Clinics in Dermatology (2008) 26, 209218

Superficial and medium-depth chemical peels

Eileen Clark, MD, Lawrence Scerri, MD
Department of Dermatology, University of Malta, Sir Paul Boffa Hospital, Floriana, Malta

Abstract The use of chemicals for facial rejuvenation has been explored since ancient times. A sound knowledge of skin anatomy and wound healing is important for understanding the principles of chemical peeling. Chemical peels are classified according to the depth of skin resurfacing produced. The main clinical indications in the cosmetic field are photoaging, dyschromias, and acne scars, which are classified according to the histologic depth of the clinical changes. Proper patient selection, skin priming, and postpeel care are of utmost importance in ensuring a satisfactory outcome. Chemical peels are combined with other rejuvenating treatments for best results in photoaging. 2008 Elsevier Inc. All rights reserved.

Introduction
Facial resurfacing techniques are used for the reversal of signs of skin aging and for the treatment of certain epidermal cutaneous lesions as well as scars, particularly acne scars. Various resurfacing modalities exist to suit the different skin types and associated conditions and range from superficial to deep. The main currently practiced skin resurfacing techniques are chemical peeling, classic dermabrasion, microdermabrasion, and ablative lasers. As a rule, the risk of procedure-related morbidity increases with the depth of resurfacing, although there is also an operator-dependent element. It is recommended to combine chemical peeling with other skin rejuvenating and resurfacing techniques for best overall results.

Historical aspects of skin resurfacing

The use of chemicals for facial skin softening and rejuvenation has been explored since ancient times. Chemi Corresponding author. Tel.: +356 22987127; fax: +356 22987131. E-mail address: lawrence.scerri@gov.mt (L. Scerri). 0738-081X/$ see front matter 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.clindermatol.2007.09.015

cal peeling may be the oldest cosmetic procedure performed that is still in use today. Four thousand years ago, Egyptians described a method of treating the skin with abrasive masks of alabaster particles. Cleopatra bathed in sour milk, whereas women in ancient Rome rubbed fermented grape skins from the bottom of wine barrels over their skin to enhance their beauty, unknowingly benefiting from the superficial exfoliative effects of the hydroxyl acids: lactic acid in milk and tartaric acid in grape skins. These acids are now common ingredients of many beauty products.1 Later in history, poultices containing mustard, sulfur, and limestone were used for similar purposes. Indian women mixed urine with pumice, and Turkish women singed their skin with fire to create a superficial form of exfoliation. Dermabrasion was also popularized in ancient Egypt, where physicians used sandpaper to treat scars. The evolution of chemical peeling and dermabrasion into the procedures commonly used today began in the early 20th century by cosmeticians, and formulas were closely guarded secrets. In 1905, Kromayer pioneered surgical planing, today known as dermabrasion.2 He is reported to have used rotating wheels and rasps for the treatment of keratosis, acne scars, and pigmentary disorders. In the postWorld War II era, many attempts were made to improve traumatic tattoo injuries sustained in the war, and standardized dermabrasion

210 procedures were developed in the early 1959s by Dr Kurtin,3 a physician, and Mr Noel Robbins,4 an engineer. At the turn of the 20th century, Mackee, a dermatologist, used phenol to treat acne scars.5 Scientific investigations on the use of phenol and trichloroacetic acid (TCA) peels for facial resurfacing, however, only began in the late 1950s and 1960s, and TCA peels did not really become popular until late 1980s. This was partly related to the diminished interest in the treatment of photoaging in the immediate postwar period as compared with the treatment of warrelated injuries.1 Also, earlier results of chemical peels were not uniformly good because there was no proper skin priming before the procedure, and the use of maintenance therapy posttreatment was lacking. It was not until 1972 that Baker and Gordon6 demonstrated the beneficial results achieved with phenol to a group of plastic surgeons. Plastic surgeons and dermatologists have now delineated indications and limitations of chemical peels and improved their safety and efficacy.

E. Clark, L. Scerri vertical polarity, with the disappearance of actinic keratosis and lentigines. There is a thinner, more compact stratum corneum, associated with a thicker, acanthotic epidermis without atypia and with a uniform dispersion of melanin. New collagen and glycosaminoglycan deposition in the dermis is also stimulated to give a tighter and firmer appearance to the skin. Dermal regeneration is a slower process, but it is usually complete within several months.8,9

Definition and classification of chemical peels

Chemical peeling is the process of applying chemicals to the skin to destroy the outer damaged layers, thus accelerating the normal process of exfoliation. Different agents have different depths of penetration, and therefore, chemical peels can be divided into 4 different groups based on the histologic level of necrosis that they cause10: 1. Very superficial (exfoliation): destruction of the stratum corneum without creating a wound below the stratum granulosum; 2. Superficial (epidermal): destruction of part or all of the epidermis, anywhere from the stratum granulosum to the basal cell layer; 3. Medium (papillary dermal): destruction of the epidermis and part or all of the papillary dermis; and 4. Deep (reticular dermal): destruction of the epidermis and papillary dermis, extending into the reticular dermis. This classification helps predict which skin abnormalities will be corrected by the particular chemical peel according to the histologic level of the peel. It also helps predict the effect the peel will have on a patient's lifestyle. A very superficial exfoliation does not hinder the patient's lifestyle, but a medium depth peel will cause erythema, edema, and pigmentation for about a week after the procedure. The associated risks of complications can also be predicted because these increase with the depth of the peel.

