Chemical Peels: Whats New and What Isnt

New but Still Works Well

Gabriella Fabbrocini, M.D.,1 Maria Pia De Padova, M.D.,2
and Antonella Tosti, M.D.3

ABSTRACT

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Chemical peeling is becoming increasingly popular for the treatment of skin
rejuvenation where it can improve damaged skin and fine wrinkles. The basic procedure
aims at obtaining a controlled chemical burn of the epidermis and/or dermis. This results in
epidermal regeneration and postinflammatory collagen neoformation with remodeling of
collagen and elastic fibers and deposition of glycosaminoglycans in the dermis. Various
chemicals have been used as peeling agents, of which the most used are the a-hydroxy
acids, such as glycolic acid, or b-hydroxy acids, such as salicylic acid. The choice of the
compound is linked to the different indications and to the depth of the desired peeling.
Phenol is still the best agent for deep peeling but requires specific indications, prescription,
and post-peeling care. Combination of different compounds is one innovation in the field
of chemical peelings. Further controlled studies are necessary to set up specific guidelines.

KEYWORDS: Chemoexfoliation, photorejuvenation, photodamage

S everal facial resurfacing techniques are used to
fight the signs of skin aging ranging from superficial to
deep; the choice depends on severity of damage, skin
type, and associated conditions. Chemical peeling is
probably the most frequently used procedure even
though it is often necessary to combine chemical peeling
with other skin rejuvenating and resurfacing techniques
for best overall results. The use of chemicals for facial
skin softening and rejuvenation has been practiced since
ancient times. Cleopatra bathed in sour milk, and
women in ancient Rome rubbed fermented grape skins
from the bottom of wine barrels over their skin to
ameliorate their skin texture, thus using the superficial
exfoliative effects of the hydroxy acids: lactic acid in milk
and tartaric acid in grape skins. These acids and their
derivatives are now common ingredients of many chem-
ical peels.1,2 The evolution of chemical peeling and
dermabrasion into the procedures commonly used today
began in the early 20th century with cosmeticians, and
for many years formulas were kept secret and managed
by the different specialists. Scientific investigations on
the use of phenol and trichloroacetic acid (TCA) peels
for facial resurfacing only began in the late 1960s, and
TCA peels became popular only in the late 1980s. In
1972, Baker and Gordon3,4 demonstrated the beneficial
effects of phenol on photoaging and other common skin
problems to a group of plastic surgeons. Since then,
plastic surgeons and dermatologists developed new com-
pounds and technologies to use chemical peelings for
different indications and to improve their safety and
efficacy.5
Dyschromias and wrinkles are the major clinical
indications for facial chemical peeling. Most wrinkles
and dyschromias are due to photodamage combined with

