Chemical Peels. Abstract. Individual Consultation. Adrianna Jackson, MD 1

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1 26 Adrianna Jackson, MD 1 1 Advanced Dermatology and Skin Care, Dermatology, Katy, Texas Facial Plast Surg 2014;30: Address for correspondence Adrianna Jackson, MD, Advanced Dermatology and Skin Care, Dermatology, 430 S. Mason Rd., Suite 101, Katy, TX ( dradri23@gmail.com). Abstract Keywords chemical peel resurfacing photodamage pigmentation rhytides Chemical peels are resurfacing procedures used for skin rejuvenation. In a controlled fashion, chemical peels induce injury at a specific depth in the skin. The wound produced by resurfacing promotes collagen remodeling and improves surface appearance. Chemical peels are categorized as superficial, medium depth, or deep according to the level of injury ( Table 1). Superficial chemical peels cause necrosis of the epidermis only, while medium-depth peels create a wound through the epidermis into the level of the upper reticular dermis. Deep chemical peels penetrate to the level of the midreticular dermis. Each resurfacing procedure addresses various aspects of pigmentation, photodamage, and skin texture. The provider must take into consideration the patient s skin type, photodamage, healing time, and possible complications before choosing the appropriate peel to give maximum improvement with the least risk of adverse events. Chemical peels date back to ancient Egypt, when various chemicals were applied to the skin for improved skin texture. The role of chemical peels has evolved over the last several decades and now plays a critical role in facial rejuvenation and aesthetic medicine. 1,2 Chemical resurfacing is the fourth most common nonsurgical cosmetic procedure performed in the United States. 3 The chemical peel strength depends on the amount of free acid present. Free acid availability (pk a )reflects the acid s Chemical peels are a method of resurfacing with a long-standing history of safety in the treatment of various skin conditions. This article reviews the classification of different chemical agents based on their depth of injury. The level of injury facilitates cell turnover, epidermal thickening, skin lightening, and new collagen formation. Preprocedural, periprocedural, and postprocedural skin care are briefly discussed.toselectthe appropriate chemical peel, the provider should evaluate the patient s expectations, medical history, skin type, and possible complications to determine the best chemical peel to achieve the desired results. Patients with Fitzpatrick skin types IV to VI have increased risk of dyspigmentation, hypertrophic, and keloid scarring. These individuals respond well to superficial and medium-depth chemical peels. Advances in the use of combination peels allow greater options for skin rejuvenation with less risk of complications. potency and is linked to the acid strength. 4 Lower pk a means more free acid available. Additionally, the chemical peel strength is affected by percentage of acid, type of vehicle used, buffering, pk a of acid preparation, and contact time. Individual Consultation The preprocedure consultation is crucial in determining whether the patient is a candidate for chemical resurfacing and the optimum chemical peel for each patient. After identifying the patient s expectations, the physician must assess the prospective patient s Fitzpatrick skin type and his or her skin condition carefully to determine potential intraprocedural and/or postprocedural complications. Once the provider decides the patient is a candidate for chemical resurfacing, the most suitable chemical agent can be selected. Important aspects of the patient s history to be addressed in the initial consultation include prior medium-depth or deep chemical peels within the last 3 months; recent facial surgery with extensive undermining; or isotretinoin therapy within the last 6 months. These clinical findings can increase the risk of postprocedural complications with medium-depth and deep chemical peels. 5,6 Prior history of abnormal scar formation such as hypertrophic and keloid scars warrants prudence during the patient selection process. Examine Issue Theme Classical and State-of-the- Art Skin Rejuvenation; Guest Editors, Lisa D. Grunebaum, MD, and Noëlle S. Sherber, MD, FAAD Copyright 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) DOI /s ISSN

