Completion of desquamation usually develops as edema resolves and may take from 4 to 7 days.⁶ Deep peeling may take as long as 14 days to heal well enough to accept the application of makeup. Up until about the 10- to 14-day stage in the healing process, skin care maintenance and cleaning are imperative to remove sloughed necrotic epidermis to prevent an infectious process. An infection could convert the peel into a deeper burn and, as a result, potential scarring.

After a week, full re-epithelialization is generally complete in more superficial peels, but may take 10 to 14 days in deeper peels. The skin may still be pink for several weeks postpeel. This may last even longer in fair-skinned individuals.⁶

28.2 Preprocedural and Intraprocedural Considerations of Chemexfoliation

TCA concentrations should be measured weight by volume.⁷ TCA is not sensitive to light and is stable on the shelf for more than 6 months.⁸ Dates of mixing should be accurately scribed on stored bottles. GA and Jessner’s Solution (14% resorcinol, 14% lactic acid, and 14% salicylic acid, in an alcohol base) will lose their potency more rapidly than TCA.⁷

Phenol, an aromatic hydrocarbon, is stable if stored in a dark, glass bottle away from the light. Because it is systemically absorbed through the skin and thought to be potentially toxic to the liver, kidneys, and myocardium, careful handling is critical. For phenol peeling, we use the formula as described in Baker’s 1962 publication, with the exception that we use distilled water rather than tap water⁹ (phenol United States Pharmacopeia [USP] 88%, 3 mL; distilled water, 2 mL; croton oil, 3 drops; Septisol soap [Sandent Co., Murfreesboro, Tennessee], 8 drops). It is the senior author’s practice to mix the solution just prior to the procedure. Phenol in high concentrations will cause precipitation of protein in the keratin layer. This keratocoagulation may slow or prevent additional penetration of the peel affecting the overall outcome.⁶

28.3 Complications and Side Effects of Superficial Chemexfoliation

The popularity of superficial and medium-depth peeling is partly attributed to their safety margins, although they do share a similar general complication profile with deep peeling. Scarring is extremely rare with superficial peels and these lower potency agents typically cause mild and transitory side effects.

Glycolic acid can be utilized at varying concentrations (20–70%). It is capable of causing dermal wounds in higher concentrations (70%) in thin-skinned individuals. Penetration can be variable especially in thicker skin, and reduced concentrations may result in a less uniform outcome.³ Whereas some patients receive excellent results, others do not; GA peels often require repeated application for optimum improvement.¹⁰ The side effect of intense erythema may occur with high-strength peeling in thin-skinned, fair-complexioned individuals.

Pyruvic acid (40–70%) is an alpha keto acid that may be an effective treatment for mild-to-moderate photoaging or active acne.¹¹ Although generally safe and effective, it can cause an intense stinging and burning sensation during application. Furthermore, powerful vapors can irritate the respiratory mucosa.³

Salicylic acid is a mild beta hydroxy acid used for general skin maintenance as well as controlling acne. In the early 1980s, Shalita demonstrated in a randomized double-blind trial that repeated low concentrations helped resolve inflammatory skin conditions.¹¹ Salicylic acid can be utilized in various concentrations typically up to 30%. Mild discomfort, burning, irritation, and erythema are quite common but the incidence of major side effects is very low.¹² The predominant risk with this superficial peeling agent is allergic reaction due to salicylate hypersensitivity.¹³ Generally, this is a very well-tolerated peel, although the physician should be aware of the rare likelihood of systemic salicylate toxicity.

Jessner’s Solution is considered a superficial peeling formula and typically reaches a depth to the upper papillary dermis. The mixture contains lactic acid, salicylic acid, and resorcinol, an alcohol that is structurally similar to phenol.¹⁴ The solution has been in use for more than 100 years as a therapeutic agent to treat hyperkeratotic epidermal lesions. The current formulation was compounded by Dr. Max Jessner to lower the concentration of any one agent and therefore decrease the risk of complications while increasing the keratolytic properties.¹⁰ A modified solution replaces resorcinol with citric acid. Generally, complications are rare with either mixture, and most complaints such as irritation and streaky erythema could be considered side effects rather than true complications. However, both salicylic acid and resorcinol have the potential for systemic toxicity. Salicylism has been reported with repeated Jessner’s peels.¹⁰ In addition, persistent erythema is an infrequent side effect and may be treated with topical corticosteroid creams.¹⁰

Similar to superficial peeling agents, medium-depth TCA peels have a proven safety record. Although TCA in higher concentrations (> 45%) may on rare occasion cause scarring,¹⁴ this is much less likely with lower concentrations or TCA combinations (e.g., TCA with Jessner’s Solution or TCA with 70% GA) commonly in use.⁷ The most frequent side effect, with high concentrations, is irregular pigmentation.⁷

Hyperpigmentation is the most common, which is almost always transient. If it is distressing to the patient, we typically use a skin-bleaching treatment such as 4% hydroquinone and 2.5% hydrocortisone. Alternatively, superficial peels such as 30% salicylic acid, or GA, or repeat medium-depth peeling may normalize pigmentation. Pretreatment and posttreatment of the skin with hydroquinone help prevent pigmentation problems in susceptible individuals.

The risk for postoperative pigmentation abnormalities is higher in individuals with dark skin. Therefore, this is more likely in Fitzpatrick skin types IV through VI. We sometimes consider those patients who present with medium pigmentation and severe deep wrinkles as candidates for medium and deep peeling, if they accept the possibility of postoperative pigment changes and the subsequent need to treat this condition.

Delayed wound healing or persistent erythema may also occur. A superficial peel will typically lose erythema in 3 to 5 days, whereas a medium peel will lose erythema in 15 to 30 days.⁷ Erythema, beyond what is expected, may be the result of contact dermatitis (▶ Fig. 28.1) or re-exacerbation of a previous skin disorder. Persistent intense redness may indicate prolonged fibroplasia, which can lead to skin thickening and scarring.⁷ If the condition is suspected, topical steroids may help. If scarring occurs, intralesional steroid injection may be of aid.⁶