Original Article 239

Chemical Peels: Deep, Medium, and Light

Sidney J. Starkman, MD1 Devinder S. Mangat, MD, FACS1

1 Mangat, Holzapfel & Lied Plastic Surgery, Cincinnati, Ohio Address for correspondence Devinder S. Mangat, MD, Mangat,
Holzapfel & Lied Plastic Surgery, 8044 Montgomery Rd, Suite 230
Facial Plast Surg 2019;35:239–247. Cincinnati, OH 45236 (e-mail: [email protected]).

Abstract Chemical peels, laser resurfacing, and dermabrasion all offer unique options for skin
Keywords resurfacing for rhytids and dyschromias. Laser resurfacing has developed over the
► chemical peel previous decades, but it is the chemical peel against which all modern forms of skin
► chemoexfoliation resurfacing are measured. Phenol–croton oil peels have been modernized and depend
► phenol–croton oil on croton oil concentration to minimize risks. Complications associated with skin
peel resurfacing are uncommon with proper technique and postoperative management.
► skin resurfacing

There has been a boom in skin care products, medical devices, fair skin, and shallow rhytids. However, the majority of
and skin rejuvenation therapies over the past few decades. This chemical peel patients will not fit this exact description.
is likely because of modern medicine increasing both the Most commonly, the Fitzpatrick scale is used to help define a
average lifespan and quality of life in the general population. patient’s skin type (►Table 1).
Due to this development, there has been a greater demand for Patients can also be rated by their skin type, texture,
treatment of age-related skin changes. As many new over-the- complexion, photoaging, and so on using categorizing
counter options in skin rejuvenation are increasingly being schemes such as the one by Glogau (►Table 2).
used by patients, they are now more prepared for medical The medical history of the patient must be reviewed before
grade chemical peels for more potent and lasting results. The any chemical peeling occurs. Relative contraindications for any
different variations of chemoexfoliation have been used for resurfacing procedure include smoking, diabetes, active or
rhytids, actinic damage, lentigines, and dyschromias. frequent herpes simplex virus infections, cutaneous radiation
The goal of the following section is to describe the most history, hypertrophic scarring, or keloid history. Photosensi-
recent knowledge about chemical peeling and to expose the tizing drugs, exogenous estrogen, and birth control pills should
previously accepted yet incorrect dogmas. Chemical peeling, be avoided because of the increased risk of hyperpigmentation.
when practiced with knowledge and good technique, can Patients should also be warned not to have plans to become
yield excellent results in skin rejuvenation. pregnant within 6 months after chemical peeling due to
elevated estrogen levels of pregnancy.1,2
Smoking and sun exposure should always be addressed in
Patient Selection
the planning stages. Chemical peels on the faces of chronic
As with any patient encounter, the initial consultation smokers can lead to poor tissue healing due to the microvas-
provides an opportunity to thoroughly assess the patient’s cular damage from smoking. It is recommended that smokers
history and physical examination. The patient must both be a stop 1 month before the peel and continue abstinence for at
physical candidate for a chemical peel and have appropriate least 6 months afterward. Likewise, it should be recommended
expectations for their postpeel results. For non-Caucasian to patients that for 3 months, prolonged sun exposure should
patients, in particular African-American patients, a personal be avoided after the peel. If this is unacceptable to the patient,
and family history of keloid and hypertrophic scar formation other options besides chemical peeling should be explored.
should caution the practitioner from aggressive resurfacing. An absolute contraindication to chemical peeling, or any
Skin-related changes such as rhytids and photodamage must facial resurfacing, is recent use of isotretinoin (Accutane).
be distinguished from other changes such as volume loss or Isotretinoin prevents reepithelialization from hair follicles
jowling. Ideally, a chemical peel patient will have blue eyes, and sebaceous glands, and chemical peeling relies primarily

Issue Theme Anything But the Knife: Copyright © 2019 by Thieme Medical DOI https://doi.org/
Nonsurgical Facial Plastic Surgery; Guest Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0039-1688944.
Editors: Deborah Watson, MD, FACS, and New York, NY 10001, USA. ISSN 0736-6825.
David B. Hom, MD, FACS Tel: +1(212) 584-4662.
240 Chemical Peels Starkman et al.