Chemical peels
Skin anatomy
A sound knowledge of skin anatomy and normal wound healing is important for understanding the principles of chemical peeling. The skin covers the entire external surface of the body, and its functions include protection, sensory perception, immunologic surveillance, thermoregulation, and control of insensible fluid loss. The skin is composed of the epidermis and dermis, which lie on the subcutaneous fat layer. Because the epidermis is devoid of blood vessels, it depends on the dermis for its nutritive supply and removal of waste through the dermoepidermal junction. The function of the dermis is primarily to sustain and support the epidermis. Epidermal appendages, including sebaceous glands, sweat glands, apocrine glands, and hair follicles, develop as downward growths from the epidermis deep into the dermis. They are lined with epithelial cells that have the potential for division and differentiation. They are therefore an important source of cells for re-epithelialization when the overlying epidermis is destroyed. Such destruction of the epidermis may occur in partial-thickness burns and traumatic abrasions; iatrogenically in chemical peeling, dermabrasion, and other skin resurfacing techniques; or in split-thickness skin graft harvesting. The face has a particular ability to reepithelialize deep cutaneous wounds because it has a very high concentration of sebaceous glands, which can also be found in the subcutaneous fat layer.7 The regeneration of the epidermis from the epidermal appendages located in the remaining dermis begins within 24 hours of wounding, and it is usually complete in 7 to 10 days. The new epidermis shows greater organization and

Clinical indications for chemical peels in the cosmetic field

Dyschromias and wrinkles are the major clinical indications for facial chemical peeling. Most wrinkles and dyschromias are due to photodamage combined with the normal aging process of the skin. Photoaging The term photoaging refers to the skin changes that are associated with chronic UV light exposure. The clinical signs of photodamaged skin include markedly increased skin roughness, mottled hyperpigmentation, loss of elasticity, wrinkling, and the development of solar lentigines and actinic keratosis. The histologic changes in the epidermis of

Superficial and medium-depth chemical peels photoaged skin are thickened stratum corneum with a thinner atrophic epidermis, epidermal atypia, and irregular dispersion of melanin. Epidermal dysplasia corresponds to the development of actinic keratosis and may result in the growth of basal or squamous cell carcinomas. In the dermis, glycosaminoglycans are decreased, and the elastic fibers degenerate. Collagen is also lost, and the relative proportion of Type I to Type III collagen is reduced.1,11 Dyschromias and wrinkles Dyschromias include ephelides (freckles), lentigines simplex, senile lentigines, flat seborrheic keratoses, nevi, melasma, and postinflammatory hyperpigmentation.12 Wrinkles may be divided according to severity.13 Fine wrinkles or crinkles are presumably due to thinning of the epidermis and upper dermis, creating a cigarette paper type of tissue, and often appear as crosshatched lines. Musclerelated wrinkles are caused by repetitive movements that create a dent in the epidermis and most of the dermis. Accordion-pleat wrinkles are due to loose redundant skin with atrophy of the epidermis, dermis, and subcutaneous tissue, as well as loss of elasticity. Folds are due to downward sagging of the skin and underlying muscles that is caused by gravity.

211 ance and feel and also a yellowish tint of the skin. In addition, the skin of some patients has a pebbly texture and scattered open comedones. On the basis of this classification of photodamaged skin, the peel must be as deep as the deepest skin problem to achieve the best results. Chemical peels create a thinner, more compact stratum corneum, associated with a thicker, acanthotic epidermis without atypia and with a uniform dispersion of melanin. Ephelides, epidermal melasma, and epidermal hyperpigmentation respond excellently to epidermal peels, whereas senile lentigines and lentigines simplex do better with papillary dermal peels. Nevi, dermal and mixed melasma, dermal and mixed postinflammatory hyperpigmentation, and seborrheic keratoses respond poorly to superficial and medium-depth chemical peels. Because peels have the ability to create a thicker epidermis, more collagen and glycosaminoglycans in the papillary and reticular dermis, and more elastic staining fibers in the dermis, they bring about an increased volume of tissue, which tightens the superficial skin layers, leading to an improvement of wrinkles. Deeper peels result in a greater deposition of collagen and glycosaminoglycans. Therefore, lighter peels help the more superficial types of wrinkles, whereas deeper peels are needed to improve deep lines. The overall results of chemical peels depend mostly on the histologic depth of the lesions. For instance, if a patient has dyschromia located in the epidermis and fine wrinkling due to papillary dermal atrophy and damage, a peel is needed that corrects papillary damage to obtain the best results because an epidermal peel will improve only the dyschromias with little or no effect on wrinkling.

