Chemical Peels

Gary D. Monheit, MD

Disclosures

Skin Therapy Letter. 2004;9(2) 

In This Article

Complications

Many of the complications seen in peeling can be recognized early on during healing stages. The cosmetic surgeon should be well acquainted with the normal appearance of a healing wound and its time frame for both medium and deep peeling. Prolongation of the granulation tissue phase beyond 1 week to 10 days may indicate delayed wound healing. This could be the result of viral, bacterial, or fungal infections, contact dermatitis interfering with wound healing, or other systemic factors. A red flag should alert the physician to carefully investigate and institute prompt treatment to forstall potential irrepairable damage that may result in scarring.

Complications can be caused either intraoperatively or postoperatively. The two inherent errors that lead to intraoperative complications are (1) incorrect peel pharmacology and (2) accidental solution misplacement. It is the physician's responsibility to know that the solution and its concentration is correct. Trichloroacetic acid concentrations should be measured weight by volume as this is the standard for measuring depth of peel. Glycolic acid and lactic acid solutions as well as Jessner's solution must be checked for expiration date as the potency decreases with time. Alcohol or water absorption may inappropriately increase the potency, so one must assure that the shelf life is appropriate. The peel solution should be applied with cotton-tipped applicators and in medium and deep peels, it is best to pour the peel solution in a secondary container rather than apply the solution spun around the neck of the bottle. Intact crystals may give the solution a higher concentration of solution as it is taken directly from its container. One should be careful to apply the solution to its appropriate location and not to pass the wet cotton-tipped applicator directly over the central face where a drop may inadvertenly get on sensitive areas such as the eyes. Saline and bicarbonate of soda should be available to dilute TCA or neutralize glycolic acid if inappropriately placed in the wrong area. Likewise, mineral oil should be present for Baker's phenol peels. Postoperative complications can result from local infection or contact dermatitis. The best deterrent for local infection is the continuous use of soaks to debride crusting and necrotic material. Strep and staph infection can occur under biosynthetic membranes or thick occlusive ointments. The use of G% acetic acid soaks seems to deter this as well as the judicious removal of the ointment with each soak. Staphelococcus, E. coli, or even Pseudomonas may result from improper care during healing and should be treated promptly with the appropriate oral antibiotic.

Frequent postoperative visits are necessary to recognize the early onset of a bacterial infection. It may present itself as delayed wound healing, ulcerations, build up of necrotic material with excessive scabbing, crusting, purulent drainage, and odor. Early recognition and institution of appropriate antibiotics will prevent the spread of infection, heal the skin, and prevent scarring.

Herpes simplex infection is the result of reactivation of the herpes simplex virus on the face and most commonly on the perioral area. A history of previous HSV infection should necessitate the use of prophylactic oral antiviral medications. Patients with a positive history can be treated with 400mg of acyclovir three times a day beginning on the day of the peel and continuing for 7-14 days, depending on whether it is a medium-depth or deep chemical peel. I prefer to treat all patients with antiviral agents irregardless of a positive history as many patients do not remember prior herpes simplex infection that may have occurred years ago. The mechanism of action of all antiviral agents is to inhibit viral replication in the intact epidermal cell. This would mean that the drug would not have an inhibitory effect until the skin is reepithelialized, which is 7-10 days in medium and deep peels. In the past, these agents were discontinued at 5 days and in treated patients, clinical infection became apparent in 7-10 days. Active herpetic infections can easily be treated with antiviral agents and caught early, they usually do not scar.

Delayed wound healing and persistent erythema are signs that the peel is not healing normally. The cosmetic surgeon must know the normal time table for each of the healing events so that he may recognize when healing is delayed or the erythema is not fading adequately. Delayed wound healing may respond to physician debridement if an infection is present. It will respond to corticosteroids, if it's due to contact allergic or contact irritant dermatitis along with the change of the offending contact agent, or protection with a biosynthetic membrane such as Flexzan® (Bertek Pharmaceuticals) or Vigilon (Bard Medical). When this diagnosis is made, these patients must be followed daily with dressing changes and a close watch on the healing skin.

Persistent erythema is a syndrome where the skin remains erythematous beyond what is normal for the individual peel. A superficial peel loses its erythema in 3-5 days, a medium-depth peel within 15-30 days, and a deep chemical peel within 60-90 days. Erythema and/or pruritus beyond this period of time is considered abnormal and fits this syndrome. It may be contact dermatitis, contact sensitization, reexacerbation of prior skin disease, or a genetic susceptibility to erythema. It, though, is a red flag that also indicates a sign of potential scarring. Erythema is the result of the angiogenic factors stimulating vasodilation which indicates the phase of fibroplasia is being stimulated for a prolonged period of time. For this reason, it can be accompanied by skin thickening and scarring. It should be treated promptly and appropriately with topical steroids, systemic steroids, intralesional steroids if thickening is occuring, and skin protection which would eliminate the factors of irritancy and allergy. If thickening or scarring becomes evident, other measures that be helpful include the daily use of silicone sheeting and the dye pulsed vascular laser to treat the vascular factors. With prompt intervention, scarring in many cases can be averted.

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