INTRODUCTION — Chemical peels are skin resurfacing procedures that can improve skin quality, texture, and appearance. A chemical peel involves the application of a caustic substance to the skin to induce controlled skin injury (table 1). Subsequent wound-healing processes can lead to improvements in hyperpigmentation, rhytides, acne scars, actinic keratoses, and other features (table 2).
In-depth knowledge of chemical peel techniques is essential for optimizing treatment outcomes and minimizing risk for adverse effects. Practical guidance for pretreatment, treatment, and post-treatment management is provided here. Information on the properties of specific peeling agents, contraindications to chemical peels, and the pretreatment assessment of candidates for chemical peels is provided separately. (See "Chemical peels: Principles, peeling agents, and pretreatment assessment".)
BASIC CONCEPTS — Chemical peels are relatively fast procedures that are most often performed on the head and neck for various indications (table 2). Chemical peels are also used to treat photodamage on the chest, arms, and, less often, the lower extremities. (See "Photoaging".)
Treatment may be performed on a focal area of skin or an entire region (eg, cosmetic unit or entire face (figure 1)). The wide variety of chemical peel agents, formulas, and techniques allows for control over the depth of resurfacing and the selection of an appropriate procedure for a specific indication.
The depth of skin injury a chemical peel induces is the major determinant of effect (table 2). Light chemical peels (also known as superficial chemical peels) cause injury limited to the epidermis and are primarily used for cutaneous hyperpigmentation and mild improvements in skin texture and acne. Medium-depth peels injure the epidermis and papillary dermis, allowing for improvement of features such as hyperpigmentation, actinic keratoses, superficial acne scars, and shallow wrinkles. In deep peels, injury extends from the epidermis into the reticular dermis, contributing to improvement in deeper acne scars and wrinkles. Both the specific peeling agent selected and application technique can influence the depth of peeling. (See "Chemical peels: Principles, peeling agents, and pretreatment assessment", section on 'Peel types' and "Chemical peels: Principles, peeling agents, and pretreatment assessment", section on 'Common peeling agents'.)
Prior to treatment, patients should be carefully assessed for an appropriate indication (table 2) and risk factors for adverse outcomes, such as a limited ability to adhere to important pre- and post-procedure skin care recommendations, active infection, immune-compromising medications, and body dysmorphic disorder. Body dysmorphic disorder may increase risk for dissatisfaction with expected outcomes. (See "Chemical peels: Principles, peeling agents, and pretreatment assessment", section on 'Precautions and contraindications' and "Chemical peels: Principles, peeling agents, and pretreatment assessment", section on 'Patient assessment' and "Chemical peels: Principles, peeling agents, and pretreatment assessment", section on 'Patient counseling' and "Body dysmorphic disorder: Clinical features", section on 'Cosmetic interventions'.)
In particular, compared with the face, other body sites (eg, neck, chest, dorsal hands) have increased risk for scarring following chemical peels. The increase in risk is due to a paucity of the adnexal structures necessary to support re-epithelialization. In general, these sites should be limited to light chemical peels, avoiding medium-depth and deep peels.
PREPARATION — Once a patient is deemed an appropriate candidate for a chemical peel and carefully counseled regarding the procedure, expected outcomes, and potential adverse effects, the need for preparatory interventions should be assessed, including skin preparation and antiviral prophylaxis. The need for these interventions is influenced by the type of chemical peel and patient characteristics. (See "Chemical peels: Principles, peeling agents, and pretreatment assessment".)
Skin preparation — Skin preparation regimens aim to promote even penetration of the peeling agent, optimize wound healing, and regulate melanocyte activity to minimize postinflammatory hyperpigmentation (PIH). Skin preparation is considered most important for medium-depth and deep peels because of greater risk for adverse effects compared with more superficial peels. (See 'Complications' below.)
Although many clinicians, including ourselves, use skin preparation for all chemical peels, the value of skin preparation has been questioned for light chemical peels. A retrospective study that assessed complications following 473 light chemical peels in patients with skin phototypes III to VI found similar rates of complications between patients given preparatory treatment (eg, hydroquinone, topical retinoids, alpha-hydroxy acids) and patients who did not receive this treatment (table 3) .