Classification of photodamaged skin 14

The classification of photodamaged skin by Rubin14 is based on the histologic depth of visible clinical changes, making the choice of the appropriate type of depth specific treatment easier. It also helps predict the morbidity associated with the treatment program and the complications risk level. Level 1 Clinical signs are due to alterations in the epidermis only. Most abnormalities are of pigmentation and texture, including freckles, lentigines, and a dull rough skin texture due to the increased thickness of the stratum corneum. Level 2 Clinical signs are due to the epidermis and papillary dermis and are also often related to abnormal pigmentation. Textural and pigmentary changes are more marked than in level 1. These patients may have actinic keratosis, liver spots (senile lentigines or flat seborrheic keratosis), and a definite increase in wrinkling. The increased wrinkling is usually seen in the infraorbital areas and lateral to the nasolabial groove, where the skin may appear atrophic and crinkled. Level 3 Clinical signs are due to alterations in the epidermis, papillary dermis, and reticular dermis. The most severe form of photodamage, level 3 is associated with many of the clinical changes seen in levels 1 and 2. These patients, however, also have marked wrinkling usually associated with a thickened leathery appear-

Techniques of application of chemical peels

Patient selection
The success of a chemical peel depends on a careful selection of patients and individualization of the treatment. Skin texture, thickness, degree of photoaging, severity of facial rhytids, and age-related gravitational changes must all be considered. Extent of skin damage As a rule, patients with mild facial rhytids and/or minimal dyschromias are the best candidates for superficial to medium-depth chemical peels. Deep rhytids and excessive facial skin are likely to respond best to traditional rhytidectomy. Some patients may benefit from both procedures because excess skin is removed by rhytidectomy, whereas the quality of the skin is addressed by the chemical peel. A minimum of 3 months is recommended between the 2 procedures to allow for complete wound healing, however. Patients' expectations should be discussed so that the extent

212 to which the facial lesions and/or photoaging will be enhanced by the procedures is understood.1 Complexion Evaluation of skin type and complexion is very important to determine which chemical peels would be suitable for the patient and which patients are at greater risk of pigmentation abnormalities complicating the peels. The Fitzpatrick classification of skin types (I-VI) is often used. It refers to the ability of skin to acquire a tan or burn after UV light exposure.15 Skin types I to III do not usually develop postinflammatory hyperpigmentation, and patients with these skin types are therefore excellent candidates for undergoing chemical peels. Patients with skin types IV to VI have a much higher risk of hypo- or hyperpigmentation complications.1 Patient's lifestyle7 The patient's lifestyle should always be considered. Compliance with pre- and postpeel treatment must be assured. The patient must be motivated enough to stick to a daily regimen for a few weeks before and after the procedure. The patient must also be able to put up with the erythema and scaling that occur after a peel. Early sun exposure has to be avoided after a peel, and outdoor occupations may therefore make a patient unsuitable for chemical peeling. Sex7 Men often have thicker and oilier skins as compared with women. This might cause uneven penetration of the peeling agent. Also, men are less likely to use camouflage makeup if pigmentary complications arise. These factors might make men less optimal candidates for chemical peels. Medical history7,16 A thorough medical and drug history is very important. Medical conditions such as cardiac, hepatic, or renal disease may influence treatment decisions and the choice of peeling agents. Exogenous estrogens, oral contraceptives, and other medications may be photosensitizing and predispose patients to pigmentation complications after chemical peeling. Prior treatments such as radiation or oral isotretinoin reduce the number of epithelial appendages, causing reepithelialization to occur more slowly, increasing the risk of scarring after a chemical peel. It is advisable that at least 12 months must elapse after treatment with isotretinoin before proceeding with a chemical peel. This will ensure some regeneration of epithelial appendages and reduce the risk of complications. A history of herpes simplex requires antiviral prophylaxis from the immediate prepeel period until re-epithelialization is complete. Some dermatologists advise prophylaxis in all patients to avoid the risks of a herpetic outbreak. Any existing lesion must heal completely before undergoing a chemical peel.

E. Clark, L. Scerri Therefore, although the technique of chemical peeling might be relatively simple, great care must be taken for proper patient and peeling agent selection to minimize the risks of complications.

Preprocedure care
Preconditioning or priming of the skin is very important to improve peel results and reduce the risk of complications. The more the pigment and the darker the complexion the longer, the preconditioning treatment should be continued before a chemical peel. A minimum period of 2 weeks is important to sufficiently prime a patient. Fulton and Porum17 suggest a step-by-step skin rejuvenation program. It is suggested that minor photoaging is reversed first with avoidance of free-radical generators, such as cigarette smoke and UV light exposure. A daily skin care regimen is then used, which produces a slight skin peeling once a week. Avoidance of unprotected sun exposure for at least 2 months before and after treatment is advised, and a broad-spectrum sunscreen must be used. -Hydroxy acids18-20 -Hydroxy acids (AHAs) are a group of organic acids derived from fruits and therefore often referred to as fruit acids. They include glycolic acid from sugar cane, citric acid from citrus fruits, and malic acid from apples, and are now manufactured in laboratories. -Hydroxy acids cause a superficial exfoliation by keratinocyte dyscohesion (ungluing) of pathologically sticky cells at the level of the stratum granulosum in the epidermis. This allows the pathologic cells to become loose and shed and therefore helps to correct an abnormally thickened stratum corneum. This effect lasts for up to 14 days after cessation of therapy. Also, the daily use of AHAs increases the epidermal thickness. In the dermis, there is an increase in the deposition of collagen and glycosaminoglycans, resulting in increased dermal thickness. -Hydroxy acids are especially good for priming patients who have a very sensitive skin, a ruddy complexion, telangiectasias, or severe sun exposure. Retinoic acid21,22 Retinoic acid is commonly used either alone or in combination with AHAs or other ingredients. It causes thinning and compaction of the stratum corneum and thickening of the epidermis. It also improves dyschromias by dispersing melanin throughout the epidermis and reverses keratinocyte atypia, thus improving or eradicating actinic keratosis. In the dermis, there is stimulation of collagen deposition and capillary arborization. These effects result in an improved skin texture; improvement of superficial dyschromias; and a pinker, rosier hue of the skin. Photosensitivity is, however, associated with this product, and patients must avoid excessive sunlight during its use.