Table 1 Fitzpatrick skin type scale

Skin type Skin color Characteristics

I White; very fair; red or blond hair; blue eyes; freckles Always burns; never tans
II White; fair; red or blond hair; blue, hazel or green eyes Usually burns, tans with difficulty
III Cream white; fair with any eye or hair color; very common Sometimes mild burn, gradually tans
IV Brown; typical Mediterranean Caucasian skin Rarely burns, tans with ease
V Dark brown; mid-eastern skin types Very rarely burns, tans very easily
VI Black Never burns, tans very easily

Table 2 Glogau skin classification scale

Group I (mild) Group II (moderate) Group III (advanced) Group IV (severe)

No keratoses Early actinic keratoses: Actinic keratoses: obvious Actinic keratoses and skin cancers
slight yellow skin yellow skin discoloration
discoloration with telangiectasias
Little wrinkling Early wrinkling: Wrinkling present at rest Wrinkling: much cutis laxa of actinic,
parallel skin lines gravitational, and dynamic origin
No scarring Mild scarring Moderate acne scarring Severe acne scarring
Little or no makeup Little makeup Wears makeup always Wears heavy layers of makeup

upon this reepithelialization for healing. The most current Another beneficial drug in the preparation of chemical peel
recommendations are to stop isotretinoin for 12 to 24 months patients is hydroquinone. Hydroquinone is mostly used in
before the peel. patients with dyschromias and lentigines or patients with
Finally, the patient and the practitioner must have agreed Fitzpatrick skin types III, IV, V, and VI due to the elevated risks
upon the reasonable expectations of the peel. The patient’s of postpeel postinflammatory hyperpigmentation (PIH). The
axillary skin can represent the final result of the chemical mechanism of hydroquinone is to block the conversion of
peel as long as this region has not previously received tyrosine to L-Dopa by tyrosinase, thereby decreasing melanin
excessive sun damage.3 production. In applicable patients, hydroquinone in a concen-
tration of 4 to 8% should be started 4 to 6 weeks before chemical
peeling. The authors use a topical preparation of 0.025% treti-
Preparation
noin, 8% hydroquinone, and 1% hydrocortisone in a moisturizing
After the patient selection and planning is completed, one must cream base. Similar to tretinoin, hydroquinone should be
address patient concerns, establish realistic expectations, and, restarted after the peel once the patient’s skin is ready to tolerate
ultimately, decide on the appropriateness to pursue the resur- it. Topical therapy is stopped 3 to 4 days before the procedure but
facing procedure. Sunscreens should be started 3 months may be restarted 1 week after the procedure. Oral antiherpetic
beforehand to prevent prepeel tanning or sunburns. Part of prophylaxis is initiated 3 days before resurfacing and continued
the purpose of this is to decrease the melanocyte activity before 5 to 7 days until reepithelialization is complete.
the peel. Topical tretinoin (Retin-A; Bausch Health Companies The first line of resistance to bacterial infection is the skin, and
Inc.) is recommended for 6 to 12 weeks before the peel. The resurfacing procedures can reduce this barrier. This can lead to
topical tretinoin has been shown to have a synergistic effect infections by cutaneous bacterial flora such as staphylococcal or
with trichloroacetic acid (TCA) peels and can sustain the effects streptococcal species. Appropriate antibacterial coverage should
of these peels.4–6 Tretinoin leads to exfoliation of stratum begin before the peel as prophylaxis. The senior author (D.S.M.)
corneum and increased melanin distribution and aids in proper uses cephalexin, 250 mg four times a day, 1 day before the peel
penetration of the peel solution. It contributes to a thickened and continues it for 7 days in the postoperative period. In
and uniform epidermis, which aids in uniform application of patients who are B-lactam sensitive, erythromycin, 250 mg
the peeling agent. four times a day, can be used. To maintain a uniform depth of
Up to 6 weeks before resurfacing, patients can be started the peeling agent, it is advisable to recommend avoiding micro-
on topical therapies to increase the rate of epithelialization, dermabrasion, waxing, or electrolysis for 3 to 4 weeks before
stabilize melanocyte activity, and reduce local inflammation. peeling.
The dosing ranges from 0.025 to 0.1%; however, no literature
has shown improved results with the higher dosing. Patients
Superficial Peels
should be counseled of the possible side effects of tretinoin,
such as erythema, flakiness, or skin irritation. If this was to The workhorse peel for plastic surgeons, dermatologists, and
occur, the dose can be reduced or the medication can be aestheticians has been the α-hydroxy acids (AHAs). AHAs are
discontinued entirely. natural fruit, carboxylic acids, with the most common AHA