In contrast, skin preparation may be more important for medium-depth to deep chemical peels. The use of retinoic acid prior to a 35% trichloroacetic acid (TCA) peel (a medium-depth peel) was associated with accelerated wound healing in a split-face and split-arm, randomized trial in 16 male patients . (See 'Dyspigmentation' below.)
Regimen — Skin preparation regimens vary among clinicians but typically begin a few weeks to a few months prior to the chemical peel. Because risk for PIH increases with increasing baseline skin pigmentation, our practice is to begin skin preparation six weeks prior to the chemical peel for patients with skin phototypes I to III and 12 weeks prior to the chemical peel for skin phototypes IV to VI (table 3).
Preparatory interventions typically include strict sun protection measures (including the use of an inorganic [mineral-based] sunscreen), a topical retinoid, and topical hydroquinone. Hydroquinone is used to combat hyperpigmentation and may be eliminated from the regimen for patients with skin phototype I due to the low risk for chemical peel-induced hyperpigmentation in this population (table 3). Alpha-hydroxy acids and polyhydroxy acid lotions may also be utilized in skin preparation regimens to help thin the stratum corneum, allowing for better penetration of other topical agents and for a more even chemical peel application:
●Sun protection – Unprotected sun exposure and tanning of the skin in the treatment area may increase risk for hyperpigmentation after a chemical peel and should be avoided prior to the peel. We instruct patients to avoid unprotected sun exposure and tanning for at least six to eight weeks prior to the chemical peel. Patients should apply a broad-spectrum sunscreen with a sun protection factor (SPF) of 30 or higher to the treatment area daily, as well as use a wide-brimmed hat. We typically suggest use of inorganic sunscreens (zinc dioxide and/or titanium dioxide as active ingredient[s]). During periods of sun exposure, sunscreen should be reapplied frequently. (See "Selection of sunscreen and sun-protective measures", section on 'Selection of sunscreen products' and "Selection of sunscreen and sun-protective measures", section on 'Proper use of sunscreens'.)
●Topical retinoids – Topical retinoids thin and smoothen the stratum corneum, facilitating improved and even penetration of peeling agents and topical agents, such as hydroquinone. Retinoids also have other effects that may augment the results of chemical peels, including promotion of collagen and elastin synthesis, restoration of normal epidermal thickness and maturation, and improvement of solar elastosis. Faster wound healing after skin resurfacing has been demonstrated in patients pretreated with tretinoin [2,3].
Tretinoin (0.05 to 0.1% cream) is commonly used in skin preparation regimens. Tretinoin is applied once daily at night. Retinaldehyde 0.1% is a less irritating alternative for patients who cannot tolerate tretinoin. (See "Acne vulgaris: Overview of management", section on 'Topical retinoids'.)
●Hydroquinone – Hydroquinone is a tyrosinase inhibitor, a key enzyme in melanogenesis. Pretreatment with hydroquinone is intended to reduce risk for PIH and support improvement in conditions presenting with hyperpigmentation, such as melasma, lentigines, and ephelides. Hydroquinone 4% is typically applied twice daily. (See "Postinflammatory hyperpigmentation", section on 'Topical hydroquinone'.)
●Alpha-hydroxy acids and polyhydroxy acids – Topical alpha-hydroxy acids (eg, 6 to 8% glycolic acid) and polyhydroxy acids (eg, lactobionic acid, gluconolactone) may be added to the skin preparation regimen. We typically incorporate them for patients with acne or severe dyschromias and prescribe once-daily application. These agents exfoliate the stratum corneum, enhancing the penetration of tretinoin and hydroquinone, and may accelerate resolution of acne comedones, furthermore, by thinning the stratum corneum.
Patients should be given clear instructions to ensure proper implementation of the skin preparation regimen. For patients undergoing facial chemical peels, the entire face is typically treated. Care should be taken to include areas that are easily missed, such as the lower eyelids, hairline, jawline, and preauricular areas.
