What Can A Series Of Deep Chemical Peels Do For 40 Year Old Woman's Skin

J Clin Aesthet Dermatol. 2018 Aug; 11(8): 21–28.

Published online 2018 Aug 1.

A Practical Approach to Chemical Peels

A Review of Fundamentals and Step-by-step Algorithmic Protocol for Treatment

Abstruse

Background: Chemoexfoliation, as well known every bit chemical peeling, is a method of targeted cutaneous ablation using specific caustic agents that let for rapid, predictable, and uniform thickness of chemoablation to a desired cutaneous depth, ultimately resulting in an improved appearance of skin. Objective: In this review, we provide an up-to-date assay of all currently available chemical peels for dermatologic use, every bit well every bit a step-by-pace instructional protocol for an algorithmic approach to treatment. Methods: A comprehensive search of the Cochrane Library, MEDLINE, and PUBMED databases was performed to place relevant literature investigating chemical peeling agents. In addition, a search of all commercially bachelor, prescription-based peeling agents was performed to place all products currently available in the U.s. market place. Results and Conclusion: Chemical peels are the third virtually commonly performed noninvasive cosmetic procedure in the Usa, with over 1,300,000 procedures performed in 2016 solitary. There has been a paradigm shift in contempo years, with lasers largely supplanting deep peels. Despite this shift, superficial peels have proliferated in both popularity and product multifariousness.

When used for the appropriate indication and with proper technique, about all peeling agents take demonstrated excellent clinical efficacy and remain an indispensable cost-constructive tool in the dermatologist's aesthetic toolbox.

Keywords: Chemical pare, Peel, Glycolic, Trichloroacetic acid, Phenol, Glogau, Aging, Photoaging, Wrinkles, Lentigo, Rhytides

Chemoexfoliation, colloquially referred to as chemical peeling, is a method of targeted cutaneous ablation induced by specific caustic agents that allows for a rapid, predictable, and compatible thickness of chemoablation to a given desired cutaneous depth, ultimately resulting in improvement in the clinical advent of skin. The goal of a chemical skin is to remove a anticipated, uniform thickness of damaged peel, which subsequently allows for normal wound healing and skin rejuvenation to occur, while simultaneously minimizing complications, such every bit scarring and unwanted pigmentary alter.

The caustic agents used for chemical peels cause controlled keratocoagulation and denaturation of the proteins within the epidermis and dermis, resulting in the release of proinflammatory cytokines and chemokines.¹ ^– ^vii Such targeted inflammation activates the normal healing signal cascade, including stimulation, evolution and degradation of new dermal collagen and elastin, reorganization of structural scaffold proteins and dermal connective tissue, and regeneration of new keratinocytes.^one ^– ^ten This results in rejuvenation and thickening of the epidermis and an increment in dermal volume.ⁱ ^– ¹⁰ Simultaneously, the keratocoagulation and subsequent exfoliation result in improvement in superficial and medium-depth dyspigmentation.¹ ^– ^ten While at that place might be subtle variability between the types of chemical agents used and their intended cosmetic event (i.eastward., reduction of redness vs. dyspigmentation vs. scarring), the general goal of a chemical peel is to meliorate the clinical advent of skin past decreasing the quantity and quality of rhytides and/or acne scars, reducing inflammatory and noninflammatory acne lesions, improving dyspigmentation, and producing an overall more than youthful advent.³

In recent years, there has been a paradigm shift in the mechanism of action and technique past which exfoliation is performed. Lasers largely take supplanted deep chemical peels because of their improved control of ablative depth, their ease of utilize, and their relative lack of systemic toxicity and side effects.^two ^– ⁴ ^, ¹¹ ^– ¹⁵ However, superficial peels take simultaneously increased in popularity, primarily due their relatively balmy properties, minimal side effects, and relative price efficiency compared to light amplification by stimulated emission of radiation devices.² ^– ^iv ^, ^eleven ^– ¹⁵ Co-ordinate to recently published data from the American Lodge of Plastic Surgeons, chemical peels are the 3rd virtually commonly performed noninvasive corrective procedure, afterwards botulinum toxins and soft tissue fillers, with over 1,300,000 procedures performed in 2016 alone.^sixteen The popularity of superficial peels has led to the inclusion of glycolic and/or lactic acids in many over-the-counter corrective products.¹ ^, ^two ^, ¹⁷ ^, ^xviii

INDICATIONS AND CONSIDERATIONS

The indications for a chemical skin are primarily corrective (Table 1) and thus should exist tailored to each patient's specific concerns and wishes for artful comeback of their skin, their ability to tolerate the mail service-procedural recovery period, and their Fitzpatrick skin type. Equally mentioned before, the blazon of chemical agent used varies according to status severity and type and the wishes of the patient. Chiefly, a patient'southward desires should be ultimately tempered with a discussion of realistic expectations and judicious clinical judgment of appropriate treatment options. Indications for chemical peels can exist broken downwardly into four broad categories: 1) rejuvenation of chronic chrono- and photoaging; 2) acne and acneiform eruptions; 4) dyspigmentation; and 3) pre-cancerous epidermal neoplasms (Table 1).^one ^– ³ ^, ⁵ ^– ⁷ ^, ¹¹ ^, ¹³ ^, ¹⁷ ^, ¹⁹ ^– ²³

Table one.

