• Swelling

Although swelling is more prominent in deeper peels, every peeling agent can cause swelling. This edema usually surfaces in 24 to 72 hours after the peel and is usually a fairly mild and expected sequelae of the procedure. In some cases, however, the edema may be severe enough to swell the eyes shut. This severe swelling may in some instances take several days to resolve. Nevertheless, this complication will be less worrisome to the patient if the possibility is raised before the procedure is done. Application of ice and proper wound care to the affected areas can serve to reduce the possibility of severe swelling. In severe cases systemic corticosteroids may be required to reduce swelling. Although some physicians routinely prescribe preoperative oral steroids for resurfacing procedures there is the possibility of impairing wound healing. It is more logical to reserve systemic steroids for the few patients who experience severe edema. See Box 16.2.

• Pain

Pain is unfortunately a very common and expected result of medium-depth and deep peels. The amount of pain experienced, of course, depends on the individual patient. Pain can range from very mild to quite severe. Medium-depth peels usually produce only a few minutes of pain, immediately after application of the peeling solution. It is rare for the medium-peel patient to require prescription strength postoperative pain medications. Topical anesthetic agents such as EMLA (2.5% lidocaine, 2.5% prilocaine) or LMX (4% lidocaine) can be used to reduce the pain of the procedure without affecting the depth of the peel penetration. Deep peels tend to involve a significantly greater amount of pain; this often crescendos several hours after the peel. Generally, the pain from deep-depth peels does not last longer than 8 to 12 hours.

• Persistent erythema

Erythema is common after all peel types. It is usually more noticeable and lasts longer in medium and deeper peels. Phenol peels usually are accompanied by erythema lasting 6 to 8 weeks before resolving. Erythema from TCA peels tends to fade in 2 to 3 weeks. Erythema is a natural response to the procedure; however, any erythema lasting longer than expected must be observed carefully for the possibility of scar formation (Figs 16.1–16.3). This ‘persistent’ erythema is best treated as soon as it is recognized with potent topical steroids. If there is no response, intralesional, oral or intramuscular steroids may be required. Resistant erythema often responds to pulsed dye lasers or intense pulsed light devices. See Boxes 16.3 and 16.4.

Figure 16.1 Persistent erythema of the neck after a 20% TCA peel

Figure 16.2 Persistent infraorbital erythema after a 35% TCA peel

Figure 16.3 Same patient as in Fig. 16.2, several weeks later, beginning to develop early hypertrophic scar in area of previous erythema

• Pruritus

Pruritus is very common after medium and deep chemical peels. It occurs after reepithelialization and may last up to several weeks. Pruritus with increased erythema or pustules that occurs during the healing period may signal a possible contact allergy to the wound care ointment being used. In this case, the offending agent should be stopped and the patient given small doses of oral prednisone. The normal pruritus from healing can be disconcerting to some patients and can be treated with oral antihistamines and topical hydrocortisone creams or ointments. The fluorinated steroids should be used carefully to avoid any atrophy or telangiectasia formation.

• Ocular injuries

All acids are potentially dangerous to the eyes. Physicians must take great care when peeling around the orbital region. Inadvertent splashing of drops of acid can occur quite easily. Also retrograde wicking of acid through tears and in to the eyes is possible. Dermatologists are taught to maintain a dry cotton tipped applicator for immediate blotting of tears or acid solution near the lashes. If an acidic peeling solution does reach the eye, rapid, copious lavage with saline will dilute the acid and usually prevent corneal damage. Lavage should be performed immediately if the patient complains of burning in the eyes. Phenolic compounds spilled in to the eye respond better to washing out with large amounts of mineral oil (Box 16.5).

• Allergic reactions

Although true allergic reactions to chemical peels are rare, they can occur. Among peeling agents, resorcinol is the best known for producing allergic reactions, usually urticarial type eruptions. There are no reports of true allergic reactions to TCA or glycolic acid peels that the authors are aware of. However, there have been reports of cholinergic urticaria triggered by TCA peeling. If allergic reactions occur, these can easily be treated by oral antihistamines. But, allergic reactions can be difficult to distinguish from the normal erythema and swelling associated with peeling. Also, if the patient has a positive history of suspected allergic reactions to any peeling agent, they can be treated prophylactically with antihistamines.