Of note, topical retinoids often induce skin irritation, particularly near the medial and lateral commissures of the eyes, oral commissures, upper eyelids, neck, and chest. Avoidance of application of retinoids near the commissures of the eyes and mouth may facilitate tolerance of topical retinoids. Less frequent (ie, once to twice weekly rather than daily) application of topical retinoids is suggested for the eyelids, neck, and chest. If skin irritation occurs, the topical retinoid can be stopped for one to two days and restarted upon improvement.
Infection prophylaxis — Infection prophylaxis typically consists of protection from reactivation of herpes simplex virus (HSV) infection.
Herpes simplex virus — Reactivation of HSV infection and spread of the infection throughout the treated area is a risk of medium-depth and deep facial resurfacing procedures and may result in scarring . Given the high prevalence of HSV infection, antiviral prophylaxis is indicated for all patients undergoing medium-depth or deep chemical peels that involve treatment of the perioral area. Antiviral prophylaxis is not typically necessary for light peels.
Regimens for prophylactic antiviral therapy vary, as documented in a 2013 review . We typically begin prophylaxis with valacyclovir the day prior to the procedure and continue for 7 days after medium-depth peels and for 14 days after deeper peels, with the intent of continuing treatment until re-epithelialization is complete. Typical dosing for valacyclovir in this setting is 500 mg twice daily .
Higher doses of valacyclovir (eg, 1 g twice per day) are utilized by some clinicians, including the author, for HSV prophylaxis in patients with multiple HSV recurrences per year, in an attempt to augment suppression given the potentially devastating consequences of HSV reactivation after a chemical peel. However, the superiority of this approach is unproven.
Some clinicians administer prophylactic treatment for herpes zoster to patients with a history of herpes zoster in the treatment area based upon concern for trauma-induced recurrence. However, recurrence of herpes zoster is less common than recurrence of HSV infection, and recurrence of herpes zoster in association with chemical peels has not been reported. (See "Epidemiology, clinical manifestations, and diagnosis of herpes zoster".)
Other infections — Prophylactic therapy for bacterial or Candida infections is not required. Some clinicians, including the author, prescribe twice-daily application of mupirocin to the nares, beginning one week prior to the chemical peel to one week after the chemical peel, in an attempt to minimize risk for Staphylococcus aureus infection. However, benefit of this approach is unproven.
Before application — Important initial interventions for all types of chemical peels include assembly of all necessary supplies, thorough skin cleansing, and provision of measures to optimize patient comfort. Additional interventions are necessary for the safe performance of phenol peels. (See 'Special precautions for phenol peels' below.)
Set up — Light and medium-depth peels are typically performed in the office setting. Deep chemical peels with phenol should be performed in a setting where cardiac monitoring, intravenous fluid administration, and perioperative advanced cardiac life support can be performed if full-face phenol peeling is planned or stronger phenol peel solutions are used. (See 'Special precautions for phenol peels' below.)
Prior to application of the peeling agent, all materials necessary for the peel should be assembled in the treatment room in a location where they are immediately accessible to the clinician. Typical supplies include:
●Acetone or 70% alcohol for skin cleansing
●Applicator (eg, cotton-tipped swab, gauze, brush)
●Peeling agent (typically poured into a glass receptacle or a small, stainless steel surgical bowl)
●Neutralizing agent for glycolic acid peels
Saline solution is appropriate for flushing the eyes for most chemical peels. We typically keep a 20 mL syringe of normal saline available. Mineral oil should be used to flush the eyes after entry of a phenol-containing peel solution. Water may increase penetration of phenol.
The patient should be positioned in a manner that allows the clinician easy access and full visibility of the entire treatment area. A surgical cap or band is used to keep hair off of the treatment area. Patients' contact lenses should be removed.
Skin cleansing — Proper cleansing of the skin promotes even penetration of the peeling agent and is crucial for optimizing outcomes of chemical peels. The goal is to remove all traces of oil or debris.
First, the patient should wash the skin with a gentle skin cleanser to remove makeup and lotions. Next, the clinician degreases the skin with either acetone or 70% alcohol. Use of acetone is preferred prior to phenol peels. A typical degreasing technique involves rubbing a 4x4 inch gauze moistened with the degreasing agent over the entire treatment area.