Indications for chemoexfoliation

PIGMENTARY DISORDERS

Lentigines

Ephelides

Melasma

INFLAMMATORY DISORDERS

Acne

Rosacea

SCARRING

Acne scarring

Traumatic scarring

Surgical scarring

CHRONOAGING

Superficial and medium-depth rhytides

PRE-CANCEROUS LESIONS

Actinic keratoses

A footstep-past-pace instructional outline for the algorithmic approach to handling is detailed in Figure ane. Clinicians should take into consideration the condition and the depth of the involved tissue being treated. For example, superficial epidermal issues, such as solar lentigines, can be treated with superficial peels, while deeper defects, such as mild-to-moderate dermatoheliosis, crave a medium or deep depth peel. In add-on, it is important to determine whether the corrective concern is treatable by resurfacing. For example, deep rhytides, laxity of the jowls, and actual ptosis are unlikely to respond to chemical peeling, regardless of treatment depth, and will respond best to surgical intervention. The most common indications for chemical peeling are chronic photoaging and hyperpigmentation.^ane ^– ³ ^, ⁵ ^– ⁷ ^, ¹¹ ^, ¹³ ^, ¹⁷ ^, ^xix ^– ²³ For chronic photoaging and hyperpigmentation, the Glogau Calibration of Photoaging^v can exist useful in stratifying patients (Figure 1).

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Chemical peel procedural flow

Chemical peels are divided into three categories, depending on the depth of the wound created by the peel (Table 2, Figure two). Superficial peels penetrate the epidermis but, medium-depth peels bear upon the entire epidermis and papillary dermis, and deep peels let for controlled tissue injury to the level of the midreticular dermis (and sometimes subcutis, if not used properly) (Effigy 3). The depth of the peel is dictated by a number of factors, including type of caustic chemic, concentration, style and number of applications, skin type, and the dermatologic condition existence treated. Of item annotation, depth of chemoexfoliation is cumulative dose-dependent; a monolayer of application allows for a more superficial level of anticipated exfoliation, with subsequent multiple layers or "passes" resulting in additive deeper peeling (Effigy 3).^v ^– ^seven ^, ¹⁹ ^- ²¹ ^, ²⁴ However, multiple applications or layers of a superficial skin, for instance, are not the same as a monolayer or single application of a medium-depth chemical skin. Furthermore, time of exposure is inversely proportional to concentration. For example, higher concentrations accomplish targeted depth of keratocoagulation in shorter exposure times. In addition, the associated downtime, healing rate, and potential for side effects are directly proportional to the depth of the peel and inversely proportional to the cosmetic event; deeper peels will have longer recovery times and pose greater risks of scarring and dyspigmentation; however, they will also result in more dramatic improvements in skin tone and texture (Table 2).⁵ ^– ⁷ ^, ¹⁹ ^– ²¹ ^, ²⁴ When used for the appropriate indication in the correct setting with the ideal technique, nearly all peels have demonstrated excellent clinical success in improving the tone and texture of facial peel and should remain an indispensable tool in the dermatologist's aesthetic toolbox, particularly with the rise healthcare costs in the United States.^ane ^– ³ ^, ⁵ ^– ⁷ ^, ¹¹ ^, ¹³ ^, ¹⁷ ^, ¹⁹ ^– ²³ ^, ²⁵ ^, ²⁶

Table two.

Classification of chemical peeling agents based on depth of tissue injury

TYPE		DEPTH OF PENETRATION	POTENTIAL SIDE Furnishings
Superficial	• AHAs such as glycolic (30–l%), lactic (10–30% or mandelic (40%) • BHAs such equally salicylic acid (thirty%) • AKAs such every bit pyruvic acid (l%)	Intraepidermal and DE junction disruption possible	Post-inflammatory pigmentary alterations, erythema, pruritus, burning, superficial desquamation/epidermolysis
Medium	• Salicylic acrid (>30%, multilayer application) • Glycolic acid (70%, with or without pretreatment primer such equally Jessner'southward solution) • TCA (30–l%, monolayer awarding, with or without pretreatment primer such as Jessner's solution^a)	Full thickness epidermis into papillary dermis	Postal service-inflammatory pigmentary alterations, superficial bacterial or fungal infection, reactivation of HSV, scarring, milia, acneiform eruption, greater thickness desquamation/epidermolysis
Deep	• TCA (>50%, monolayer awarding, with pretreatment primer such as Jessner'southward solution) • Bakery-Gordon phenol peel (detergent, croton oil as an epidermolytic agent, phenol, and water for dilution to fifty–55% phenol)	Full thickness epidermis, papillary dermis and mid-reticular dermis	Post-inflammatory pigmentary alterations, secondary bacterial or fungal infection, reactivation of HSV, scarring, milia, acneiform eruption, cardiotoxicity/arrhythmia (due to systemic assimilation of phenol, seen in 34–50% of patients), hepatotoxicity, nephrotoxicity

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Visual representation of intended depth of chemoexfolliatian by blazon of amanuensis used—superficial peels penetrate only the epidermis; medium-depth peels impact the unabridged epidermis and a portion of the papillary dermis; and deep peels aim to penetrate to the the level of the midreticular dermis.

