The document provides a history of chemical peels, beginning in ancient Egypt and continuing through developments in the late 19th and 20th centuries. It describes the histological changes that occur with peeling, including the regeneration of epidermis and formation of new collagen. Medium peels are described as causing necrosis of the epidermis and inflammation within the papillary dermis, improving skin texture and removing lesions in moderately photodamaged skin. Various techniques and agents used for medium peels are outlined, including combinations of trichloroacetic acid, Jessner's solution, and glycolic acid.

1. Facial Chemical PeelsFacial Chemical Peels

2. HistoryHistory
Egypt - first evidence ofEgypt - first evidence of
exfoliants useexfoliants use
– Sun-damaged skin was aSun-damaged skin was a
sign of lower rank insign of lower rank in
societysociety
– Sour milk- contain lacticSour milk- contain lactic
acid, an alpha-hydroxy acidacid, an alpha-hydroxy acid
commonly used todaycommonly used today
Turks - use fire toTurks - use fire to
produce a thermalproduce a thermal
exfoliationexfoliation

3. HistoryHistory
1882 P.G Unna, German dermatologist1882 P.G Unna, German dermatologist
described resorcinol, salicylic acid, phenol,described resorcinol, salicylic acid, phenol,
trichloroacetic acidtrichloroacetic acid
1903 Mackee began using phenol for acne1903 Mackee began using phenol for acne
scarring (Chairman of dermatology at NYU)scarring (Chairman of dermatology at NYU)
1961 Baker and Gordon presented a peel1961 Baker and Gordon presented a peel
formula with one patient with a 3 month followformula with one patient with a 3 month follow
up, became the standard formulaup, became the standard formula
1966 Baker published results in 250 patients1966 Baker published results in 250 patients

4. AgingAging
Define as the process ofDefine as the process of
system's deteriorationsystem's deterioration ((Hanbook ofHanbook of
the Biology of Agingthe Biology of Aging 2006)2006)
Facial skin changes is one ofFacial skin changes is one of
the most apparent examples ofthe most apparent examples of
agingaging

5. HistologyHistology
Actinic changes - photochemical effects of solarActinic changes - photochemical effects of solar
radiation exposureradiation exposure
– Disorderly arrangement of epidermisDisorderly arrangement of epidermis
– Degeneration of the elastic networkDegeneration of the elastic network
– Mottled pigmentationMottled pigmentation
– Lymphocytic infiltrationLymphocytic infiltration
– Decrease in collagenDecrease in collagen
– Flattening of the dermal-epidermal junctionFlattening of the dermal-epidermal junction
– Epidermal cell atypiaEpidermal cell atypia
– Increased melanocytes, but they were unevenlyIncreased melanocytes, but they were unevenly
distributed and contained variable amounts of melanindistributed and contained variable amounts of melanin

6. Peel Skin HistologyPeel Skin Histology
Chemical burn of the epidermis and the outerChemical burn of the epidermis and the outer
dermisdermis

7. Peel Skin HistologyPeel Skin Histology
First 2 to 5 days - Regenerates from follicularFirst 2 to 5 days - Regenerates from follicular
and eccrine duct epitheliumand eccrine duct epithelium

8. Peel Skin HistologyPeel Skin Histology
Fresh, orderly, organized epidermisFresh, orderly, organized epidermis

9. Peel Skin HistologyPeel Skin Histology
At 2 weeks - newAt 2 weeks - new
collagen formationcollagen formation
begins and maybegins and may
continue up to 1 yearcontinue up to 1 year
– New bands of dermisNew bands of dermis
2- to 3-mm-thick2- to 3-mm-thick
– Thin, compact, parallelThin, compact, parallel
collagen bundlescollagen bundles
arranged horizontallyarranged horizontally
along the epidermal-along the epidermal-
dermal matrixdermal matrix

10. Peel Skin HistologyPeel Skin Histology
Other changesOther changes
– Melanocytes contain fine, evenly distributedMelanocytes contain fine, evenly distributed
melanin granulesmelanin granules
– Impaired melanin synthesis with a generalizedImpaired melanin synthesis with a generalized
bleaching effectbleaching effect
– Decrease lymphocytic infiltrationDecrease lymphocytic infiltration

11. Treat cutaneous lesionsTreat cutaneous lesions
Replace atypicalReplace atypical
keratinocytes with normalkeratinocytes with normal
epidermal cellsepidermal cells
Kligman concluded thatKligman concluded that
chemical peel reduced thechemical peel reduced the
development of newdevelopment of new
neoplasmsneoplasms
Litton decreased the rate ofLitton decreased the rate of
appearance of precancerousappearance of precancerous
and early cancerous lesionsand early cancerous lesions
after a phenol chemical peelafter a phenol chemical peel