Comfort measures — Discomfort during light chemical peels is usually limited to a transient, mild burning sensation during application that is generally well tolerated. A small electric fan or forced-air cooling unit is helpful for reducing discomfort. Anesthesia is not typically necessary.
Medium-depth and deep chemical peels can be painful and typically require greater intervention. Oral analgesia with a nonsteroidal anti-inflammatory drug (NSAID), administration of an oral or intramuscular sedative, and use of a refrigerated forced-air cooling unit may be sufficient for medium-depth peels. Opioid analgesics may also be utilized. Intravenous sedation is an option for select patients requiring a greater degree of anesthesia, usually for patients receiving full-face phenol peels.
Topical anesthetics can hydrate the skin and accelerate penetration of peeling agents. Therefore, use of topical anesthetics should be approached with caution and reserved for clinicians experienced with chemical peels.
Special precautions for phenol peels — Systemic absorption of phenol can result in cardiac arrhythmias. Therefore, cardiac monitoring (continuous electrocardiography, blood pressure, and pulse oximetry) is indicated during phenol peels that involve peeling of more than a single cosmetic unit or more than 1% total body surface area (figure 1) . Patients with hepatic or renal insufficiency have increased risk for toxicity. (See "Chemical peels: Principles, peeling agents, and pretreatment assessment", section on 'Precautions and contraindications'.)
In addition, intravenous hydration should be administered prior to and during the procedure to minimize the concentration of phenol in serum. If only one cosmetic unit is being treated, having the patient drink 1 liter of water during the procedure can be sufficient .
Permanent hypopigmentation is a potential complication of phenol peels that is most likely to occur in individuals with skin phototypes IV to VI (table 3). Although select phenol formulations have been utilized successfully on skin phototypes IV and V, deep chemical peeling in this population should be reserved for clinicians with expertise in chemical peeling, and patients should be advised of the potential for this complication. (See 'Dyspigmentation' below.)
Application — Application of chemical peels is typically performed quickly with a cotton-tipped swab or gauze. A specialized sable or goat hair brush is an option for light chemical peels; brushes can speed application and reduce waste of the peel solution .
Sequence — Chemical peels may be applied to focal areas of skin (eg, a single scar or cosmetic unit) or to an entire region (eg, face). In some patients, achievement of the desired effect may require application of different peels in different cosmetic units (ie, segmental peeling). For example, deep perioral wrinkles may require a deep peel while a light chemical peel is sufficient for improving mild photodamage elsewhere . Similarly, clinicians with expertise in skin resurfacing may combine chemical peels and laser resurfacing in one treatment setting, utilizing a medium-depth peel for most of the face and a fractionated carbon dioxide (CO2) laser for areas of deeper resurfacing [9,10].
A predetermined sequence of application helps to ensure timely application of the peeling agent, avoidance of missed areas, and prevention of unintentional repeat application. A carefully planned sequence also allows for the shortest duration of application on the most sensitive areas of skin when the entire face is treated.
Typically, the application sequence for light and medium-depth facial peels begins with the forehead and temples, proceeds to the cheeks and chin, then concludes with perioral and periocular skin. The agent is feathered at the margins of the hairline, just below the jawline, ears (helix and lobes), and into the brows to minimize the development of lines of demarcation after healing .
To reduce the risk of phenol toxicity during deep chemical peels, phenol is usually only applied to one small area of skin at a time. The face is subdivided into sections that are treated at 15-minute intervals, such as the forehead, one cheek, the alternate cheek, nose and perioral area, and the periorbital region. The applicator swab should only be slightly moist. More solution can be applied to the deeper wrinkles and scars to achieve deeper peeling in those areas. The phenol solution should be swirled periodically to prevent separation of the components between applications.
