This report reflectsthe best data available at the time the report was prepared, butcaution should be exercised in interpreting the data; the resultsof future studies may require alteration of the conclusions orrecommendations set forth in this report.

Reprint requests: American Academy ofDermatology, P.O. Box 4014,
Schaumburg, IL 60168-4014.
J AM ACAD DERMATOL 1995;33:497-503.
Copyright 1995 by the American Academy of Dermatology, Inc.

Guidelines of care for chemical peeling

Guidelines/OutcomesCommittee: Lynn A. Drake, MD, Chairman, Scott M. Dinehart,MD, Robert W. Goltz, MD, Gloria F. Graham, MD, Maria K. Hordinsky, MD, Charles W. Lewis, MD, David M.Pariser, MD, StuartJ. Salasche, MD, John W. Skouge, MD, Maria L. Chanco Turner, MD,Stephen B. Webster, MD, Duane C. Whitaker, MD, Barbara Butler, CPA-SDR Consultant, and Barbara J. Lowery, MPH

Task Force onChemical Peeling: Harold J. Brody, MD, Chairman, Thomas H.Alt, MD, and Nia K. Terezakis, MD

I. Introduction

The American Academy of Dermatology’s Guidelines/Outcomes Committee is developing guidelines of care for our profession. The development of guidelines will promote the continued delivery of quality care and assist those outside our profession in understanding the complexities and scope of care provided by dermatologists. For the benefit of members of the American Academy of Dermatology who practice in countries outside the jurisdiction of the United States, the listed treatments may include agents that are not currently approved by the U.S. Food and Drug Administration.

II. Definition

Chemical peeling (chemexfoliation) for the treatment of certain cutaneous diseases or conditions or for aesthetic improvement consists of the application of one or more chemical exfoliating agents to the skin, resulting in destruction of portions of the epidermis and/or dermis and the regeneration of new epidermal and dermal tissues. See Table I for definitions of some terminology used in this document.

III. Rationale

A. Scope

These guidelines identify the indications for chemical peeling, the chemicals used, their application, associated precautions, and post-peeling care and findings. Chemical peeling is used to treat actinic damage and may play a role in preventing the sequelae of actinic damage, including precancerous lesions. The following conditions may be amenable to chemical peeling:

1. Photoaging

a. Actinic keratoses

b. Solar elastosis

c. Solar lentigines

d. Dermatohelios

e. Pigmentary alterations

f. Elastotic rhytides

g. Other

2. Pigmentary disturbances

a. Melasma

b. Postinflammatory pigmentary changes

c. Other

3. Rhytides

a. Actinic

b. Dynamic

c. Sleep

d. Other

4. Other

a. Superficial scarring

b. Radiation keratoses

c. Acne vulgaris and rosacea, scarring and nonscarring

d. Warts

e. Milia

f. Sebaceous hyperplasia

g. Dermatosis papulosa nigra

h. Other

_______________________________________________________

Table I. Listof commonly used definitions, abbreviations, and terminology

1. Baker/Gordon formula: The classic diluted 55% phenol formula used in deep peeling

2. Coating: The application of the chemical peel wounding solution with the resulting frost, dependent chiefly on the concentration of peeling agent, but also on the condition and the location of the skin, among other factors.

3. Cosmetic unit: A singular division of the face; e.g., periorbital, perioral, right cheek, left cheek, forehead, nose

4. Deep peel: Peel utilizing the Baker/Gordon or Litton diluted phenol formula

5. Fitzpatrick skin type: A classification of skin color and response to sunlight. I-III, white skin; IV, moderate brown skin; V, dark brown; VI, black (see Table II)

6. Frost: Immediate whitening of skin after application of certain peeling agents.

7. Jessner’s solution or a Combes’ peel: 14% each of salicylic acid, lactic acid, and resorcinol in alcohol

8. Litton’s formula: A diluted 55% phenol formula used in deep peeling

9. Multiple applications: The reapplication of an additional coat of solution after frosting has already occurred and approximately 10 minutes has passed