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Bones cosmetic subunits are divided by the solid bluish lines into brow (including temples and glabellar area), periorbital area, olfactory organ, cheeks, perioral expanse, and mentum. In full general, chemical peels should be performed craniocaudally, starting with the forehead, and proceeding inferiorly. Passes should be based on 1) desired level of ablation and 2) relative thickness of the epidermis/dermis. Danger zones are demarcated by the solid cerise circles and include the medial canthi and the periapical triangles/nasojugal grooves. Special care should exist taken to protect these areas (i.due east. with petrolatum jelly and cotton fiber balls or gauze pads) as the caustic agents used during peeling tend to pool in these concavities and tin can cause undesired excessive keratocoagulation.

SUPERFICIAL PEELS

Superficial peels result in controlled keratocoagulation and liquefaction of the cells bars to the epidermis, which range from very mild chemoexfoliation of the corneal cell layer down to the basal cell layer.¹ ^, ² ^, ³ ^, ⁷ ^, ¹⁷ ^, ²⁴ The goal of superficial peeling is to treat weather condition bars to the epidermis, while minimizing recovery downtime and adventure of side furnishings. Currently, superficial peels largely comprise low-to-medium strength alpha-hydroxy acids (AHA) (e.1000., xxx–l% glycolic and 10–30% lactic acid) and, more recently, xl% mandelic acid.^one ^, ^two ^, ³ ^, ²⁷ ^– ³¹ Additionally, low concentrations or monolayer applications of beta-hydroxy salicylic acrid (xxx%) or alpha-keto pyruvic acid (l%) will provide fantabulous superficial chemoexfoliation as well (Table two, Figure 1).^one ^– ³ ^, ²¹ ^, ³² ^– ³⁴

With application of whatever caustic agent to the skin, subsequent keratocoagulation (i.eastward., protein denaturation of keratin and collagen) results in a "white frost" to appear on the skin where the chemical agent has been applied. This is an important clinical indicator of pare depth and a marker of duration of exposure. Level I frosting appears clinically as erythema with a stringy or patchy light frosting. Level II frosting appears as a uniform, white-coated frosting with underlying erythema showing through. Level III frosting, which is associated with penetration through the papillary dermis, appears equally solid white enamel frosting with fiddling to no background erythema.⁵ ^, ⁷ ^, ¹⁷ ^– ²⁰ With superficial peels, the goal is to achieve petty to no frosting (Level I at most), as clinically evident frosting often indicates exfoliation into the dermis (Figure i).¹ ^, ² ^, ⁵ ⁷ ^, ²¹

Normally used superficial peels. Glycolic acid. The most popular and time-tested superficial peeling amanuensis is glycolic acid, an AHA derived from sugar cane. It is the smallest and simplest AHA in terms of chemical construction, and is also a highly hydrophilic molecule with the greatest bioavailability of all the AHAs.³⁵ ^– ³⁷ When properly used, superficial exfoliation with glycolic acrid at concentrations of 30 to fifty% has demonstrated excellent clinical efficacy in the treatment of superficial hyperpigmentation, balmy-to-moderate chrono- and photoaging, and fine rhytides.ⁱ ^– ^three ^, ⁵ ^, ⁷ ^, ⁹ ^, ¹⁵ ^, ¹⁷ ^, ^xviii ^, ²¹ Glycolic acid is often considered the first-line choice of chemical peeling agents for treatment of melasma.ⁱ ^– ⁱⁱⁱ ^, ⁵ ^, ⁷ ^, ⁹ ^, ¹⁵ ^, ¹⁷ ^, ¹⁸ ^, ²¹ ^, ³⁸ ^, ³⁹ For superficial chemoexfoliation, most concentrations range from 20 to 50%, with higher concentrations (seventy%) entering the medium-depth category. Glycolic acrid is the prototypical non-self-neutralizing AHA (i.due east., keratocoagulation volition keep to occur as long every bit the caustic agent remains on the peel). Thus, conscientious awarding and diligent observation of time and clinical signs of reaction completion (due east.g., erythema and frosting) are essential. Reaction completion of glycolic acid is achieved by introducing an alkaline neutralizing agent (e.m., sodium bicarbonate neutralization). Clinicians should annotation that neutralization of any acid with whatever base is an exothermic process; thus, patients should be warned that a transient increase in warmth, burning, or stinging will likely occur during neutralization.

