CHAPTER 37
Chemical Peels

Jon D. Perenack¹ and Brian W. Kelley²

¹Department of Oral and Maxillofacial Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA

²Private Practice, Carolinas Center for Oral and Maxillofacial Surgery, Charlotte, North Carolina, USA

The use of a chemical exfoliant to injure specific tissue layers to lessen fine facial rhytids, decrease dispigmentation and actinic changes, and rejuvenate damaged areas in a minimally invasive manner.

Indications

1. Photo dyspigmentation
2. Superficial rhytids
3. Melasma
4. Acne vulgaris
5. Ephelides

Contraindications

1. Active cutaneous infection (i.e., herpes)
2. Ice-pick or deep atrophic acne scars
3. Allergy to agent
4. Extreme sunburn
5. Open wounds (open acne wounds will propagate peel depth)
6. Unrealistic patient expectations
7. Patient is unable or unwilling to perform postoperative management
8. Caution with patients using skin sensitizers (e.g., Retin-A, Retinol, and Accutane)

Anatomy

• Epidermis: Layers from superficial to deep: stratum corneum, stratum granulosum, stratum spinosum, and stratum basale
• Dermis: Layers from superficial to deep: papillary dermis and reticular dermis

Pretreatment Protocol for Chemical Peel Patients

1. Commercially prepared skin systems that contain tretinoin 0.05–0.1% and 4% hydroquinone, such as Obagi Nu-Derm (Skin Specialists PC, Omaha, NE, USA), are available and are recommended for 4–6 weeks prior to the application of a peel in order to allow for a more uniform depth of peel and to minimize complications associated with melasma and postinflammatory pigmentation.
2. Valacyclovir (Valtrex) is recommended beginning the day prior to the peel and for 7–14 days post peel.

Procedure: Medium-Depth Chemical Peel

1. All patient consents are reviewed and signed, and all patient questions are answered. All patient makeup is removed, and the maxillofacial skeleton is prepped with alcohol from the hairline to a point several inches below the inferior border of the mandible.
2. For medium-depth and deep peels, intravenous sedation is performed.
3. The patient is positioned supine on the surgical table. The skin is degreased with acetone, and standard nerve blocks are performed with long-acting a local anesthetic within the areas of the anticipated peel.

4. A pre-peel is performed with Jessner's solution to include the forehead, the periorbital region (the upper lids and thin tissue below the lower lid lash lines are avoided), the nasal bridge, the perioral region, and the lower face to the inferior border of the mandible (Figure 37.2). After the Jessner's solution has dried and a thin layer of frosting has occurred, 25–35% trichloracetic acid (TCA) is applied to the above-mentioned regions with 4 × 4 gauze (Figure 37.3).

5. When using TCA solution, it is important to wait several minutes after the application of the solution in order to allow for frosting of the tissue to assess the depth of the peel. The peel is typically carried into the hairline in order to minimize any demarcations of the peel. Areas such as the central forehead, glabellar region, and peri-oral region contain thicker tissue and are resilient to peels. Additional solution may be applied to these areas. The use of a cotton-tipped applicator may be used to rub the solution into areas such as deep peri-oral and glabellar rhytids. The upper eyelids are avoided in medium to deep peels, and the ciliary margin is the upper extent of the lower lids’ involvement. The solution is feathered as the inferior border of the mandible is reached in order to prevent a line of demarcation to the thinner and more vulnerable cervical tissue. Additional layers of TCA may be applied until the desired amount of frosting is observed (Figure 37.4) and the desired depth of penetration is reached.
6. Once the desired depth of the peel has been reached, a facial moisturizing cream is applied to the facial skeleton. In the immediate recovery period, the use of cool compresses and/or a fan will aid in minimizing immediate postoperative discomfort.

Figure 37.1. Pre-peel patient demonstrating a Glogau II Fitzpatrick II skin type.

Figure 37.2. After application of acetone and Jessner's solution. Note light frosting to the face.

Figure 37.3. After first application of 30% trichloracetic acid. Note a thin transparent frost indicating that the papillary dermis has been reached. Also note the avoidance of the thin tissue of the periorbital and cervical regions.

Figure 37.4. After second application of 30% trichloracetic acid. Note a solid, thicker frost indicating that the upper reticular dermis has been reached. This layer indicated the stopping point for the medium-depth peel.

Postoperative Management

1. Moisturizing cream: The patient is required to keep the peeled area moisturized at all times during the postpeel period. Moisturizing creams prevent drying and crusting of the peeling areas, and they provide patient comfort while the skin re-epithelializes. Depending on the depth of the peel, moisturizing creams may be combined with topical antibiotics.
2. Analgesics: Prescribed based on the depth of the peel and adjunct procedures performed at the time of the peel.
3. Valacyclovir: Continued 7–14 days post peel.
4. Wound care: Should be initiated on postpeel day 2. Involves lightly washing the peeled area with mild soap in a blotting fashion several times a day and then reapplying the moisturizing cream. Avoid scrubbing, itching, picking, or pulling at sloughing skin as this may cause scar and keloid formation. Pre-peel skin care systems are typically restarted 2 weeks after the chemical peel.
5. Sunblock: Direct sun exposure is avoided, and SPF 30 or above is necessary to minimize the stimulation of melanocytes and further postinflammatory hyperpigmentation (PIH).

