Chemical Peels In Aesthetic Dermatology (1) [621747]

ORIGINAL ARTICLE
Chemical peels in aesthetic dermatology: an update 2009
TC Fischer,†E Perosino,‡F Poli,§MS Viera,–B Dreno,**,* For the Cosmetic Dermatology European
Expert Group1
†Skin and Laser Center, Potsdam, Germany
‡Practice for Dermatology and Aesthetic Medicine, Rome, Italy
§Department of Dermatology, Henri Mondor Hospital, Cre ´teil, France
–zCentroderm – Center for Dermatology and Laser, Madrid, Spain
**Unit of Skin Oncology, University Hospital Center, Nantes, France*Correspondence: B Dreno. E-mail: [anonimizat]
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 thepeeling agent, concentration, frequency and pressure of the application. The usual classification of chemical peelscomprises superficial, medium and deep peels. For superficial peels alpha-hydroxy-acids and most recentlylipo-hydroxy acid are used to induce an exfoliation of the epidermis. Medium-depth agents such as trichloroaceticacid (< 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 ofindications, 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
Chemical peels are methods to cause a chemical ablation of
defined skin layers to induce an even and tight skin as a result ofthe regeneration process. The actual peeling procedure involvesthe application of a caustic chemical substance to destroy layers of
the skin such that they are then spontaneously eliminated over
several days and repair mechanisms of the epidermis and dermisare induced. The mechanical action of peeling, even when limitedto the epidermis, is able to stimula te regeneration via pathways in
the dermis that are not well understood. The depth of destructiondepends on the substance used and its concentration. The use ofchemical peels has been reported since antiquity, but a standard-ized and scientifically based technique has emerged only over the
past decades.History
The earliest use of caustic preparations for peeling procedures was
described in the Egyptian medicine in the Ebers papyrus as earlyas 1550 BC.
1,2Reports are also found in the ancient Greek and
Roman literature. Over the past centuries, some formulas have
apparently been transmitted by gyp sy populations. Dermatologists
began to show interest in peeling in the 19th century. In 1874 inVienna, the dermatologist Ferdinand von Hebra used the tech-nique to treat melasma, Addison’s disease and freckles. In 1882 inHamburg, Paul G. Unna described the actions of salicylic acid,resorcinol, trichloroacetic acid (TCA) and phenol on the skin.Their initial work was followed by that of many other authors.
1
The use of phenol was developed after World War I in France.3
In England, MacKee had already wo rked with phenol for the treat-
ment of scars, but he did not publish his results until 1952.4
Meanwhile, in the United States during the 1940s, Eller and Wolff1Supported by La Roche Posay.
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provided the first systematic description on the use of phenol,
resorcine, salicylic acid and CO 2for the treatment of scars.5The
modern era of peeling began in the 1960s with the development ofmodified phenol solutions (addit i o no fc r o t o no i l ,s e p t i s o la n d
water) by Baker and Gordon
6and histological assessment of peel-
ing results by comparing phenol and TCA peels.7The scientific
basis for TCA peels was extended in the 1970s and early 1980s bythe comparison of the histological effects of three TCA concentra-tions.
8In parallel, at that time, alfa-hydroxy acids (AHA) were
developed by van Scott and Yu as more superficial peels for hyper-keratosis.
9Subsequently, peeling with glycolic acid, the most com-
monly used AHA, was developed.10The description of
combinations of two superficial peeling substances (Jessner’s solu-
tion and TCA 35%) by Brody and Haily11and later by Mon-
heit12to achieve medium-depth effects provided further progress
in the development of chemical peels. The latest development isthe use of lipo-hydroxy acid (LHA).
13
Classification
Chemical peels are classified into three categories based on thedepth of destruction caused by the treatment
14:
dSuperficial peels, which exfoliate epidermal layers withoutgoing beyond the basal layer.
dMedium-depth peels, which reach the upper layers of thedermis down to the papillary dermis.
dDeep peels, which remove the papillary dermis and reachthe 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,T C Ai su s e df o rs u p e r fi c i a l ,m e d i u m – d e p t ho rd e e pp e e l s ,depending on its concentration. Furthermore, combinations ofsubstances that each act as superficial peels may add up to syn-ergistic effect of a medium-depth peel (e.g. Jessner’s solutionand TCA 35%).