After neutralization, the skin may be rinsed or cleansed gently. Post-obit application, an initial erythema might become red and is often accompanied by edema. Stringy or patchy light frosting (Level I) might subsequently develop, indicating epidermolysis with separation of the epidermis from the underlying dermis. Development of frank or uniform frosting (≥Level II) indicates deeper devastation into the dermis and is not desirable, as this is meant to exist a relatively superficial peel. Exfoliation typically occurs over several days, and reepithelialization is consummate within 7 to 10 days.¹ ^, ^two ^, ⁷ ^, ⁸ ^, ^nine ^, ²¹

Lactic and mandelic acids. More recently, lactic and mandelic acids have emerged as pop single agents for superficial peeling, largely due to their equivalent efficacy compared to gold-standard glycolic acid, which has a relatively balmy discomfort profile with minimal associated downtime and risk.¹ ^– ³ ^, ¹⁷ ^, ²⁷ ^, ²⁸ ^, ³⁰ ^, ³⁹

Lactic acid, which is structurally identical to glycolic acid with the exception of an additional methyl group at the β-carbon terminate, has a lower pKa and thus a lower pH than glycolic acid at equivalent concentrations, assuasive for efficient chemoexfolation at lower concentrations.³⁵ ^– ³⁷ ^, ⁴⁰ Clinically, lactic acid has demonstrated comparable efficacy in the treatment of photodamage, superficial hyperpigmentation, and fine rhytides compared to standard glycolic acid peels.Because lactic acid has a lower pH than glycolic acid, a lower concentration is oftentimes used to achieve an equivalent depth of keratocoagulation compared to glycolic acid, which allows a favorable side consequence profile and recovery time. As with glycolic acid, neutralization is necessary, and exfoliation afterwards treatment typically occurs over several days with consummate reepithelialization in 7 to 10 days.¹ ^, ^two ^, ¹⁷ ^, ²⁷ ^, ²⁸ ^, ³⁹

Mandelic acid, a elementary phenolic alpha-hydroxy acrid, is substantially an effluvious glycolic acid with a benzene band attached to the alpha-carbon where the hydroxyl grouping is attached.²⁹ Given this unique structure, mandelic acid is soluble in both water and polar organic solutions, which results in a more uniform penetration through lipid-rich areas of skin.²⁹ ^, ³⁵ ^– ³⁷ Clinically, mandelic acrid has demonstrated efficacy in the treatment of superficial erythema and dyspigmentation, also as efficacy in the reduction of cutaneous sebum production.¹ ^, ^three ^, ³⁰ ^, ³⁹ Comparatively, the results of mandelic acid peels are more subtle than that of superficial glycolic acid peels; all the same, the side effects and subsequent downtime of mandelic acrid are comparatively less, which allows more frequent "touch ups" and shortened intervals between treatment sessions.ⁱ ^, ⁱⁱⁱ ^, ³⁰ ^, ³⁹ Patients often experience minimal desquamation, and reepithelialization is often complete within 3 to 5 days.

Salicylic and pyruvic acids.In addition to the same AHAs, salicylic acrid, a beta-hydroxy acrid, and pyruvic acid, an alpha-keto acid, have as well demonstrated clinical efficacy as unmarried agents for superficial peeling when used in lower concentrations or with monolayer application technique.¹ ^– ³ ^, ²¹ ^, ³² ^– ³⁴

Salicylic acid has a chemical structure like to that of mandelic acid, with the key divergence being that the carboxyl group is directly attached to the benzene ring and the hydroxyl group is attached to the β-carbon of the benzene ring, ortho to the carboxyl group.³⁵ ^– ³⁷ This makes salicylic acid poorly soluble in water, only highly lipophilic. In addition, given its depression pKa and small molecular size, salicylic acid demonstrates easy, rapid, and deep penetration through the lipid barriers of the epidermis. Clinically, this translates into excellent efficacy in the handling of cutaneous disorders involving excess sebum product, namely acne vulgaris. In fact, 30% salicylic acrid is often considered the "aureate standard" superficial peel for the treatment of acne and has demonstrated fantabulous clinical efficacy for the handling of mild-to-moderate inflammatory papulopustular acne vulgaris and comedonal acne.^one ^– ^three ^, ^vii ^, ^xviii ^, ²¹ ^, ³³ ^, ³⁴ ^, ⁴¹ ^– ⁴³ It is less unremarkably used every bit an amanuensis for photorejuvenation and hyperpigmentation, compared to the other aforementioned peels; however, clinical efficacy for those indications has been demonstrated.ⁱ ^– ⁱⁱⁱ ^, ⁷ ^, ¹⁸ ^, ²¹ ^, ³³ ^, ³⁴ ^, ⁴¹ ^– ⁴³ Given its high lipophilicity, salicylic acid exhibits potent cumulative dose consequence; in other words, multiple layers or excessive awarding of the acrid tin crusade rapid keratocoagulation beyond the epidermis into the papillary dermis. Salicylic acid, unlike glycolic acid and the other AHAs, is self-neutralized by the skin'due south own endogenous lipoproteins.^seven ^, ²¹ ^, ³³ ^, ³⁴ ^, ⁴¹ ^– ⁴³ However, cumulative dose exposure remains critical, and conscientious attention to length of application fourth dimension and signs of reaction completion are necessary to forbid unwanted, excessive keratocoagulation. Exfoliation after treatment typically occurs over several days, and reepithelialization is complete inside 7 to 10 days.⁷ ^, ²¹ ^, ³³ ^, ³⁴ ^, ⁴¹ ^– ⁴³

