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DOI: 10.1111/j.1468-3083.2009.03409.x
ORIGINAL ARTICLE
Abstract
Background Objectives Peelings are among the oldest and most widespread aesthetic procedures used in
aesthetic dermatology worldwide. More than 50 commercial peelings are currently available on the European market.
Materials and Methods In the present review, we summarise the current knowledge on chemical peels.
Results Conclusions
A state-of-the-art peeling procedure will take into account the depth of the targeted
structure and the skin condition of the patient to choose carefully among the variables such as chemical class of the
peeling agent, concentration, frequency and pressure of the application. The usual classification of chemical peels
comprises superficial, medium and deep peels. For superficial peels alpha-hydroxy-acids and most recently
lipo-hydroxy acid are used to induce an exfoliation of the epidermis. Medium-depth agents such as trichloroacetic
acid (< 50%) cause an epidermal to papillary dermal peel and regeneration. Deep peels using trichloroacetic acid
(> 50%) or phenol based formulations reach the reticular dermis to induce dermal regeneration. The success of any
peel is crucially dependent on the physicians understanding of the chemical and biological processes, as well as of
indications, clinical effectiveness and side effects of the procedures.
Received: 19 November 2008; Accepted: 20 July 2009
Keywords
chemical peels, glycolic acid, lipo-hydroxy acid, phenol, photoaging, trichloroacetic acid
Conflict of interest
None declared.
Introduction
History
Fischer et al.
282
Classification
Chemical peels are classified into three categories based on the
depth of destruction caused by the treatment14:
Superficial peels, which exfoliate epidermal layers without
going beyond the basal layer.
Medium-depth peels, which reach the upper layers of the
dermis down to the papillary dermis.
Deep peels, which remove the papillary dermis and reach
the reticular dermis.
Some authors discriminate between very superficial (exfoliation)
and superficial (epidermal) peels. The depth of peeling depends
on several factors the substance used, its concentration, the
pH of the solution and the time of application. For example,
TCA is used for superficial, medium-depth or deep peels,
depending on its concentration. Furthermore, combinations of
substances that each act as superficial peels may add up to synergistic effect of a medium-depth peel (e.g. Jessners solution
and TCA 35%).
d
Pre-treatment
A pre-treatment cleansing step directly prior to the actual application of the chemical peel substance is a consistent part of every
peeling protocol. It is crucial to obtain a homogeneous penetration
of the peel and thus a uniform result.14 The application technique
is very simple. The skin is first systematically and thoroughly
cleansed to remove fats and oils and to eliminate debris from the
stratum corneum some authors use acetone for this.14 The skin
is then rinsed and dried (Table 3).
Treatment
Because of the relevance to the final treatment result and the rate of
complications, the importance of a consistent pre-treatment phase
cannot be underestimated.13 Therefore, any doubt regarding the
reliability of the patient should disqualify for a peeling procedure.
The purpose of the pre-treatment phase is to prepare the skin
for the peeling process and for the following regeneration phase.
To achieve this, tretinoin is usually applied for one month beforehand because its action on the skin facilitates a more homoge-
Post-peeling care
283
enhancing breakdown and decreasing cohesiveness, causing desquamation.20 Superficial peels with AHA also increase epidermal
activity of enzymes, leading to epidermolysis and exfoliation.21
Glycolic acid is extremely hydrophilic and has a low pH that varies
with the concentration of the acid (e.g. unbuffered solutions of
80% concentration have a pH of 0.5, 10% concentration has pH
1.7).21 Glycolic acid peels typically need to be properly neutralized
to stop the acidification of the skin; applying acid to the skin saturates the ability of cells to resist acidification and excess acid must
be neutralized to avoid burning the skin.21 AHA peels can be neutralized by basic solutions, such as ammonium salts, sodium bicarbonate or sodium hydroxide.21
The LHA molecule acts on the corneosome corneocyte interface to detach individual corneosomes cleanly.22 The corneosome
is detached from adjacent corneocytes without fragmentation, suggesting that LHA probably acts on transmembrane glycoproteins.
This action occurs at the compactum disjunctum interface and
does not affect keratin fibres or the corneocyte membrane.22 LHA
also stimulates renewal of epidermal cells and the extracellular
matrix, with an effect that is similar to the effect of the reference
compound retinoic acid. In contrast to many other peeling chemicals, LHA has a pH that is similar to that of normal skin (5.5) and
does not require neutralization.
Fischer et al.
284
Deep peels. Deep peels act in the reticular dermis, while med-
Beta-hydroxy acids
ium-depth peels target the papillary dermis and stimulate new collagen deposition, decrease elastic fibres and increase activated
fibroblasts.23,24 Deep peels coagulate proteins, which produces the
frosting seen clinically, and produce complete epidermolysis.21 In
addition, phenol peels restructure the basal layer by incapacitating
melanocytes and inhibiting transfer of melanosomes to nearby
keratinocytes.21 Deep peels can also destroy the papillary dermis,
restoring the dermal architecture.21
Salicylic acid has been used for a long time, but is used much less
frequently since the advent of peeling with AHA. This superficial
peel is employed at weekly sessions for 68 weeks.27,28,29 A peel
using a lipophilic derivative of salicylic acid, lipo-hydroxy acid
(LHA), has recently been introduced.13 It is the newest product in
this category. The LHA is used in 5% and 10% concentrations.