10. Occlusion: The application of occlusive adhesive-type tape after phenol-based solutions have been applied ________________________________________________

B. Issue

Physician qualifications

1. General

a. The physician should have completed residency training or be board-certified in an appropriate specialty such as dermatology.

b. The physician should have knowledge of the skin and subcutaneous tissues including

five star hotel in Ponta1) Structural and functional differences of facial, neck, extremity, torso, and other skin to be peeled

2) Variation in skin anatomy of each facial cosmetic unit

3) The pathology and natural history of photodamage

4) Aspects of wound healing after chemical peeling, such as

a) Coagulation and inflammation

b) Angiogenesis

c) Granulation tissue formation

d) Reepithelialization

e) Collagen remodeling

f) Other

2. Specific

a. The physician should have appropriate training and experience in chemical peeling during residency, or

b. Appropriate course(s) specifically to learn chemical peeling techniques and procedures that may include

1) Multiple applications of chemicals (see Table I)

2) Methods and appropriate taping technique for occluded deep phenol peels, or

c. Appropriate experience at the surgical table

IV. Diagnosticcriteria

A. Clinical

1. History

a. General medical history as appropriate

b. Relative (not absolute) contraindicating factors

1) All peels

a) Previous recent (2 to 6 months) facial undermining surgery (blepharoplasty, rhytidectomy, brow lift, liposuction) in the treatment area, except for the most superficial peels

b) Active herpes simplex in treatment area

c) Current medications

d) Immunocompromising diseases (possibility of delayed healing, increased susceptibility to infection, or excessive pigmentation after peeling)

e) Previous facial radiation therapy that might impair the ability of the skin to regenerate

f) Recent isotretinoin treatment (may be a contraindication to peeling based on type of peel and on dose and duration of treatment with isotretinoin)

g) Keloids

h) Other

2) Medium or deep peels

a) Smoking may interfere with healing, increase the risk of scarring, and accelerate the return of rhytides.

b) Fitzpatrick skin types IV-VI (see Table II) may be more likely to have problems with pigmentation.

c) Other

3) Deep phenol peels

a) History of cardiac or hepatorenal disease if application to more than one cosmetic unit is planned (see (Table I)

b) Other

c. Other

1) Realistic expectations and physical and emotional stability of the patient to tolerate the procedure and recovery

a) Optional test spot may be performed, especially in anxious patients

b) Ability of patient to apply medications or dressings before and/or after peels should be ascertained.

2) Determine patient's willingness to use long-term cosmetic camouflage if pigmentary abnormalities persist.

3) Other

2. Physical examination

a. General physical examination as appropriate

b. Skin color, e.g., Fitzpatrick skin type I-VI (see Table II), to ascertain pigmentary response after peeling. Optional test spot may or may not aid in predicting color change.

c. Degree of photoaging to ascertain type of peel to be performed (i.e., superficial, medium, or deep) on each cosmetic unit

d. Degree of sebaceous activity (oily vs dry)

e. Laxity of periorbital skin

f. Presence of keloid or hypertrophic scar on face versus other areas

g. Presence of infection in area to be peeled

h. Photodocumentation for comparison of baseline and post-therapy appearance may be helpful

i. Other cutaneous pathology

B. Diagnostic tests

1. Preprocedural skin biopsy when indicated

2. Electrocardiography, chemistry profile, urinalysis, as indicated, especially for deep phenol peels

3. Other

C. Inappropriate diagnostic tests

Not applicable

D. Exceptions

Not applicable

E. Evolving diagnostic tests

Not applicable

_____________________________________________________________

Table II.Fitzpatrick skin type

V. Recommendations

A. Treatment

1. Medical

Not applicable

2. Surgical

The types of peeling are stratified as superficial, medium, or deep skin depth of the tissue destroyed. The choice of which type to use on a cosmetic unit of skin depends on the degree of photoaging and the factors in the above sections on history and physical examination.