12. Patient SelectionPatient Selection
"The ideal patient is a thin-skinned female"The ideal patient is a thin-skinned female
with fair complexion and fine rhytids."with fair complexion and fine rhytids."
Skin type and the amount of photodamageSkin type and the amount of photodamage
presentpresent
Fitzpatrick classified the skin typesFitzpatrick classified the skin types
– Color and acute solar radiation responseColor and acute solar radiation response
The Glogau classification based on theThe Glogau classification based on the
degree of photoagingdegree of photoaging

13. Fitzpatrick ClassificationFitzpatrick Classification
Fitzpatrick skin type I and type II are good candidatesFitzpatrick skin type I and type II are good candidates
Type III and greater - increased risk pigment complicationsType III and greater - increased risk pigment complications
TypeType ColorColor Tanning responseTanning response
II WhiteWhite Always burns, never tansAlways burns, never tans
IIII WhiteWhite Usually burns, tans less than averageUsually burns, tans less than average
IIIIII WhiteWhite Sometimes burns mildly, tans about averageSometimes burns mildly, tans about average
IVIV BrownBrown Rarely burns, tans more than average and with easeRarely burns, tans more than average and with ease
VV Dark brownDark brown Very rarely burns, tans very easilyVery rarely burns, tans very easily
VIVI BlackBlack Never burns, tans very easilyNever burns, tans very easily

14. Glogau classificationGlogau classification
GroupGroup ClassificationClassification Skin characteristicsSkin characteristics PeelPeel
II MildMild Little wrinkling or scarring and noLittle wrinkling or scarring and no
keratoseskeratoses
SuperficialSuperficial
IIII ModerateModerate Early wrinkling, mild scarring, andEarly wrinkling, mild scarring, and
sallow color with early actinicsallow color with early actinic
keratoseskeratoses
MediumMedium
IIIIII AdvancedAdvanced Persistent wrinkling, discolorationPersistent wrinkling, discoloration
with telangectasias and actinicwith telangectasias and actinic
keratoseskeratoses
MediumMedium
IVIV SevereSevere Wrinkling—superficial to deepWrinkling—superficial to deep
actinic keratoses ± skin canceractinic keratoses ± skin cancer
Medium to DeepMedium to Deep

15. Aesthetic IndicationsAesthetic Indications
RhytidsRhytids
SpottySpotty
hyperpigmentationhyperpigmentation
Superficial acneSuperficial acne
scarringscarring

16. Therapeutic IndicationsTherapeutic Indications
Actinic keratosesActinic keratoses
Superficial basal cellSuperficial basal cell
carcinomascarcinomas
Lentigo malignaLentigo maligna
lentigineslentigines
MelasmaMelasma
(discoloration of skin(discoloration of skin
caused by pregnancy)caused by pregnancy)

17. ContraindicationsContraindications
RelativeRelative
ContraindicationsContraindications
– Darker skin typeDarker skin type
(Fitzpatrick IV-VI)(Fitzpatrick IV-VI)
– History KeloidHistory Keloid
– History of herpes infectionsHistory of herpes infections
– Cardiac abnormalitiesCardiac abnormalities
– A history of diabetesA history of diabetes
mellitus or previous facialmellitus or previous facial
irradiationirradiation
– Unrealistic patientUnrealistic patient
expectationsexpectations
– TelangiectasiasTelangiectasias
– Anticipation of inadequateAnticipation of inadequate
photo protectionphoto protection
AbsoluteAbsolute
ContraindicationsContraindications
– Significant hepatorenalSignificant hepatorenal
diseasedisease
– HIV-positive patientHIV-positive patient
– SignificantSignificant
immunosuppressionimmunosuppression
– Emotional instability orEmotional instability or
mental illnessmental illness
– Ehlers-Danlos syndromeEhlers-Danlos syndrome
– Scleroderma or collagenScleroderma or collagen
vascular diseasesvascular diseases
– Accutane treatment (withinAccutane treatment (within
6–12 months before)6–12 months before)