1
Department of Systematic Pathology, Section of Dermatology, Uni-
versity of Naples Federico II, Naples, Italy; 2Nigrisoli Private Hospital,
Bologna, Italy; 3Department of Dermatology, University of Bologna,
Bologna, Italy.
Address for correspondence and reprint requests: Antonella Tosti,
M.D., Department of Dermatology, University of Bologna, via
Massarenti 1, Bologna 40138, Italy (e-mail: antonella.tosti@unibo.it).
Skin Rejuvenation; Guest Editor, Kenneth Beer, M.D., F.A.A.D.
Facial Plast Surg 2009;25:329336. Copyright # 2009 by Thieme
Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001,
USA. Tel: +1(212) 584-4662.
DOI 10.1055/s-0029-1243082. ISSN 0736-6825.
329
330 FACIAL PLASTIC SURGERY/VOLUME 25, NUMBER 5 2009
the normal aging process. The term photoaging indicates
some skin modifications associated with chronic photo-
exposure; these include increased skin roughness, dish-
omogeneous hyperpigmentation, reduction of elasticity,
wrinkling, and development of solar lentigo and actinic
keratosis. Wrinkles may be classified according to se-
verity.6 Progressive thinning of the epidermis and upper
dermis, which produces cigarette paper skin, causes
wrinkles. Repetitive muscular movements that create a
dent in the epidermis and most of the dermis cause
wrinkles related to muscles, which involve the glabella
and the periorbital and perioral areas. Deeper wrinkles
are due to loose redundant skin with atrophy of the
epidermis and reduction of the dermis and subcutaneous
tissue associated with reduction of elasticity. Gravity
causes folds with downward sagging of the skin and
underlying muscles. Rubin6 developed a classification of
photodamaged skin based on the histologic depth of the
damage with the purpose of select treatment according
to specific skin aging: the peel must be as deep as the
deepest skin problem to achieve the best results. This
also helps in predicting morbidity and risk of complica-
tions associated with the treatment program. Clinical
experience showed that common skin problems such as
ephelides, melasma, and epidermal hyperpigmentation
respond in an excellent way to epidermal peels, whereas
senile lentigines and lentigines simplex need deeper peels
with involvement of dermis. Dermal melasma, dermal
postinflammatory hyperpigmentation, and seborrheic
keratoses are not successfully treated with superficial
and medium-depth chemical peels.
Chemical peels create a thinner, more compact
stratum corneum, associated with a thicker, well-repre-
sented normal epidermis with uniform distribution of
melanin. The histologic studies performed by Ditre et al7
showed an increase in collagen and glycosaminoglycans
in the papillary and reticular dermis and increased elastic
staining in the dermis. The increased volume of tissue
tightens the superficial skin layers, leading to an im-
provement of skin aging problems. Deeper peels result in
a greater deposition of collagen and glycosaminoglycans.
Therefore, superficial peels help the more superficial
types of wrinkles, whereas deeper peels are needed to
improve deep lines. The results of chemical peels depend
mostly on the histologic depth of the lesions. Fine
wrinkling can benefit from epidermal peels, but wrinkles
associated with papillary dermal atrophy and damage
need deeper peels that correct papillary damage.
AGENTS USED FOR CHEMICAL PEELING
Many agents are available for chemical peeling. New
agents are constantly researched, and old agents are used
in different combinations and formulations.8 To be
familiar with the peeling agent(s) is very important to
understand their safety profile and efficacy.
Classification of Peeling Agents9
Peeling agents are classified according to their capacity
of penetration and therefore the deepness of induced
chemoexfoliation. Many variables can alter the penetra-
tion of the peeling including:
1. Chemical structure and concentration of the peeling
agent.
2. Number of applications and pressure applied during
the application.
3. Preparation of the skin in the weeks preceding the
peel.
4. Cleansing of the skin before the peel.
5. Phototype of patients skin, according to
Fitzpatricks classification.
6. Anatomic region.
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Chemical peels and peeling agents can be classified
as very superficial, superficial, medium deep, and deep.
1. Very superficial agents include the following:

Glycolic acid, 30 to 50%, applied briefly (1 to 2 minutes).

Jessner solution, applied in one to three coats.

Low-concentration resorcinol, 20 to 30%, applied
briefly (5 to 10 minutes).

TCA 10%, applied in one coat.
2. Superficial agents include the following:

Glycolic acid, 50 to 70%, applied for a variable time
(2 to 5 minutes).

Pyruvic acid, 40 to 50%, applied for a variable time
(3 to 5 minutes).

Jessner solution, applied in 4 to 10 coats.

Resorcinol, 40 to 50%, applied for 30 to 60 minutes.

TCA, 10 to 30%.
3. Medium-depth agents include the following:

Glycolic acid 70%, applied for a variable time (3 to 15
minutes).

Pyruvic acid 60%, applied for a variable time (3 to 5
minutes).

TCA, 35 to 50%.

Augmented TCA (carbon dioxide plus TCA 35%.
Jessner solution plus TCA 35%; glycolic acid 70% plus
TCA 35%).
4. Deep agents include the following:

Phenol 88%.