2 Jackson 27 Table 1 Classification of chemical peels by depth of injury Peel type Depth (μm) Level of injury Chemical agent Superficial very light < 100 Injury to the stratum corneum þ/ stratum granulosum; exfoliation of the stratum corneum Superficial light 100 Necrosis of the entire epidermis down to the basal layer; stimulate regeneration of new epithelium Medium depth 200 Wound extends through the epidermis and papillary dermis þ/ upper reticular dermis; increased collagen production Deep > 400 Necrosis to part or all of the mid-reticular dermis; leads to new collagen production patients for facial vellus hairs to confirm the presence of intact pilosebaceous units. Individuals with complete absence of pilosebaceous unit from prior X-ray or radiation therapy may have delayed reepitheliazation. 7 Poor wound healing, as a result of poor nutritional status, nicotine use, or immunosuppression, is a contraindication to chemical peels. 4 Obtain a history of past or current skin infections or open wounds such as herpetic infections that require prophylactic antiviral therapy. The risk of eczema herpeticum necessitates the use of prophylactic antiviral therapy. For medium-depth or deep chemical peels, all patients must be treated prophylactically with acyclovir 400 mg three times daily or valacyclovir 500 mg twice daily, beginning 1 to 2 days before the day of the procedure. The recommended duration of antiviral treatment is 10 to 14 days. 8 Physicians must take caution when performing peels in patients on systemic medications such as oral contraceptives and hormonal agents that increase hyperpigmentation. If possible, individuals should discontinue photosensitizing medications during the periprocedural period. 4 Patients with a history of particular skin conditions such as rosacea, seborrheic dermatitis, atopic dermatitis, psoriasis, vitiligo, or active retinoid dermatitis may experience postprocedural complications, including exacerbation of skin disease, protracted erythema, delayed healing, or contact dermatitis. For example, chemical peels may unmask telangiectasias and cause an amplified inflammatory response in individuals with rosacea. 9 During the physical exam, the physician should closely evaluate the patient s skin type and the degree of photodamage. The Fitzpatrick skin type classification will help the physician determine patient tolerability and response to Low potency AHA Salicylic acid 10 20% TCA Retinoic acid 40 70% GA/AHA 25 30% TCA Jessner solution Solid CO 2 Vi Peel Nomelan Fenol KH Melanage 35 50% TCA (not recommended) Jessner þ 35% TCA 70% glycolic acid þ 35%TCA Hetter VL (phenol) Solid CO2 þ 35% TCA > 50% TCA Hetter all around Stone 100 (Grade 2) Exoderm-Lift Baker Gordon phenol peel Abbreviations: AHA, alpha-hydroxy acid; CO 2, carbon dioxide; GA, glycolic acid; TCA, trichloroacetic acid. Adapted from Bolognia JL, Jorizzo JL, Rapini RP, et al, eds. Dermatology. 2nd ed. Spain: Mosby; Table Rullan P, Karam AM. Chemical peels for darker skin types. Facial Plast Surg Clin North Am. 2010;18(1): Table 2. Tung R, Rubin MG. Procedures in cosmetic dermatology series: Chemical peels. 2nd ed. Saunders; Box 2.1 and Box 2.2. various chemical agents ( Table 2). Photoaging is likely the single most common condition for which chemical resurfacing procedures are often performed. 9 The Glogau system quantifies photodamage ( Table 3). Both the Fitzpatrick skin type scale and Glogau photoaging classification system are used to objectively assess the appropriate chemical peel for an individual patient. Patients with Glogau type I skin are usually young with mild photoaging and would benefit most from a superficial peel in conjunction with medical and/or cosmeceutical therapy. Patients with Glogau type II would benefit from a medium-depth peel, medical management such as a retinoid and/or α-hydroxy acid (AHA). 9 Individuals with Glogau type III skin usually benefit from medical treatment with a medium-depth peel, deep peel, dermabrasion, or laser resurfacing. Deep chemical peel, dermabrasion, or laser therapy in combination with medical therapy may be indicated in patients with Glogau type IV skin. In spite of this, surgical operation including rhytidectomy, blepharoplasty, or scar revision is often necessary in addition to resurfacing to achieve clinical improvement with Glogau type IV skin. 9 Individuals with Fitzpatrick skin types I and II are at low risk for postprocedural pigmentation complications. They can usually be treated with any depth of chemical peels. In contrast, those patients with Fitzpatrick skin types IV to VI have a greater risk of developing hyperpigmentation or hypopigmentation and should avoid deeper peels. in Darker Skin Types The benefits and complications of chemical resurfacing differ between various racial and ethnic groups. Patients with ethnic