Superficial and medium-depth chemical peels Because AHAs and retinoic acid have different modes of action, with retinoic acid acting mainly on the stratum corneum, whereas AHAs act mainly on the stratum granulosum, they are often used in combination, especially in patients with thick, oily skin. Reducing wound healing time The use of retinoic acid and AHAs accelerates the skin turnover from the normal 28 days to 10 to 12 days. Facial re-epithelialization after a 35% TCA is speeded up by about 24 hours. They are usually used for at least 4 weeks before the procedure. Achieving uniform penetration of the peeling agent23 The stratum corneum, which provides a protective barrier on the skin, varies in thickness over different areas of the face. Therefore, its ability to block the penetration of a peeling agent also varies in different areas. Thinning the stratum corneum facilitates a uniform penetration of the peeling agent. This is achieved with the use of AHAs and retinoic acid. Decreasing the risk of postinflammatory hyperpigmentation23 Chemical peels may induce postinflammatory hyperpigmentation. Because retinoic acid and glycolic acid enhance the dispersion of melanin granules through the epidermis, they have a skin-lightening effect and are therefore helpful in reducing the incidence of postinflammatory hyperpigmentation. Other bleaching agents such as hydroquinone, and kojic acid, inhibit tyrosinase. This blocks the conversion of tyrosine to L-dopa and may decrease skin's ability to produce melanin, therefore decreasing the risk of hyperpigmentation. They are usually started about 2 weeks before the peel and continued for 2 or 3 months after the peel. Azelaic acid is also used as a bleaching agent, but it is less effective and more irritating to many patients. The use of bleaching agents is especially important in patients undergoing peels to improve hyperpigmentation and in those who have a great risk of developing postinflammatory hyperpigmentation. Preparation for postpeel maintenance regimen23 Maintenance therapy after a peel is important to achieve and maintain best results. This usually involves the use of retinoic acid, bleaching agents, and sunscreens. It is important that the patient is started on the products to be used after the peel before the procedure is performed, so that any temporary sensitivity reaction of the products in the immediate postpeel days, occurring because the skin is more sensitive during this time, may be differentiated from a specific allergic reaction to the product. Skin cleansing The patient should thoroughly cleanse the face with nonresidue soap the day before the peel and should not apply makeup or moisturizers. Immediately before starting the

213 procedure, the skin is cleansed to remove any remaining traces of makeup or oils, using ether, acetone, or isopropyl alcohol. Cleansing the skin before a chemical peel is of utmost importance to prevent uneven penetration of the peeling agent.

Postoperative care
The healing process after a chemical peel must be as rapid as possible so as to avoid infections with bacteria, including Pseudomonas, yeasts such as Candida, or viruses such as herpes. Infections may deepen the wounds, extending the peel from superficial to a deep peel, with the concomitant risks of scaring. Deep peels may be prophylactically treated with antimicrobials, but more superficial peels are simply kept moist with the application of petrolatum-based products. After re-epithelialization, and when skin appearance is back to normal, a regime of AHAs, retinoic acid, bleaching creams, moisturizers, and sunscreens should be restarted. Sun exposure must be avoided for 6 weeks after the peel to minimize the risks of postinflammatory hyperpigmentation.

Classification of peeling agents 24

Peeling agents are classified according to the depth of peel they cause. Many variables can alter the depth of peeling a chemical agent can cause, including the following: 1. The nature and concentration of the peeling agent; 2. The number of coats applied/length of time the agent is in contact with the skin; 3. Technique of application (painted or rubbed in); 4. Priming of the skin in the weeks preceding the peel; 5. Cleansing and degreasing the skin before the peel; 6. Type of patient's skin; and 7. Anatomical location of the peel. It is therefore very important to standardize peeling procedures by treating all patients in a similar manner, using same skin priming and cleansing procedures before peeling and similar techniques of application of the peeling agent. Peeling agents can be classified as follows. Very superficial agents include the following: Glycolic acid, 30% to 50%, applied briefly (1 to 2 minutes); Jessner solution, applied in 1 to 3 coats; Low-concentration resorcinol, 20% to 30%, applied briefly (5 to 10 minutes); and TCA 10%, applied in 1 coat. Superficial agents include the following: glycolic acid, 50% to 70%, applied for a variable time (2 to 20 minutes); Jessner solution, applied in 4 to 10 coats;

214 Resorcinol, 40% to 50%, applied for 30 to 60 minutes; and TCA, 10% to 30%. Medium-depth agents include the following: Glycolic acid 70%, applied for a variable time (3 to 30 minutes); TCA, 35% to 50%; and Augmented TCA (carbon dioxide plus TCA 35%; Jessner solution plus TCA 35%; glycolic acid 70% plus TCA 35%). Deep agents include the following: Phenol 88% and Baker-Gordon phenol formula.