Pyruvic acid, the smallest alpha-keto acid, is structurally a carboxylic acid with a functional ketone moiety. Information technology has similar lipophilic and keratolytic backdrop equally salicylic acrid but has less lipophilicity.³⁵ ^– ³⁷ It is also partially hydrophilic, giving it backdrop of both salicylic acid and glycolic acid. Clinically, pyruvic acid peels accept demonstrated efficacy in the treatment of acne vulgaris and associated disorders of backlog sebum product, too as mild photoaging and superficial hyperpigmentation.³² It is commonly used as a superficial peeling agent for inflammatory and comedonal acne. Comparatively, withal, pyruvic acrid is not equally efficacious as that of salicylic acrid in the handling of acne vulgaris and associated disorders involving excess sebum production.³² ^, ⁴¹ ^, ⁴² This is likely due to salicylic acid's greater lipophilic properties and easier penetration through the lipid barriers of the epidermis. Unlike salicylic acrid but much like other AHAs, pyruvic acid is not self-neutralizing and will continue to cause keratocoagulation for the duration of exposure to the pare until it is neutralized with an alkaline solution. Exfoliation afterwards treatment typically occurs over several days, and reepithelialization is consummate inside five to ten days.³²

Over-the-counter superficial peels. In addition to the aforementioned physician-form chemical peeling agents, there are many over-the-counter, low concentration, superficial chemical peeling agents (eastward.grand., 3–ten% glycolic acid and balmy fruit-derived acids [citric, tartaric, or malic]). These formulations cause mild, gradual exfoliation over several weeks and can exist used every bit pre-skin primers to potentiate the effects of a higher concentration peel. Give-and-take of these peels is beyond the scope of this review.

MEDIUM-DEPTH PEELS

Medium-depth peels allow for controlled keratocoagulation through the dermis and into the papillary dermis. This results in deeper regenerative changes that can target pathology both within the epidermis and the superficial dermis and tin can often be performed in a single setting. When used appropriately and with proper technique, medium-depth peels have demonstrated fantabulous clinical efficacy in the treatment of fine rhytides, chronic actinic photodamage, superficial hyperpigmentary disorders (e.g., melasma), superficial acne scars, and even actinic premalignant changes as field therapy. ² ^, ⁱⁱⁱ ^, ⁵ ^, ^seven ^– ⁹ ^, ¹⁵ ^, ¹⁹ ^– ²³

Normally used medium-depth solutions. The original criterion for medium-depth chemoexfoliation was a fifty% TCA solution.² ^, ^three ^, ⁵ ^, ⁷ ^– ⁹ ^, ¹⁵ ^, ¹⁹ ^– ²³ Information technology was, and to a certain extent however is, a popular and frequently used peel to treat fine rhytides, actinic photodamage, hyperpigmentation, and even actinic-related premalignant changes, such as actinic keratoses.^two ^, ^three ^, ⁵ ^, ⁷ ^– ⁹ ^, ¹⁵ ^, ^xix ^– ²³ However, TCA used at college concentrations has a relatively high risk of complications, including dyschromia, scarring, and occasionally bacterial superinfection and cutaneous herpes simplex virus (HSV) reactivation.² ^, ³ ^, ⁵ ^, ⁷ ^– ⁹ ^, ¹⁵ ^, ¹⁹ ^– ²³ ^, ⁴⁴ Thus, employ of high-concentration TCA (>50%) has fallen out of favor as a unmarried-amanuensis chemical peel.

The nearly mutual chemical agents currently used for medium-depth peeling are seventy% glycolic acid and 35 to 50% TCA, with or without adjuvant combination products (e.thousand., Jessner's solution [comprising 14g resorcinol, 14g salicylic acid, 14mL lactic acid in ethanol constituted to 100mL] or solid carbon dioxide [CO2]).² ^, ⁱⁱⁱ ^, ⁵ ^, ⁷ ^– ^nine ^, ¹⁵ ^, ^xix ^– ²³ In addition, multiple layered applications of twenty to 40% salicylic acid and pyruvic acid are also used for medium-depth peeling, though not traditionally considered medium-depth peels.