• Folliculitis/acne

In patients who are already prone to acne, a chemical peel can exacerbate a break out. Shortly after the peel, multiple erythematous tender papules can appear; this is most commonly due to the emollient creams used during the healing phase of the treatment. Treating this can be difficult since most topical acne agents irritate sensitive skin which is recovering from a peel. Patients are best treated with oral antibiotics such as tetracycline (500 mg bid) or minocycline (100 mg bid) to improve the acne. These eruptions can be expected to resolve in about a week in most cases.

• Infection

Because the acids used as peeling agents are bacteriocidal, infection is less likely to develop after chemical peels compared to other skin procedures. However, occlusive ointments containing vegetable fats, petrolatum, and various moisturizers can promote the growth of pathogens such as species of Streptococcus, Staphylococcus and Pseudomonas (Fig. 16.4). The use of topical antibiotic ointments intranasally can help to decrease the risk of infection in susceptible individuals. To decrease the possibility of infection, patients should be instructed to remove excess crusted or necrotic skin using compresses of 0.5% acetic acid soaks (to 1 cup warm water, add 1 teaspoon white vinegar) three times a day and followed by gentle washing. However, as soon as the crusts disappear, the acetic acid should be discontinued, since it is an irritant and will slow down healing.

Figure 16.4 Pseudomonas sp. infection after a peel

Postpeel infections can be very dangerous because they commonly lead to scarring. When they occur, early and aggressive treatment with broad-spectrum antibiotics is necessary. Bacterial cultures and gram stains can be helpful in determining the proper antibiotic to be used since differentiating between infections can be difficult in the background of healing skin. Candida infections can also occur in some patients and are difficult to diagnose since the epidermis is eroded (Fig. 16.5); however, a gram stain will show the organism. These should be treated appropriately with oral ketoconazole or fluconazole (Diflucan).

Figure 16.5 Candida infection starting in the perioral area several days following a 35% TCA peel

• Herpes recurrence

Patients should be asked about their prior history of herpes simplex outbreaks. A recurrence can be triggered by the trauma induced by a chemical peel. Due to the lack of a fully formed epidermis, herpetic infections in peeled skin usually present as an erosion rather than as a vesicle. The most consistent sign of a herpes reactivation is pain; thus all painful lesions occuring after a peel should be treated as such. Patients with a history of outbreaks should be treated prophylactically with 200 to 400 mg of oral acyclovir three times a day or valacyclovir (Valtrex) 500 mg twice a day; however, some patients may experience outbreaks without any history of prior occurrence. Patients who present with erosions should be treated with higher doses of acyclovir (400 mg 4–5× per day) or valacyclovir (500 mg 3× daily), to prevent scarring. Because some instances of impetigo can be confused with herpetic infection, especially during healing from a peel, resistant lesions should be cultured and treated with the appropriate broad-spectrum antibiotic as well.

• Ecchymosis

Ecchymosis is a rare complication of chemical peeling that can occur in the infraorbital area of some patients (Fig. 16.6). It is usually only seen in those individuals who experience severe edema after the peel. Patients with significant actinic damage and cutaneous atrophy are also more likely to experience this problem. This complication is mostly a cosmetic one since it resolves spontaneously, but patients who are at risk should be informed of the possibility. Treating the swelling before the ecchymosis appears to be the best prevention.

Figure 16.6 Infraorbital purpura following 35% TCA peel

• Hypopigmentation

Lighter pigmentation is a normal result of peeling. In patients with fairer complexions, treated skin usually reverts toward its original pre-sun-damaged state. Since peeling agents cause exfoliation, the amount of melanin dispersed in the epidermis will be decreased as these cells are sloughed off. This lightening is expected and transient in epidermal peels. If the entire epidermis through the basal layer is removed, the melanocytes responsible for pigment will also be removed. Thus with dermal peels, temporary hypopigmentation is expected since new melanocytes will need time to migrate into the new epidermis. Permanent hypopigmentation, however, is a complication of peeling (Fig. 16.7). It occurs more commonly in darker skinned individuals. Usually this appears in a haphazard distribution, which is often due to uneven penetration of peeling agents and can be quite noticeable. Infection and/or scarring can also lead to hypopigmentation. Hypopigmentation can be particularly severe in those individuals who have type III or darker skin. Phenol peels can produce a unique form of hypopigmentation that results in a porcelain appearance to the skin that is not noticeable until the erythema has faded. This has been referred to as the ‘alabaster statue’ look, and appears to be due to a direct melanotoxic effect of phenol.