Facial Plastic Surgery Vol. 35 No. 3/2019

 Chemical Peels Starkman et al. 241

being glycolic acid or 2-hydroxyethanoic acid. Glycolic acid is not have systemic toxicities, and it is very easy to store as it does
derived from sugarcane and is generally used in a concentra- not require refrigeration in its crystalline form. However, the
tion of 20 to 70%.6,7 Salicylic acid, in concentrations of 20 to risk of scarring with TCA is much higher than with phenol-
30%, is also used in superficial chemical peels. based peeling solutions. TCA concentrations of 50% or greater
α-hydroxy acids penetrate through the epidermis and into greatly increase the possibility of scarring.10 There have been
the most superficial layer of the papillary dermis. They work no additional techniques that have proven beneficial in redu-
by diminishing the cohesion between the keratinocytes of cing this risk of scarring.11
the stratum granulosum. This leads to the sloughing of the Providers have been combining 35% TCA solutions with
abnormal cells and thins the stratum corneum. These ben- other less potent agents to achieve medium-depth peels with-
efits generally last for 2 to 3 weeks. out the risks of scarring. The depth of penetration of the 35%
A false sense of security should be avoided with AHAs. TCA peel solution is enhanced by an additional solution being
Glycolic acid can have a persistent effect and penetrate deeply first applied as an epidermolytic. This technique was first
if not neutralized with water. If glycolic remains unneutralized, described by Brody using CO2 ice and acetone to create an
the deeper penetration can lead to healing problems, crusting, epidermal break for the TCA solution that follows.12
and scarring. The anticipated end of a glycolic acid peel proce- Monheit described another combination peel: Jessner’s
dure should be erythema and light peeling of the epidermis.8 solution followed by 35% TCA. Jessner’s plays the role of
Jessner’s solution (14 g of salicylic acid, 14 g of lactic acid, penetrating the epidermis, and TCA is then applied once the
14 g of resorcinol in 100 mL of ethanol) is a superficial Jessner’s solution has dried.13 Frosting does not occur imme-
peeling agent with a high safety profile. The number of coats diately, unlike with phenol peels, and 3 to 4 minutes must be
applied determines the depth of penetration. If one to three allowed for the full frost to form. Once the frost occurs,
coats are applied, exfoliation of the stratum corneum occurs. additional coats can be applied to reach the desired depth of
If 5 to 10 coats are applied, the depth of penetration con- peel. Care is taken with additional applications of TCA, as this
tinues down to the basal layer. has a cumulative effect and leads to a deeper peel.14 This can
increase the chances of hypopigmentation and scarring.
There are also combination peels made out of glycolic acid
Deep Peels
and 35% TCA, as described by Coleman and Futrell. His
The deep peel treats the deep rhytids of the lateral canthal and histological examinations demonstrated that it penetrated
perioral regions by penetrating down to the reticular dermis. slightly deeper than Jessner–TCA combination peels.15
While the papillary dermis is thought to heal through reorga- Brody researched the complications of these three com-
nization, the reticular dermis is thought to heal through bination peels and found that their risks of scarring were less
scarring.9 With deep chemical peeling, the risk of scarring is than 1%. This scarring risk placed them on par with other skin
higher and additional recovery time is necessary. resurfacing modalities such as phenol–croton oil peels or CO2
The workhorse deep chemical peel agent was the Baker– laser resurfacing.
Gordon formulation; however, this lost some popularity as
TCA peels and CO2 laser surfacing rose into the field. The Baker–
Modified Phenol–Croton Oil Peels
Gordon peel did offer arguably unparalleled treatment for
deep facial rhytids, but the irreversible hypopigmentation The all-or-none qualities of the Baker-Gordon phenol–croton
risk and the cardiac/renal toxicity limited its applicability. oil peel has led to TCA peel solutions taking a prominent role
Another option for deep peels is the 50% TCA peel; in modern-day chemical peel practices. The literature on
however, a significant percentage of patients develop scar- deep chemical peels began in the 1950s and 1960s when
ring with this formulation. This catastrophic complication plastic surgeons first adopted the phenol–croton oil solu-
halted the application of this strength of TCA solution. tions. Litton was the first to present these formulas to the
Notwithstanding the risks of the Baker–Gordon peel, it American Society of Plastic and Reconstructive Surgery in
does have a role in the correct scenario. It is a very effective the late 1950s. Soon afterward, the classic formula was
peeling option in patients with deepened rhytids in distinct credited to Baker in the early 1960s.16
facial subunits with Fitzpatrick skin types I and II. None- Around this time in the 1960s, Adolph Brown wrote exten-
theless, a high level of technique and caution must be used to sively about phenol–croton oil peels. He presented three
avoid overly deep peeling with this solution. A uniform doctrines of phenol peeling. First, increasing the concentration
application of peeling solution with attention to the devel- of phenol (80–90%) would work to prevent further penetration
oping frost will help prevent potential complications. by creating an immediate keratocoagulation. Second, adding a
saponin to the solution would increase the depth of penetra-
tion. Third, the role of croton oil was merely to buffer the
Medium-Depth Peels
solution. This led to many believing that phenol was the sole
The modern-day chemical peel discussions center around the active ingredient within the Baker formula. This resulted in the
medium-depth peeling agents. Medium-depth peels penetrate belief that phenol in lower concentrations was more danger-
through the epidermis and the papillary dermis and cause ous because of deeper penetration and that croton oil had no
some inflammation in the upper reticular dermis. Traditionally, role in the depth of peel. These beliefs lasted until they were
the standard medium peel has been the 35% TCA peel. It does questioned by Gregory Hetter in the 1990s.