Pre-, peri-, and post-treatment guidelines using medium-depth peels. As mentioned earlier, depth of peeling is straight correlated with cumulative dose exposure of the skin to a given acid. In other words, for any given length of exposure, college concentrations of a given acid will cause deeper chemoexfolation, as will multiple layers of application or multiple "passes" over the same area. With medium-depth peels, this tin can exist of disquisitional concern, equally exfoliation down into the papillary dermis is often achieved with a single first-pass application. Thus, combination treatments with a pre-treatment agent (e.m., Jessner's solution or solid CO2), followed by a lower concentration of a medium-depth acid(e.g., l–70% glycolic acrid or 35% TCA) have become increasingly popular due to their demonstrated equal clinical efficacy to the original fifty% TCA peels of the past. These combination treatments provide a more uniform and controlled depth peeling with a greater safety margin and a reduced incidence of dyschromias and scarring.^two ^, ^three ^, ⁵ ^, ⁷ ^– ⁹ ^, ^fifteen ^, ¹⁹ ^– ²³

Application of Jessner's solution or solid CO2 with acetone, an older technique, prior to the application of glycolic acrid or TCA results in a more homogenous disruption of the epidermal barrier and a more than thorough removal of natural oils from the skin, providing greater penetration of the acid and a more compatible frosting.^two ^, ^three ^, ^v ^, ⁷ ^– ^ix ^, ¹⁵ ^, ¹⁹ ^– ²³ Furthermore, the resultant frosting is ofttimes better controlled, with less take a chance of "hot spots" that can occur with higher concentrations of TCA or glycolic acid.² ^, ³ ^, ⁵ ^, ^seven ^– ⁹ ^, ¹⁵ ^, ¹⁹ ^– ²³

Medium-depth peels are often performed with balmy pre-operative sedation and nonsteroidal anti-inflammatory agents (NSAIDs), as this depth of peeling does take considerably higher levels of associated pain. NSAIDs are particularly helpful in reducing swelling and hurting and are often given preoperatively to help mitigate post-operative inflammatory sequelae.^{half dozen} ^, ⁷ ^, ¹⁵ ^, ¹⁹ ^– ²¹ ^, ²⁴ ^, ²² ^– ²³ With medium-depth peels, proper awarding technique is critical, equally is fugitive unnecessary, inadvertent reapplication with excess peel solution. It is recommended that the face up exist peeled sequentially: forehead to temples showtime, followed by cheeks and mentum, and finally the delicate cutaneous lips and eyelids. Careful feathering of the solution into the hairline and around the rim of the jaw and brow conceals the demarcation line between peeled and nonpeeled areas. Clinicians should be particularly careful when applying peeling solution to the eyelid, and it is recommended to leave 2 to 3mm of hat margin as a "safety zone" to forbid solution from inbound into the eyes. With medium-depth peeling, achievement of Level II to 3 frosting is the goal.^six ^, ⁷ ^, ¹⁵ ^, ¹⁹ ^– ²¹ ^, ²⁴ ^, ²² ^– ²³ Often, Level 2 frosting is sufficient for adequate depth of reaction. Occasionally, however, deeper Level III frosting is necessary in areas of thicker skin or heavier actinic damage. Proper technique will allow for compatible and even application, eliminating the need for unnecessary reapplication and the risk of excessive keratocoagulation. If frosting is incomplete or uneven, the peeling solution should exist advisedly reapplied to areas of demand only. Most medium-depth chemical peels use a Level II frosting, and this is peculiarly true over eyelids and areas of sensitive skin. Those areas with a greater tendency for scar formation, such as the zygomatic arch, the bony prominences of the jawline and chin, the eyelids, and the vermillion border, should just attain a maximum of Level II frosting.

Postoperatively, in that location is an immediate burning sensation as the skin solution is applied, merely this subsides as frosting is completed. With glycolic and TCA peels, keratocoagulation will continue as long as the caustic amanuensis remains on the skin.⁶ ^, ^vii ^, ^fifteen ^, ¹⁹ ^– ²¹ ^, ²⁴ ^, ²² ^– ²³ Thus, conscientious technique and diligent observation of process time and clinical signs of reaction completion (e.thousand., erythema and frosting) are essential. Reaction completion is accomplished past neutralizing with an alkaline metal agent such every bit sodium bicarbonate. It is of import to note that neutralization of any acid with any base is exothermic; thus, during neutralization, patients might experience a transient increment in feeling sof warmth, called-for, or stinging of the handling surface area.³⁵ ^– ³⁷ Subsequent edema, erythema, and desquamation are expected. With peels that target the periorbital and forehead areas, significant eyelid edema can occur and might fifty-fifty result in temporary closure. For the outset 24 hours, NSAIDs, soaks with dilute bleach or vinegar, and cool compresses with ice packs are useful in ameliorating some of the immediate postoperative swelling and pain. A bland emollient or mupirocin ointment should be applied to all treated areas for the first 24 hours postal service-handling, and daily after that. Following treatment with medium-depth peels, the erythema initially intensifies, peaking four to 5 days post-handling. Exfoliation is complete within 10 to 14 days.^six ^, ⁷ ^, ¹⁵ ^, ^xix ^– ²¹ ^, ²⁴ ^, ²² ^– ²³

