsequent “resurfacing” with new epidermal and dermal connective tissue. Chemical peels induce exfoliation, which, in turn, stimulates inflammation, neocollagenesis, and collagen remodeling. The main indications for peels include rhytids, photodamage, actinic damage, acne scarring, and pigment changes. The process results in the appearance of fewer rhytids, improved skin texture, and more even pigmentation.

Chemical peels create a thinner, more compact stratum corneum, as well as a thicker epidermis and more uniform distribution of melanin. The increased volume of tissue tightens the superficial skin layers, leading to an improvement of skin appearance. Common skin problems such as ephelides, melasma, and epidermal hyperpigmentation can be treated with epidermal peels, but senile lentigines and lentigines simplex require deeper peels. Depth of wound mostly determines cosmetic result and is influenced by many factors, such as chemical concentration, duration of contact, number of layers applied, and agent.

CLASSIFICATION OF PEELS BY DEPTH

Superficial chemical peels penetrate the epidermis and can reach as far as the papillary dermis. These agents remove the stratum corneum without inducing necrosis. The deep-ithelialization stimulates epidermal growth and reduces fine lines, rhytids, and sun damage. The most commonly used superficial chemical peels are glycolic acid (40% to 70%), trichloroacetic acid (10% to 20%), Jessner’s solution, salicylic acid, and tretinoin.

Medium-depth peels extend to the deep papillary dermis and often to the superficial reticular dermis. These peels are associated with greater collagen remodeling and longer durations of posttreatment erythema. In terms of the agents used, 35% trichloroacetic acid is often combined with solid CO₂, Jessner’s solution, or 70% glycolic acid. A superficial peeling agent is applied, which acts to break the epidermal barrier and allow more complete penetration of the 35% trichloroacetic acid.

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