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16 Complications


Like all medical procedures, chemical peeling has many potential side effects that should be clearly understood before beginning. Anticipating these complications can help to lessen or eliminate their occurrence. When side effects are anticipated, there is less likelihood of an event that surprises the patient or the physician. Results in peeling vary from patient to patient and so does the potential for complications. However, as always, a good physician–patient relationship and adequate understanding of the risks versus benefits of the procedure is critical.

The leading cause of complications in chemical peeling is inadequate training. Obtaining a comprehensive knowledge of the scientific literature is the obvious first step before embarking on any new procedure. After this, training at the operating table with an experienced operator is vital (in the USA this would preferably be in a formal ABMS approved residency such as Dermatology). Mistakes due to lack of training can cause huge errors in chemical peeling.

Recently, companies which market simplified chemical peel systems or ‘cookbook peel kits’ to physicians with little or no training in this procedure have targeted non-physicians. They sell chemical peel kits and weekend training to physicians willing to delegate the peels to a variety of office personnel. This inferior practice has resulted in numerous patient injuries and countless malpractice lawsuits. Only physicians who are properly trained in this technique, such as those certified by the American Board of Dermatology, should perform chemical peeling. Delegating this procedure to non-physicians is, in our opinion, dangerous, regardless of the training of the physician.

Proper storage, preparation, and handling of caustic peeling substances are absolutely necessary. Errors in formulations of the acids used for peeling can result in solutions that are much stronger than intended. Physicians must have an understanding of the different types of peeling agents and their intended uses. Additionally, the physician should be well versed in the proper application of chemical peeling solutions in order to avoid peeling deeper than intended. Although many complications of chemical peeling can be corrected, it is important to try to avoid those that are unnecessary.

Each peeling agent carries with it a unique set of possible complications; however, there are some complications that can occur no matter which solution is used. Obviously, the more aggressive the agent employed the more potential for error and side effects. Likewise, more aggressive, deeper application techniques have increased risk. Prior to beginning a peel, all of the potential dangers of the procedure should be weighed against its potential benefits in order to maximize desired results and minimize problems. See Table 16.1 and also see Box 16.1.

Table 16.1 Sequelae versus adverse reactions and complications of chemical peels

Minor sequlae Adverse reactions Complications
Lines of demarcation
Persistent erythema
Herpes reactivation
Arrythmias (phenol)
Toxicity (salicylic)
Corneal damage

Box 16.1

Key features

Complications Possible in All Types of Peel

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 16.116.3). 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 16.3 Same patient as in Fig. 16.2, several weeks later, beginning to develop early hypertrophic scar in area of previous erythema

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