Baker-Gordon phenol formula.
Depth of penetration of chemical peelings can be
judged and controlled as follows:
1. Development of diffuse homogeneous erythema in-
dicates epidermal penetration.
2. Development of white frost indicates coagulative
necrosis of the papillary dermis.
3. Development of gray-white frost indicates coagula-
tive necrosis of the reticular dermis.

CHARACTERISTICS OF MAIN CHEMICAL
PEEL AGENTS
a-Hydroxy Acids
This family includes numerous naturally occurring
acids derived from different fruits and natural products:
glycolic acid, which is present in sugarcane; lactic acid,
which is present in sour milk; malic acid, which is
present in apples; citric acid, which is present in lemon
and orange; and tartaric acid, which is present in grapes.
a-Hydroxy acids (AHAs) act by inducing epidermol-
ysis followed by desquamation within a few minutes of
application. The concentration of the acid and the
vehicle of the formulation determine the intensity of
the AHA peel. In general, gel formulations have a
slower penetration time and are easier to control.
Among AHAs, glycolic acid is the most used commer-
cial peeling agent. Chemical peeling by physicians is
usually performed with a 30 to 70% glycolic acid
solution. AHA peels are controlled by neutralization.
The most used neutralizing agent is 10% sodium
carbonate solution. These peelings require very good
training as risk of excessive penetration is high. Dermal
scarring can occur with 70% solution if the peeling is
not well controlled.
b-Hydroxy Acids
Salicylic acid (ortho-hydroxybenzoic acid) is the
b-hydroxy acid family member that is used for chem-
ical peeling. Salicylic acid is a naturally occurring
substance found in the bark of the willow tree. In
concentrations of 3 to 5%, it acts as a keratolytic agent
and enhances the penetration of other peeling agents
and topical preparations. It is also a well-documented
comedolytic agent. Salicylic acid is one of the older
peeling agents with first documented use by Unna, a
German dermatologist. Salicylic acid is a flexible
substance that can be formulated in many types of
vehicles.10
Trichloroacetic Acid
Trichloroacetic acid (TCA) was first described by
Roberts in 1926.11 It is an inorganic compound, that
is present in crystalline form. For the purposes of
chemical peeling, it is mixed with 100 mL distilled
water to create the desired concentration. The risk of
postinflammatory dyschromias and scarring increases
with higher concentrations of TCA. It may be used
alone or in combination with other agents such as
glycolic acid or salicylic acid. Trichloroacetic acid is
self-neutralizing and does not require water or bicar-
bonate to terminate the peeling action. The mechanism
of action of TCA is to precipitate epidermal proteins
and cause cellular necrosis.
CHEMICAL PEELS/FABBROCINI ET AL 331
Pyruvic Acid
Pyruvic acid is an a-ketoacid, a chemical group that has
properties of both acids and ketones.1214 Griffin first
showed that 60% pyruvic acid in ethanol was effective
as a peeling agent.15 According to his personal experi-
ence, a more even penetration can be obtained by
combining 5 cc of the acid solution with eight drops
of an emulsifying agent such as polyethylene laurel
ether and one drop of croton oil, which acts as an
epidermolytic inflammatory agent. This solution is
similar to Bakers phenol formula.16
Jessner Solution and Modified Formula
Formulated by Dr. Max Jessner, this combination is an
excellent superficial peeling agent. The Jessner solution
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formula includes:
Resorcinol 14 g
Salicylic acid 14 g
Lactic acid (85%) 14 g
Ethanol (sufficient quantity to make 100 mL)
The advantage of this formulation is that there is
a synergistic effect between the three keratolytic agents,
and an additional benefit of a skin-lightening agent
(resorcinol) as one of the components.17
The modified formula is characterized by differ-
ent concentrations of lactic acid (17%), salicylic acid
(17%), citric acid (8%), and ethanol (sufficient quantity
to make 100 mL). The limitation of Jessner solution is
the necessity to store the solution in a dark bottle to
prevent photo-oxidation. The phenolic compound, re-
sorcinol, may also create some depigmentation problems
in dark skin types V and VI.18
Resorcinol
The use of resorcinol in chemical peels at concentrations
of 10%, 20%, and 30% was first proposed by Unna in