18. Patient PreparationPatient Preparation
History of herpes infectionsHistory of herpes infections
– Prophylaxis with Valtrex or Acyclovir for 2 wksProphylaxis with Valtrex or Acyclovir for 2 wks
Skin preparationSkin preparation
– Vitamin A derivative therapy 4 weeks before theVitamin A derivative therapy 4 weeks before the
procedureprocedure
Speeds epidermal healingSpeeds epidermal healing
Thins stratum corneumThins stratum corneum
Increases the depth of a chemical peelIncreases the depth of a chemical peel
– Stop sun exposure - 2 months before theStop sun exposure - 2 months before the
procedureprocedure

19. Chemical Peel DepthsChemical Peel Depths
SuperficialSuperficial
– Epidermal lossEpidermal loss
MediumMedium
– Injury to superficialInjury to superficial
dermisdermis
DeepDeep
– Mid-dermal injuryMid-dermal injury

20. Chemical PeelChemical Peel
Frosting - keratin proteinFrosting - keratin protein
denaturationdenaturation
– Level I - erythema withLevel I - erythema with
streaky surface whiteningstreaky surface whitening
– Level II - white-coatedLevel II - white-coated
frosting with erythemafrosting with erythema
showing throughshowing through
– level III - solid whitelevel III - solid white
enamel frosting with little orenamel frosting with little or
no background of erythemano background of erythema
(penetration through the(penetration through the
papillary dermis)papillary dermis)

21. Superficial PeelsSuperficial Peels
Necrosis of the epidermisNecrosis of the epidermis
Healing time from 1 to 4 daysHealing time from 1 to 4 days
Improve pigmentary irregularitiesImprove pigmentary irregularities
Improve minor surface changesImprove minor surface changes
Fresher appearance to facial skinFresher appearance to facial skin

22. Superficial PeelsSuperficial Peels
Different SolutionsDifferent Solutions
– 10% to 20% Trichloracetic10% to 20% Trichloracetic
acid (TCA)acid (TCA)
– Jessner's solutionJessner's solution
(resorcinol, 14 g; salicylic acid, 14 g;(resorcinol, 14 g; salicylic acid, 14 g;
lactic acid, 14 mL; ethanol, 100 mL)lactic acid, 14 mL; ethanol, 100 mL)
– Glycolic acid (50% to 70%)Glycolic acid (50% to 70%)
Level I frostingLevel I frosting
PostoperativePostoperative
– Mild cleanser, moisturizersMild cleanser, moisturizers
and sunscreensand sunscreens
Glycolic acid can be usedGlycolic acid can be used
to peel skin of all skinto peel skin of all skin
types with minimal risktypes with minimal risk

23. Medium PeelMedium Peel
Necrosis of the epidermis & inflammation withinNecrosis of the epidermis & inflammation within
the papillary dermisthe papillary dermis
Improvement of skin texture in moderateImprovement of skin texture in moderate
photodamaged skin (grade II Glogau)photodamaged skin (grade II Glogau)
Removes of epidermal or superficial lesionsRemoves of epidermal or superficial lesions
– Actinic keratosesActinic keratoses
– Repair mild rhytidesRepair mild rhytides
– Improve pigmentary dyschromiasImprove pigmentary dyschromias
– Improve depressed scarsImprove depressed scars

24. Trichloracetic acid (TCA)Trichloracetic acid (TCA)
TCA approaching 50% or higher were used toTCA approaching 50% or higher were used to
achieve injury to the superficial dermisachieve injury to the superficial dermis
At this concentration TCA is unreliable andAt this concentration TCA is unreliable and
associated with a higher incidence ofassociated with a higher incidence of
complications (complications (pigmentary dyschromia, textural change, andpigmentary dyschromia, textural change, and
even scarringeven scarring))
Combination of products improves theCombination of products improves the
absorption of the lower concentration of TCAabsorption of the lower concentration of TCA
without the associated complicationswithout the associated complications
– Solid CO2 freezing with trichloracetic acid 35%Solid CO2 freezing with trichloracetic acid 35%
– Jessner's solution + 35% TCAJessner's solution + 35% TCA
– Glycolic acid 70% plus 35% TCAGlycolic acid 70% plus 35% TCA

25. Medium PeelMedium Peel
BrodyBrody
– First developed solid CO2 applied with acetone to the skinFirst developed solid CO2 applied with acetone to the skin
– Freezing technique break the epidermal barrier for a more evenFreezing technique break the epidermal barrier for a more even
and complete penetrationand complete penetration
MonheitMonheit
– Jessner's solution destroyed the epidermal barrier by breakingJessner's solution destroyed the epidermal barrier by breaking
up individual epidermal cellsup individual epidermal cells
ColemanColeman
– 70% glycolic acid before the application of 35% TCA.70% glycolic acid before the application of 35% TCA.
– Results similar to that of Jessner's solutionResults similar to that of Jessner's solution
Deeper penetration of the 35% TCA and a more evenDeeper penetration of the 35% TCA and a more even
application of the peeling solutionapplication of the peeling solution
Phenol 88% by itself will give a medium-depth peelPhenol 88% by itself will give a medium-depth peel