General principles of peeling procedures
The process and the technique of a peeling procedure are largelydetermined by the chemical’s nature and the concentration of theapplied peeling substance. However, most peeling procedures fol-low a typical sequence of steps.
Pre-peeling preparation (priming)
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.13Therefore, 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 before-hand because its action on the skin facilitates a more homoge-neous penetration of the peel, leading to a more consistent result.
Moreover, preparation with tretin oin also facilitates to accelerate
the post-procedural healing process.
13–15The concentration of
tretinoin used depends on skin tolerance. In case of intolerance,tretinoin can be replaced by an AHA. To prevent post-inflamma-
tory hyperpigmentation, the epidermal melanogenesis needs to be
inactivated
13,14by the daily use of sunscreens. In patients with a
dark phototype, an additional treatment with a hydroquinone-based preparation may be required.
In patients with a history of herp es infection, medium-depth or
deep peels are preceded with oral anti-herpes treatment started theday before the procedure and continued for 1 week after.
13,14This
prevents the majority of herpes outbreaks during post-peeling
healing (Table 3).
Pre-treatment
A pre-treatment cleansing step directly prior to the actual applica-
tion of the chemical peel substance is a consistent part of everypeeling protocol. It is crucial to obtain a homogeneous penetrationof the peel and thus a uniform result.
14The 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.14The skin
is then rinsed and dried (Table 3).
Treatment
The peeling agent is then applied using, for example, compresses,cotton, an applicator or a brush . Contact time depends on the
caustic agent used and the desired depth. The peel is neutralized
with sodium bicarbonate or water, as necessary.
Each session is terminated with the application of a hydrating
and healing cream. Some authors place bandages after treatmentwith medium-depth and deep peels.
13Treatment can involve the
entire face or only a part. In the latter case, facial anatomy isdivided into four aesthetic units (upper lip, both cheeks and fore-head; fig. 1).
16,17Each unit is treated in its entirety to avoid an
excessively visible demarcation line between treated and untreated
zones.15
Patients should be advised that the treatment may be painful:
dUsually, just a simple sensation of heat is experienced with
superficial peels.
dWith medium-depth peels, more intense pain may requirelocal anaesthesia with an anaesthetic cream.
dDeep peels result in very intense pain that normally neces-sitates general anaesthesia.
Post-peeling care
After a superficial peeling, simple hydration is all that is required.14
For medium peel, downtime is necessary for about one week.Post-operative treatment to accelerate healing is required and isbased on moisturizers. For deep peels, post-operative care is
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required for 10 days and unsightliness imposes social isolation
during this time; healing care, bas ed on moisturizers or bandages,
and daily attentive surveillance are undertaken.14Photoprotection
with sunscreens is recommended for several weeks, especially formedium and deep peels.
14Prophylactic herpes treatment is often
administered to patients suffering from frequent infections, espe-
cially for medium and deep peels.14
Frequency of application
Superficial peels, especially with AHA and beta-hydroxy acids(BHA), require 4–6 applications, generally 2–4 weeks apart.
14Dee-
per peeling products are applied only once.15
Histological changes after peeling
The histological changes observed evidently depend on the depthof peeling. However, all types of peels cause inflammation andinduce healing phenomena that repair the zones damaged by thecaustic agent (Table 4).
18,19
Superficial peeling involves the epidermis and the outermost
part of the dermis. The epidermis becomes thinner and its regen-eration is caused by multiplication of the epidermal cells. New lay-
ers of epidermis are produced. In the dermis, an inflammation
provokes neocollagenesis.
13Stimulation of the epidermis induces
the production of cytokines that, in turn, stimulate the activationo ffi b r o b l a s t s .T h efi b r o b l a s t sp r o d u c ec o l l a g e nt y p e1a n dt y p e4as well as elastin fibres. Medium peeling removes the epidermisand reaches the papillary dermis. The regeneration of skin is
mainly from cells of the hair follicles, which are present deeperthan the areas destroyed by the peeling process. New layers of epi-dermis are formed and collagenesis is stimulated.
13
Deep peeling destroys the epidermis, superficial dermis and
reaches the reticular dermis. The regeneration of the epidermis is
also from cells of the hair follicles. The production of new collagenand ground substance is very important.