Facial Plastic Surgery Vol. 35 No. 3/2019

242 Chemical Peels Starkman et al.

Hetter’s experiments refuted the previously described Table 3 Hetter peel formulations (stock solution ¼ 24 mL þ 1
dogmas of the mid-20th century. A solution of 18% phenol mL croton oil [4% croton oil])
without croton oil demonstrated minimal postpeel effect.
With a 35% phenol solution, mild keratolysis occurred with Croton oil % 0.2% 0.4% 0.8% 1.2% 1.6%
no dermal effect. It was only with an 88% phenol solution that a Distilled 5.5 mL 5.5 mL 5.5 mL 5.5 mL 5.5 mL
papillary dermal effect took place. More substantial postpeel water
effects were noticed once croton oil was added to the phenol Septisol 0.5 mL 0.5 mL 0.5 mL 0.5 mL 0.5 mL
solution. Additionally, varying croton oil concentrations had USP 3.5 mL 3.0 mL 2.0 mL 1.0 mL 0 mL
different results. A 0.7% croton oil concentration solution phenol 88%
required a 7-day recovery period, whereas a 2.1% croton oil Stock 0.5 mL 1.0 mL 2.0 mL 3.0 mL 4.0 mL
concentration required an 11-day recovery period. Hetter thus solution
postulated that higher concentrations of phenol (88%) without containing
phenol and
septisol peel more deeply than lower concentrations (50 and
croton oil
35%). He concluded that increasing the concentrations of
Total 10 mL 10 mL 10 mL 10 mL 10 mL
croton oil in phenol formulations results in deeper peels.
Hetter also realized that the healing times would be
shortened by diluting the concentration of croton oil in these Technique
formulas, signifying a shallower depth of penetration. He
expanded on this by claiming that the concentration of The skin must be sufficiently prepared before applying the
phenol, in fact, had little to do with the depth of penetration. peeling solution. This starts with a vigorous cleaning with acne
Obagi was the first to suggest that different concentrations of wash or septisol the evening before and the morning of
these formulas should be applied to the discrete subunits of the chemical peel. Preoperative oral sedation, 10 mg of diaze-
the face. Hetter used this postulation to apply varying pam and 100 mg of Dramamine, helps to relieve patient anxiety.
concentrations of croton oil to the facial subunits (►Fig. 1). The antihistamine serves to reduce oral secretions and protect
He found that the temple and lateral brow could only with- the patient’s airway during the sedation. As the patient will
stand concentrations up to 0.6%, the cheeks and forehead have had nothing to drink since the previous night, intravenous
could only tolerate concentrations up to 0.8%, and the fluids should be started prior to bringing the patient to the
perioral region could tolerate croton oil concentrations up procedure room.
to 1.6% before the risk of complications rose. Lastly, Hetter Preoperative marking consists of marking the patient’s
felt that 1% croton oil solutions were the upper threshold for submandibular shadow while in the upright position. This
safe use to avoid serious risk of hypopigmentation. helps to prevent noticeable delineation between the peeled