26. Patient PreparationPatient Preparation
Vigorous cleaning and degreasing areVigorous cleaning and degreasing are
necessary for even penetrationnecessary for even penetration
– Septisol and acetoneSeptisol and acetone
– Debrided of stratum corneum and excessiveDebrided of stratum corneum and excessive
scalescale
A splotchy peel is usually the result ofA splotchy peel is usually the result of
uneven penetration of peel solutionuneven penetration of peel solution
because of residual oil or stratumbecause of residual oil or stratum
corneumcorneum

27. Medium PeelMedium Peel
TCA is painted evenlyTCA is painted evenly
– Forehead to temple toForehead to temple to
cheeks and finally to thecheeks and finally to the
lips and eyelidslips and eyelids
– Eyelids within 1 to 2 mm ofEyelids within 1 to 2 mm of
the lower eyelid marginthe lower eyelid margin
Amount of TCA deliveredAmount of TCA delivered
is dependent on:is dependent on:
– Number of applicationsNumber of applications
– Degree of saturationDegree of saturation
– Pressure applied to thePressure applied to the
skinskin
– Contact timeContact time

28. Medium PeelMedium Peel
White frost appears completeWhite frost appears complete
on the treated area within 30on the treated area within 30
seconds to 2 minutesseconds to 2 minutes
Before re-treating an area oneBefore re-treating an area one
should wait at least 3 to 4should wait at least 3 to 4
minutes before determining forminutes before determining for
asymmetryasymmetry
Eyelid skin and bonyEyelid skin and bony
prominences have a highprominences have a high
propensity for scarring (limitedpropensity for scarring (limited
to a level II frosting)to a level II frosting)
An assistant standby withAn assistant standby with
sterile eye wash in case agentsterile eye wash in case agent
spills into the eyespills into the eye

29. Jessner's TCA peel for moderate photoaging skin,
Glogau level II.
A, Preoperative view demonstrating rhytides,
lentigenes, keratoses, and sallow skin.
B, Jessner's solution applied to face.
C, Full application 35% TCA with a level III
frosting.
D. Four days after chemical peel.
E, Six months after chemical peel

30. Medium PeelMedium Peel
Dark crusts peels off on day 5 to 7 thenDark crusts peels off on day 5 to 7 then
erythema appears and soon fadeerythema appears and soon fade
Repeat medium-depth chemical peelRepeat medium-depth chemical peel
should not be performed for at least 1 yearshould not be performed for at least 1 year
There is improvement of collagenThere is improvement of collagen
thickness progressing over a 6- to 13-thickness progressing over a 6- to 13-
month periodmonth period

31. Deep Chemical PeelDeep Chemical Peel
Glogau III and IV photoaging skinGlogau III and IV photoaging skin
– Deeper grooves and wrinklesDeeper grooves and wrinkles
Deep peels are usually performed using theDeep peels are usually performed using the
Baker-Gordon solutionBaker-Gordon solution
– Phenol 88% 3 mL, Septisol 8 drops, Croton oil 3Phenol 88% 3 mL, Septisol 8 drops, Croton oil 3
drops, Distilled water 2 mLdrops, Distilled water 2 mL
Septisol acts as a surfactant which results inSeptisol acts as a surfactant which results in
more even penetrationmore even penetration
Croton oil is epidermolytic enhancing theCroton oil is epidermolytic enhancing the
absorption of phenolabsorption of phenol

32. Deep Chemical PeelDeep Chemical Peel
Phenol >80%Phenol >80%
– Keratin protein binds to the phenol creatingKeratin protein binds to the phenol creating
large molecules preventing further penetrationlarge molecules preventing further penetration
of the peel solutionof the peel solution
Phenol <50%Phenol <50%
– produce deeper penetration and moreproduce deeper penetration and more
destruction than desireddestruction than desired

33. Tape OcclusionTape Occlusion
Occlusion of theOcclusion of the
peeling solution withpeeling solution with
tape increases itstape increases its
penetration creatingpenetration creating
injury to the mid-injury to the mid-
reticular dermisreticular dermis