13With phenol peeling, a
number of modifications have been reported after several weeks.19
In the epidermis, and in comparison with untreated zones, epider-mal architecture returns to normal. Melanocytes are present anddistributed uniformly. Basal cells contain small melanin grainsdistributed homogeneously. The histological signs of lentigines
and actinic keratosis found in untreated zones are no longer
visible. The thickness of the basal membrane is homogeneous. Inthe dermis, a new sub-epidermal band of collagen and a band2–3 mm thick appears. It is located above the dermis where elas-tolysis occurs, the part of the dermis unaffected by peeling. Thesub-epidermal band is composed of compact bundles of collagenarranged parallel to the skin surface. New elastic fibres form anetwork of fine fibres, often parallel to those of collagen. These
modifications can be observed up to 20 years after Phenol peeling.
19
Mechanisms of action of peels
Superficial peels. Glycolic acid targets the corneosome by
enhancing breakdown and decreasing cohesiveness, causing des-quamation.
20Superficial 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 varieswith the concentration of the acid (e.g. unbuffered solutions of80% concentration have a pH of 0.5, 10% concentration has pH1.7).
21Glycolic acid peels typically need to be properly neutralized
to stop the acidification of the skin; applying acid to the skin satu-rates the ability of cells to resist acidification and excess acid mustbe neutralized to avoid burning the skin.
21AHA peels can be neu-
tralized by basic solutions, such as ammonium salts, sodium bicar-
bonate or sodium hydroxide.21
The LHA molecule acts on the corneosome ⁄corneocyte inter-
face to detach individual corneosomes cleanly.22The corneosome
is detached from adjacent corneocytes without fragmentation, sug-gesting 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.
22LHA
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 contr ast to many other peeling chemi-
cals, LHA has a pH that is similar to that of normal skin (5.5) anddoes not require neutralization.
Medium peels. Medium-depth peels, such as TCA, cause
coagulation of membrane proteins and destroy living cells of the
Figure 1 Facial treatment areas for the peeling procedure.
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epidermis and, depending on the concentration, the dermis.21
New, healthy keratinocytes replace abnormal cells and stimulate
the skin to produce new collagen.21The depth of skin necrosis
correlates closely with the potency of the medium-depth peel.
Deep peels. Deep peels act in the reticular dermis, while med-
ium-depth peels target the papillary dermis and stimulate new col-lagen deposition, decrease elastic fibres and increase activatedfibroblasts.
23,24Deep peels coagulate proteins, which produces the
frosting seen clinically, and pr oduce complete epidermolysis.21In
addition, phenol peels restructure the basal layer by incapacitatingmelanocytes and inhibiting transfer of melanosomes to nearbykeratinocytes.
21Deep peels can also destroy the papillary dermis,
restoring the dermal architecture.21
Chemical substances used for peelings
Alfa-hydroxy acids
Among superficial peels, the most commonly used product is gly-
colic acid. It is used in solutions at concentrations varying between25% 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. Gly-colic acid is always used over several sessions (generally 6) severalweeks apart. As sessions progress, the concentration of the solutionused and application time are progressively increased depending
on tolerance and the result obtained after preceding sessions.
15
Other AHA exist, including lactic acid,25pyruvic acid26and man-
delic acid, but are used less frequently.
Beta-hydroxy acids
Salicylic acid has been used for a long time, but is used much lessfrequently since the advent of peeling with AHA. This superficialpeel is employed at weekly sessions for 6–8 weeks.
27,28,29A peel
using a lipophilic derivative of salicylic acid, lipo-hydroxy acid(LHA), has recently been introduced.
13It is the newest product in
this category. The LHA is used in 5% and 10% concentrations.
Resorcin or resorcinol
Resorcin is generally used in preparations, the most widely usedbeing Jessner’s solution,
14the formula of which is: 14 g of resor-
cinol, 14 g of salicylic acid, 14 mL of lactic acid, ethanol q.s.100 mL. This provides a superficial peel
14and the preparation is
used in a single session. Some authors combine Jessner’s solutionwith a 35% TCA peel in the same session to obtain a medium-depth peel.
12,30Resorcin is not used in some European countries.
