Erythema is normal after all types of peels, but persistent erythema is a consequence of angiogenic variables stimulating vasodilation, which indicates that the fibroplasia is being stimulated for prolonged period of time. Thus, it can prompt skin thickening and scarring (Nikalji et al. 2012).

Some known reasons for persistent erythema are the utilization of topical tretinoin just prior and after the procedure, oral isotretinoin administration preceding the peel, alcoholic beverages ingestion(Spira et al. 1974), contact dermatitis, contact sensitization, and some previous skin conditions (rosacea, atopic dermatitis, lupus erythematosus).

Medium and deeper peels have more prominent and long-lasting erythema. Erythema normally vanishes in 3–5 days in superficial peel, 15–30 days in medium peel, and 60–90 days in deep peel (Monheit 2004). If it continues after the time expected, it should be evaluated since there is a chance of scar development.

Persistent erythema must be dealt with as soon as it is diagnosed with strong topical steroids for 1–2 weeks, hats and sunscreens and continued emollients. Sometimes, cosmetic cover can be utilized to diminish the erythema during treatment. Intralesional, oral, or intramuscular steroids can be used in cases with no response. Persistent erythema has a tendency to respond well with intense pulsed light or pulsed dye laser devices (Tung and Rubin 2011).

Setting expectations before the procedure is mandatory, as patients will appreciate being informed of what to expect in the postpeel period (Levy and Emer 2012).

Unintentional spillage of any chemical peel agent in the eyes can prompt corneal harm , so it is essential for the doctor to be truly cautious when peeling around the eye. If an inadvertent spillage happens, the eyes should be rinsed with saline to prevent corneal harm. If phenol peels have been used, flushing should be done with mineral oil rather than saline (Nikalji et al. 2012).

An approach to avoid this complication is to have a cotton tipped applicator for quick removal of tears close to the lashes and a syringe filled with saline in case of an accident with the acid solution inside the eyes (Tung and Rubin 2011). An ophthalmologist should be consulted in these cases.

Cases of cicatricial ectropion have been reported in phenol-peeled patients, and lower eyelid ectropion has reportedly occurred in patients undergoing deep-eyelid peel in conjunction with a blepharoplasty (Dailey et al. 1998). The predisposing factors are older patients with senile lid laxity, patients who have experienced previous transcutaneous blepharoplasty, and patients with flimsy skin (Nikalji et al. 2012). Most of the time, this complication is self-limited and does not need specific treatment, just conservative care (massaging of lower lid skin, adequate taping of the eyelid, especially at night and protection of the globe with artificial tears) (Mendelsohn 2002).

All agents used in peels are possible to cause swelling, although it happens more often in deeper peels. The edema is expected and appears in 24–72 h after the procedure, and it may take several days to recover. Usually, it is a fairly mild edema, yet it can be sufficiently extensive to close the eyes. Knowing this can happen, advising the patient is a way to keep them less worried if this occurs. Ice, antihistamines (loratadine 10 mg, hydroxyzine 25 mg, diphenhydramine 25–75 mg at night), and proper wound care are ways to avoid severe swelling. Systemic steroids, such as prednisone or methylprednisolone, should be utilized in patients who develop severe edema. Some physicians choose to use it preventively, however, it can lead to a bad healing (Tung and Rubin 2011).

Pain is an expected and very ordinary outcome of medium-depth and deep peels. The intensity of pain fluctuates from patient to patient, and it can vary from low intensity to very high. In medium-depth peels, the pain lasts just a few minutes after the application of the peeling, and it is usually not necessary to recommend pain medicine to the patients. During the procedure, 2.5% lidocaine +2.5% prilocaine or 4% lidocaine can be utilized to lessen the pain without influencing the peel penetration. Deep peels usually create more pain and it tends to increase hours after the procedure, enduring a maximum of 8–12 h (Tung and Rubin 2011). Prolonged sun exposure, deficient application of sunscreen, utilizing topical retinoid or glycolic acid instantly after peels can incite this complication (Nikalji et al. 2012). Incomprehensibly, in a few patients, sunscreens can cause themselves contact sensitization or irritant dermatitis (Uday et al. 2007). Pain and burning is normally experienced during a peel procedure in sensitive skin.