Precautions — Periocular skin should be treated carefully to minimize risk for entry of the peeling agent into the eye. The applicator should only be slightly moist, and a safety margin of untreated skin should be left near the eyelid margin. Care should be taken to ensure that excess peel solution is not left on or around the eyelids, and any tears should be dried immediately. Furthermore, the passing of containers or swabs containing the peel solution over the patient's eyes should be avoided to prevent dripping or spilling onto the eyes.
Treatment endpoints — The peeling agent utilized and the desired depth of peeling determine the amount of time a chemical peel agent should remain on the skin. The major factors used to identify treatment endpoints include time and the physical appearance of the skin.
Time — A time endpoint is commonly employed for light peels and is particularly critical for glycolic acid peels. Glycolic acid solution is applied quickly (within 15 to 20 seconds). Once the desired contact time is reached, glycolic acid must be neutralized with copious amounts of 5% sodium bicarbonate or water. The concentration of glycolic acid and contact times are slowly increased with subsequent treatments. We often begin with 50% glycolic acid applied for 30 seconds from the moment application of glycolic acid begins. We slowly increase the contact time with each subsequent peel up to a maximum of two minutes for patients undergoing a series of peels.
Salicylic acid (20 to 30%) and Jessner's peel solutions are often left on the skin for six minutes. Slightly deeper penetration of the epidermis can be achieved through application of more solution to the skin or application of firm pressure as the solution is rubbed into the skin. After six minutes, the skin is wiped with a wet washcloth to remove the peel solution. However, the action of salicylic acid and Jessner's solution on the skin is self-limited, and application of a neutralizing agent is not necessary to conclude the peel.
Physical — The appearance of skin after application, assessed by the level of frosting, identifies the treatment endpoint for medium-depth and deep chemical peels.
Epidermal sliding is a helpful clinical endpoint for medium-depth trichloroacetic acid (TCA) peels. The "epidermal sliding sign" is an exaggerated wrinkling of the skin that occurs when papillary dermal edema forms and disrupts the anchoring fibrils between the epidermis and dermis. This allows the epidermis to be more freely movable, resulting in exaggerated wrinkling when the skin is pinched. Epidermal sliding is a transient sign that will disappear when the peel coagulates the epidermal proteins with dermal proteins, indicating that the peel depth has reached the superficial reticular dermis.
Frosting describes a whitened appearance of the skin. The degree of frosting correlates with the depth of penetration of the chemical peel:
●Level 1 frost – A light, nonorganized, nonhomogenous frost with mild erythema (picture 1). Frosting should be absent or speckled at the endpoint of a light chemical peel. Due to a paucity of adnexal structures to support re-epithelialization compared with facial skin, a level 1 frost is the suggested endpoint for neck, chest, forearm, and hand chemical peels .
●Level 2 frost – A solid, organized, more homogenous frost (picture 1). The superficial vascular plexus in the papillary dermis remains intact, indicated by associated erythema (pink sign). A level 2 frost is the standard endpoint for a medium-depth chemical peel.
●Level 3 frost – A solid, organized frost with loss of the pink sign. Loss of the pink sign results from vasospasm of capillary loops in the papillary dermis. A level 3 frost indicates that the peel has crossed the full thickness of the papillary dermis and has reached the upper reticular dermis.
Further penetration of the peeling agent into the mid-reticular dermis will result in a "grayish" frost. This appearance correlates with increased risk for hypopigmentation and scarring.
The pink sign may be difficult to appreciate in patients with highly pigmented skin. The epidermal sliding sign is useful for identifying the treatment endpoint for medium-depth peels in these patients.
Achievement of the desired degree of frosting (and, accordingly, the depth of a chemical peel) is modulated through the type and concentration of the peeling agent(s) and, for medium-depth peels with TCA, is frequently adjusted further with the number of applications. At least two to three minutes should pass after an application to allow the TCA to penetrate before determining the degree of frost insufficient and applying more TCA.
Some practitioners perform combination peels, in which a superficial peeling agent (eg, glycolic acid, Jessner's solution) is used to achieve disruption of the epidermis (keratolysis) followed by achievement of a level 2 frost with one or more applications of 35% TCA. Applying pressure and rubbing the TCA solution into the skin during application can also augment the depth of penetration.