Trichloroacetic acid
Trichloroacetic acid has been used as a peel for a long time.The depth of peeling depends on the TCA concentration:
Table 1 Indications and contraindications for peeling procedures
Treatment
stepsPeeling
agentPeeling level
Superficial Medium-deep Deep
AHA ⁄BHA ⁄LHA TCA 35% or combinations TCA > 50%, phenol
Indications Photoaging
Roughness, yellow stainsFine lines; keratosisSolar lentigines
Pigmentary disorders
MelasmaPost-inflammatory
Retentional acne ± comedone
extractionPhotoaging
Fine linesWrinkles
Pigmentary disordersSuperficial atrophic scarsSevere photoaging
Pigmentary disordersScars
Contraindications Absolute Pregnant, nursing patients,
6 months isotretinoin treatmentActive herpes simplex; cold soresFitzpatrick skin types V-VIPregnant, nursing patients,
6 months isotretinoin
treatment
Active herpes simplex; cold
sores
Fitzpatrick skin types IV–VIPregnant, nursing patients,
6 months isotretinoin treatmentActive herpes simplex; cold soresFitzpatrick skin types IV–VIPhenol: insufficient kidney function
Relative Cold sores: 4–6 weeks after
healing
Botulinum toxin: 1–2 weeks afterCollagen injections: 2 weeks
before or after
Facial surgery: 6 weeks after
oedema
Laser: 8 weeks after
Electrolysis and dying: 7 days
before or after
Waxing, depilatories: 3 weeks
afterQuestionable patient
compliance
Regular sun exposureHeavy cigarette smokingInactive but recurring herpes
infections
Oral oestrogen intake
History of hypertrophic
scarring
Connective tissue disordersAdvanced AIDS stages
TCA, trichloroacetic acid; AHA, alfa-hydroxy acids; BHA, beta-hydroxy acids; LHA, lipo-hydroxy acid.
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between 10% and 30% is considered a superficial peel; above
30% provides a medium-depth peel. The concentration used
generally does not exceed 50%.14The depth of the peeldepends not only on the concentration, but also on the time
of application. The depth reached is precise as a function of
symptomatology (Table 1),14,31,32but requires considerable
Session 2
10%
Before 10 min
1 day 3 days
Figure 2 Clinical effect of a single treatment with lipo-hydroxy acid.
Before After 4 sessions 5%/10%/10%/10%
Figure 3 Clinical effect after four treatments.
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experience. A TCA peel is thus highly operator-dependant.
There is no need to neutralize the product.
Phenol
Phenol is used in solution and there are many formulas.14Treatment
is very painful and requires general anaesthesia or deep sedation.The risk of heart failure requires ca rdiac monitoring; therefore, hos-
pitalization is obligatory.
33Phenol is used for deep peels and is a dif-
ficult product to use. Laser resurfacing is generally preferred now.34
Indications
Indications can be divided into two groups; those for which thereis an indisputable consensus and those reported in very rare cases.
Recognized indications
dWrinkles . Peels are part of the classical strategy for managing
skin ageing.14,34,35Superficial peels act on fine superficial lines
(figs 2 and 3). Some peels can modulate both epidermal and
dermal signs of ageing, especially through epidermal thicken-ing and dendrocytic hyperplasia. Medium-depth and deep
peels result in neocollagenesis and so are active against med-
ium-sized wrinkles (figs 4–6). Very few comparative studieson peels have been conducted. In one, LHA peel (withoutneutralization) was compared with glycolic acid (20% and50% with neutralization) in a split-face study of mild to mod-erate facial ageing. Wrinkle improvement was noted in 41%on the LHA side and 30% on the glycolic acid side.
36
dComplexion, melasma and lentigines . (1) Superficial peels
result in a regular epidermal structure with uniform distri-
bution of melanin and the elimination of melanin accu-mulations.
18Clinically, superficial peels impart a radiant
complexion, treat melasma at the dermal–epidermal junc-tion and improve lentigines.
14,32In the study comparing
LHA and glycolic acid discussed above, 46% of womenshowed an improvement in pigment disorders on theLHA side vs. 34% on the glycolic acid side.