With medium-depth peels, the concentration and corporeality of each agent that is applied modulates the intensity of keratocoagulation and thus the effectiveness of the peel. The nuances in concentration, variation of combination types, and treatment method can be adapted according to the patient'southward Fitzpatrick skin type and specific skin condition being treated. For a patient with avant-garde photoaging, such as crow'south feet or rhytides in the periorbital and/or perioral area, with medium-depth changes on the remaining face, a medium-depth skin tin can be used to equally an adjuvant or neoadjuvant to laser resurfacing or deep chemical peeling.^three ^, ¹³ ^, ^fifteen

DEEP PEELS

With the advent and rapid improvements in lasers, deep peeling has fallen out of favor in recent years, as lasers let for precise and anticipated ablation that result in consistently reproducible and uniform thickness tissue vaporization with lower incidences of scarring and postoperative complications. Furthermore, the systemic toxicities associated with deep peeling are virtually nonexistent with lasers.⁴ ^, ¹¹ ^, ¹² ^, ¹³ ^, ^fifteen ^, ²⁴ However, deep peels have been used successfully for near one-half a century, and when used with advisable technique in the proper setting, they take produced reliable and durable loftier-quality results.² ^, ⁵ ^– ⁷ ^, ¹⁰ ^, ²¹ ^, ²⁵ ^, ²⁶ ^, ⁴⁵ The ideal candidate for deep peeling procedures is a patient with moderate-to-severe chrono- and photoaging (e.g., chronic actinic damage with deep furrowed rhytides and/or meaning hyperpigmentation, such as those in Glogau Group III or 4).^two ^, ⁵ ^, ^vi ^, ⁷ ^, ^ten ^, ¹⁷ ^, ²¹ ^, ²⁵ ^, ²⁶

Usually used deep-depth solutions. The two most commonly used deep peels are high concentration TCA (≥50%), and the phenol peel. As previously discussed, loftier concentration TCA peels accept fallen out of favor due to frequent complications, a high incidence of scarring, and meaning unpredictability in ablative depth.² ^, ⁴ ^– ⁷ ^, ¹⁰ ^, ²¹ ^, ²⁴ ^– ²⁶ When using pure phenol peels, the undiluted, high concentration of phenol causes rapid keratocoagulation, producing a liquefactive "plug" of denatured protein that inhibits further chemical peeling. As a result, pure phenol provides only medium-depth ablation and is rarely used in chemical peeling.⁵ ^– ^vii ^, ¹⁰ ^, ²¹ ^, ²⁵ ^, ²⁶ ^, ⁴⁵

The Baker-Gordon phenol peel, adult nearly fifty years agone, uses a phenol formulation consisting of a detergent, croton oil as an epidermolytic amanuensis, phenol, and h2o for 50 to 55% dilution pct. This dilution allows for deeper and more uniform keratocoagulation than full forcefulness phenol.^seven ^, ¹⁰ ^, ²¹ ^, ²⁵ ^, ²⁶ The Baker-Gordon phenol peel, considered to be the original deep chemical skin, provides reliable and consistent deep chemoexfoliation into the level of the mid-reticular dermis and is the preferred agent of pick for deep peeling.^five ^– ⁷ ^, ¹⁰ ^, ²¹ ^, ²⁵ ^, ²⁶ ^, ⁴⁵

The Bakery-Gordon phenol solution has 2 methods of application: occluded and unoccluded. The occluded method is accomplished by applying an occlusive (waterproof) dressing (petroleum jelly dressing may also exist used) over the treatment surface area immediately post-obit awarding of the solution, thus achieving maximum penetration of the phenol acid. This penetration is particularly useful for treatment of deep, furrowed rhytides and severe Glogau Group Four photodamaged skin. Information technology results in keratocoagulation that extends into the midreticular dermis and, if used incorrectly the subcutis and fascia,.⁷ ^, ^ten ^, ²¹ ^, ²⁵ ^– ²⁶ The unoccluded method involves more skin cleansing, lipid removal, as well equally application of more peel solution, than the occluded method, but does not provide equally deep of chemoexfoliation every bit the occluded method.⁷ ^, ^ten ^, ^twenty ^, ²¹ ^, ²⁵ ^, ²⁶ ^, ⁴² ^, ⁴³