3 28 Jackson Table 2 Fitzpatrick skin classification based on skin tone and the patient s cutaneous reaction to ultraviolet sun exposure Skin type Color Skin reaction to first summer exposure I Very white or freckled Always burn, never tan II White Usually burn, but sometimes tan III White to olive Sometimes burn, tan moderately and gradually IV Moderate brown Rarely burn, tan with ease V Dark brown Very rarely burn, tan very easily VI Black No burn, tan very easily Adapted from Bolognia JL, Jorizzo JL, Rapini RP, et al, eds. Dermatology. 2nd ed. Spain: Mosby; Table Taylor SC, Badreshia-Bansal S, Callender VD, Gathers RC, Rodriguez DA. Chemical peels. In: Treatments for skin of color. Saunders; 2011: Table 1. Rullan P, Karam AM. Chemical peels for darker skin types. Facial Plast Surg Clin North Am. 2010;18(1): Table 1. Tung R, Rubin MG. Procedures in cosmetic dermatology series: Chemical peels. 2nd ed. Saunders; Table 2.1. Table 3 Glogau photoaging classification also referred to as the wrinkle scale Type I: No wrinkles Early photoaging Mild pigmentary changes No keratoses Minimal wrinkles Younger patient 20s or 30s Minimal or no makeup Type II: Wrinkles in motion Early-to-moderate photoaging Early senile lentigenes visible Keratoses palpable but not visible Parallel smile lines beginning to appear lateral to the mouth Patient age late 30s or 40s Usually wears some foundation Type III: Wrinkles at rest Advanced photoaging Obvious dyschromia Visible keratoses Wrinkles even when not moving Patient age 50s or older Always wears heavy foundation Type IV: Only wrinkles Severe photoaging Yellow-gray skin color Prior skin malignancies Wrinkled throughout with no normal skin Patient age 60s or 70s Cannot wear make-up cakes and cracks Adapted from Bolognia JL, Jorizzo JL, Rapini RP, et al, eds. Dermatology. 2nd ed. Spain: Mosby; Table Tung R, Rubin MG. Procedures in cosmetic dermatology series: Chemical peels. 2nd ed. Saunders; Box 2.4. skin respond well to superficial and medium-depth peeling agents. However, individuals with Fitzpatrick skin types IV to VI are at greater risk for dyschromias after medium-depth or deep chemical resurfacing. The physician must exercise great caution with selection of the chemical peel. Acne vulgaris and pigmentary dyschromias are two of the most common cutaneous conditions seen in skin of color. The most common indications for chemical peeling in dark skin include pigmentary disorders, such as postinflammatory hyperpigmentation (PIH) and melasma, acne vulgaris, scarring, pseudofolliculitis barbae, textural changes, and oily skin. 3 PIH/melasma will be covered in more detail in the article entitled Treatment of Unwanted Pigment in this issue. PIH is an acquired excess of melanin production that occurs after there is damage or irritation to the skin. Melasma is also an acquired pigmentary dyschromia with hypermelanosis. The exact cause of melasma is unknown, although genetics and sun exposure are considered important contributing factors. 3 Melasma can be classified into epidermal, mixed, or dermal type. Acne vulgaris, PIH, and epidermal type melasma respond well to superficial and medium-depth peels. Mixed and dermal melasma are very difficult to treat due to the deeper pigment. Deep chemical peels may improve deep pigment; however, the potential risk of hyperpigmentation outweighs the benefit of deep chemical peeling. A test spot is recommended in some patients to evaluate their tolerability for chemical peels and may be useful when there is concern about the adverse event of postprocedural pigmentation. 10 It is important to counsel patients with darker skin types about the pre- and post-peel treatment. For 2 to 12 weeks before the peel, lightening agents such as hydroquinones, steroids, kojic acid, azelaic acid, and antioxidants may be used to gradually lighten pigmentary dyschromias, and are particularly effective when used in combination with retinoic acid or AHAs, which promote exfoliation of the epidermis. 4,11 Because of the increased epidermal turnover, it is recommended in darker skin tones that retinoids be discontinued 1 to 2 weeks before peeling to avoid complications of dyschromia and scarring. Agents containing lower strength AHA, polyhydroxy acids, and β-hydroxy acids (BHA) are less

4 Jackson 29 aggressive than retinoids and can be used up to 1 or 2 days before peeling darker skin types. 4 Sun protection with daily use of a broad-spectrum sunscreens and vigilant sun avoidance for at least 2 months pre- and post-peel treatment are imperative to preventing hyperpigmentation. 4 Individuals with a personal history of PIH may benefit from a single dose of oral corticosteroid (prednisone mg) to decrease inflammation immediately after medium-depth and deep peels, as a result reducing the risk of PIH. 9 Topical corticosteroids for 1 or 3 days post-peel are also useful to prevent PIH for superficial peels in darker skinned patients. Postprocedure, the physician should advise the patient to avoid peeling or scratching to avoid PIH. In skin of color, it is recommended to start with low concentrations of peeling agents such as tretinoin, glycolic acid, salicylic acid, and Jessner solution. These peels have a lower risk of postprocedure complications compared with superficial trichloroacetic acid (TCA) (25 30%) peels. 