Complications

Early Complications

1. Discomfort, edema, and tissue erythema: Common to all peels; corresponds to the depth of the peel.
2. Hyperpigmentation: Frequently occurs within the recovery period, especially with early sun exposure. Hyperpigmentation is typically transient and responds to tretinoin and 4% hydroquinone.
3. Prolonged flaking after a peel: Requires generous moisturizer application and avoidance of restarting topical retinoids.
4. Milia formation: Treated by sterilely unroofing the lesion.
5. Wound infection (bacterial or fungal): Symptoms include increasing deep erythema, pruritis, and discomfort around the third to fifth days after the peel. Early suspicion of an infection should be managed with cultures and sensitivities, systemic antibiotics, and acetic acid solution rinses. Fungal infections are managed with topical and systemic antifungal agents.
6. Herpes labialis: Suspected if the classic vessicular eruption appears. Antiviral therapy dosage is changed from a preventative to a treatment dosage.

Late Complications

1. Persistent erythema (greater than 2–3 months): May be caused by early sun exposure; however, persistent erythema may be an early indicator of scarring and future keloid formation.
2. Scarring and keloid formation: If an eschar forms post peel that does not shed for greater than 14 days, one can expect some degree of scarring, keloid formation, and pigmentary disturbances. Thickening consistent with keloid formation may be treated upon recognition with monthly intralesional injections of triamcinolone acetomide (10 mg/ml) and/or 5-fluorouracil (off-label use). Selective treatment with CO₂ or an erbium-doped yttrium aluminum garnet (Er:YAG) laser can be helpful in releasing and smoothing scars.
3. Depigmentation: Areas of depigmentation are typically observed for 3 to 6 months for return of pigmentation. After 6 months, it can be assumed that a permanent depigmentation has occurred.

Key Points

1. As a general rule, the deeper the depth of the peel, the greater the possible improvements, and the greater the potential complications.
2. Superficial peel depth varies (0.02–0.06 mm) depending on the chemical exfoliant used and the number of applications. Superficial peels injure the epidermis without extending into the dermis. Indications for superficial-depth peels include superficial dispigmentation, solar lentigines, and/or minimal photo damage.
3. Medium-depth peels span from the superficial papillary dermis to the upper reticular dermis (0.45 mm). Indications for medium-depth peels include moderate rhytids, melasma, pigmentary dyschromia, actinic keratosis, depressed scars, and ephelides.
4. Deep chemical peels have a goal depth of the midreticular dermis (0.6 mm). They are the most aggressive type of chemical exfoliant, are associated with the highest potential for complications, and are indicated for moderate to deep rhytids and depressed scars.
5. Jessner's solution (14 g each of resorcinol, salicylic acid, and lactic acid [85%] mixed in 95% ethanol to make a quantity of 100 mL) may be used to perform superficial peels or as a pre-peel for medium and deep chemical peels. The use of acetone and Jessner's solution prior to the application of a stronger chemical exfoliant will remove the oily, keratinized superficial layer of the skin and allow the second, more aggressive chemical agent a more uniform depth of penetration and a better final result.
6. Peel depth may be assessed based upon the type of frosting achieved after the application of the peeling solution. A thin, transparent frost with a pinkish background indicates that the peel has reached the papillary dermis. A solid, thick frost indicates that the peel has reached the upper reticular dermis. A thick, white-gray frost indicates that the peel has reached the midreticular dermis and that subsequent application of solution should be avoided.

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Case Report

Case Report 37.1. Medium-depth peel. A 42-year-old female presents with a chief complaint of “inconsistent skin tone and fine wrinkles.” The patient admits to excessive sun exposure through her second and third decades of life as well as a 15-pack/year history of smoking. Physical exam demonstrates a Glogau II Fitzpatrick II skin type, ephilides, pigmentary dyschromia, depressed acne scars, and moderate rhytids (Figure 37.1). The patient was placed on a 6-week pre-peel skin regimen of Obagi Nu-Derm followed by a medium-depth skin-resurfacing procedure utilizing Jessner's solution and 30% trichloracetic acid. (See also Figures37.2, 37.3, 37.4, 37.5, and 37.6.)

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Figure 37.5. Postpeel day 3. Patient demonstrates tissue erythema, edema, and evidence of early peeling.

Figure 37.6. Two months post peel with dramatic improvements to facial rhytids, acne scars, and pigmentary disturbances.

References

1. Avrum M.R., Tsao, S., Tannous, Z. and Avram, M., 2007. Color atlas of cosmetic dermatology. New York: McGraw-Hill; pp. 38–40.
2. Bensiman, R.H., 2009. Chemical peels. In: F.R. Nahai and F. Nahai, eds. Minimally invasive facial rejuvenation. Amsterdam: Elsevier.
3. Coleman, W.P., 3rd. 2001. Dermal peels. Dermatologic Clinics, 19(3), 405–11.
4. Coleman, W.P. and Lawrence, N., 1998. Skin resurfacing. Baltimore: Williams & Wilkins; 10–84.
5. Saags, H., 1989. Civilization before Greece and Rome. New Haven, CT: Yale University Press.
6. Wolff, K., Goldsmith, L.A., Katz, S.I., Gilchrest, B.A., Paller, A.S. and Leffell, D.J., 2008. Fitzpatrick's dermatology in general medicine. 7th ed. New York: McGraw-Hill; pp. 2369–70.