Some practitioners utilize a glycerin/blue dye mixture to dilute 30% TCA to a concentration of 20 to 24%, giving a blue-colored solution that allows for easy monitoring of the application of the solution in enough coats to achieve a level 2 frost .
The rapid appearance of a solid, organized, white frost is expected for phenol chemical peels. The speed with which phenol peels penetrate the skin leaves very little margin for error.
POSTPROCEDURE COURSE AND CARE — The recovery time following a chemical peel rises with increasing depth of the peel. Careful skin care (gentle cleansing, regular use of emollients, sun protection, and avoidance of rubbing or picking the skin) is performed during the recovery period to support wound healing and minimize risk for complications.
Close adherence to postprocedure skin care is most important for medium-depth and deep chemical peels given the greater degree of skin injury compared with light peels. Patients should receive written instructions to assist with correct performance of wound care recommendations.
With light and medium-depth peels, the treated skin will form a protective covering on the treated area until the skin beneath has healed enough to push this mask off. Patients should be discouraged against trying to prematurely peel the skin, as it will predispose them to infection, prolonged erythema, and postinflammatory hyperpigmentation (PIH). In contrast, phenol peels tend to heal with a wetter and more exudative wound, necessitating more compresses and emollients during the healing process.
Pain is not expected after light or medium-depth chemical peels. After deep chemical peels, discomfort characterized by a burning sensation is common for the first 24 hours. Patients who develop unexpected pain, purulence, or any type of exudate after a chemical peel should be evaluated immediately for infectious complications. Patients who develop findings suspicious for herpes labialis after medium-depth or deep peels should also be promptly examined. (See "Treatment and prevention of herpes simplex virus type 1 in immunocompetent adolescents and adults" and 'Infection' below.)
Light peels — The recovery time following a light chemical peel is three to four days. The skin is mildly erythematous for one to two days and will exhibit slight desquamation for three to four days.
We typically provide patients with the following instructions for skin care during the healing period:
●Wash twice per day with a gentle cleanser and apply a light, noncomedogenic moisturizer
●Apply a noncomedogenic, mineral-based sunscreen every morning on top of the moisturizer
●Avoid rubbing or picking flaking skin
●Avoid direct sun exposure to minimize risk for sunburn and hyperpigmentation
Patients can resume their regular skin care regimens once the skin has healed.
Medium-depth peels and deep peels — The time between the chemical peel and complete re-epithelialization after medium-depth and deep chemical peels is 7 to 8 days and 8 to 10 days, respectively. Skin edema is usually prominent and may continue to worsen during the first two days. The skin then develops a darkened, mask-like appearance, which is followed by desquamation and subsequent re-epithelialization. Desquamation in deep peel areas may reveal skin with a moist appearance and a layer of yellowish exudate.
Skin erythema is common and expected after re-epithelialization. Erythema typically resolves completely within one month for medium-depth peels and two to three months for deep peels .
We typically provide patients with the following instructions for skin care during the healing period:
●Apply a clean, moldable ice pack (eg, small plastic bag of frozen peas) to the eyes and cheeks for 10 minutes each hour during the first one to two days, while awake, to minimize swelling.
●Wash the face in the morning and before bedtime with a gentle cleanser, using a patting motion. Do not rub. Do not use a washcloth. Splash water to rinse the face, then gently pat the skin dry with a clean towel. Gently apply a bland ointment emollient after washing. The emollient should be rubbed between the palms of the hand then patted, not rubbed, onto the skin.
●At noon and in the late afternoon, perform an astringent soak using gauze soaked in aluminum acetate solution. Wet the gauze and lay it on the skin for approximately 10 minutes. Do not rinse the solution from the skin. Reapply the bland ointment following each soak.
●Deep peel areas may benefit from soaking gauze in diluted vinegar (one teaspoon white vinegar in two cups of bottled water) and applying these compresses to the peeled area for 10 minutes every one to two hours. The diluted vinegar compresses are believed to help reduce bacterial overgrowth on the moist, healing wound .
●Avoid picking or rubbing the skin.
Wound dressings may or may not be used.