Figure 16.7 Hypopigmentation from a 50% TCA peel

• Hyperpigmentation

Pigmentary changes can occur with any depth of peeling (Fig. 16.8). However, patients with lighter skin tones (Fitzpatrick type I–II) are less likely to develop hyperpigmentation. Individuals with types III to VI skin can undergo peels, but they must be made aware of their greater risk of hyperpigmentation as well as color differences in peeled vs non-peeled skin (Fig 16.9). Postinflammatory hyperpigmentation is more likely if the patient has experienced this before from other skin injuries. A test area may be done in those individuals who are wary of these types of changes (Fig. 16.10); however, it must be mentioned that hyperpigmentation may still occur in spite of a negative test site.

Figure 16.8 Postinflammatory hyperpigmentation from a 35% TCA peel

Figure 16.9 Postinflammatory hyperpigmentation from a glycolic–TCA peel

Figure 16.10 Postinflammatory hyperpigmentation following a test patch of 35% TCA

If hyperpigmentation occurs hydroquinone 4% or higher is the mainstay of treatment. Once the skin is sufficiently healed, tretinoin can be added to increase the bleaching effect. Commercial or compounded formulations that include these agents and a topical steroid are also useful. Patients should be advised to use sunscreens and avoid unnecessary sun exposure to the peeled areas as this can prevent further pigment changes and lessen the duration of the darker areas. Also, patients using birth control pills, estrogens, or other photosensitizing agents are at greater risk for this complication. Patients should be encouraged to avoid these if possible. Likewise, patients who would become pregnant within 6 months of the peel have higher risk of hyperpigmentation, even if strict sun avoidance is maintained. Those with darker skin types may require treatment to prevent or diminish post-inflammatory hyperpigmentation for up to 1 year postoperatively. Patients with preexisting hyperpigmentation may best be treated with superficial peels every 2 to 4 weeks in order to avoid the increased potential for post-inflammatory hyperpigmentation from deeper peels (Box 16.6).

• Telangiectasia

Although some superficial telangiectasia can be treated effectively with chemical peeling, the majority of these are deeper and become more prominent after a peel. Telangiectasia may become more noticeable after removal of the surrounding actinic changes or pigmentation. Patients should be warned of this possibility before the procedure to avoid surprise. If the patient is unhappy with the telangiectasia intense pulsed light devices, vascular lasers, or electrosurgery can be used to remove them.

• Skin textural changes

Differences in the depth of a peel can result in visible textural changes in the skin. These can be due to a patient’s inherent response to the peeling agent or improper technique. The peel must evenly penetrate the overlying damaged skin, otherwise the results will be uneven. All cosmetics, oils, and other agents that could potentially decrease penetration of the peel should be removed meticulously; poor cleansing can lead to variations in peel depth producing a bad result. Patients should also be advised to avoid oily products the day before the peel. The peeling agent must be applied uniformly to avoid deeper penetration in some areas. Repeeling or light microdermabrasion of areas of uneven texture may help improve this problem.

• Milia

The development of milia, or inclusion cysts, after a chemical peeling typically occurs about 2 to 3 weeks after reepithelialization. The occurrence of these is probably exacerbated by the use of emollient creams that can occlude the pilosebaceous ducts. Retinoic acids used before and after the peel can decrease the occurrence of milia. Since the retinoic acids can interfere with wound healing and may cause further irritation, it is best to resume them only after erythema has subsided. The treatment for inclusion cysts is extraction by needle or lancet, or electrodessication. Because milia will usually regress spontaneously, it is also acceptable to defer treatment unless the patient asks for extraction.

• Demarcation lines

After a chemical peel, an obvious line of pigmentary change may form where the peeled skin meets unpeeled skin. The most common areas for demarcation lines to occur are below the mandible, near the eyes, and periorally. To avoid this complication peels must be carried out beyond the desired area by about 5 mm and should be feathered (by using lower acid concentrations or less aggressive peeling application) into the surrounding skin to create a normal fade. On the mandible, the peel should be carried out below the angle of the jaw and onto the neck (Fig. 16.11). However, patients who later undergo a facelift procedure may have this line raised up to the face. To create an even appearance around the eyes, peels should be applied right up to the lashes on the lower lids and to the supratarsal crease on the upper lids (Fig. 16.12). When peels are done on the perioral area only, the peel must continue into the nasolabial folds, but not onto the cheeks (Fig. 16.13). Another problematic area is the hairline. In those with receding hairline the peel should be continued onto the scalp. Repeeling of the affected areas is the best remedy for demarcation lines.