Linz hôtelsa. Therapeutic agents used by type of peeling

1) Superficial-depth peeling

Generally epidermal wounding is obtained. The therapeutic agent can be applied to all Fitzpatrick skin types weekly, biweekly, or monthly.

a) Resorcinol: 10% to 50% pastes

b) Jessner’s solution or Combes’ mixture: applied to the skin undiluted in multiple coats

c) Tretinoin: may be used to prepare the skin before peeling or to prolong results after peeling

hoteles baratos Sopotd) a -Hydroxy acids (glycolic acid, lactic acid)

(1) Utilized in unbuffered or buffered forms

(2) Lactic acid is present in Jessner’s solution

(3) Under prolonged contact, deeper penetration may occur

e) Salicylic acid

(1) Fifty percent salicylic acid ointment may be used under occlusion for treatment of nonfacial areas.

(2) Reversible salicylism may occur (tinnitus, dizziness, headache)

f) Trichloroacetic acid (TCA) 10% to 35%

(1) Ten percent to 25% TCA produces a superficial peel under ordinary circumstances, not penetrating through the epidermis

(2) 35% TCA may or may not penetrate through the epidermis after a single application and is classified as a superficial peel; with multiple applications it may penetrate into the papillary dermis and is less superficial and more medium in depth.

g) Other

2) Medium-depth peeling

Wounding through the papillary dermis, down to the upper reticular dermis

a) TCA 50% -- single frost only

b) Combinations with lower strength TCA to enable increased depth with less risk of complications

(1) Solid carbon dioxide (CO₂) before TCA 35% applications

(a) Single or multiple frosts

(b) Fitzpatrick skin types I-IV only (see Table II)

(2) Jessner’s solution applied before 35% TCA application
Single or multiple frosts

(3) Glycolic acid applied and washed off before 35% TCA application

c) Additives to augment peeling agents such as methyl salicylate plus 35% TCA

d) Full-strength phenol, USP 88%--the undiluted phenol penetrates less than the diluted phenol utilized in deep peeling

e) Other

3) Deep-depth peeling to the mid reticular dermis

a) Baker/Gordon phenol formula unoccluded or occluded (see Table I)

b) Litton’s phenol formula, unoccluded or occluded (see Table I)

c) Other

b. Preparation

1) Obtain informed consent

2) Keratotic lesions may be removed before peeling

3) Selection of defatting agents and cleansers can affect the depth of the peel.

a) Acetone

b) Alcohol

c) Combination

d) Other

4) Selection and appropriate use of various applicators for procedure, including but not limited to cotton tip, cotton balls, sable brush, gauze pad

5) Appropriate selection of medications such as topical tretinoin, antiviral agents, and systemic cortisone derivatives for administration before, during, and/or after procedure, as indicated

6) Other

c. Procedure

The mode of application affects the evenness of application and the penetration of the peeling agents. The following may be considered.

1) Cautious application of any peeling agent, especially around periorbital area. Spillage of solution in the eye must be avoided.

2) Proper dilution of agents (e.g., necessary with glycolic acid, optional with low-strength TCA) after application to avoid excessive penetration

3) Slow application of phenol-based peels to the face, pausing 10 to 15 minutes between each cosmetic unit to avoid cardiac toxicity

4) Accurate facial diagrammatic mapping or similar documentation in the patient’s chart to illustrate which peeling technique was applied to each cosmetic unit

5) Other

d. Precautions during procedure

1) Controllable risks

a) Incorrect formula applied

b) Solution spillage onto patient or staff

c) Outdated solutions that are either too strong or too weak

d) Other

2) Appropriate selection of sedatives, monitoring, and hydration according to the agents employed (usually with phenol peels, only if performed in more than one cosmetic unit)

3) In deep phenol peels in more than one cosmetic unit, the physician should understand pertinent aspects of

a) Cardiac monitoring

b) Intramuscular or intravenous sedation

c) Analgesia

d) Hydration

e) Other

See "Guidelines of Care for Office Surgical Facilities, Parts I (JAM ACAD DERMATOL 1992;26:763-5) and II" (Ibid: 1995;33:265-70)