4 When TCA concentrations of 10 to 30% are utilized in skin types IV to VI, frost is not desired in dark skin because it increases the risk of adverse events such as pigmentation and scarring. 4 Glycolic acid peels can improve skin texture and acne when treating darker skin types with sensitive skin. When using glycolic acid peels in skin of color, the agent should be neutralized immediately if erythema or epidermolysis occurs. The Vi Peel (Vitality Institute Medical Products, Culver City, CA) is a preferred peel safe for use in skin of color. The Vi Peel is a premixed formula containing TCA (10 12% in alcohol), phenol (10 12%), salicylic acid (10 12%), tretinoin ( %), and 4% vitamin C. The home regimen consists of two night applications of towelettes with the same percentage of tretinoin oil and vitamin C. The Melanage Peel (SkinLuma, LLC, Stony Creek, CT) is designed for dark skin types with melasma and PIH. It is available as a kit that includes 1% tretinoin solution, a powder formulation of hydroquinone, which is freshly mixed at the time of use with 10% azelaic acid, 10% lactic acid, and 10% phytic acid. Physicians can make up to a 14% hydroquinone peel, which is left as a mask for up to 8 hours on the skin. The patient removes the peel at home. The home kit regimen includes a ready-to-mix bleaching cream consisting of 4% hydroquinone and to 0.75% tretinoin with an optional 0.7% hydrocortisone for possible irritation applied nightly for 2 months. The key features of this peel are that it is weakly acidic, noncorrosive, minimally inflammatory, and causes no protein precipitation. It can be performed once yearly, and can be followed by optional series of three to four minipeels during the year. 12 The Nomelan Fenol KH (SESDERMA; S.L. Rafelbunyol, Valencia, ES) includes TCA, phenol, hydroquinone, kojic acid, glycolic acid, α-arbutin, ascorbic acid, salicylic acid, phytic acid, mandelic acid, and retinoic acid mixed in an alcohol base. 12 The peel mixture is applied for 3 to 5 minutes, followed by application of a 10% retinol/1% retinyl propionate cream for 6 to 8 hours. The home kit contains 10% vitamin C/ 5% niacinamide and a cream with 15% lactic acid, 4% retinol, and 1% retinyl propionate. 12 The newer modified versions of phenol formulas consist of phenol peels where the percentage of croton oil directly affects the absorption of phenol and thus the cardiac and renal toxicity of the phenol component. The lower strength modified phenol formulas are safe in darker skin types as compared with the early Baker Gordon phenol peel. Some physicians have used modified phenol peels to treat hyperpigmentation in darker skin types. 12 Common phenol formulas include Hetter all around (35% phenol, 0.4% croton oil), Hetter VL (30% phenol, 0.1% croton oil), Delasco Stone 100 (60% phenol, 0.2% croton oil), and the patented Exoderm (Exoderm I.M.C., Germany) (64% phenol, % croton oil). Preprocedural and Intraprocedural Skin Priming Skin priming is a critical part of the peeling process and significantly affects the efficacy of the peel. Skin priming is defined by two phases: (1) pretreatment and (2) preparation. 4 The pretreatment period occurs 2 to 4 weeks before the peel. The purpose of pretreatment is to enhance the results of the chemical peel. Two primary goals of both phases are to thin the stratum corneum, improve uniform active agent penetration, accelerate healing, and reduce the risk of PIH and/or scarring. Pretreatment with tretinoin 0.05% cream for at least 2 weeks may accelerate healing. Other agents used in the pretreatment phase include hydroquinone, salicylic acid, glycolic acid, kojic acid, retinol, azelaic acid, topical steroids, and sunscreen. Preparation involves those measures that occur immediately before and leading into the peel. 4 Degreasing with acetone, rubbing alcohol, or Septisol (MERCK & Co., Whitehouse Station, NJ) (triclosan) is essential for penetration, as most agents are not lipid soluble. Additional depth-enhancing agents used by other authors such as Jessner solution, glycolic acid, solid CO 2, fluorescing agents, topical anesthetics, and chlorhexidine gluconate may be applied before the chemical peel. 4 Description of Superficial Peels Superficial peels cause necrosis of all or part of the epidermis and may reach the papillary dermis. These peels are divided into two varieties very light and light. 9 With very light peels, the level of injury is typically limited to the stratum corneum, but the injury may reach the stratum granulosum. 9 The agents for very light peels include low potency AHAs, salicylic acid, 10 to 20% TCA, and tretinoin Light peels cause necrosis of the entire epidermis including the basal layer. Light peels include agents such as 70% glycolic acid, 25 to 35% TCA, Jessner solution, and solid carbon dioxide (CO 2 )slush. 13,15 Superficial peels are well tolerated by patients of all skin types. Additionally, superficial peels have limited down time after treatment. Superficial peels treat acne and its postinflammatory erythema, mild photoaging, actinic keratoses, solar lentigines, and pigmentary dyschromias. Because of the level of injury by the superficial peels, patients require multiple treatments on a weekly-to-monthly basis to achieve the desired result. Superficial peels do not provide