E. Clark, L. Scerri Different patients may require different number of coats to achieve the same level of peel. This is because penetration of the solution depends on a number of factors, including the preparation of the skin, the thickness of the corneum, and the sensitivity of the skin. Four to 6 minutes should be allowed after application of a coat of the solution to evaluate the full skin reaction to the solution. During the healing phase, it is important for the patient to use a bland moisturizer to relieve the tight, masklike feel of the skin. A mild topical steroid may be applied if there is persistent stinging or sensitivity. Makeup may be used in the healing phase, but scrubs, masks, astringents, toners, or retinoic acid and AHAs may only be applied after 48 hours after the peel has healed. The advantages of Jessner solution are that the peel is very superficial and safe and rarely goes deeper than one would expect. A fairly uniform peel is created, and there is a significant amount of exfoliation, which is ideal for treating dyschromias. Concentration of resorcinol is low, and therefore, there is a very low risk of resorcinol toxicity. Disadvantages include erythema and discoloration, which are associated with this peel and which may be quite difficult to cover up with makeup. Complications, including allergic reactions, are very rare. Toxicity to salicylic acid only occurs if the area being treated is very large, such as when treating the face, chest, arms, and lower legs simultaneously. Infections are very rare because the peel is only intraepidermal. Erythema may complicate Jessner peels, but it is always self-limiting. This can be treated with a mild topical steroid and emollients.

Specific chemical peels

Jessner peels 25
Jessner solution is used for light peels alone or in preparation for a TCA peel. The preparation is made from salicylic acid, 14 g; resorcinol, 14 g; lactic acid (85%), 14 g; and ethanol to 100 mL. Its shelf life is 2 years if the container is opened only for 5 minutes every month, and it darkens with age and exposure to light and air. The solution is applied to the skin with a soft applicator in patients with thin sensitive skin or rubbed in with gauze squares in patients with thick sebaceous skin. The depth of the peel depends on the number of coats of solution applied. A very superficial Jessner peel results in faint erythema, which may be associated with a light powdery-looking whitening of the skin surface. This is not frosting (coagulation) but probably simply the precipitation of chemicals on the skin and can be easily wiped off. This level of peel (level 1) created with 1 to 3 coats of Jessner solution is very superficial and only causes mild flaking of the skin for 1 or 2 days or none at all. A level 2 peel is created with the application of more (4-10) coats of the solution. There is increased erythema and some pinpoints of true white frosting. There is mild to moderate burning and stinging, which lasts for 15 to 30 minutes. In the next 1 to 3 days, a mild red-brown discoloration develops, and the skin feels tight. Exfoliation then follows for 2 to 4 days, with moderate flaking but rarely actual peeling. Further coats of Jessner solution create a level 3 peel, where there is prominent erythema and increased areas of frosting associated with a moderate amount of stinging. At this level, exfoliation usually lasts 8 to 10 days, and there might be actual peeling apart from the dry flaking of the skin. Crusting and weeping does not occur, however, because it is still an intraepidermal peel.

Glycolic acid peels 26

Glycolic acid is the most commonly used AHA as a peeling agent. Its natural source is sugar cane, but it is manufactured in the laboratory for use as a chemical peel. It can be used as a daily skin care product in low concentrations of 5% to 15%. Greater concentrations of 30% to 70% are used for chemical peels. The higher the concentration, the deeper the peel they produce. -Hydroxy acid peels are used commonly for several reasons. They are systemically safe and nontoxic and produce superficial peels capable of significant effects but with few complications. They are also well tolerated by patients. All AHA peels need to be neutralized to terminate their action on the skin when the desired depth of wounding has been achieved. Neutralization is best affected by applying an alkaline solution such as sodium bicarbonate, which causes a lot of fizzing on the face. Other neutralizing agents do not cause such fizzing. Washing the face with water is also good but may not remove all the glycolic acid. Therefore, the depth of a glycolic acid peel depends on the strength of the glycolic acid and the length of time this is left on the skin neutralized. Seventy percent free glycolic acid left on the skin for 15 minutes causes a