13(2) Med-
ium-depth or deep peels are also effective on lentigines
and improve the complexion.14,32However, they are
contraindicated for melasma as they may cause post-
Figure 4 Clinical effect of deep phenol peel on wrinkles (baseline
and 3 months post-peel). Photos courtesy of Dr Torsten Walker.
Figure 5 Clinical effect of deep phenol peel on wrinkles (baseline
and 7 months post-peel). Photos courtesy of Dr Torsten Walker.
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inflammatory hyperpigmentation that aggravates the initial
symptomatology. Precautions associated with their use are
proportional to the darkness of the skin to be treated.36,37
dScars . Medium-depth and occasionally deep peels are used
on relatively shallow scars to elevate the base of the scarby neocollagenesis and to lower the edges by the abrasion
they cause. They are often proposed to treat regular shal-
low acne scars.14,38–40
dActinic keratosis . Some authors have proposed using
medium-depth or deep peels to treat profuse actinic
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 Jessner’s solution. Photos courtesy of Dr Torsten Walker.
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keratoses.12,13,41Recently, Hantash and colleagues con-
ducted a prospective, randomized, 5-year trial to evaluatethe ability of chemical peeling (30% TCA) as a prophy-laxis against actinic keratoses.
42The 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 comparedwith that of a control group ( P= 0.07).
42
dAcne : Some authors have proposed superficial peels as
adjuvant treatments for acne (fig. 7); they act as comedo-lytic agents
43–47but have no effect on seborrhoea.46Super-
ficial peels can result in improvement in both skinappearance and texture,
29but have very few effects on
atrophic or hypertrophic scars; they may also improve
penetration of topical acne therapies.45Best results may
occur when these peels are used in patients with oily skinand seborrhoea. Peels should be used as an adjunctivetreatment to the appropriate topical and oral medications.Depending on the climate, the type of peel may be rotatedon a seasonal basis. Acne flare is possible with peels, andpatients 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 glycolicacid 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).
47Both
treatments were effective, but the effect of salicylic acid was sus-
tained longer and this peel was associated with fewer side-effectscompared with that of glycolic acid.
47In acne prone women, LHA
reduced both the number and the s ize of microcomedones, the
acne precursor lesions.48The same study also showed that unplug-
ging the follicle was associated with lower bacterial loads in the fol-licle and a reduction in follicular size.
48We can hypothesize that
the lipophilic form of salicylic acid could increase the effect ofsuperficial peeling; this effect may be attributable to a better pene-tration into the sebaceous follicle.
Other indications
Peeling has been proposed to treat flat warts,26Pseudofolli-
culitis barbae,37trichoepitheliomas,49rhinophyma,50generalizedlinear epidermal naevus51and tumour prophylaxis in xero-
derma pigmentosum.52There is relatively little documentation
on these indications, which are sometimes based on an oldand unconfirmed publication. Considerable caution is thusrequired in these cases. Anecdotally, the authors have had
good experience with superficial peels for keratosis pilaris, par-
ticularly on the arms, legs and backs. Peels may also be usefulto enhance the results of laser therapy or other concomitantlyused procedures. The different indications and contraindica-tions are summarized in Table 1.
Side-effects management and prevention of
complications
All peels should be managed with care to minimize the potential
for side-effects; the level of expertise in administering peels isvitally important to ensure a good outcome. Generally, the depthof peel correlates with the potential for side-effects and the bene-fit⁄risk ratio changes with increasingly deeper peels. Superficial
peels very rarely cause complications, which are usually not severe– transient mild hyperpigmentation, redness during the first nightand a flare-up of pimples have been reported.
14Medium peels
cause marked redness for several days, followed by desquamation
that can be quite significant. There is a high risk of hyperpigmen-tation and solar lentigines following treatment. Therefore, a strin-gent photoprotection with sunscr eens is recommended for several
weeks. Because of the risk of hyperpigmentation, medium-depthpeels are unsuitable for phototype V or VI patients. There is alsoan increased risk of herpes infection.
6
For deep peels, the risk of complications is significant,
particularly post-operative in fections and, more importantly,
pigmentation problems such as frequent early transient hyper-pigmentation followed by hypopigmentation, or even total andpermanent achromia. Deep peels are, therefore, performed onlyin patients with light phototypes. These are currently used toa lesser extent because of the greater risk of complications. Ina recent study, a rate of cardiac complications (most notablyarrhythmia) of 7% has been reported for phenol peels.