5 30 Jackson improvement in wrinkles or deep furrows that are attained with deeper peels. Adjuvant therapy with retinoids and/or lightening agents enhances the clinical results. AHAs are carboxylic acids naturally found in many foods. AHAs used for peeling include glycolic, lactic, citric, and malic acids. The most widely used formulations of AHAs are glycolic and lactic acid. Lactic acid, derived from sour milk, and glycolic acid, found in sugarcane juice, have been used for centuries to treat acne, photoaging, melasma, lentigines, and keratosis pilaris and improve skin texture, color, and wrinkles. Lactic acid acts as a humectant, which causes hydrophilic absorption of water, and a keratolytic, which exfoliates superficial layers of the epidermis. AHAs thin the stratum corneum with subsequent formation of a fresh new epithelium. Glycolic acid concentrations range from 20 up to 70%. Following application, it must be neutralized with sodium bicarbonate or plain water. In low concentrations, glycolic acid decreases the cohesion of corneocytes by promoting exfoliation of the outer layers of the stratum corneum. 16 Glycolic acid improves signs of photoaging, melasma, lentigines, acne, seborrheic keratosis, keratosis pilaris, and warts. Glycolic acid can be used in combination with 5-fluorouracil for the treatment of pre skin cancer conditions, such as actinic keratoses and actinic cheilitis, as a so-called fluorhydroxy pulse peel. Salicylic acid is a BHA derived from willow bark, wintergreen leaves, or sweet birch. Salicylic acid can be used in concentration of 20 or 30% for the treatment of acne, rosacea, melasma, hyperpigmentation, mild photoaging, and texturally rough skin. Salicylic acid peels are tolerated in all Fitzpatrick skin types I to VI. Most over-the-counter formulations of salicylic contain only 2% salicylic acid. It is also used in combination with other keratolytic ingredients as part of the Jessner solution. Salicylic acid also exhibits anti-inflammatory and antimicrobial properties, producing less irritation than AHAs. 4 It is a lipophilic chemical that penetrates the pilosebaceous unit yielding an anticomedogenic effect. During application of salicylic acid, patients experience only mild stinging and discomfort. A white precipitate, representing crystallization of the salicylic acid, is visible after 30 seconds to 1 minute following peel application. Some authors suggest timing is unnecessary because there is very little absorption of the active agent after 2 minutes. 4 After 3 to 5 minutes, gently clean the face with tap water and a soapless cleanser to remove any residual salicylic acid precipitate. Unlike glycolic acid peels, salicylic acid peels do not require neutralization. Cool compresses after application can soothe the skin. General contraindications for salicylic acid include pregnancy, breast-feeding, and salicylate allergy. Salicylism, or salicylic acid toxicity, is characterized by nausea, disorientation, central nervous system reactions, hearing loss, and tinnitus. 4,9 TCA can be used for superficial peels in concentration of 10 to 35%. TCA causes protein precipitation in the skin that results in frost. Frost is a whitish hue of skin due to keratin agglutination ( Fig. 1). Depth of the peel can be correlated with the intensity of the frost. 4 The coagulation of proteins leads to exfoliation without vesiculation. 9 After the agent is applied, erythema with a white frost is noted within 1 minute. Repeated application with more vigorous rubbing can be used to achieve a deeper peel. TCA does not require neutralization after application. 17 There is no systemic toxicity with TCA peels. Jessner solution is a superficial chemical peel with keratolytic activity. This peel has been used for more than 100 years in the treatment of acne and hyperkeratotic skin disorders. Jessner solution combines resorcinol (14 g), salicylic acid (14 g), and 85% lactic acid (14 g) in 95% ethanol qs ad (quantity sufficient to make) (100 ml). The keratolytic agents in Jessner solution cause corneocyte cohesion within the stratum corneum and subsequently producing intercellular Fig. 1 (A) Patient with Glogau type II photoaging. (B) White frost after application of 30% TCA.