Among superficial peels, the most commonly used product is glycolic acid. It is used in solutions at concentrations varying between
25% and 70% and at a pH between 1 and 3; tolerance is generally
good. The higher the concentration and the lower the pH, the
more intense the peeling will be, but it remains superficial. Glycolic acid is always used over several sessions (generally 6) several
weeks apart. As sessions progress, the concentration of the solution
Resorcin or resorcinol
Peeling
agent
Superficial
Peeling level
Medium-deep
Deep
Photoaging
Roughness, yellow stains
Fine lines; keratosis
Solar lentigines
Pigmentary disorders
Melasma
Post-inflammatory
Retentional acne comedone
extraction
Photoaging
Fine lines
Wrinkles
Pigmentary disorders
Superficial atrophic scars
Severe photoaging
Pigmentary disorders
Scars
Absolute
Relative
Questionable patient
compliance
Regular sun exposure
Heavy cigarette smoking
Inactive but recurring herpes
infections
Oral oestrogen intake
History of hypertrophic
scarring
Connective tissue disorders
Advanced AIDS stages
Indications
Contraindications
TCA, trichloroacetic acid; AHA, alfa-hydroxy acids; BHA, beta-hydroxy acids; LHA, lipo-hydroxy acid.
285
Session 2
10%
Before
10 min
1 day
3 days
Before
Fischer et al.
286
Indications can be divided into two groups; those for which there
is an indisputable consensus and those reported in very rare cases.
Recognized indications
d
287
Figure 6 Clinical effect of deep phenol peel on wrinkles (baseline and 11 months post-peel). Photos courtesy of Dr Torsten Walker.
Figure 7 Clinical effect of trichloroacetic acid 25% with Jessners solution. Photos courtesy of Dr Torsten Walker.
Fischer et al.
288
keratoses.12,13,41 Recently, Hantash and colleagues conducted a prospective, randomized, 5-year trial to evaluate
the ability of chemical peeling (30% TCA) as a prophylaxis against actinic keratoses.42 The results showed that
treatment with TCA peels significantly reduced actinic
keratoses and was associated with a trend towards longer
time to development of new actinic keratoses compared
with that of a control group (P = 0.07).42
Acne: Some authors have proposed superficial peels as
adjuvant treatments for acne (fig. 7); they act as comedolytic agents4347 but have no effect on seborrhoea.46 Superficial peels can result in improvement in both skin
appearance and texture,29 but have very few effects on
atrophic or hypertrophic scars; they may also improve
penetration of topical acne therapies.45 Best results may
occur when these peels are used in patients with oily skin
and seborrhoea. Peels should be used as an adjunctive
treatment to the appropriate topical and oral medications.
Depending on the climate, the type of peel may be rotated
on a seasonal basis. Acne flare is possible with peels, and
patients should be counselled about the possibility of flare
so that they do not become discouraged.
A recent split-face, blinded study compared a series of six glycolic
acid 30% peels on one side of the face vs. six salicylic acid 30%
peels on the other side in patients with facial acne (n = 20).47 Both
treatments were effective, but the effect of salicylic acid was sustained longer and this peel was associated with fewer side-effects
compared with that of glycolic acid.47 In acne prone women, LHA
reduced both the number and the size of microcomedones, the
acne precursor lesions.48 The same study also showed that unplugging the follicle was associated with lower bacterial loads in the follicle and a reduction in follicular size.48 We can hypothesize that
the lipophilic form of salicylic acid could increase the effect of
superficial peeling; this effect may be attributable to a better penetration into the sebaceous follicle.
d
Other indications
Peeling has been proposed to treat flat warts,26 Pseudofolliculitis barbae,37 trichoepitheliomas,49 rhinophyma,50 generalized
linear epidermal naevus51 and tumour prophylaxis in xeroderma pigmentosum.52 There is relatively little documentation
on these indications, which are sometimes based on an old
and unconfirmed publication. Considerable caution is thus
required in these cases. Anecdotally, the authors have had
good experience with superficial peels for keratosis pilaris, particularly on the arms, legs and backs. Peels may also be useful
to enhance the results of laser therapy or other concomitantly
used procedures. The different indications and contraindications are summarized in Table 1.
Redness
Transient hyperpigmentation
Pimples
Peeling level
Medium-deep
TCA 35% or combinations
Redness
Herpes
Hyperpigmentation
Lentigines
Deep
TCA >50%, phenol
Pain
Redness
Herpes
Transient hyperpigmentation
Infection
Hypopigmentation
Permanent achromia
Heart failure (phenol)
TCA, trichloroacetic acid; AHA, alfa-hydroxy acids; BHA, beta-hydroxy acids; LHA, lipo-hydroxy acid.