Superficial and medium-depth chemical peels dermal wound as deep as 40% TCA. For this reason, it is safer to start with 50% glycolic acid, which can be left on the skin longer. Preparations of glycolic acid that have a lower pH create more burning, stinging, irritation, and erythema and are therefore less tolerated by patients than preparations with a higher pH. Also, preparations with a lower pH may penetrate the skin more unevenly, causing areas of accidental deeper peeling. The depth of the peel may also be affected by the sensitivity of the skin, excessive priming of the skin, and any recent wounding of the skin. When applying a glycolic acid peel, a few precautions should be taken. Firstly, the neutralizing agent must be ready at hand. Application of the acid to the whole face should be done rapidly so that different parts of the face would not be exposed to the acid for different periods. It is also advisable to start the peel from the forehead because this area can tolerate a slightly longer period in contact with the acid. Once the whole face has been treated, one should watch out for areas of erythema or epidermolysis because these must be neutralized immediately. Some areas of the face may absorb the acid faster. These include areas such as the alar groove, nasolabial fold, lateral canthus, oral commissures, and just inferior to them on the chin. Reasons for this increased sensitivity are a thinner stratum corneum or underlying xerosis. It is therefore advisable to protect these vulnerable areas with a thin smear of petrolatum before the chemical peel application. A fan may be used during the procedure to alleviate the mild stinging or burning discomfort associated with this procedure. As time passes, the depth of the glycolic acid peel increases, and this can be seen clinically as the skin becomes pink first, changing to red, signifying intraepidermal wounding. Gray-white coloring and vesiculation occur with epidermolysis or separation of the epidermis from the dermis and hydration. Frosting signifies dermal injury. The depth of the peel performed depends on what lesions are being treated. Therefore, only superficial epidermal necrosis may be required to treat some patches of hyperpigmentation, although one must be careful because it might make postinflammatory hyperpigmentation worse. For significant improvement of wrinkling, one needs to create epidermal necrosis and dermal inflammation. Healing takes around 5 to 7 days, and there is crusting during this time. The deeper the peel, however, the larger is the risk of complications. For postpeel care, a bland emollient applied often during the day is all that it is usually needed. The normal maintenance regimen of AHAs should be started again when skin sensitivity and appearance are back to normal. Glycolic acid peels may be repeated as often as there is evidence of additional improvement with each peel. A few weeks must elapse before repeating the peel to allow for resolution of any dermal inflammation that may have occurred.

215 Glycolic acid peels can be applied to other sun-damaged areas including the neck, chest, and dorsum of the hands. There is an improvement of mottled hyperpigmentation and fine wrinkling, but significant wrinkling and dark pigmentation are usually resistant to the treatment. Peels should be superficial in nonfacial areas to avoid scarring.

Trichloroacetic acid peels 1,27,28

Trichloroacetic acid can be used to create superficial, medium, or deep peels. Apart from variables such as patient's skin type, adequacy of skin priming, layers of acid applied, and technique of application, the most important factor affecting the depth of the peel is the concentration of TCA used. Concentrations of 10% to 25% are used for intraepidermal peels, whereas 30% to 40% are used for papillary dermal peeling. It is most commonly used for medium-depth peels, especially to treat pigmentation disorders and early facial rhytids. The skin is prepared and cleansed as for other peels. Trichloroacetic acid is applied using cotton tipped applicators or gauze sponges, with the patient best seated with the head elevated at 45 for comfort and to avoid pooling of acid. Special attention should be paid around wrinkles, so that the acid gets to the bottom of the wrinkles. Overlap of coats should be avoided to prevent deep wounding. The peel should be carried through the eyebrows and also a little beyond the hairline and below the jawline. The depth of the peel can be judged from the appearance of the skin. Trichloroacetic acid is a chemical cauterant that coagulates proteins in the skin. A very light application produces minimal erythema, and this corresponds to a very superficial peel removing mostly the stratum corneum. A superficial epidermal peel is created when the skin shows some erythema with irregular patches of light frosting. This should heal after 2 to 4 days of light flaking. Uniform white frost on a background of erythema signifies a full-thickness epidermal peel that heals after about 5 days. When no erythema shows through a solid white frost, it is assumed that the peel has extended to the papillary dermis, and this takes up to 7 days to heal. A cream or ointment with 1% hydrocortisone may be applied immediately after the procedure to soothe the skin. During the healing phase, great care should be taken of the skin. In the healing phase, sun exposure must be avoided. Heavy exercise and sweating must also be avoided, and the face should not be unnecessarily touched. Peeling usually starts after about 2 days around the perioral region and continues from the central face outward, making the face unsightly for 4 to 6 days. It is important to keep the skin moist with the use of bland emollient creams or ointments during this time to avoid premature peeling. Trichloroacetic acid can also be used for nonfacial peels, but care must be taken so as not to perform dermal peels because of the risk of scarring. It may therefore be advisable to use lower TCA concentrations for nonfacial peels.

216

E. Clark, L. Scerri that is more prone to scaring. It is therefore very important to dab off any tears and immediately wash those that fall. The neck may be protected with a layer of petrolatum.