6The
different side-effects and complications are summarized in
Table 2.
Table 2 Side-effects and complications for peeling procedures
Peeling level
Superficial Medium-deep DeepAHA ⁄BHA LHA TCA 35% or combinations TCA >50%, phenol
Potential
side-effects ⁄complicationsRedness
Transient hyperpigmentationPimplesRedness
HerpesHyperpigmentationLentiginesPain
RednessHerpesTransient hyperpigmentation
Infection
HypopigmentationPermanent achromiaHeart failure (phenol)
TCA, trichloroacetic acid; AHA, alfa-hydroxy acids; BHA, beta-hydroxy acids; LHA, lipo-hydroxy acid.
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Table 3 Clinical effect after four treatments
Treatment steps Peeling agent Peeling level
Superficial Medium–deep DeepAHA (glycolic acid, pyruvic acid) BHA
(salicylic acid, LHA)TCA 35% or combinations TCA >50% phenol
Preparation (Priming) Time 1–2 weeks prior to first session 2–3 weeks prior to session
Purpose To prepare the skin by starting
the exfoliating process
To optimize and homogenize thepenetration of the peel solutionTo prepare the skin by starting
the exfoliating process
To regulate pigment content inpatients with strong pigmentation
Solutions LHA Cleansing gel
LHA solution(0.25% LHA)LHA Serum
(0.45% LHA)Topical AHA or BHA
Topical retinoidsVitamin CVitamin ECreams and solutions containing:
Topical retinoidsVitamin C ⁄vitamin E
Depigmenting solution
(e.g. hydroquinone
1.0⁄dexamethasone
0.02 ⁄tretinoin 0.0125 ⁄Ung. emulsif.
nonion. ad 20.0)
Procedures Daily cleansing
Gel and ⁄or solution
daily skin careLHA Serum, 0.45% LHADaily application
over 3 weeksDaily application over 3 weeks Daily application
over 3 weeks
Purpose Cleaning and degreasing of skin
prior to treatment to achieve
homogenous peeling resultsNo sedation or analgosedationCleaning and degreasing of skin prior
to treatment to achieve homogeneous
peeling resultsSedationCleaning and
degreasing of skin
prior to treatment toachieve homogeneouspeeling resultsAnalgosedation
Solutions LHA Solution (0.25%)
degreasing wipe (vaseline)Hexachlorophene
cleanser
Acetone or
acetone–alcohol mixtureGauze padsDiazepam 5–10 mg p.o.Hexachlorophene cleanser
Acetone or acetone–alcohol mixture
Gauze pads
Diazepam 5–10 mg p.o.± Non-steroidal antiphlogisticsHexachlorophene cleanser
Acetone or acetone–alcohol
mixture
Gauze padsDiazepam 5 mg + pentazocin15 mg i.v.+ Regional block (bupivacaine)+ Non-steroidal antiphlogistics1.0–1.5 l volume infusion
Procedure Eye protection (patient and
physician)
Cleansing (no rinsing)Degreasing with wipe (vaselineprotection for sensitive areas)Eye protection
(patient and physician)
Cleansing withhexachloropheneThorough rinsing withwater, dryDegreasing with
acetone or
acetone–alcohol mixture(vaseline protection forsensitive areas)Eye protection (patient and physician)
Cleansing with hexachlorophene
Thorough rinsing with water, dryDegreasing with acetone oracetone–alcohol mixture (vaselineprotection for sensitive areas)Eye protection (patient
and physician)
Cleansing with hexachloropheneThorough rinsing with water, dryDegreasing with acetone oracetone–alcohol mixture(vaseline protection for
sensitive areas)
ECG control required
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Table 3 Continued
Treatment steps Peeling agent Peeling level
Superficial Medium–deep DeepAHA (glycolic acid, pyruvic acid) BHA
(salicylic acid, LHA)TCA 35% or combinations TCA >50% phenol
Treatment Time + ++ +++ ++++
Purpose Exfoliation of epidermal layer Actual peeling process Actual peeling processSolutions Cotton-tip applicators
LHA solution (5%, 10%)Brush or gauze
AHA (e.g. glycolic acid 20%)Cotton-tip or gauze
TCA alone (e.g. 35–50%)TCA combination(e.g. Jessner’s solution+ TCA 35%)Cotton-tip or gauze, (waterproof tape)