Hetter first created his formulations using phenol at 33% to and unpeeled area of the neck. The patient is then placed in
carry croton oil at one drop (0.35%), two drops (0.7%), and three the supine position.
drops (1.1%) of concentrations. However, he soon switched to a Supraorbital, infraorbital, and mental nerve blocks are
more standardized system of measurement rather than rely- performed with 50:50 mixture of 2% lidocaine and 0.5%
ing on a dropper, which is naturally unreliable. He converted bupivacaine. Local anesthetic is also applied through a field
one drop into 1 cm3 and used this conversion to make a stock block over the areas to be peeled. Epinephrine will slow the
solution of 0.04 mL of croton oil per 1 mL of phenol. From this, clearance of the phenol and is thus avoided. The face is
he could make different croton oil formulations of 0.4, 0.8, 1.2, meticulously degreased with an acetone-soaked gauze. Any
and 1.6% in a constant phenol concentration (►Table 3). remaining skin oil on the patient’s face will impair the uniform
application of the peeling agent. Some authors like Obagi and
Hetter suggest using a wrung-out 2-inch by 2-inch gauze for
the application of the peeling agent. However, However, the
senior author (D.S.M.) feels that using a wide cotton-tipped
applicator allows for superior control of application.
As opposed to TCA where the frost can take 3 to 4 minutes
to occur, with phenol-based chemical peels, the frosting
occurs almost immediately. This means that the uniformity
of depth, and need for reapplication, is almost immediately
obvious to the provider in a phenol-based peel. Medium-
depth peels should result in a level II to III frost (►Fig. 2).17
• Level I: erythema with stringy or blotchy frosting.
• Level II: white coat with erythema showing through (it
should be used for eyelids and areas of bony prominences,
such as zygomatic arch, malar region, and chin, which all
have a higher rate of scarring).
Fig. 1 Facial subunit markings demonstrating various concentrations • Level III: solid white frost with little or no background
of peel solution, as described by Hetter. erythema.

Facial Plastic Surgery Vol. 35 No. 3/2019

 Chemical Peels Starkman et al. 243

of the lower eyelid margin and then stopped. The sedated

patient can develop tearing during the peeling procedure,
and these tears should be wiped away to prevent the peeling
solution from tracking up along the tear into the eye. The
upper eyelid lacks the sebaceous glands that are necessary
for reepithelialization following a peel, and therefore the peel
solution is not applied to this area.
The patient can experience an immediate burning sensa-
tion if there were any areas of inadequate local anesthesia. In
this case, the sensation will last for approximately 15 to
30 seconds. The burning sensation can then return approxi-
mately 30 minutes later and can last for the remainder of the
procedure day. The bupivacaine in the local anesthetic blocks
should provide anesthesia for hours following the peel. This
is a part of the reason why it is critical to apply comprehen-
sive local anesthetic blocks to the peeled areas.