Figure 16.11 To avoid demarcation lines during a full face procedure, the peel should be feathered into the hairline and extend below the angle of the jaw and onto the neck

Figure 16.12 Avoid demarcation lines on the eye. These designated areas indicate where to start and stop peeling in the periocular region

Figure 16.13 To avoid demaration lines in the perioral region, the peel should continue to the nasolabial fold and treat the entire cosmetic unit

• Scarring

Although uncommon in chemical peeling, scarring is the most difficult complication for both physicians and patients to deal with (Figs 16.14 and 16.15). Physicians should always warn patients beforehand of this possibility and should be aware of patients who are more at risk of developing scarring. Any patient with a history of poor wound healing, keloid formation or excessive actinic damage, as well as patients who are undergoing deep peeling into the reticular dermis, are more likely to have some degree of scarring. Nonfacial skin such as the neck, dorsal hands, and chest do not have sufficient follicular structures to undergo deep peeling without risk of scarring (Fig 16.16 and 16.17). Furthermore, physicians should be careful not to repeel areas that have not had adequate time to heal from a prior peel or other injury. Isotretinoin has also been associated with increased incidence of scarring, owing to disruption of collagenase production; thus, patients who have been on this treatment should wait at least 6 months before having a medium to deep chemical peel (Box 16.7).

Figure 16.14 Hypopigmentation, scarring, and persistent erythema 6 months following an aggressive 35% TCA peel

Figure 16.15 Scarring following a commercial peel of the face

Figure 16.16 Hypertrophic scars of the chest after a TCA peel by an aesthetician

Figure 16.17 Delayed healing and scarring after a non-physician TCA peel of the hands

Some early signs that scarring may be occurring are persistent erythema and pruritus. If these should occur, the patient should be treated immediately with a high potency topical steroid. This approach must be weighed against the risks of prolonged steroid use such as atrophy and telangiectasias. Delayed healing is another warning sign of incipient scars (Fig. 16.17). If peeled skin fails to reepithelialize as expected, aggressive intervention with biologic dressings and antibiotic coverage may remedy this problem. Generally wounds that have not reepithelialized within 2 weeks have a good chance of scarring. If scars occur, they are best treated initially with an intralesional injection of steroids. Massage and compression over time can also sometimes be helpful in softening scars. Steroid impregnated tape can soften firm scars. Pulsed dye lasers and intense pulsed light devices are helpful in improving red scars. See Box 16.8.

• Resorcinism

Resorcinol is a hydrocarbon that has about a quarter of the potency of phenol; if it is applied in excess, resorcinol can produce systemic toxicity. Resorcinol has the potential to cause poisoning, resulting in varying degrees of diarrhea, nausea, vomiting, dizziness, drowsiness, severe headache, nervousness, bradycardia, shortness of breath, diaphoresis and/or paralysis. The best way to avoid this complication is to avoid applying it to large areas such as the back, or to limit the concentration of the resorcinol in the peel.

• Salicylism

Salicylic acid, which is used in the Jessner’s and Combe’s formulas, can have a profound toxic effect if excessive amounts are absorbed. The common presentations of salicylism are tinnitus, nausea, vomiting, and deep and rapid breathing, gastrointestinal irritation, and possibly stroke. Ingestion of aspirin with application of salicylic acid might produce synergistic effects. Patients should be advised of the symptoms and warned to limit intake of aspirin.

• Phenol toxicity

Phenol is toxic when used in high doses. Phenol is metabolized in the liver and excreted by the kidneys. Although it has the potential to cause hepatorenal toxicity, this is not usually seen in chemical peels because the dose absorbed is not high enough. The most common systemic effect seen with phenol peeling is cardiotoxicity. The majority of phenol is absorbed within the first 30 minutes of its application. Thus, higher doses over a short amount of time are more likely to have systemic effects. The toxicity produces arrhythmias despite prior normal heart function. The occurrence of these arrhythmias is not linked to age, sex or the use of saponified vs non-saponified formulations. To prevent this life-threatening complication, phenol peels should not be performed over large areas at the same time. All patients should be well hydrated before a phenol peel: oral or intravenous hydration may be used, especially in full facial phenol peeling. If side effects do occur, cessation of the peel and administration of intravenous lidocaine may become necessary.