Daily cleansing
Gel and or solution
daily skin care
LHA Serum, 0.45% LHA
Cleaning and degreasing of skin
prior to treatment to achieve
homogenous peeling results
No sedation or analgosedation
Time
Solutions
Procedures
Purpose
Solutions
Procedure
Preparation (Priming)
Cleaning and
degreasing of skin
prior to treatment to
achieve homogeneous
peeling results
Analgosedation
Hexachlorophene cleanser
Acetone or acetonealcohol
mixture
Gauze pads
Diazepam 5 mg + pentazocin
15 mg i.v.
+ Regional block (bupivacaine)
+ Non-steroidal antiphlogistics
1.01.5 l volume infusion
Eye protection (patient
and physician)
Cleansing with hexachlorophene
Thorough rinsing with water, dry
Degreasing with acetone or
acetonealcohol mixture
(vaseline protection for
sensitive areas)
ECG control required
Hexachlorophene cleanser
Acetone or acetonealcohol mixture
Gauze pads
Diazepam 510 mg p.o.
Non-steroidal antiphlogistics
Daily application
over 3 weeks
Hexachlorophene
cleanser
Acetone or
acetonealcohol mixture
Gauze pads
Diazepam 510 mg p.o.
Eye protection
(patient and physician)
Cleansing with
hexachlorophene
Thorough rinsing with
water, dry
Degreasing with
acetone or
acetonealcohol mixture
(vaseline protection for
sensitive areas)
Deep
TCA >50% phenol
Peeling level
Mediumdeep
TCA 35% or combinations
Superficial
AHA (glycolic acid, pyruvic acid) BHA
(salicylic acid, LHA)
Purpose
Peeling agent
Treatment steps
Solutions
Procedure
Daily application of a
sunscreen product with an
SPF 15 or higher with
UVA UVB for 23 months
usually no antiviral treatment
required
Frequency
Purpose
No
Neutralization
15 days
Procedure
Time
Cotton-tip applicators
LHA solution (5%, 10%)
Solutions
2 months
To prevent infection and enhance
wound healing
prevent pigmentation disorders
Bland emollient cream
Antibiotic skin cream (e.g. refobacine)
0.25% Acetic acid
Non-steroidal anti-inflammatory drugs
(e.g. acetyl salicylic acid)
Leave occlusion for 1248 h
Debridement by soaking with acetic
acid solutions and compresses
Open and or occlusive application
of emollient and or antibiotic creams
Daily application of a sunscreen
product with an SPF 15 or higher
with UVA UVB for 612 months
Antiviral pre- and post-treatment
required (e.g. acyclovir 400 mg 2 day)
Yes
++++
Deep
TCA >50% phenol
12 months
1528 days
(4)-6-(8)
Yes
Yes
Cotton-tip or gauze
TCA alone (e.g. 3550%)
TCA combination
(e.g. Jessners solution
+ TCA 35%)
+++
Peeling level
Mediumdeep
TCA 35% or combinations
Brush or gauze
AHA (e.g. glycolic acid 20%)
++
TCA, trichloroacetic acid; AHA, alfa-hydroxy acids; BHA, beta-hydroxy acids; LHA, lipo-hydroxy acid.
General remarks
Post-treatment
+
Exfoliation of epidermal layer
Time
Treatment
Superficial
AHA (glycolic acid, pyruvic acid) BHA
(salicylic acid, LHA)
Purpose
Peeling agent
Treatment steps
Table 3 Continued
290
Fischer et al.
291
Table 4 Depth reached by a trichloroacetic acid peel as a function of the clinical aspect obtained.
Degree of
frosting
Cloudy
Slightly
white
Clearly white
Intensely and
uniformly white
Greywhite
Crimping
++
++
Firmness
++
+++
++++
+++++
Oedema
++
+++
++++
Depth
Epidermis
Epidermis
Papillary dermis
Papillary dermis
Upper dermis
Medium dermis
Conclusion
Chemical peels represent a flexible and useful tool for improving
skin texture and the effects of ageing. Peels are available in a variety of formulations that allow the clinician to individualize therapy
to the patients presentation. This technique is indicated for a
range of skin problems, including wrinkles, acne and pigmentary
changes. In addition, peels may be used with other techniques as
part of a multimodality approach to improve skin texture and
resurface skin.
Three major points are essential for successful chemical peels:
Clinical concept peeling is more than an ablative technique: the process uses the inflammatory reaction and
dermal stimulation proactively to modify the skin.
Pre- and post-procedure skin never underestimate the
role of the pre- and post-treatment for the efficacy of
the peel. It will determine the level of re-epithelialization, remodelling effects as well as scaring recovery
time.
Side-effects the level of expertise of a dermatologist is
crucial for the rate of side-effects and for the final peel
results. Superficial peels are easy to perform and their benefit ratio risk is very good.
d
Acknowledgements
The Cosmetic Dermatology European Expert Group supported by La Roche Posay. Photos courtesy of Dr Torsten
Walker, Deutschland.
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4 MacKee G, Karp F. The treatment of post-acne scars with phenol. Br J
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5 Eller JJ, Wolff S. Skin peeling and scarification. JAMA 1941; 116: 934
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