4) Safety considerations

a) Neutralizing agents for office use

(1) Water (TCA and a -hydroxy acids)

(2) Vegetable oil (phenol)

b) Eyewash solution

c) Adequate ventilation

d) Compliance with Occupational Safety and Health Administration requirements

e) Plan for managing medical emergencies

f) Consider using acid-resistant plastic containers or fresh solution

g) Other

5) Other

ERROR MSGe. Considerations in postoperative care

1) Medications, ointments, and dressings can enhance or retard re-epithelialization and healing

2) Appropriate intervention methods, when needed, based on a comprehensive understanding of the healing process may include the following:

a) Antibiotics/antivirals

b) Cortisone: topical, tape-impregnated, intralesional, systemic

c) Silicone polymer dressings

d) Observation

e) Ultrasound to soften scars

f) Other

3) Appropriate camouflage or cosmetic coverage for the patient

4) Post-healing precautions and medications, as needed, may include the following:

a) UV light protection

b) Hydroquinone

c) Tretinoin

d) a -Hydroxy acids

e) Topical steroids

f) Combinations

g) Other

5) Compliance with photoprotection recommendations after all peel types

6) Frequency of postoperative follow-up visits depends on the depth of the peel and the individual patient’s needs.

7) Other

f. Postoperative findings

1) Usual and expected postoperative findings, which are variable and are based on type of peel and patient response, may include the following:

a) Edema

b) Erythema

c) Vesiculation

d) Crusting

e) Scaling

f) Pigmentary changes

g) Other

2) Occasional postoperative complications may include the following:

a) Pigmentary alterations - may be treated with sunscreens, tretinoin, corticosteroids, hydroquinone, or a -hydroxy acids

(1) Hyperpigmentation

(2) Hypopigmentation

(3) Depigmentation

(4) Lines of demarcation

(5) Accentuation of nevi

(6) Combination of above

b) Prolonged erythema or pruritus - may require cortisone or other treatment

c) Textural changes

(1) Enlarged pores - transient

(2) Lines of demarcation - in all peel types

(3) Telangiectases - in medium or deep peels

d) Milia

e) Psychologic depression after peel, possibly necessitating treatment

f) Other

3) Rare postoperative complications may include the following:

a) Medium and deep peels, rare in superficial peels

(1) Scarring (aggravated by previous facial surgery, constrictive taping, previous or current isotretinoin use, preexisting ectropion, hereditary predisposition, actinic dermal skin quality or thickness, quality of after-peel care)

(a) Hypertrophic

(b) Atrophic

(c) Keloidal

(2) Ectropion (in patients with tendency for ectropion)

(3) Infection - treatment with appropriate topical or systemic antibiotics may be indicated.

(a) Bacterial

(b) Viral

(c) Fungal

(4) Delayed healing

(5) Other

b) Deep phenol peels

(1) Hypotension and shock

(2) Laryngeal edema (full-face, heavy smokers)

(3) Cardiac arrhythmias (full-face, phenol)

(4) Other

c) Other

(1) Atrophy

(2) Cold sensitivity if CO₂ slush is used

(3) Other

g. Repeat peeling may be indicated as follows.

1) Superficial peeling - repetitive peeling is expected and may occur at weekly, biweekly, monthly, or longer intervals.

2) Medium peeling - usually can be repeated in 3 months

3) Deep peeling - usually can be repeated in 6 months regionally

4) Other

3. Other

Other modalities that may be used in conjunction with chemical peeling include the following:

a. Soft tissue fillers before or after chemical peeling. Interval of 2 to 3 months or longer between peeling and injection will allow proper integration into the skin.

b. Tretinoin and/or hydroquinone before and/or after peel skin care, as appropriate

c. Chemical peeling in combination with dermabrasion, laser abrasion, or cryosurgery as appropriate

d. Other

B. Evolving treatments

a. a -Hydroxy acids - under prolonged contact, deeper penetration may occur

b. Azelaic acid - the utilization of azelaic acid cream to treat acne in superficial peeling is a potential future use as an adjunct to all types of peeling.

