DOI: 10.1111/j.1468-3083.2009.03409.

x JEADV

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, Creteil, France

zCentroderm Center for Dermatology and Laser, Madrid, Spain

**Unit of Skin Oncology, University Hospital Center, Nantes, France
*Correspondence: B Dreno. E-mail: brigitte.dreno@wanadoo.fr

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
Chemical peels are methods to cause a chemical ablation of
defined skin layers to induce an even and tight skin as a result of
the regeneration process. The actual peeling procedure involves
the 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 dermis
are induced. The mechanical action of peeling, even when limited
to the epidermis, is able to stimulate regeneration via pathways in
the dermis that are not well understood. The depth of destruction
depends on the substance used and its concentration. The use of
chemical peels has been reported since antiquity, but a standard-
ized and scientifically based technique has emerged only over the
past decades.
1
Supported by La Roche Posay.
History
The earliest use of caustic preparations for peeling procedures was
described in the Egyptian medicine in the Ebers papyrus as early
as 1550 BC.1,2 Reports are also found in the ancient Greek and
Roman literature. Over the past centuries, some formulas have
apparently been transmitted by gypsy populations. Dermatologists
began to show interest in peeling in the 19th century. In 1874 in
Vienna, the dermatologist Ferdinand von Hebra used the tech-
nique to treat melasma, Addisons disease and freckles. In 1882 in
Hamburg, 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 worked 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 Wolff

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provided the first systematic description on the use of phenol,
resorcine, salicylic acid and CO2 for the treatment of scars.5 The
modern era of peeling began in the 1960s with the development of
modified phenol solutions (addition of croton oil, septisol and
water) by Baker and Gordon6 and histological assessment of peel-
ing results by comparing phenol and TCA peels.7 The scientific
basis for TCA peels was extended in the 1970s and early 1980s by
the comparison of the histological effects of three TCA concentra-
tions.8 In parallel, at that time, alfa-hydroxy acids (AHA) were
developed by van Scott and Yu as more superficial peels for hyper-
keratosis.9 Subsequently, peeling with glycolic acid, the most com-
monly used AHA, was developed.10 The description of
combinations of two superficial peeling substances (Jessners solu-
tion and TCA 35%) by Brody and Haily11 and later by Mon-
heit12to achieve medium-depth effects provided further progress
in the development of chemical peels. The latest development is
the use of lipo-hydroxy acid (LHA).13
Classification
Chemical peels are classified into three categories based on the
depth of destruction caused by the treatment14:
d Superficial peels, which exfoliate epidermal layers without
going beyond the basal layer.
d Medium-depth peels, which reach the upper layers of the
dermis down to the papillary dermis.
d 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 syn-
ergistic effect of a medium-depth peel (e.g. Jessners solution
and TCA 35%).
General principles of peeling procedures
The process and the technique of a peeling procedure are largely
determined by the chemicals nature and the concentration of the
applied 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.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 before-
hand because its action on the skin facilitates a more homoge-
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Fischer et al.
neous penetration of the peel, leading to a more consistent result.
Moreover, preparation with tretinoin also facilitates to accelerate
the post-procedural healing process.1315 The 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
inactivated13,14 by 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 herpes infection, medium-depth or
deep peels are preceded with oral anti-herpes treatment started the
day before the procedure and continued for 1 week after.13,14 This
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 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
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 treatment
with medium-depth and deep peels.13 Treatment can involve the
entire face or only a part. In the latter case, facial anatomy is
divided into four aesthetic units (upper lip, both cheeks and fore-
head; fig. 1).16,17 Each 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:
d Usually, just a simple sensation of heat is experienced with
superficial peels.
d With medium-depth peels, more intense pain may require
local anaesthesia with an anaesthetic cream.
d Deep 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 is
based on moisturizers. For deep peels, post-operative care is
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Chemical peels in aesthetic dermatology
Figure 1 Facial treatment areas for the peeling procedure.
required for 10 days and unsightliness imposes social isolation
during this time; healing care, based on moisturizers or bandages,
and daily attentive surveillance are undertaken.14 Photoprotection
with sunscreens is recommended for several weeks, especially for
medium and deep peels.14 Prophylactic 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 46 applications, generally 24 weeks apart.14 Dee-
per peeling products are applied only once.15
Histological changes after peeling
The histological changes observed evidently depend on the depth
of peeling. However, all types of peels cause inflammation and
induce healing phenomena that repair the zones damaged by the
caustic 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.13 Stimulation of the epidermis induces
the production of cytokines that, in turn, stimulate the activation
of fibroblasts. The fibroblasts produce collagen type 1 and type 4
as well as elastin fibres. Medium peeling removes the epidermis
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283
and reaches the papillary dermis. The regeneration of skin is
mainly from cells of the hair follicles, which are present deeper
than 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 collagen
and ground substance is very important.13 With 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 and
distributed uniformly. Basal cells contain small melanin grains
distributed 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. In
the dermis, a new sub-epidermal band of collagen and a band
23 mm thick appears. It is located above the dermis where elas-
tolysis occurs, the part of the dermis unaffected by peeling. The
sub-epidermal band is composed of compact bundles of collagen
arranged parallel to the skin surface. New elastic fibres form a
network 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.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 satu-
rates the ability of cells to resist acidification and excess acid must
be neutralized to avoid burning the skin.21 AHA 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.22 The 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.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 chemi-
cals, LHA has a pH that is similar to that of normal skin (5.5) and
does not require neutralization.
Medium peels. Medium-depth peels, such as TCA, cause
coagulation of membrane proteins and destroy living cells of the
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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.21 The 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 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
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 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. Gly-
colic acid is always used over several sessions (generally 6) several
weeks apart. As sessions progress, the concentration of the solution
Table 1 Indications and contraindications for peeling procedures
Treatment Peeling
steps agent Superficial
AHA BHA LHA
Indications Photoaging
Roughness, yellow stains
Fine lines; keratosis
Solar lentigines
Pigmentary disorders
Melasma
Post-inflammatory
Retentional acne comedone
extraction
Contraindications Absolute Pregnant, nursing patients,
6 months isotretinoin treatment
Active herpes simplex; cold sores
Fitzpatrick skin types V-VI
Relative Cold sores: 46 weeks after
healing
Botulinum toxin: 12 weeks after
Collagen 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
after
TCA, trichloroacetic acid; AHA, alfa-hydroxy acids; BHA, beta-hydroxy acids; LHA, lipo-hydroxy acid.
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Fischer et al.
used and application time are progressively increased depending
on tolerance and the result obtained after preceding sessions.15
Other AHA exist, including lactic acid,25 pyruvic acid26 and man-
delic acid, but are used less frequently.
Beta-hydroxy acids
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.
Resorcin or resorcinol
Resorcin is generally used in preparations, the most widely used
being Jessners solution,14 the 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 peel14 and the preparation is
used in a single session. Some authors combine Jessners solution
with a 35% TCA peel in the same session to obtain a medium-
depth peel.12,30 Resorcin 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:
Peeling level
Medium-deep Deep
TCA 35% or combinations TCA > 50%, phenol
Photoaging Severe photoaging
Fine lines Pigmentary disorders
Wrinkles Scars
Pigmentary disorders
Superficial atrophic scars
Pregnant, nursing patients, Pregnant, nursing patients,
6 months isotretinoin 6 months isotretinoin treatment
treatment Active herpes simplex; cold sores
Active herpes simplex; cold Fitzpatrick skin types IVVI
sores Phenol: insufficient kidney function
Fitzpatrick skin types IVVI
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
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Chemical peels in aesthetic dermatology 285