1882. His formula was later modified to obtain higher
concentrations.19,20 Resorcinol is soluble in water,
ether, and alcohol and has bactericidal and keratolytic
properties.
The modified Unna paste has the following for-
mula:
Resorcinol 40 g
Zinc oxide 10 g
Ceyssatite 20 g
Benzoinated axungia 28 g
Phenol Preparations
Phenol and croton oil solutions are used for deep
peelings.21 Phenol (C5H5OH) or carbolic acid is an
aromatic hydrocarbon derived from coal tar that can be
made from the partial oxidation of benzene. Ninety-
eight percent phenol appears as transparent crystals,
332 FACIAL PLASTIC SURGERY/VOLUME 25, NUMBER 5 2009
while liquefied phenol consists of 88% USP solution of
phenol in water. Phenol has antiseptic and burning
properties.
Croton oil derives from the seed of the plant
Croton tiglium and is now commercially prepared as
croton resin. It contains free hydroxyl groups, which
cause skin vesiculation even in low doses. Deep
peeling solutions based on phenol penetrate the
skin to the midreticular dermis and induce production
of new collagen. Phenol-based peel requires
full cardiopulmonary monitoring with intravenous
hydration throughout the procedure. Intravenous se-
dation or regional blocks make the procedure pain-
free.
PROCEDURE
General Principles
The general principles of chemical peeling are very easy.
To achieve the best results, it is important to be familiar
with the peeling agent. Thin skin peels faster than thick
skin. The main factors influencing the depth of the
induced skin damage (superficial, medium, or deep) are
(a) the concentration of the agent, (b) the pressure to the
skin during the application, (c) the number of coats, and
(d) the time of application.
TECHNIQUES OF APPLICATION
OF CHEMICAL PEELS
Patient Selection
The success of a chemical peel depends on a careful
selection of patients and individualization of the
treatment. As a rule, patients with mild facial rhytides
and/or minimal dyschromias are the best candidates
for superficial to medium-depth chemical peels
(Figs. 13). In patients with deep rhytides and ex-
cessive facial skin, peelings should be combined with
traditional plastic surgery interventions. Evaluation of
skin type and complexion is very important to deter-
Figure 1 Mild photoaging (A) before and (B) after 30% TCA. Note improvement of skin texture and hyperpigmentation.
mine which chemical peels would be suitable for the
patient and to avoid complications such as pigmenta-
tion abnormalities. The Fitzpatrick classification of
skin types (I to VI) is useful for this purpose. The
choice of different agents has advantages and dis-
advantages (Table 1).
Patients Lifestyle22
The patients lifestyle should always be considered.
Compliance with pre- and post-peel treatment must be
ensured. The patient must be motivated enough to stick
to a daily regimen for a few weeks before and after the
procedure.
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Preparation of the Skin
For optimal results, preparation of the skin in the weeks
before the procedure is very important. In our experi-
ence, topical retinoic acid preparations used daily for 3 to
6 weeks prior to the procedure may create better and
more even penetration of the peeling solution in seba-
ceous and hyperkeratotic skins. We did not find any
benefit of this regimen in thin-skinned patients. Stand-
ard photography and informed consent should always be
obtained before the procedure for all types of peelings.
Skin Cleansing
The patient should thoroughly cleanse the face with
non-residue soap the day before the peel and should not
apply makeup or moisturizers. Immediately before start-
ing the procedure, the skin is cleansed to remove any
remaining traces of makeup or oils, using ether, acetone,
or isopropyl alcohol. Cleansing the skin before a chem-
ical peel is very important to prevent uneven penetration
of the peeling agent.
Pre-peeling Preparation
In patients with a history of recurrent herpes simplex,
it is necessary to prescribe prophylaxis with systemic
 CHEMICAL PEELS/FABBROCINI ET AL 333

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Figure 2 (A) Mild photoaging with hyperpigmentation of the decollete treated with combination peeling with 25% salicylic
acid and 25% TCA. (B) White frosting indicating dermal penetration. (C) Complete reepithelialization 15 days after the
procedure. Note homogeneous improvement of the pigmentary lesions.