Postoperative Period
A thick coat of emollient is applied to all of the peeled skin
areas once the last area of frosting dissipates and only
erythema remains. These emollients are not occlusive and
Fig. 2 A level III frost after application of phenol–croton oil solution, therefore do not affect the depth of the peel. The patient is
with a white frost over the treated skin. instructed to maintain a steady coat of this emollient over
their entire peeled region by reapplying four to five times per
The facial subunits are divided by the severity of lenti- day or as often as needed. This is continued for the duration
gines, rhytids, and photodamage, as well as skin thickness. of the postpeel period until fresh skin is visible and the area
The senior author (D.S.M.) uses 0.8% croton oil Hetter solu- has fully peeled.
tion in areas of thicker skin and deeper rhytids (Glogau III The healing process consists of four stages. The first stage
and IV), such as the glabella and perioral regions. Intermedi- occurs over the first 12 hours and consists of facial inflam-
ate areas (Glogau II and III) are treated with 0.4% croton oil mation. The epidermis becomes leathery and begins to
Hetter solution. An 89% phenol solution is used for feathering separate from the dermis. The underlying treated dermal
along the borders of the peeled areas to achieve an even layer will become necrotic and being to slough. The applied
postpeel result. A classic Baker formula can be used in emollient helps in removing this necrotic skin from the
patients who are Fitzpatrick types I or II and have severe underlying tissues. The second stage is desquamation, which
Glogau IV rhytids in the upper lip. occurs over the next 3 to 7 days (►Fig. 3). This exposed the
Between each facial subunit, 10 to 15 minutes are allowed underlying erythematous dermis. The third stage is reepithe-
for adequate clearance of the phenol. The Hetter solution lialization, which partially coincides with desquamation and
requires less clearance time due to lower phenol compared occurs between days 2 and 10 following the peel. Reepithe-
with the Baker–Gordon peel. The entire face can be peeled lialization will be demonstrated by the changes in dermal
over 30 to 60 minutes. In case a minor supraventricular color from bright red to a lighter shade of pink. The final stage
arrhythmia occurs, the peel should be paused until the is fibroplasia and occurs toward the end of the first week and
patient returns to normal sinus rhythm. continues for 12 to 16 weeks following the peel. This final
The peel should continue up to and even into the hairline period is when the full benefits of the chemical peel become
when applying the peeling solution to the forehead and tem- apparent (►Figs. 4–11). During this time, the skin will
poral regions. Phenol and croton oil will not affect the pigment undergo new collagen formation, reorganization of the col-
of the hair follicles. Additionally, the peel should continue just lagen, and neoangiogenesis.
over the vermilion border in the perioral area. This is because The patient is instructed to avoid any direct, prolonged
the margin of each peeled region will have a distinct line of sun exposure for 12 weeks following the peel. During this
reactive hyperemia. These lines of hyperemia should be period, the skin is vulnerable to ultraviolet light exposure
included and peeled when peeling adjacent facial subunits to and is at a risk of resultant hyperpigmentation. The senior
prevent any resultant lines of demarcation. The skin can be author (D.S.M.) also recommends avoidance of sunscreens
stretched taut for deep wrinkles of the perioral region to evenly for the first 6 weeks. Many chemical sunscreens include the
apply the peel to these rhytids. Unlike with glycolic acid peels, ingredient para-aminobenzoic acid, which can cause
phenol–croton oil peels do not need to be neutralized because erythema, irritation, and induration of the healing skin. It
of the completed reaction as demonstrated by the frost. is also recommended that women avoid birth control pills
An area to exercise caution is in the lower eyelid region. during this same time period, as the increased estrogens can
The phenol–croton oil peel should be applied to within 3 mm lead to hyperpigmentation.

Facial Plastic Surgery Vol. 35 No. 3/2019

244 Chemical Peels Starkman et al.

Fig. 3 Desquamation of the skin that takes place in the first 7 days
following a phenol–croton oil peel.

Fig. 5 Post phenol–croton oil peel photograph with reduction of the

fine rhytids and treatment of the photoaged skin.