34. Deep Chemical PeelDeep Chemical Peel
Face is divided into six aestheticFace is divided into six aesthetic
subunitssubunits
– Forehead, perioral region,Forehead, perioral region,
bilateral cheeks, nose, andbilateral cheeks, nose, and
periorbital regionperiorbital region
– 15-minute time interval between15-minute time interval between
unitsunits
White frost that is carried 2 to 3White frost that is carried 2 to 3
mm across the vermilion bordermm across the vermilion border
Lower eyelids need to be treatedLower eyelids need to be treated
to within 1 to 2 mm of the ciliaryto within 1 to 2 mm of the ciliary
marginmargin
Upper eyelid above supratarsalUpper eyelid above supratarsal
foldfold

35. Deep Chemical PeelDeep Chemical Peel
Erythema may take months to resolveErythema may take months to resolve
Evaluated in 3 to 4 days to observe the amountEvaluated in 3 to 4 days to observe the amount
of wound healing and residual crustingof wound healing and residual crusting
Sun avoidance 6 weeks and minimize sunSun avoidance 6 weeks and minimize sun
exposure for up to 6 months (Sunscreen with anexposure for up to 6 months (Sunscreen with an
SPF of 3)SPF of 3)
Splotchy hyperpigmentation (2 – 6 weeks)Splotchy hyperpigmentation (2 – 6 weeks)
– Retin A, hydroquinone and triamcinolone may provideRetin A, hydroquinone and triamcinolone may provide
an improvementan improvement

36. Deep Chemical PeelDeep Chemical Peel

37. Phenol ToxicityPhenol Toxicity
Cardiotoxic & eliminated hepatic and renalCardiotoxic & eliminated hepatic and renal
Monitored settingMonitored setting
– Cardiac status, pulse-oximetry, and blood pressureCardiac status, pulse-oximetry, and blood pressure
Volume loading with intravenous fluids before, during,Volume loading with intravenous fluids before, during,
and after phenol peelingand after phenol peeling
Botta advocates force diuresis (furosemide given 10 minBotta advocates force diuresis (furosemide given 10 min
before phenol)before phenol)
Waiting as much as 20 to 30 minutes between unitWaiting as much as 20 to 30 minutes between unit
RecognizeRecognize
– First - CNS stimulation,First - CNS stimulation,
Tremors, hyperreflexia, and hypertension.Tremors, hyperreflexia, and hypertension.
– Later - CNS depression, respiratory failure, hypotension, andLater - CNS depression, respiratory failure, hypotension, and
cardiac arrhythmias ensuing rapidly.cardiac arrhythmias ensuing rapidly.

38. SequelaeSequelae
– Pigmentary changesPigmentary changes
– Persistence of rhytidsPersistence of rhytids
– Prolonged erythemaProlonged erythema
– Hypertrophic subepidermalHypertrophic subepidermal
healinghealing
– MiliaMilia
– Skin pore prominenceSkin pore prominence
– Increased prominence ofIncreased prominence of
telangiectasiastelangiectasias
– Darkening and growth ofDarkening and growth of
preexisting nevipreexisting nevi
ComplicationsComplications
– Skin infectionSkin infection
Herpes simplex virusHerpes simplex virus
Pseudomonas organismsPseudomonas organisms
Staphylococcus/StreptocoStaphylococcus/Streptoco
ccus organismsccus organisms
Candida organismsCandida organisms
– EctropionEctropion
– Cardiac arrhythmiasCardiac arrhythmias
– Renal failureRenal failure
– Facial scarringFacial scarring

39. HyperpigmentationHyperpigmentation

40. HypopigmentationHypopigmentation

41. Herpes outbreakHerpes outbreak

42. Candida infectionCandida infection

43. Pseudomonal infectionPseudomonal infection

44. ScarringScarring

45. ConclusionConclusion
Chemical peeling is an technique that removesChemical peeling is an technique that removes
superficial lesions and improves the texture of skinsuperficial lesions and improves the texture of skin
Careful patient selection and education are crucial toCareful patient selection and education are crucial to
both the patient's final result and his or her satisfactionboth the patient's final result and his or her satisfaction
Learning the technique is a small part of the process;Learning the technique is a small part of the process;
postoperative care and close patient follow-up arepostoperative care and close patient follow-up are
equally importantequally important
Clinical and histological changes are long-lasting (15 toClinical and histological changes are long-lasting (15 to
20 years) and may be permanent for some patients20 years) and may be permanent for some patients
A complication can also be permanent!A complication can also be permanent!

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