Pre, peri-, and postal service-treatment guidelines using deep-depth peels. Information technology is important to stress that any patient undergoing deep chemical peeling should exist fully educated on and bespeak an agreement of the risk factors, increased morbidity, and potential complications involved with the procedure, so that the benefits versus risks can be advisedly weighed. With an experienced surgeon, deep peeling is a reliable and safe method of treating severely photoaged and actinic-damaged pare, including deep perioral and periorbital rhytides and furrowed rhytides along the brow and cheek, and ameliorating pre-cancerous changes that unremarkably occur in astringent photoaged skin.⁵ ^– ⁷ ^, ¹⁰ ^, ²¹ ^, ²⁵ ^, ²⁶ ^, ⁴⁵ Deep peeling should be performed in an ambulatory surgical setting or role surgical suite, as systemic toxicity resulting from cutaneous absorption of the chemical agent is a concern. Practitioners should provide adequate preoperative sedation and intravenous hydration, especially when using phenol peels, to minimize the phenol concentration in the patient's serum that results from inevitable cutaneous absorption. Phenol is highly arrhythmogenic, metabolized by the liver and excreted by the kidney, and any patient with a history of cardiac arrhythmia and/or hepatic or renal dysfunction should not undergo phenol peeling.^iv ^, ⁶ ^, ⁷ ^, ^ten ^, ²¹ ^, ²⁴ ^– ²⁶ Cardiac monitoring is recommended for potential periprocedural toxicity assessment.⁴ ^, ⁶ ^, ⁷ ^, ¹⁰ ^, ²¹ ^, ²⁴ ^– ²⁶ Post-obit a deep-skin procedure, the postoperative inflammatory phase of wound healing commences immediately, with deep, dark, dusky edematous erythema that volition evolve into full-thickness epidermal necrosis with serosanginous exudate, crusting, and sterile pyoderma within 24 to 48 hours.⁴ ^, ^vi ^, ⁷ ^, ¹⁰ ^, ²¹ ^, ²⁴ ^– ²⁶ Inflammation might be severe, and the eyes might dandy shut. During this initial phase, it is important for the patient to apply cool compresses, ice packs, and NSAIDs to command inflammation, and gentle debridant soaks with dilute vinegar solution to remove necrotic epidermal debris and prevent thick chaff formation from the serosanguinous exudate.⁴ ^– ^seven ^, ²¹ ^, ²⁴ ^– ²⁶ Because the skin has lost its entire epidermal barrier, transmembrane water loss is significant. Routine, repetitive awarding of a bland emollient and oral hydration are essential to avoiding potential complications.⁴ ^– ⁷ ^, ²¹ ^, ²⁴ ^– ²⁶ ^, ⁴⁴ With deep chemical peels, reepithelialization does not commence until Day three or 4, post-procedure, after the inflammatory response has subsided, and continues for fourteen days or longer.⁴ ^– ^seven ^, ¹⁰ ^, ²¹ ^, ²⁴ ^– ²⁶ ^, ⁴⁴ ^, ⁴⁵ Maintaining a moist occlusive bulwark with bland emollients allows for rapid reepithelialization and reduces the likelihood of delayed wound healing or scar contracture.^four ^– ⁷ ^, ¹⁰ ^, ²¹ ^, ²⁴ ^– ²⁶ ^, ⁴⁴ ^, ⁴⁵ Because deep peeling causes keratocoagulation and exfoliation down to the mid-reticular dermis, both bacterial and candidal superinfections of the wound site and potential HSV reactivation are serious potential complications. Patients with a history of orolabial HSV should begin rubber antiretroviral therapy ane to ii days prior to peeling and should continue information technology until full reepithelialization has occurred, generally 10 to fourteen days post-treatment.⁴ ^– ⁷ ^, ¹⁰ ^, ²¹ ^, ²⁴ ^– ²⁶ ^, ⁴⁴ ^, ⁴⁵ For prevention of bacterial superinfection, mupirocin ointment can be used as the bland emollient for the first few days after treatment, and debridant soaks with dilute vinegar might exist of added antimicrobial consequence. Candidal superinfection is uncommon but should be astutely monitored during follow-upward. If there is whatsoever suspicion of candidal superinfection, prompt oral antifungals, such as fluconazole, should be initiated. Fibroplasia, neoangiogenesis, and neocollagen formation will continue well beyond the initial treatment menstruation, upwards of six months post-treatment.^ten ^, ²⁵ ^, ²⁶ ^, ⁴⁴ ^, ⁴⁵

SUMMARY

Analysis of the available literature reveals the following: chemical peels are the third nearly commonly performed noninvasive cosmetic procedure in the United States, with over ane,300,000 procedures performed in 2016 alone. Indications for treatment can exist classified into 4 categories: chronic chrono- and photoaging, acne and acneiform eruptions, dyspigmentation, and pre-cancerous epidermal neoplasms. Selection of agent blazon is determined past a number of factors, including handling indication, desired depth of ablation, pertinent examination findings, Fitzpatrick pare blazon, and relevant dermatologic history of the patient. When used for the appropriate indication with the proper technique, nearly all skin solutions and depths have demonstrated excellent clinical success in improving skin tone and texture, and are cost-effective compared to invasive procedures. Chemical peels should remain indispensable tools in the dermatologist'southward artful toolbox, particularly in light of the current rising healthcare costs in the Us.

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