Fig. 4 Preoperative photograph of a patient with diffuse fine rhytids Fig. 6 Preoperative photograph of a patient with severe photo-
and photoaged skin. damage and moderate dyschromias and fine rhytids.

Facial Plastic Surgery Vol. 35 No. 3/2019

 Chemical Peels Starkman et al. 245

Fig. 9 Post phenol–croton oil peel photograph with treatment of

perioral rhytids.

Fig. 7 Post phenol–croton oil photograph with treatment of the

photodamage, dyschromias, and rhytids.

Fig. 10 Preoperative photograph of a patient with diffuse fine rhytids

in the perioral, malar, and periorbital regions.
Fig. 8 Preoperative photograph of the perioral region with severe rhytids.

tion is a supraventricular tachycardia that occurs within

30 minutes of starting the peel and can evolve into paroxysmal
Complications
atrial tachycardia, ventricular tachycardia, paroxysmal ventri-
Cardiac Arrhythmias cular contractions, and, possibly, atrial fibrillations. The best
Even in patients who have been properly selected and ade- way to manage any of these aforementioned progressive
quately hydrated before their chemical peel, a reversible arrhythmias is to prevent them from occurring in the first
cardiac arrhythmia can possibly occur. The common presenta- place. As soon as a supraventricular tachycardia, or other

Facial Plastic Surgery Vol. 35 No. 3/2019

246 Chemical Peels Starkman et al.

overly deep peel or from inattentive postoperative care.

Again, the risk of scarring is significantly elevated in iso-
tretinoin users. The practitioner should check to confirm that
the patient is clearly producing skin oils after the patient has
stopped isotretinoin. Once developing, the scars can be
treated with silicone sheeting coverings and intralesional
corticosteroids injections (Kenalog 20 mg/mL) every 2 to
3 weeks. It is important to exercise caution in the injections
of steroids, as overinjection can lead to atrophy and skin
depressions. As most scars will be erythematous, a flash-
lamp pulsed dye laser is helpful over multiple treatments.

Infections
In the case of a patient presenting with signs of cellulitis or
infection, an appropriate antibiotic regimen should be
immediately started and continued for a 7- to 10-day course.
Similarly, herpetic viral infections can be problematic for a
patient’s natural recovery. In the case of a herpetic outbreak
despite appropriate prophylactic dosing of antivirals, a
course of valacyclovir, 1 g three times a day for 10 days,
should be used.

Postoperative Erythema
Postoperative erythema after a peel is common in all peel
patients and is not unusual for it to last longer than pre-
dicted. Hydrocortisone (2.5%) lotion is commonly prescribed
to aid in the resolution of this erythema. As this erythema is
eventually subsiding in the weeks following the peel, some
Fig. 11 Post phenol–croton oil photograph with treatment of diffuse fine patients will develop PIH. The typical scenario for this is in a
rhytids. patient with excessive sun exposure following the peel or
with Fitzpatrick skin types III and VI. This can be managed
with a combination of 0.05% retinoic acid, 2.5% hydrocorti-
irregular rhythm, is noted, the peel should be immediately sone cream, and 4% hydroquinone cream.
paused and adequate hydration should continue. At this point,
the rhythm should eventually return to normal sinus rhythm
Hypopigmentation
as the phenol is cleared. The phenol peel may proceed carefully
with attention to the rhythm monitor once the rhythm has One of the most severe complications of chemical peeling is
returned to normal. In the rare instance that the rhythm does hypopigmentation. This is most likely because of phenol’s
not naturally return to a normal rhythm, proper medical ability to eliminate melanocyte’s ability to produce melanin.
procedures should be undertaken for that aberrant rhythm. Hypopigmentation is much more readily noticeable when
single facial subunits are peeled rather than the whole face.
Delayed Reepithelialization This complication was more common in the past when
Any area of the face that does not fully reepithelialize within deeper peels such as the classic Baker formulation were
10 days should be considered prolonged.18 This phenom- used, as well as postoperative occlusive dressing applica-
enon is more common with deeper phenol peels (Baker tions. Hypopigmentation is unfortunately irreversible, and
formula) and TCA peels. It is important to rule out the all patients who experience some level of this should be
presence of underlying infections or contact irritants and advised about the potential need for makeup usage.
not merely dismiss prolonged healing times as coinciden-
tally. The risk of scarring can rise precipitously if these areas
Conclusion
are not checked daily and treated accordingly.
Phenol–croton oil chemical peels have withstood the test of
time and are still considered the standard against which
Scarring
other facial resurfacing procedures are judged. More
The most likely areas for scarring to occur are in the upper lip recently, the widely expanded knowledge of croton oil, and
or over areas with prominent underlying bone structure such its various concentrations, has yielded many options for
as the mandible. Scarring most commonly is because of an specializing treatment for different facial subunits, skin