Patients can restart their regular skin care regimen once re-epithelialization is complete. Sun exposure should be avoided for one month. Exercise should be avoided until the skin has fully re-epithelialized (seven to eight days).
COMPLICATIONS — Complications, such as ocular injury, infection, dyspigmentation, prolonged erythema, and scarring, can occur and require prompt recognition and treatment [14,16].
Irritant or allergic contact dermatitis may also occur as a result of products applied after the chemical peel. Contact dermatitis is managed with the elimination of any potentially irritating skin care products; switching to cleansing with water; and applying a bland, petrolatum-based ointment to the skin. A low-potency corticosteroid ointment can be applied, when needed, for two to three days.
Ocular injury — Entry of chemical peeling agents in the eye can result in corneal injury. The eye should be copiously rinsed immediately. Saline solution can be used to rinse the eye for most chemical peels. Mineral oil should be used to rinse the eye following entry of phenol peeling solutions because water may increase penetration of phenol. A prompt ophthalmologic evaluation is indicated following ocular exposure to a chemical peel agent if the patient notices any irritation or discomfort, especially from a phenol-based peel solution.
Infection — Viral, bacterial, or candidal infections can follow chemical peels. Regression of healing, pain, purulent drainage, and ulceration require a prompt evaluation for infection.
Bacterial infections due to S. aureus, Pseudomonas aeruginosa, or other bacteria may occur as early as 24 hours after the chemical peel. Potential manifestations include honey-colored crusting, pustules, erythematous papules, pain, or swelling. The diagnosis is confirmed via culture and sensitivity testing. Treatment involves oral antibiotic therapy.
Herpes simplex virus infection presents with moderately painful, small ulcerations that may rapidly spread within the treatment area. Signs of infection often appear two to three days after the chemical peel . Infection may be confirmed with polymerase chain reaction, direct fluorescent antibody, or viral culture. Oral antiviral therapy is indicated, or if the patient is already on antiviral prophylaxis, the dose will need to be increased. (See "Treatment and prevention of herpes simplex virus type 1 in immunocompetent adolescents and adults" and 'Infection' above.)
Candida infection typically presents as erythematous, pruritic papules several days after the chemical peel. A potassium hydroxide preparation is useful for rapid identification of Candida infection. Treatment with an oral antifungal with activity against Candida is indicated.
Dyspigmentation — Risk for chemical peel-induced postinflammatory hyperpigmentation (PIH) increases with increasing skin pigmentation and is most likely to occur in individuals with skin phototypes III to VI. PIH often becomes evident three to four weeks after the procedure. PIH is generally transient but often takes three to six months to resolve. Implementation of treatments for PIH, such as strict sun protection, topical hydroquinone, and light chemical peels, may accelerate improvement. (See "Postinflammatory hyperpigmentation", section on 'Treatment'.)
Permanent hypopigmentation can occur as an adverse event of deep chemical peels or in association with complications, such as infection or scarring. This differs from the lightening of skin color that can occur as a normal consequence of chemical peeling, as epidermal melanin is removed during peeling (pseudohypopigmentation) .
Prolonged erythema — Prolonged erythema usually occurs in the setting of deep chemical peels and is thought to result from the action of angiogenic factors during the healing process [14,17]. Other associations include infection, delayed healing, recent use of topical or oral retinoids, alcohol consumption, contact dermatitis, and pre-existing skin conditions associated with facial erythema (eg, rosacea) [14,16].
Postpeel erythema often improves spontaneously, and with the exception of patients with areas of intense erythema, treatment is usually reserved for erythema that persists beyond the expected period (eg, remaining one to two months after a medium-depth chemical peel or three to four months after a deep peel). The best approach to treatment has not been established. Our approach consists of judicious use of a midpotency topical corticosteroid (triamcinolone acetonide 0.1% cream or ointment) for one or two days of each week. Patients for whom erythema causes significant psychologic distress can be treated with a low-fluence pulsed dye laser to accelerate resolution.