6 Jackson 31 and intracellular edema within the upper epidermis following continued application. 8 The clinical endpoint is erythema and streaky frosting. It is self-neutralizing and multiple applications can be performed to obtain a deeper injury. The tretinoin peel, also known as retinoic acid peel, is based on a solution of tretinoin (1 5%) in propylene glycol. 4 This peel causes shedding of the stratum corneum while increasing epidermal thickness to smooth skin texture and decrease melanin content. 11,12 Because tretinoin is oxidized by ultraviolet light, the peel should be performed in the late afternoon. The peel is kept on the skin for at least 4 hours. These peels may be less irritating and as effective as other superficial chemical peels. Conversely, tretinoin peels can induce strong erythema. 3 Retinoic acid in combination with other chemical agents may be used to treat acne, photoaging, lentigines, and rhytides. Solid carbon dioxide (CO 2 ) slush has been used alone as a superficial peel and in combination with TCA to obtain a deeper peel. With a boiling point 78 C, the dry ice form of CO 2 is dipped in an acetone alcohol mixture and applied to the skin for 5 to 15 seconds. It is useful in the treatment of acne scars and allows deeper penetration of TCA. 17 Medium-Depth Peels Medium-depth chemical peels consist of controlled necrosis of the epidermis extending to part or all of the deep papillary dermis, with variable wounding to the upper reticular dermis. The wound healing process occurs over the next 3 months. During this time, medium-depth peels increase collagen production with papillary dermal edema and the development of a mid-dermal band of thick fibers. 9 As opposed to superficial peels that require multiple treatments, mediumdepth peels are generally done as a single procedure due to the level of wound injury and the continued clinical improvement months after treatment. Medium-depth peels are recommended for the treatment of mild-to-moderate photodamage, rhytides, melasma, actinic keratoses, solar lentigines, skin texture, and seborrheic keratoses. The classic medium-depth peel was 40 to 50% TCA because of its ability to improve fine rhytides, actinic damage, and preneoplasias. However, it is generally no longer used as a single-agent peel due to the high risk of complications, namely, scarring and dyspigmentation. These postprocedural complications are more common in TCA strengths greater than 50%. 18 The current use of medium-depth chemical peels utilizes 35% TCA with an initial application of a priming agent, such as Jessner solution, 70% glycolic acid, or solid CO 2. As a result of the damage to the epidermis produced with the initial peel, the level of TCA penetration is deep and better controlled. Because there is less risk of dyschromias and scarring, these combination peels have replaced TCA alone as the gold standard for medium-depth peels. Jessner-35% TCA has broad ranges of uses for mild-tomoderate photoaging, pigmentary dyschromias, lentigines, and epidermal growths. The Jessner solution is applied first and after 1 to 2 minutes, when the Jessner solution is completely dry, 35% TCA is then applied. Upon application of the Jessner solution, there is an immediate burning sensation. There is minimal discomfort, which begins to subside as frosting occurs and resolves by the time of completion. 9 In some cases, a topical amid anesthetic can be applied before a medium-depth peel, for pain relief. 19 Cool compresses after chemical peel application provide symptomatic relief, otherwise neutralization is not required. In addition, Jessner-35% TCA has demonstrated similar resolution of widespread facial actinic keratoses as compared with 5-fluorouracil. 20 The 70% glycolic acid and 35% TCA peel combination gives similar peel results as that accomplished with degreasing and Jessner solution before 35% TCA peel. The combination of 70% glycolic acid gel (glycogel), rather than solution, and 35 to 40% TCA has been used to treat nonfacial skin. This peel combination has reported efficacy in the treatment of lentigines, actinic keratoses, and solar purpura on the neck, chest, arms, hands, legs, back, abdomen, and balding scalp. 