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.

between 10% and 30% is considered a superficial peel; above depends not only on the concentration, but also on the time
30% provides a medium-depth peel. The concentration used of application. The depth reached is precise as a function of
generally does not exceed 50%.14 The depth of the peel symptomatology (Table 1),14,31,32 but requires considerable

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Figure 4 Clinical effect of deep phenol peel on wrinkles (baseline
and 3 months post-peel). Photos courtesy of Dr Torsten Walker.
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.14 Treatment
is very painful and requires general anaesthesia or deep sedation.
The risk of heart failure requires cardiac monitoring; therefore, hos-
pitalization is obligatory.33 Phenol 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 there
is an indisputable consensus and those reported in very rare cases.
Recognized indications
d Wrinkles. Peels are part of the classical strategy for managing
skin ageing.14,34,35 Superficial 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-
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Figure 5 Clinical effect of deep phenol peel on wrinkles (baseline
and 7 months post-peel). Photos courtesy of Dr Torsten Walker.
ing and dendrocytic hyperplasia. Medium-depth and deep
peels result in neocollagenesis and so are active against med-
ium-sized wrinkles (figs 46). Very few comparative studies
on peels have been conducted. In one, LHA peel (without
neutralization) was compared with glycolic acid (20% and
50% 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
d Complexion, 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.18 Clinically, superficial peels impart a radiant
complexion, treat melasma at the dermalepidermal junc-
tion and improve lentigines.14,32 In the study comparing
LHA and glycolic acid discussed above, 46% of women
showed an improvement in pigment disorders on the
LHA 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.14,32 However, they are
contraindicated for melasma as they may cause post-
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Chemical peels in aesthetic dermatology 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.

