A Practical Approach to Chemical Peels: A Review of Fundamentals and Step-by-step Algorithmic Protocol for Treatment

Abstract

Background: Chemoexfoliation, also known as chemical peeling, is a method of targeted cutaneous ablation using specific caustic agents that allow 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 analysis of all currently available chemical peels for dermatologic use, as well as a step-by-step instructional protocol for an algorithmic approach to treatment. Methods: A comprehensive search of the Cochrane Library, MEDLINE, and PUBMED databases was performed to identify relevant literature investigating chemical peeling agents. In addition, a search of all commercially available, prescription-based peeling agents was performed to identify all products currently available in the United States market. Results and Conclusion: Chemical peels are the third most commonly performed noninvasive cosmetic procedure in the United States, with over 1,300,000 procedures performed in 2016 alone. There has been a paradigm shift in recent years, with lasers largely supplanting deep peels. Despite this shift, superficial peels have proliferated in both popularity and product diversity. When used for the appropriate indication and with proper technique, nearly all peeling agents have demonstrated excellent clinical efficacy and remain an indispensable cost-effective tool in the dermatologist's aesthetic toolbox.

Keywords: Aging; Chemical peel; Glogau; Glycolic; Lentigo; Peel; Phenol; Photoaging; Rhytides; Trichloroacetic acid; Wrinkles.

Conflict of interest statement

FUNDING: No funding was provided for this article. DISCLOSURES: The authors have no conflicts of interest relevant to the content of this article.

Figures

FIGURE 1.

Chemical peel procedural flow

FIGURE 2.

Visual representation of intended depth of chemoexfolliatian by type of agent used—superficial peels penetrate only the epidermis; medium-depth peels affect the entire epidermis and a portion of the papillary dermis; and deep peels aim to penetrate to the the level of the midreticular dermis.

FIGURE 3.

Basic cosmetic subunits are divided by the solid blue lines into forehead (including temples and glabellar area), periorbital area, nose, cheeks, perioral area, and mentum. In 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 red circles and include the medial canthi and the periapical triangles/nasojugal grooves. Special care should be taken to protect these areas (i.e. with petrolatum jelly and cotton balls or gauze pads) as the caustic agents used during peeling tend to pool in these concavities and can cause undesired excessive keratocoagulation.