4 The combination peels with glycolic acid need to be neutralized within 2 minutes to inhibit further penetration of the chemical agents. The TCA chemical reconstruction of skin scars (CROSS) is a technique for treatment of deep ice pick and fibrotic acne scars as well as enlarged pores. The procedure utilizes a sharpened wooden applicator or toothpick to deeply deliver TCA in higher concentration (65 100%). The TCA necroses the epidermis and deep dermal tunnel causing neosynthesis of dermal collagen, elastin, and ground structure to elevate atrophic scars and narrow enlarged pores. During the application, each scar is treated until white frosting appears, which typically occurs within 10 seconds. To achieve significant clinical improvement, five or more courses of CROSS technique must be repeated at 4- to 6-week intervals. In patients with Fitzpatrick skin types IV to VI, physicians must warn about pigmentary complications. Some physicians have used TCA applications of lower concentration, 10 to 30%, for one or two sessions in Asian skin without major side effects. 4 Deep Peels Deep chemical peels cause a wound extending into the midreticular dermis. These peels are indicated for patients in Glogau groups III and IV with moderate-to-severe photodamage and advanced rhytides. Deep chemical peels result in new collagen formation. The depth of injury produces significant necrosis and patients have an extended period of healing following treatment. Deep peels include the use of either TCA in concentrations greater than 50% or phenol containing solutions. Due to the risk of scarring and other complications with super potent concentrations of TCA, this chemical agent is not recommended for deep chemical peeling. Thus, phenol-containing preparations are the treatment of choice for deep chemical peels. Baker Gordon formula phenol peel is the traditional deep peel and has been used effectively for decades. The depth of injury causes necrosis extending into the midreticular dermis with new collagen formation. Undiluted 88% phenol has a limited depth of penetration because it causes complete coagulation of epidermal keratin proteins, thus unsuccessfully producing a deep injury. Baker Gordon phenol includes 88% phenol, 2 ml distilled water, 8 drops

7 32 Jackson Table 4 Combination peels with various chemical agents Chemical peel Key ingredients Indications Manufacturer Illuminize Peel Photodamaged skin SkinMedica (SkinMedica, Salicylic acid Rhytides Carlsbad, CA) Mandelic acid Pigmentary dyschromias Resorcinol Skin types I VI Phytic acid Canberepeatedevery2weeks Malic acid Panthenol Soap bark extract Vitalize Peel Salicylic acid Lactic acid Resorcinol Panthenol Saponins Additional component: Retinoic acid 0.3% Mild to moderate Rhytides Acne Acne scarring Hyperpigmentation Melasma Photodamage Skin types I VI Can be repeated every 3 4 weeks SkinMedica Rejuvenize Peel Intensive Resurfacing Masque Pigment Balancing Masque Salicylic acid Lactic acid Resorcinol Panthenol Isoceteth-20 Additional component: Retinoic acid 0.3% 18.0% Saccharum officinarum extract (source of glycolic acid) 2.0% Camellia oleifera leaf extract (green tea) 0.5% Retinol (vitamin A) 0.5% Niacinamide (vitamin B 3 ) 40% Glycolic acid 10% Citric acid 27% Vitamin C 4% Emblica Moderate to severe Rhytides Acne Acne scarring Hyperpigmentation Melasma Photodamage Skin types I IV caution with V VI Can be repeated every 4 6 weeks Photoaged/photodamaged skin Roughskintexture Acne Congested pores Hyperpigmentation Can be repeated every 2 4 weeks Hyperpigmentation Fade dark spots Improve skin tone Increase radiance Diminish fine lines and wrinkles Series of 4 6 proceduresevery 2weeks SkinMedica is Clinical by Innovative Skin Care (INNOVATIVE SKINCARE, Burbank, CA) SkinCeuticals (L OrealUSA,Inc., New York, NY) Micropeel Plus 30 Solution 30% salicylic acid and 3% glycolic acid 20 Solution 20% salicylic acid and 3% glycolic acid Acne and PIH Reduce acne blemishes and related dark spots Improve skin tone Increase radiance Series of 4 6 proceduresevery 2weeks SkinCeuticals Obagi Blue Peel Radiance 20% Salicylic acid Blend of lactic and glycolic acid, also willow bark and licorice root extracts Mild-to-moderate rhytides Pigmentary dyschromias Skin types I VI Obagi Medical (Obagi Medical Products, Inc., Long Beach, CA) Adapted from respective proprietary peels information pamphlets and websites.