c. Jessner’s solution applied before glycolic acid application

d. Pyruvic acid, 60% to 70%

e. Augmenting techniques

The addition of augmenting agents to chemical peeling agents is of unknown risk and benefit at this time. Their depth is unknown.

f. Other

C. Miscellaneous

Not applicable

VI. Supportingevidence

See Bibliography (Appendix)

VI. Disclaimer

Adherence to these guidelines will not ensure successful treatment in every situation. Further, these guidelines should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. For the benefit of members of the American Academy of Dermatology who practice in countries outside the jurisdiction of the United States, the listed treatments may include agents that are not currently approved by the U. S. Food and Drug Administration.

Appendix.Bibliography
Ayres S III.Superficial chemosurgery in treating aging skin. Arch Dermatol1962;85:125-33.
Baker TJ, Gordon HL. Chemical peel with phenol. In: Epstein E,Epstein E Jr, eds. Skin surgery. Philadelphia: WB Saunders,1987:423-38.
Brody HJ. Chemical peeling. St Louis: Mosby-Year Book, 1992.
Brody HJ, ed. Special issue: chemical peels. J Dermatol SurgOncol 1989;15:916-1024.
Brody HJ, Alt TH. Chemical peeling. In: Coleman WP, Hanke CW, Alt TH, et al, eds. Cosmetic surgery of the skin. Philadelphia: BCDecker, 1991:65-88.
Brody HJ, Hailey CW. Medium-depth chemical peeling of the skin:avariation of superficial chemosurgery. J Dermatol Surg Oncol1986;12:1268-75.
Brown AM, Kaplan LM, Brown ME. Phenol-induced histological skinchanges: hazards, technique, and uses. Br J Plast Surg1960;13:158-69.
Clark RE, Weingold OH, Hirsh E, et al. TCA chemical peeleffecti8ve for extensive actinic keratoses. Skin Allergy News1991;22:34.
Collins PS. The chemical peel. Clin Dermatol 1987;5:57-74.
Drake LA, Ceilley RI, Cornelison RL, et al. Guidelines of carefor office surgical facilities. Part I. J AM ACAD DERMATOL1992;26:763-5.
Drake LA, Ceilley RI, Cornelison RL, et al. Guidelines of carefor office surgical facilities. Part II. Self-Assessmentchecklist. J AM ACAD DERMATOL 1995;33:265-70.
Klein DR, Little JH. Laryngeal edema as a complication ofchemical peel. Plast Reconstr Surg 1983;71:419-20.
Kligman AM, Baker TJ, Gordon HL. Long-term histologic follow-upof phenol face peels. Plast Reconstr Surg 1985;75:652-9.
Lawrence N, Cox SE, Cockerell CJ, et al. A comparison of theefficacy and safety of Jessner’s solution and 35%trichloroacetic acid vs 5% fluorouracil in the treatment ofwidespread facial actinic keratoses. Arch Dermatol1995;131:176-81.
Matarasso SL, Glogau RG. Chemical face peels. In: Thiers BH,O’Donoghue MN, eds. Dermatologic Clinics. Philadelphia: WBSaunders, 1991:131-50.
McCollough EG, Langston PR. Dermabrasion and chemical peel: aguide for facial plastic surgery. New York: Thieme MedicalPublishers, 1988:53-112.
Roenigk RK. Retinoids, dermabrasion, chemical peel and keloids.In: Reonigk RK, Roenigk HH Jr, eds. Surgical dermatology:advances in current practice. St. Louis: Mosby, 1993:376-83.
Stegman SJ. A comparative histologic study of the effects ofthree peeling agents and dermabrasion on normal and sun-damagedskin. Aesthet Plast Surg 1982;6:123-35.
Stegman SJ, Tromovitch TA, Glogau RG. Chemical peels. In:Cosmetic dermatologic surgery. Chicago: Year Book MedicalPublishers, 1990:35-58.
Van Scott EJ, Yu RJ. Alpha hydroxy acids: procedures for use inclinical practice. Cutis 1989;43:222-8.