Chemical peels have a long history in skin rejuvenation and pre-date the use of lasers by decades. More than one million skin peels are performed each year which makes them one of the most common non-surgical cosmetic skin treatments. Their popularity is due to their relatively low cost of use and how they can be used in combination with microdermabrasion and light and laser skin therapies.
Chemical peels result in numerous clinical benefits including a visible reduction in fine lines and wrinkles, lightening hyperpigmentation, improving acne and rosacea, and as a treatment method for precancerous skin lesions. Despite how many peels are currently done, they are probably underutilized in many plastic surgery practices.
The most common chemical peels are the superficial AHA peels of lactic and glycolic acids whose effects are limited to the stratum corneum. (epidermis) They are the mainstay of skin rejuvenation due to their ability to do them in the office without any form of anesthesia and their quick recovery. They are essentially the mainstay of what most estheticians use. They are excellent refreshening peels but should not be thought of by patients as a therapeutic peel that will have an immediate effect on fine lines and wrinkles. They simply do not penetrate that deep.
They have historically been applied as single-acid peels but they have more downtime when used this way due to increased inflammation and irritation. This is why the use of blended peels has been a real chemical peel advance in recent years and now dominates how they are used. Many different combinations are available and the historic Jessner’s solution (salicylic acid, lactic acid, and resorcinol) is the ‘grandfather’ of the blended peel approach. Most recently, new ingredients have become available for use in making blended peel solutions. These include pyruvic acid, azelaic acid, and mandelic acid. These new ingredients are excellent exfoliating agents with very low risk profiles. Most major manufacturers now make blended peels, each one which touts the merits of their own mixtures. All of them are good, and when used in the right hands, probably produce similar results.
For greater therapeutic effect, one must consider medium-depth peels which can rival what similar-depth lasers can do. The most versatile chemical peel that I as a plastic surgeon use is the combination Jessner’s and Trichloroacetic acid (TCA) peel. This is a peel that can be done in the office as a stand alone procedure or the operating room in combination with other procedures. The application of a Jessner’s solution first acts as a keratolytic agent that allows the subsequent application of TCA to penetrate deeper and more evenly. For superficial wrinkles, a 25% TCA can be used but deeper wrinkles require a 35% concentration. This peel penetrates deep enough that both dermis and epidermis need to be regenerated, resulting in significant skin changes. The great thing about this peel is its versatility, being able to be done comfortably in the office (with a little sedation) or on top of raised facelift flaps in the operating room. It has a great margin of safety and range of effectiveness, not being too deep but with more effect than a superficial AHA peel.
These intermediate depth chemical peels are particularly useful around the eye and mouth area for fine wrinkle reduction. When applied they create a ‘frosting’ as they penetrate and are automatically self-neutralizing once the white frost has occurred.
Despite the hype and marketing of lasers and mechanical methods of skin treatments, chemical peels have persisted in this highly competitive field. They provide an inexpensive and very safe alternative. With the many new peels that are available, more patients with various skin types and conditions can be treated. Between AHA peels for refreshening and maintenance and TCA peels for visible wrinkle reduction, good results can be safely and predictably obtained. Light-based (hyperpigmentation) and laser (vascular)therapies can be done and peels put on right after, allowing for multimodality skin rejuvenation treatments.
Dr. Barry Eppley
Indianapolis, Indiana