Chemical Peels

Gary D. Monheit, MD


Skin Therapy Letter. 2004;9(2) 

In This Article

Indications and Patient Selection

Analyzing the patient with photoaging skin must take into account skin color and skin type as well as degree of photoaging. Pigmentary risks are generally not a great problem with very superficial and superficial pigment chemical peeling, but may become a significant problem with medium and deep chemical peeling. It can also be a significant risk when regional areas such as lips and eyelids are deep peeled, creating a significant color change in these cosmetic units from the rest of the face. The physician must inform the patient of this and other potential problems, especially if the skin type is III through VI. He must justify whether the benefits of the procedure outweigh these risks and, in addition, plan for the appropriate techniques to prevent these unwanted changes in color.

The Glogau system classifies severity of photodamage, taking into account the degree of epidermal and dermal degenerative effects.[2] The categorization is I through IV, ranging from mild, moderate, advanced and severe photodamaged skin. These categories are devised to project which patients need therapeutic intervention. Category I or minimal degree photodamage can be treated with light chemical peeling and medial treatment. Category II and III would entail medium-depth chemical peeling while category IV would need deep peeling or resurfacing plus cosmetic surgical intervention for gravitational changes.

The peeling agent is a chemical escharotic that damages the skin in a therapeutic manner. It is important that the physician understand the patient's skin and its ability to withstand this damage. The epidermis and stratum corneum have a barrier function against noxious chemicals and some skin types withstand the damage to a greater degree than others, while particular skin disorders have a greater tendency to produce side-effects and complications from chemical peels, due to poor barrier function or exaggerated inflammatory reactions. Patients with extensive photodamage may require stronger peeling agents and repeated applications of medium-depth peeling solutions to obtain therapeutic results. It is for this reason a careful evaluation of skin types and problems must be assessed.

Herpes simplex can be a post-operative problem with significant morbidity. Patients susceptible should be pre-treated with antiherpetic agents such as acyclovir or valcyclovir to prevent herpetic activation. These patients can be identified in the pre-operative consultation and placed on appropriate therapy at the time of the chemical peel. All anti-herpetic agents act by inhibiting viral replication in the intact epidermal cell. The significance of this in peeling is that the skin must be reepithelialized before the agent has its full effect. Thus, the antiviral agent must be continued in deep chemical peeling for the entire two weeks, or in medium-depth peeling for at least ten days.[3]


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