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
d Scars. Medium-depth and occasionally deep peels are used
on relatively shallow scars to elevate the base of the scar
by neocollagenesis and to lower the edges by the abrasion
they cause. They are often proposed to treat regular shal-
low acne scars.14,3840
d Actinic keratosis. Some authors have proposed using
medium-depth or deep peels to treat profuse actinic

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keratoses.12,13,41 Recently, Hantash and colleagues con-
ducted a prospective, randomized, 5-year trial to evaluate
the ability of chemical peeling (30% TCA) as a prophy-
laxis 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
d Acne: Some authors have proposed superficial peels as
adjuvant treatments for acne (fig. 7); they act as comedo-
lytic agents4347 but have no effect on seborrhoea.46 Super-
ficial 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 sus-
tained 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 unplug-
ging the follicle was associated with lower bacterial loads in the fol-
licle 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 pene-
tration into the sebaceous follicle.
Other indications
Peeling has been proposed to treat flat warts,26 Pseudofolli-
culitis barbae,37 trichoepitheliomas,49 rhinophyma,50 generalized
Table 2 Side-effects and complications for peeling procedures
Superficial
AHA BHA LHA
Potential Redness
side-effects complications Transient hyperpigmentation
Pimples
TCA, trichloroacetic acid; AHA, alfa-hydroxy acids; BHA, beta-hydroxy acids; LHA, lipo-hydroxy acid.
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Fischer et al.
linear epidermal naevus51 and tumour prophylaxis in xero-
derma 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, par-
ticularly 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 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 is
vitally important to ensure a good outcome. Generally, the depth
of 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 night
and a flare-up of pimples have been reported.14 Medium 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 sunscreens is recommended for several
weeks. Because of the risk of hyperpigmentation, medium-depth
peels are unsuitable for phototype V or VI patients. There is also
an increased risk of herpes infection.6
For deep peels, the risk of complications is significant,
particularly post-operative infections and, more importantly,
pigmentation problems such as frequent early transient hyper-
pigmentation followed by hypopigmentation, or even total and
permanent achromia. Deep peels are, therefore, performed only
in patients with light phototypes. These are currently used to
a lesser extent because of the greater risk of complications. In
a recent study, a rate of cardiac complications (most notably
arrhythmia) of 7% has been reported for phenol peels.6 The
different side-effects and complications are summarized in
Table 2.
Peeling level
Medium-deep Deep
TCA 35% or combinations TCA >50%, phenol
Redness Pain
Herpes Redness
Hyperpigmentation Herpes
Lentigines Transient hyperpigmentation
Infection
Hypopigmentation
Permanent achromia
Heart failure (phenol)
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 Table 3 Clinical effect after four treatments
Treatment steps Peeling agent
Superficial
AHA (glycolic acid, pyruvic acid) BHA
(salicylic acid, LHA)
Preparation (Priming) Time 12 weeks prior to first session
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Purpose To prepare the skin by starting
the exfoliating process
To optimize and homogenize the
penetration of the peel solution
Solutions LHA Cleansing gel
LHA solution
(0.25% LHA)
LHA Serum
(0.45% LHA)
Procedures Daily cleansing
Gel and or solution
daily skin care
LHA Serum, 0.45% LHA
Purpose Cleaning and degreasing of skin
prior to treatment to achieve
homogenous peeling results
No sedation or analgosedation
Solutions LHA Solution (0.25%)
degreasing wipe (vaseline)
Procedure Eye protection (patient and
physician)
Cleansing (no rinsing)
Degreasing with wipe (vaseline
protection for sensitive areas)
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2009 The Authors
Peeling level
Mediumdeep Deep
TCA 35% or combinations TCA >50% phenol
23 weeks prior to session
To prepare the skin by starting
the exfoliating process
To regulate pigment content in
patients with strong pigmentation
Topical AHA or BHA Creams and solutions containing:
Topical retinoids Topical retinoids
Vitamin C Vitamin C vitamin E
Vitamin E Depigmenting solution
(e.g. hydroquinone
Chemical peels in aesthetic dermatology
1.0 dexamethasone
0.02 tretinoin 0.0125 Ung. emulsif.
nonion. ad 20.0)
Daily application Daily application over 3 weeks Daily application
over 3 weeks over 3 weeks
Cleaning and degreasing of skin prior Cleaning and
to treatment to achieve homogeneous degreasing of skin
peeling results prior to treatment to
Sedation achieve homogeneous
peeling results
Analgosedation
Hexachlorophene Hexachlorophene cleanser Hexachlorophene cleanser
cleanser Acetone or acetonealcohol mixture Acetone or acetonealcohol
Acetone or Gauze pads mixture
acetonealcohol mixture Diazepam 510 mg p.o. Gauze pads
Gauze pads Non-steroidal antiphlogistics Diazepam 5 mg + pentazocin
Diazepam 510 mg p.o. 15 mg i.v.
+ Regional block (bupivacaine)
+ Non-steroidal antiphlogistics
1.01.5 l volume infusion
Eye protection Eye protection (patient and physician) Eye protection (patient
(patient and physician) Cleansing with hexachlorophene and physician)
Cleansing with Thorough rinsing with water, dry Cleansing with hexachlorophene
hexachlorophene Degreasing with acetone or Thorough rinsing with water, dry
Thorough rinsing with acetonealcohol mixture (vaseline Degreasing with acetone or
water, dry protection for sensitive areas) acetonealcohol mixture
Degreasing with (vaseline protection for
acetone or sensitive areas)
acetonealcohol mixture ECG control required
(vaseline protection for
sensitive areas)
289
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Table 3 Continued