Figure 3 (A) Severe photoaging treated with 18% TCA as the patient asked for a mild procedure. (B) Note mild improvement
of the skin texture and wrinkles.
334 FACIAL PLASTIC SURGERY/VOLUME 25, NUMBER 5 2009

Table 1 Advantages and Disadvantages of the Main Table 1 (Continued )

Chemical Peels
Given the appearance of the white precipitate, uniformity
Glycolic acid of application is easily achieved
Advantages After several minutes the peel can induce an anesthetic
Very mild erythema effect thereby increasing patient tolerance
Mild desquamation Disadvantages
Short postoperative period Limited depth of peeling
Useful in photodamage Minimal efficacy in patients with significant photodamage
Disadvantages Trichloroacetic acid
Burning sensation and erythema during application Advantages
No uniformity of application Low-cost procedure
Neutralization is mandatory Uniformity of application and penetration
Necrotic ulcerations if time of application is too long Depending on frost, it is possible to control the degree
and/or skin pH is reduced of penetration with different concentrations
Jessner solution Disadvantages

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Advantages Stinging and burning sensation during the application
Excellent safety profile High concentrations are not recommended in skin types
Can be used in all skin types V and VI
Substantial efficacy with minimal downtime Hypo/hyperpigmentation can occur
Enhances the penetration of TCA Phenol
Disadvantages Advantages
Concerns regarding resorcinol toxicity, including thyroid Useful in patients with photodamage
dysfunction Useful in patients with perioral wrinkles
Manufacturing variations Useful in patients with atrophic acne scars
Instability with exposure to light and air Useful for facial skin rejuvenation
Increased exfoliation in some patients Disadvantages
Pyruvic acid Cardiotoxicity
Advantages Hyperpigmentation
Very mild erythema
Mild desquamation
Short postoperative period
Can be used in skin types III and IV
Disadvantages antivirals, from the day before the procedure until
Intense stinging and burning sensation during the application full reepithelialization. Generally, it is not necessary
Neutralization is mandatory to discontinue use of any of the patients medications
Pungent and irritating vapors for the upper respiratory including anticoagulants, aspirin, or nonsteroidal anti-
mucosa inflammatory or antihypertension drugs. Systemic
Resorcinol isotretinoin is a strict contraindication to peeling.
Advantages This drug should be interrupted at least 6 months
Easy to perform before the procedure in patients with thick sebaceous
Uniformity of application and penetration skin and 1 year for patients with thin skin. According
Useful in acne, postinflammatory hyperpigmentation, to our experience with superficial and medium-
and melasma deep peeling, smoking does not have any adverse
Not painful (the burning sensation during the peeling is effect on post-peel healing or on the extent of the
usually mild) results.
Disadvantages
Desquamative effect aesthetically unacceptable Application
Unsafe in Fitzpatrick skin type higher than V The patient should sit in a comfortable position, wear a
Cannot be used in summer disposable hair cap, and be instructed to keep the eyes
Resorcinol may be a sensitizing and toxic agent closed during the procedure.
Salicylic acid A zinc oxide paste should be applied at the lip and
Advantages eyelid commissures.
An established safety profile in patients with skin Always keep the container with the peeling agents
types I to VI on the side of the patient to avoid inadvertent dropping.
Excellent in patients with acne The modality of application depends on formulation.
Liquid products are better applied using a fan brush; gel

