Chemical Peels

Gary D. Monheit, MD


Skin Therapy Letter. 2004;9(2) 

In This Article

Deep Chemical Peeling

Glogau Level III and IV photodamage requires deep chemical peeling. This entails the use of either trichloroacetic acid above 50%, or the Gordon-Baker phenol peel. Laser resurfacing can also be used to reliably reach this level of damage. TCA above 45% has been found to be unreliable and dangerous with a high incidence of scarring and postoperative complications. For this reason, it is not included as a preferred treatment method for deep chemical peeling. The Baker-Gordon phenol peel has been used successfully for over 40 years for deep chemical peeling and produces reliable results. It is a labor-intensive procedure that must be taken seriously as all major surgical procedures are.

The patient requires preoperative sedation with an intravenous line and preoperative IV hydration. Usually a liter of fluid is given preoperatively and in addition, a liter of fluid is given during the procedure. This is helpful in decreasing the phenol concentration from the serum. For this reason, one must be concerned with phenol absorption through the skin and the resultant serum concentration of phenol through cutaneous absorption. Methods to limit this include:

  1. IV hydration prior to the procedure and during the peel to flush the phenolic products through the serum.

  2. Extending the time of application for a full-face peel over one and one-half hours. Baker's solution is applied to each cosmetic unit with a fifteen-minute wait in between each unit. That is, the forehead, cheeks, chin, lips, and eyelids are each given a fifteen-minute period of time for a total of an hour to an hour and a half for the procedure.

  3. All patients are monitored and if there is any electrocardiographic abnormality, i.e., PVC or PAC, the procedure is stopped and the patient is watched carefully for other signs of toxicity.

  4. Many physicians believe that O2 given during the procedure can be helpful in preventing arrhythmic complications.

  5. Any patient with a history of cardioarrhythmia, hepatic or renal compromise, or on medications that give a propensity for arrhythmias, should not undergo the Baker-Gordon phenol peel.[10]

The patient undergoing deep chemical peeling must recognize the significant risk factors, the increased morbidity, and possible complications involved in this procedure so that the benefits can be weighed positively against these particular factors. In the hands of those that do this technique regularly, it is a reliable and safe method of rejuvenating advanced to severe photoaged skin including deeper perioral rhytids, periorbital rhytids and crow's feet, forehead lines and wrinkles, as well as the other textural and lesional changes associated with the more severe photoaging process.

There are two methods for deep chemical peeling: Baker's formula phenol unoccluded, and Baker's formula phenol occluded with tape. Occlusion is accomplished with the application of waterproof zinc oxide tape such as _inch Curity® tape. The tape is placed directly after the phenol is applied to each individual cosmetic unit. Tape occlusion increases the penetration of the Baker's phenol solution and is particularly helpful for deeply lined "weather-beaten" faces. A taped Baker's formula phenol peel creates the deepest damage in mid-reticular dermis and this form of chemical peeling should only be performed by the most knowledgeable and experienced cosmetic surgeons who understand the risks of over penetration and deep damage to the reticular dermis. The unoccluded technique as modified by McCollough involves more skin cleansing and application of more peel solution. On the whole, this technique does not produce as deep a peel as the occluded method.

The Baker-Gordon formula for this peel was first described in 1961, and since then has been used successfully for over 25 years. The Baker-Gordon formula of phenol penetrates further into the dermis than full-strength undiluted phenol because full-strength phenol allegedly causes an immediate coagulation of epidermal keratin proteins and self blocks further penetration. Dilution to approximately 50-55% in the Baker-Gordon formula causes keratolysis and keratocoagulation resulting in greater penetration. The liquid soap, Septisol®, is a surfactant that reduces skin tension allowing a more even penetration. Croton oil is a vesicant and epidermolytic agent that enhances phenol absorption. The freshly prepared formula is not miscible, but rather is a suspension and must be stirred in a clear glass medicine cup immediately before application to the patient. Though the mixture can be stored in an amber glass bottle for short periods, this is usually unnecessary and should be reformulated on a regular basis.

The four stages of wound healing are apparent after a deep chemical peel. They include: (1) inflammation, (2) coagulation, (3) reepithelializaiton, and (4) fibroplasia. At the conclusion of the chemical peel, the inflammatory phase has already begun with a brawny, dusky erythema that will progress over the first 12 hours. This is an accentuation of the pigmented lesions on the skin as the coagulation phase separates the epidermis producing serum exudation, crusting, and pyoderma. It is during this phase that it is important to use debridant soaks and compresses as well as occlusive salves. These will remove the sloughed, necrotic epidermis and prevent the serum exudate from hardening as crust and scab. I prefer the use of _% acetic acid soaks found in the vinegar/water preparation (1 teaspoon white vinegar, 1 pint warm water), as it is antibacterial, especially against Pseudomonas and gram negatives. In addition, the mildly acidic nature of the solution is physiologic for the healing granulation tissue, and mildly debridant, as it will dissolve and cleanse the necrotic material and serum. I prefer to use bland emollients and salves such as Vaseline® petrolatum, Eucerin®, or Aquaphor®, as the skin can be monitored carefully day by day for potential complications.

Reepithelializtaion begins on day 3 and continues until day 10-14. Occlusive salves promote faster reepithelialization and less tendency for delayed healing, which may occur with dry crusting. The final stage of wound healing —fibroplasia, will continue well beyond the initial closure of the peeled wound and continues with neoangiogenesis and new collagen formation for 3 or 4 months. Prolonged erythema may last 2-4 months in unusual cases of sensitive skin or with contact dermatitis. New collagen formation can continue to improve texture and rhytides for a period up to 4 months during this last phase of fibroplasia.


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