Facial Plastic Surgery Vol. 35 No. 3/2019

 Chemical Peels Starkman et al. 247

types, thicknesses, and so on. A strong familiarity with the 7 Yu RJ, Van Scott EJ. Alpha-hydroxy acids: science and therapeutic
fundamentals and techniques of chemical peeling can result use. J Cosmet Dermatol 1994;1(Suppl 1):12
8 Van Scott EJ, Yu RJ. Alpha hydroxy acids: procedures for use in
in predictable and excellent results.
clinical practice. Cutis 1989;43(03):222–228
9 Lee KC, Wambier CG, Soon SL, et al , on behalf of the International
Conflicts of Interest
Peeling Society(IPS). Basic chemical peeling—superficial and
The authors have no conflicts of interest to disclose. medium-depth peels. . J Am Acad Dermatol 2018 (e-pub ahead
of print). doi:10.1016/ j.jaad.2018.10.079
10 Brody HJ. Variations and comparisons in medium-depth chemical
peeling. J Dermatol Surg Oncol 1989;15(09):953–963
References 11 Dinner MI, Artz JS. Chemical peel–what’s in the formula? Plast
1 Brody HJ. Complications of chemical peeling. J Dermatol Surg Reconstr Surg 1994;94(02):406–407
Oncol 1989;15(09):1010–1019 12 Brody HJ. Chemical Peeling and Resurfacing. St. Louis, MO: Mosby;
2 Nikalji N, Godse K, Sakhiya J, Patil S, Nadkarni N. Complications of 1997:109–110
medium depth and deep chemical peels. J Cutan Aesthet Surg 13 Monheit GD. Advances in chemical peeling. Facial Plast Surg Clin
2012;5(04):254–260 North Am 1994;2:5–9
3 Brody HJ. Complications of chemical resurfacing. Dermatol Clin 14 Herbig K, Trussler AP, Khosla RK, Rohrich RJ. Combination Jess-
2001;19(03):427–438, vii–viii ner’s solution and trichloroacetic acid chemical peel: technique
4 Kim IH, Kim HK, Kye YC. Effects of tretinoin pretreatment on TCA and outcomes. Plast Reconstr Surg 2009;124(03):955–964
chemical peel in guinea pig skin. J Korean Med Sci 1996;11(04): 15 Coleman WP III, Futrell JM. The glycolic acid trichloroacetic acid
335–341 peel. J Dermatol Surg Oncol 1994;20(01):76–80
5 Popp C, Kligman AM, Stoudemayer TJ. Pretreatment of photoaged 16 Monheit GD. Medium-depth chemical peels. Dermatol Clin 2001;
forearm skin with topical tretinoin accelerates healing of full- 19(03):413–425, vii
thickness wounds. Br J Dermatol 1995;132(01):46–53 17 Hetter GP. An examination of the phenol-croton oil peel: Part III. The
6 Hevia O, Nemeth AJ, Taylor JR. Tretinoin accelerates healing after plastic surgeons’ role. Plast Reconstr Surg 2000;105(02):752–763
trichloroacetic acid chemical peel. Arch Dermatol 1991;127(05): 18 Szachowicz EH, Wright WK. Delayed healing after full-face che-
678–682 mical peels. Facial Plast Surg 1989;6:8–13

Facial Plastic Surgery Vol. 35 No. 3/2019