products can be applied with cotton-tipped applicators
or gloved fingers.
Treatment should start on facial areas with thicker
skin.
Apply the peeling agent on the forehead first,
from side to side, and then on the cheeks, the nose, and
the chin. The periocular and perioral regions should be
treated last. For obtaining a homogeneous peeling,
repeat the application in regions that do not show
erythema or frosting.
Postoperative Care
The healing process after a chemical peel must be as
rapid as possible to avoid infections that may deepen the
wounds, extending the peel from superficial to deep,
with increased risks of scarring. Deep peels may be
prophylactically treated with antimicrobials, but super-
ficial and medium-deep peels are simply kept moist with
the application of petrolatum-based products. After
reepithelialization, and when skin appearance is back
to normal, a regimen of AHAs, retinoic acid, bleaching
creams, moisturizers, and sunscreens should be restarted.
Sun exposure must be avoided for 6 weeks after the peel
to minimize the risks of postinflammatory hyperpig-
mentation.
COMBINATION PEELS
Combination peels are used to enhance the penetration
of low-concentration TCA, or other acids, thus mini-
mizing the risks of scarring while the acid still penetrates
as deeply as 50% TCA. The most commonly used
combinations are as follows.
Jessner Solution and TCA (Monheit Peel)23
Gary Monheit described this peel combination. After
preparing the skin, one to four layers of Jessner solution
are applied until there is generalized erythema. Thirty-
five percent TCA is then applied, which penetrates more
rapidly, uniformly, and deeply than if applied on its own.
These peels can be repeated every 3 to 4 months to
maintain an improvement of fine wrinkles.
Solid Carbon Dioxide and TCA
This combination, which has been studied by Dr. Hal
Brody, is used in different areas of the skin affected
by deep wrinkles. Wrinkles are first treated with
solid carbon dioxide dipped in a solution of acetone and
alcohol to help it glide over the skin. Time of application
influences the depth of peeling. When the burning or
tingling sensation from the carbon dioxide has subsided,
TCA 35% is applied to the whole face.
CHEMICAL PEELS/FABBROCINI ET AL 335
Glycolic Acid and TCA24
After normal priming of the skin, 70% glycolic acid is
applied to the skin for 2 minutes without prior cleaning
of the skin. Trichloroacetic acid 35% is then applied.
This combination is thought to result in a more uniform
and deeper peel than TCA used alone.
Jessner Solution and Glycolic Acid6
Dr. Larry Moy studied this technique, and it is per-
formed applying from one to three coats of Jessner
solution, causing a diffuse erythema. The skin is then
treated with 70% glycolic acid. This procedure again
produces a more uniform glycolic acid peel. Risk of
overpeel for the patient is high, and for this reason strict
monitoring is necessary.
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CHEMICAL PEELS IN DARK SKIN
Although pigmentary complications are more common
in high photo types recent studies show that superficial
peelings can be performed safely in darker racial-ethnic
groups.2530
DISCUSSION
The main indications of chemical peelings include pho-
toaging, prevention of skin cancer in severe photoaging,
melasma, postinflammatory hyperpigmentation, acne
and seborrhea, and acne scars.31,32 Chemical peelings
are very useful in the management of photoaging and
may even delay the necessity of plastic surgery interven-
tions. Chemical peelings are a simple procedure, except
for the deep peeling with phenol applied on the whole
face, which requires hospitalization and intense care. It is
however important to keep in mind that complications
are not rare, even with superficial peelings, and that a
proper training for each peeling agent is necessary to
avoid excessive penetration.
Although the literature on chemical peeling is
extensive, there are few studies with adequate designs
and good quality. We were able to retrieve more than
400 articles illustrating different procedures and indica-
tions of peeling agents but only very few controlled and
randomized studies. In general, studies showed benefits
(greater for medium-deep peelings) with minimal or no
complications.33 Histologic studies performed on ani-
mals, comparing the different agents, showed that all the
main compounds used for chemical peeling (glycolic
acid, salicylic acid, pyruvic acid) can be useful to reduce
the oxidative stress.
Many chemicals are available for peeling today,
and new agents will be developed in the near future.
Research is important to better understand action and
efficacy of the old agents and to establish their optimal
336 FACIAL PLASTIC SURGERY/VOLUME 25, NUMBER 5 2009
formulations and concentrations as well as the advan-
tages in combining different chemicals.
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