Ice application right after the procedure diminishes the pain and burning sensation (Nikalji et al. 2012). When applying deep peels, the utilization of powerful analgesics might be necessary. Likewise, topical calamine cream can be utilized to sooth the skin. Topical steroids such as hydrocortisone or fluticasone are used to diminish the inflammation, emollients moisturize the skin, and sunscreens can be utilized to anticipate postinflammatory hyperpigmentation (Nikalji et al. 2012).

It happens because of re-epithelialization, normally starts in the initial 2 weeks after treatment and persists for around 1 month, and it is more common after medium- and deep-chemical peels. If it occurs with increased erythema or pustules, beware of a possible contact allergy to the cream being utilized in wound care (Tung and Rubin 2011). Some patients can be truly disturbed because of the pruritus and ought to be given oral antihistamines and topical hydrocortisone creams. In order to avoid atrophy or telangiectasia, fluorinated steroids must be utilized with care.

In susceptible patients, chemical peels can prompt an outbreak of folliculitis or acne . Soon after the peel, numerous erythematous delicate papules can show up, mostly because of the emollient creams utilized in this period. The treatment for this condition is difficult since most topical acne agents are irritative to a recovering skin. Oral antibiotics (tetracycline 500 mg bid/minocycline 100 mg bid) can be utilized in these cases and the eruptions usually vanish in a week (Tung and Rubin 2011).

Allergic contact dermatitis is more frequent with resorcinol , salicylic acid , kojic acid, and lactic aci d (Nikalji et al. 2012). Any peel can cause irritant dermatitis , particularly when utilized with high frequency, improper high concentration, or if vigorous skin preparation using acetone or another degreasing solution is applied.

The hypersensitive response normally caused by resorcinol is an urticarial type eruption. Agents as trichloroacetic acid (TCA) or glycolic acid have no report of genuine allergic reactions; however, the TCA can lead to cholinergic urticaria (Tung and Rubin 2011). If an allergic reaction happens, it can be solved by the use of antihistamines. The challenge is to differentiate an allergic reaction from the erythema and swelling expected from the peel but, if the patient has a background of allergic reaction by any peeling agent, they should be given antihistamines prophylactically.

It normally occurs in younger patients with loose periorbital skin. Deeper peels, especially alpha-hydroxy acids, can lead to epidermolysis, vesiculation, and blistering particularly in delicate territories, such as nasolabial fold and perioral range. Trichloroacetic acid 50% and glycolic acid 70% can cause blistering . To avoid this complication, the nasolabial folds, internal canthus of the eye, and corners of the mouth should be protected with petroleum jelly (Nikalji et al. 2012).

It normally occurs in the infraorbital region in some patients, being an uncommon complication of chemical peelings. It is strongly associated with severe edema after peels, with patients that have cutaneous atrophy or with patients with actinic damage (Tung and Rubin 2011). It vanishes spontaneously and the best prevention is to treat the swelling before ecchymosis appears, always letting the patient at risk be aware of the possibility.

Superficial telangiectasia can be adequately managed with chemical peels; however, most of them are profound and become more noticeable after a peel, since circumjacent actinic changes and pigmentatio n are removed with the peel. Advising patients this can occur anticipates surprises.

If they are still disturbed about it, intense pulsed light, electrosurgery, or vascular lasers can be used to clear the telangiectasia (Tung and Rubin 2011). Patients already with telangiectasias might notice worsening after phenol peeling (Gadelha and Costa 2009).

A herpes recurrence can occur after the injury induced by a chemical peeling, so the patient must be asked about herpes simplex outbreaks. The onset of the herpes eruption might vary from 5 to 12 days or even longer (Gadelha and Costa 2009). Since there is not a fully formed epidermis because of the peel, the herpes lesions are not vesicular, but they appear as exulcerations and often ulceration, with 2 to 3 mm, round shaped, isolated or in areas with extensive confluent erythema on the base. The treatment is acyclovir (400 mg 4–5×/day) or valacyclovir (500 mg 3×/day) (Spira et al. 1974). The prophylactic treatment is oral acyclovir (200–400 mg 3×/day) or valacyclovir (500 mg 2×/day) beginning 2–3 days before the procedure and completing 14 days after it (Nikalji et al. 2012). The treatment aim is to avoid scarring, although herpes infections normally resolve without scarring (Gadelha and Costa 2009; Tung and Rubin 2011). Lasting lesions should be cultured and treated with broad-spectrum antibiotics since it is hard to differentiate impetigo and herpetic infection during the healing period of a peel.