8 Jackson 33 Septisol, and 3 drops croton oil. In the Baker Gordon formula, the addition of tap water reduces the concentration of phenol to 50 to 55%. Septisol (triclosan) acts as a surfactant that decreases skin tension, causing deeper penetration of phenol. Croton oil is a vesicant keratolytic agent that permits deeper penetration of the phenol into the dermis than is allowed with full-strength phenol. 21 Recent studies of the effects of this peel using varying concentrations of both phenol and croton oil have suggested that the resurfacing efficacy is more correlated with the amount of croton oil than to that of phenol. 21,22 The Baker Gordon phenol peel takes a substantial length of time. The face is divided into smaller cosmetic units. An approximate 15-minute waiting period is required after treatment of each cosmetic unit, spreading the entire procedure over 60 to 90 minutes, and further preventing elevated systemic concentrations of phenol. 23 Following application, occlusive tape or petrolatum can be applied if a deeper wound is desired. These peels can produce premature ventricular contraction or premature atrial contraction. 24 Intravenous fluids are given before and during the peel application to limit the serum concentration of phenol. These peels require cardiac and pulmonary monitoring including continuous electrocardiography, pulse oximetry, and blood pressure monitoring throughout the procedure. If arrhythmias occur, the procedure must be abruptly terminated and careful evaluation for toxicity. 24 Supplemental oxygen throughout the procedure may have a protective effect against cardiac arrhythmias. 9 The Baker Gordon phenol formula has two main variations of deep chemical peeling, the occluded and unoccluded. Occlusion of the peeling solution with zinc oxide tape or other artificial barrier product increases penetration of the peel by preventing evaporation of the phenol from the skin. This allows the solution to penetrate deeper and extend the injury into the mid-reticular dermis. This technique is particularly useful for deeply wrinkled faces, but should be utilized only by experienced physicians because of the higher risk of complications. 25 The unoccluded technique, Beeson McCollough formula, usesaggressive cleansing of the skin and heavier application of Baker Gordon solution. This enhances the efficacy of the solution but without deep penetration like an occluded peel. Both methods are safe and effective in rejuvenating deep furrows, photoaged textural changes, and pigmentary irregularities associated with severe photodamage. Combination Peels Complications and Postprocedural Care Complications may arise after any chemical peel, but are more common following medium-depth or deep chemical peels. To prevent complications, there must be careful selection of the suitable patient and appropriate chemical resurfacing agent. Because PIH remains the most common complication in patients with darker skin types, patients with Fitzpatrick skin types IV to VI should receive superficial or medium-depth peels to prevent the risk of hyperpigmentation ( Table 4). Intraprocedural complications occur as a result of improper technique or problems with the chemical agent used. When applying the chemical peel, avoid uneven application and observe the degree of frosting. The degree of frosting can correlate with the depth of injury and should be used to determine the endpoint of treatment. Excessive frosting from overapplication and use of higher concentration peeling agents can result in deep skin injury. During chemical peeling, appropriate eye rinse solutions should be readily available in case of unintended eye exposure to the chemical agent. Specifically, saline is used to dilute TCA, mineral oil is used to dilute Baker Gordon phenol solutions, and bicarbonate is used to neutralize glycolic acid. 9 Adverse systemic effects rarely occur with chemical resurfacing. Nevertheless, systemic complications such as cardiac arrhythmias are associated with phenol solutions. For this reason, phenol solution peels must be performed with caution, in healthy patients, and under cardiopulmonary monitoring. To avoid rapid absorption of phenol and potential cardiac arrhythmias, there must be a waiting period of 10 to 15 minutes after the treatment of each cosmetic area on the face. For this reason, one must allow 60 to 90 minutes procedure time for patients undergoing full-face phenol peels. The guidelines for cardiac monitoring of various phenol concentrations have yet to be established. Some physicians defer cardiac monitoring when treating less than two cosmetic areas or less than one-third of the face. Additionally, premixed peels, such as the Vi Peel, with lower concentrationcontaining phenol may be administered in office without cardiac monitoring. Salicylic acid peels pose a risk of salicylate hypersensitivity. Furthermore, there is a theoretical risk of salicylate or resorcinol toxicity with use of Jessner solution when applied to body surface areas greater than the face and neck. After the chemical peel resurfacing is complete, the treated area(s) should be covered with a bland emollient such as Aquaphor, petrolatum jelly, or Biafine (Valeant Pharmaceuticals North America, LLC, Bridgewater, NJ). If the patient exhibits immediate erythema, a topical or oral steroid can be prescribed. Most importantly, apply broad-spectrum sunscreen to the treated area(s) and counsel the patient on the importance of sun avoidance and sun protection. Postprocedural complications include delayed wound healing, bacterial infection, herpes simplex infection, prolonged erythema, contact dermatitis, scarring, textural abnormalities, PIH, and hypopigmentation. The early recognition and management of these complications is essential for a successful resolution. For viral, bacterial, or fungal infection, culture the area and immediately prescribe antimicrobial therapy. Post-peel hyperpigmentation may be treated with topical retinoids and skin lightening agents such as hydroquinone. 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