Phenol solution (e.g. Baker–Gordonsolution:phenol 50%, 2% croton oil)TCA combination (e.g. Jessner’s
solution + TCA 35%)
Procedure Application to facial units
in order of fig. 2.1–3 layers, depending on skin typeApplication to facial units
Variable number of layersAppliction to facial regions
Combinations:
1. Jessner’s solution2. TCA solution
(variable number of layers)Applcation to each facial region with
5–15 min intervals between regionsOne application per region (occlusionwith waterproof tape)
Neutralization No Yes Yes Yes
Frequency 4 (4)-6-(8) 1 1
Post-treatment Time 15 days 15–28 days 1–2 months 2 months
Purpose To stabilize and enhance the
exfoliating processTo prepare skin for next
peeling procedureTo prevent infection and
pigmentation disordersTo enhance the regeneration
processTo prevent infection and enhance
wound healingprevent pigmentation disorders
Solutions LHA cleansing gel
LHA solution(0.25% LHA)LHA serum(0.45% LHA)Topical AHA or BHA in
Topical retinoidsVitamin C ⁄vitamin EBland emollient cream
NaCl solution or acetic acidsoaked compresses alternativelyNon-steroidal anti-inflammatorydrugs (e.g. acetyl salicylic acid)Bland emollient cream
Antibiotic skin cream (e.g. refobacine)0.25% Acetic acidNon-steroidal anti-inflammatory drugs(e.g. acetyl salicylic acid)
Procedure Daily cleansing with gel
and⁄or solution, no rinsing
Daily skin care, LHA serum
0.45% LHADaily application over 3 weeks
Thorough rinsing requiredSoak face 4–5 times in first 24 h
Apply bland emollient cream andwet NaCl or acetic acid soaked
compresses alternativelyLeave occlusion for 12–48 h
Debridement by soaking with aceticacid solutions and compresses
Open and ⁄or occlusive application
of emollient and ⁄or antibiotic creams
General remarks Daily application of a
sunscreen product with anSPF 15 or higher withUVA ⁄UVB for 2–3 months
usually no antiviral treatment
requiredDaily application of a sunscreen
product with an SPF 15 or higherwith UVA ⁄UVB for 6 months
Optional antiviral treatment(e.g. acyclovir 400 mg 2 ·⁄d)Daily application of a sunscreen
product with an SPF 15 or higherwith UVA ⁄UVB for 6–12 months
Antiviral pre- and post-treatmentrequired (e.g. acyclovir 400 mg 2 ·⁄day)
TCA, trichloroacetic acid; AHA, alfa-hydroxy acids; BHA, beta-hydroxy acids; LHA, lipo-hydroxy acid.ă2009 The Authors
JEADV 2010, 24, 281–292 Journal compilation ă2009 European Academy of Dermatology and Venereology290 Fischer et al.

Conclusion
Chemical peels represent a flexible and useful tool for improving
skin texture and the effects of ageing. Peels are available in a vari-ety of formulations that allow the clinician to individualize therapyto the patient’s presentation. This technique is indicated for arange of skin problems, including wrinkles, acne and pigmentarychanges. In addition, peels may be used with other techniques aspart of a multimodality approach to improve skin texture andresurface skin.
Three major points are essential for successful chemical peels:
dClinical concept – peeling is more than ‘‘an ablative tech-
nique’’: the process uses the inflammatory reaction anddermal stimulation proactively to modify the skin.
dPre- and post-procedure skin – never underestimate the
role of the pre- and post-treatment for the efficacy ofthe peel. It will determine the level of re-epithelial-ization, remodelling effects as well as scaring ⁄recovery
time.
dSide-effects – the level of expertise of a dermatologist is
crucial for the rate of side-effects and for the final peelresults. Superficial peels are easy to perform and their ben-efit⁄ratio risk is very good.
Acknowledgements
The Cosmetic Dermatology European Expert Group – sup-
ported by La Roche Posay. Photos courtesy of Dr Torsten
Walker, Deutschland.
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