Intense erythema — Intense erythema is different from prolonged erythema, manifesting with focal areas of extreme redness that can be a harbinger of scarring. These areas are prone to develop along bony prominences (orbital rim, jawline, zygoma) and can be asymptomatic or pruritic.
In the absence of treatment, areas of intense erythema may progress to a hypertrophic scar or keloid. We closely monitor the patient for scar development and treat with triamcinolone acetonide 0.1% cream or ointment applied one to two days per week plus pulsed dye laser therapy. Pulsed dye laser sessions can be repeated weekly, biweekly, or monthly depending on the patient's response to treatment and the severity of the erythema .
Scarring — Scarring is an uncommon adverse effect that is most likely to occur in the setting of deep peels, particularly in the setting of treatment of the neck, chest, or dorsal hands and factors contributing to delayed or poor wound healing .
Hypertrophic scars or keloids that develop following chemical peels are managed similarly to scars secondary to other events. Examples of therapeutic options include high-potency topical corticosteroids, intralesional corticosteroid injections, intralesional fluorouracil, and pulsed dye laser therapy . (See "Keloids and hypertrophic scars".)
ASSESSMENT OF EFFECT — Light chemical peels generally induce subtle improvements, and performance of a series of at least several light peels is usually necessary to achieve a more noticeable effect. Mild, incremental improvements in features such as skin texture and dyspigmentation may be visible soon after each peel, whereas features such as comedonal acne may require several peels before the appearance of a clinically relevant effect. (See "Light-based, adjunctive, and other therapies for acne vulgaris", section on 'Office-based superficial chemical peels'.)
Cosmetic benefits of medium-depth and deep chemical peels involve effects on cutaneous collagen, and clinical improvement can occur over several months as collagen remodeling continues. Repeating medium-depth peels is generally not indicated for at least three months. Repetition of a deep chemical peel is typically avoided for at least one year.
SUMMARY AND RECOMMENDATIONS
●Chemical peels comprise a group of procedures in which caustic substances are applied to the skin to induce a controlled skin injury. Healing after injury can lead to improvements in multiple features, such as dyspigmentation, wrinkles, acne scars, and actinic keratoses (table 2). (See 'Basic concepts' above and "Chemical peels: Principles, peeling agents, and pretreatment assessment".)
●Chemical peels are divided into light, medium-depth, and deep chemical peels based upon the depth of skin injury induced in the skin. Injury from light chemical peels is limited to the epidermis. Medium-depth peels injure the dermis and papillary dermis, and deep chemical peels involve injury extending into the reticular dermis. (See 'Basic concepts' above.)
●Skin preparation regimens are commonly initiated prior to chemical peels, although the value of routine performance of skin preparation has been debated. Herpes simplex virus infection prophylaxis is indicated for all patients undergoing medium-depth or deep perioral or full-face chemical peels. (See 'Preparation' above.)
●Proper preparation on the day of the chemical peel is crucial for achieving optimal results, minimizing risk for adverse effects, and optimizing patient comfort. All necessary materials should be assembled prior to application of the chemical peel agent, and skin in the treatment area should be adequately cleansed. Phenol has cardiotoxic effects, and cardiac monitoring is often necessary for phenol chemical peels. (See 'Before application' above.)
●Application of chemical peel agents should be performed carefully to avoid excessive application, insufficient application, and entry of chemical peel solutions into the eye. The sequence of application should be planned prior to the start of treatment. (See 'Application' above.)
●The peeling agent utilized and the desired depth of skin injury determine the treatment endpoint for a chemical peel. The endpoint for light chemical peels is often based upon contact time with the skin. Physical signs, such as frosting and the epidermal sliding sign, are used to guide the endpoints for medium-depth and deep chemical peels. (See 'Treatment endpoints' above.)
●Gentle skin care is implemented after chemical peels to support healing and reduce risk for complications. This typically includes gentle cleansing, regular use of emollients, sun protection, and avoidance of additional trauma to the skin. (See 'Postprocedure course and care' above.)
●Complications of chemical peels requiring prompt recognition or treatment include ocular injury, infection, dyspigmentation, prolonged erythema, intense erythema, and scarring. (See 'Complications' above.)
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