Chemical Peels: A Comprehensive Guide for Dermatologists

Chemical peels remain one of the most effective in-office treatments for a range of skin concerns. This guide covers patient selection, peel selection, application protocols, and management of complications.

Classification of Chemical Peels

Superficial Peels (Epidermis)

• Glycolic Acid (20-70%)
• Salicylic Acid (20-30%)
• Lactic Acid (30-50%)
• Mandelic Acid (30-50%)

Indications: Mild acne, fine lines, melasma, PIH, dullness Downtime: Minimal (1-3 days) Frosting: None to minimal

Medium-Depth Peels (Papillary Dermis)

• TCA (20-35%)
• Jessner's Solution + TCA
• Combination Peels

Indications: Moderate photoaging, acne scars, deeper pigmentation Downtime: 5-10 days Frosting: Level II-III

Deep Peels (Reticular Dermis)

• Phenol
• High-strength TCA (>35%)

Indications: Severe photoaging, deep wrinkles Downtime: 14-21 days Frosting: Level III (white frosting)

Patient Selection

Ideal Candidates

• Realistic expectations
• No active infections
• Fitzpatrick types I-III for medium/deep peels
• Compliant with pre and post-care

Contraindications

Absolute:

• Active HSV infection
• Open wounds
• Recent isotretinoin use (<6 months)
• Pregnancy/breastfeeding (for certain agents)

Relative:

• Darker skin types (Fitzpatrick IV-VI) - requires caution
• History of keloids
• Unrealistic expectations
• Recent laser/surgery (<2 weeks)

Pre-Treatment Protocol

2-4 Weeks Before

1. Skin Preparation

   • Tretinoin 0.025-0.05% nightly
   • Hydroquinone 4% (if treating pigmentation)
   • Sunscreen SPF 50+ daily

2. Prophylaxis

   • Antiviral (for HSV history)
   • Consider antibiotics for medium/deep peels

3. Patient Education

   • Expected downtime
   • Post-care requirements
   • Realistic outcomes

Application Protocol

Step 1: Cleansing & Degreasing

• Use acetone or 70% isopropyl alcohol
• Ensure complete removal of oils

Step 2: Protection

• Petroleum jelly on corners of eyes, nostrils, lips
• Protect hairline

Step 3: Application

• Start conservatively (lower strength, shorter time)
• Apply evenly using gauze or brush
• Work in systematic sections

Step 4: Monitoring

• Watch for frosting level
• Monitor patient discomfort
• Time accurately

Step 5: Neutralization (if applicable)

• Use appropriate neutralizer
• Rinse thoroughly with cool water

Post-Treatment Care

Immediate (0-3 days)

• Apply soothing cream 3-4x daily
• Ice packs for discomfort
• Avoid sun exposure
• No makeup

Early Recovery (4-7 days)

• Gentle cleansing
• Continue moisturizing
• Begin SPF 50+ when going out
• Flaking/peeling expected - DO NOT PICK

Late Recovery (7-14 days)

• Resume gentle actives (if cleared by provider)
• Continue sun protection religiously
• Moisturize regularly

Managing Complications

Hyperpigmentation (PIH)

• Most common in darker skin types
• Prevention: Proper patient selection, sun protection
• Treatment: Hydroquinone, tranexamic acid

Infection

• Rare but serious
• Prevention: Prophylactic antibiotics for medium/deep peels
• Treatment: Appropriate antimicrobials

Scarring

• Very rare with superficial peels
• Prevention: Avoid deep peels in at-risk patients
• Treatment: Refer to specialist

Clinical Pearl

Start Low, Go Slow: Begin with lower strengths and shorter contact times, especially in:

• First-time patients
• Darker skin types
• Sensitive skin
• Summer months

Conclusion

Chemical peels are powerful tools when used appropriately. Proper patient selection, preparation, and post-care are as important as the peel itself. With experience and caution, excellent results can be achieved safely.

Continued education and hands-on training are essential for mastering chemical peel techniques.