Combination peels
Combination peels are used to enhance the penetration of a low-concentration TCA, or other acids, thus minimizing the risks of scarring while the acid still penetrates as deeply as 50% TCA. The most commonly used combinations are as follows. Jessner solution and TCA (Monheit peel)29 This peel combination was popularized by Cary Monheit. After priming the skin as for other peels, 1 to 4 layers of Jessner solution are applied until there is generalized erythema with areas of light frost. Thirty-five percent TCA is then applied, which penetrates more rapidly, uniformly, and deeply than if it were applied on its own, especially if the patient's skin is thick and sebaceous. These peels can be repeated every 3 to 4 months to maintain an improvement of the fine lines of aging. Solid carbon dioxide and TCA This combination, which has been studied by Dr Hal Brody, is used to peel different areas of the skin to different extents. After priming the skin as for other peels, areas that need deeper peeling, such as wrinkles or rims of scars, are first treated with solid carbon dioxide dipped in a solution of acetone and alcohol to help it glide over the skin. The longer the time and the greater the pressure exerted when applying the solid carbon dioxide, the deeper the peel. When the burning or tingling sensation from the carbon dioxide has subsided, 35% (or other concentrations) TCA is applied to the whole face. Glycolic acid and TCA30 After normal priming of the skin, 70% glycolic acid is applied to the skin for 2 minutes without prior cleaning of the skin. Trichloroacetic acid 35% is then applied. This combination is thought to result in a more uniform and deeper peel than TCA used alone. Jessner solution and glycolic acid31 This technique was studied by Dr Larry Moy. It involves priming the skin and then applying 1 to 3 coats of Jessner solution, causing the skin to become diffusely erythematous. The skin is then treated with 70% glycolic acid. This procedure again produces a more uniform glycolic acid peel. Also, exfoliation from the use of Jessner solution is combined with the stimulatory effects of glycolic acid. It is also a risky procedure because the skin is already red from the application of Jessner solution, and it is easy to then overpeel the patient.

Premature peeling
Premature peeling predisposes the underlying skin to risks of infection, persistent erythema, postinflammatory hyperpigmentation, and scarring. It may occur accidentally or may be the result of picking at the peeling skin. If nonreepithelialized tissue (moist looking) is exposed, patients should be started on regimens of oral antibiotics until reepithelialization occurs. Aggressive wound care management may include the use of topical antibiotics and hydrocolloid dressings. Topical steroid ointment or cream is used if epithelialized bright red skin is exposed on premature peeling.

Infection
Infections occur more commonly with deep peels and deepen the peels, thus increasing the risk of scarring. Common bacterial pathogens include staphylococci and streptococci. Pseudomonas and nitrobacteria infections also occur. Infections are treated with topical and oral antibiotics. Topical ointments are applied frequently to help keep the wound moist and enhance healing. Herpetic outbreaks may occur, usually starting on the lip or above the vermilion border. They usually present as painful erosions, and outbreaks are prevented with the use of prophylactic oral acyclovir. Thrush may also occur along the lips and oral mucosa and may be treated with oral itraconazole or fluconazole.

Acneform eruptions
These may occur during or just after the peeling phase and present as multiple tender erythematous follicular papules. They respond to the oral antibiotics used in the treatment of acne such as tetracycline, minocycline, or erythromycin.

Postinflammatory hyperpigmentation
Postinflammatory hyperpigmentation occurs more frequently in patients with dark complexion. It may develop very soon after the peel or months later, and it is often the result of early sun exposure after the peel. Sun avoidance and the daily use of sunscreen are very important for its treatment. Oral contraceptives may exacerbate hyperpigmentation, and if possible, they should not be used during the peripeel period. Epidermal postinflammatory hyperpigmentation responds well to various treatments, whereas dermal hyperpigmentation, not so well. Bleaching agents such as hydroquinone and kojic acid may be used to gradually lighten the pigmentation, especially in combination with retinoic acid or AHAs, which cause the shedding of the

Complications 1,16
Tears
Tears coming down the cheek can dilute the acid applied on the cheek and drip onto the neck, causing a peel in an area

Superficial and medium-depth chemical peels epidermis. Light peels that do not create inflammation, such as 10% TCA, Jessner solution, or 50% to 70% glycolic acid may be used to treat postinflammatory hyperpigmentation.

217 peels in experienced hands still render this resurfacing modality an attractive option, although considerable time has passed since the first peels appeared on the market and in spite of the development of more modern rejuvenating techniques. It is, however, recommended to combine chemical peels with other rejuvenating techniques to achieve the best end result and patient satisfaction. The deep peels are somewhat less popular nowadays because of the associated prolonged downtime and increased risk of complications.

Hypopigmentation
Peels that cause exfoliation lighten the skin because of the shedding of cells containing melanin. In deep peels where the entire epidermis is removed, new melanocytes migrate to the epidermis from the hair follicles, and this takes 2 to 3 months. With reticular peels, some areas of permanent hypopigmentation frequently result because of the destruction of melanocytes in the hair follicles. Most patients with this problem require cosmetics to camouflage the affected areas.