Treatment steps Peeling agent Peeling level

Superficial Mediumdeep Deep
AHA (glycolic acid, pyruvic acid) BHA TCA 35% or combinations TCA >50% phenol
(salicylic acid, LHA)

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Treatment Time + ++ +++ ++++
Purpose Exfoliation of epidermal layer Actual peeling process Actual peeling process
Solutions Cotton-tip applicators Brush or gauze Cotton-tip or gauze Cotton-tip or gauze, (waterproof tape)
LHA solution (5%, 10%) AHA (e.g. glycolic acid 20%) TCA alone (e.g. 3550%) Phenol solution (e.g. BakerGordon
TCA combination solution:
(e.g. Jessners solution phenol 50%, 2% croton oil)
+ TCA 35%) TCA combination (e.g. Jessners
solution + TCA 35%)
Procedure Application to facial units Application to facial units Appliction to facial regions Applcation to each facial region with
in order of fig. 2. Variable number of layers Combinations: 515 min intervals between regions
13 layers, depending on skin type 1. Jessners solution One application per region (occlusion
2. TCA solution with waterproof tape)
(variable number of layers)
Neutralization No Yes Yes Yes
Frequency 4 (4)-6-(8) 1 1
Post-treatment Time 15 days 1528 days 12 months 2 months
Purpose To stabilize and enhance the To prevent infection and To prevent infection and enhance
exfoliating process pigmentation disorders wound healing
To prepare skin for next To enhance the regeneration prevent pigmentation disorders
peeling procedure process
Solutions LHA cleansing gel Topical AHA or BHA in Bland emollient cream Bland emollient cream
LHA solution Topical retinoids NaCl solution or acetic acid Antibiotic skin cream (e.g. refobacine)
(0.25% LHA) Vitamin C vitamin E soaked compresses alternatively 0.25% Acetic acid
LHA serum Non-steroidal anti-inflammatory Non-steroidal anti-inflammatory drugs
(0.45% LHA) drugs (e.g. acetyl salicylic acid) (e.g. acetyl salicylic acid)
Procedure Daily cleansing with gel Daily application over 3 weeks Soak face 45 times in first 24 h Leave occlusion for 1248 h
and or solution, no rinsing Thorough rinsing required Apply bland emollient cream and Debridement by soaking with acetic
Daily skin care, LHA serum wet NaCl or acetic acid soaked acid solutions and compresses
0.45% LHA compresses alternatively Open and or occlusive application
of emollient and or antibiotic creams
General remarks Daily application of a Daily application of a sunscreen Daily application of a sunscreen
sunscreen product with an product with an SPF 15 or higher product with an SPF 15 or higher
SPF 15 or higher with with UVA UVB for 6 months with UVA UVB for 612 months
UVA UVB for 23 months Optional antiviral treatment Antiviral pre- and post-treatment
usually no antiviral treatment (e.g. acyclovir 400 mg 2 d) required (e.g. acyclovir 400 mg 2 day)
required
TCA, trichloroacetic acid; AHA, alfa-hydroxy acids; BHA, beta-hydroxy acids; LHA, lipo-hydroxy acid.

Journal compilation 2009 European Academy of Dermatology and Venereology

2009 The Authors
Fischer et al.
Chemical peels in aesthetic dermatology
Table 4 Depth reached by a trichloroacetic acid peel as a function of the clinical aspect obtained.
Degree of Cloudy Slightly Clearly white
frosting white
Crimping 0 ++
Firmness 0 + ++
Oedema 0 0
Depth Epidermis Epidermis Papillary dermis
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 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:
d Clinical concept peeling is more than an ablative tech-
nique: the process uses the inflammatory reaction and
dermal stimulation proactively to modify the skin.
d 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-epithelial-
ization, remodelling effects as well as scaring recovery
time.
d 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 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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Journal compilation 2009 European Academy of Dermatology and Venereology