References
1. Mendelsohn JE. Update on chemical peels. Otolaryngol Clin North Am 2002;35:55-72. 2. Cortez EA. Chemical face peeling. Otolaryngol Clin North Am 1990; 23:947. 3. Kurtin A. Corrective surgical planning of the skin. Arch Dermatol Syph 1953:389-95. 4. Robbins N. Dr Abner Kurtin, Father of ambulatory dermabrasion. J Dermatol Surg Oncol 1988;14:425-31. 5. Baker TJ, Stuzin JM, Baker TM. Facial skin resurfacing. St. Louis (MO): Quality Medical Publishing; 1998. 6. Baker TJ, Gordon HL. The ablation of rhytids by chemical means: a preliminary report. J Fla Med Assoc 1961;48:451. 7. Revis DR, Seagle MB. Skin resurfacing: chemical peels; 2005. Available at URL: http://www.emedicine.com/ent/topic625.htm. 8. Burris LM, Roenigk HH. Chemical peels as a treatment for skin damage from excessive sun exposure. Dermatol Nurs 1997;9:99-104. 9. Collins PS. The chemical peel. Clin Dermatol 1987;5:57-74. 10. Rubin MG. Manual of chemical peels. Philadelphia: JB Lipincot; 1992. p. 20. 11. Taylor CR, Stern RS, Leyden JJ, et al. Photoaging, photodamage and photoprotection. J Am Acad Dermatol 1990;22:1-15. 12. Rubin MG. Manual of chemical peels. Philadelphia: JB Lipincot; 1992. p. 9. 13. Rubin MG. Manual of chemical peels. Philadelphia: JB Lipincot; 1992. p. 14. 14. Rubin MG. Manual of chemical peels. Philadelphia: JB Lipincot; 1992. p. 5. 15. Fitzpatrick TB. The validity and practicality of sun reactive types I through VI. Arch Dermatol 1998;124:869-75. 16. Deborshi R. Ablative facial resurfacing. Dermatol Clin 2005;23: 549-60. 17. Fulton JE, Porumb S. Chemical peelstheir place within the range of resurfacing techniques. Am J Clin Dermatol 2004;5:179-87. 18. Elson M. The utilization of glycolic acid in photoaging. Cosmet Dermatol 1992;5:12-5. 19. Van Scott EJ, Yu RJ. Hyperkeratinization, corneocyte cohesion and alpha hydroxyl acids. J Am Acad Dermatol 1984;11:867-79. 20. Van Scott EJ, Yu RJ. Alpha hydroxy acids: procedures for use in clinical practice. Cutis 1989;43:222-8. 21. Ellis CN, Weiss JS, Hamilton TA, et al. Sustained improvement with prolonged topical tretinoin (retinoic acid) for photoaged skin. J Am Acad Dermatol 1990;23:629-37. 22. Gardner S, Weiss J. Clinical features of photodamage and treatment with topical tretinoin. J Dermatol Surg Oncol 1990;16:925-31. 23. Rubin MG. Manual of chemical peels. Philadelphia: JB Lipincot; 1992. p. 45-7. 24. Rubin MG. Manual of chemical peels. Philadelphia: JB Lipincot; 1992. p. 21-2. 25. Rubin MG. Manual of chemical peels. Philadelphia: JB Lipincot; 1992. p. 79-88.

Persistent erythema
Although erythema is common and quite normal after any peel, patches of erythema persisting for more than 3 weeks may be a sign of developing hypertrophic scars and are best treated with a class 1 potent topical corticosteroid. Pulsed dye laser may also be used, but it is more expensive and leaves unsightly purpura lasting up to 3 weeks.

Scarring
Although uncommon, there is an increased risk of scarring in certain patients. These include those with a known history of poor healing and keloid formation, patients undergoing deep peels or a second peel very soon after a previous peel or surgery without waiting for adequately skin healing, patients who have been previously treated with isotretinoin especially in the previous year, and patients who develop an infection during the peel. Scarring may take different forms. It may develop as hypopigmented, flat, shiny, sheetlike areas. There may also be atrophic scars, hypertrophic scars, or keloid formation. Hypertrophic scars occur most commonly along the mandibular border and in the perioral region. Most scars are secondary to other complications such as infection or premature peeling, and therefore, a careful monitoring of the patient in the postpeel phase is very important for early detection and treatment of such complications. At least 1 year should have elapsed after the use of isotretinoin before any peel is attempted. Hypertrophic scars and keloids are best treated with potent corticosteroids topically or intralesionally. Close follow-up is necessary. Resistant scars may be treated with dermabrasion or pulsed dye laser followed by compressive silicone sheeting therapy.

Conclusions
The largely predictable outcome and the favorable riskbenefit ratio of superficial to medium-depth chemical

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26. Rubin MG. Manual of chemical peels. Philadelphia: JB Lipincot; 1992. p. 89-102. 27. Dinner MI, Artz JS. The art of trichloroacetic acid chemical peel. Clin Plast Surg 1998;25:53-62. 28. Rubin MG. Manual of chemical peels. Philadelphia: JB Lipincot; 1992. p. 110-25.

E. Clark, L. Scerri
29. Monheit GD. The Jessner's and TCA peel: a medium-depth chemical peel. J Dermatol Surg Oncol 1989;15:945-50. 30. Coleman WP, Futrell IM. The glycolic acidtrichloroacetic acid peel. J Dermatol Surg Oncol 1994;20:76-80. 31. Rubin MG. Manual of chemical peels. Philadelphia: JB Lipincot; 1992. p. 130-53.