the chemical peel

5 The Chemical Peel

Paul S. Collins, MD

From the Department of Dermatology, Tulane University School of Medicine, and Louisiana State University Medical School, New Orleans, L43ukiana

Histont

As long as the ravages of age and nature leave their toll on the human face, humanity will continue its search for methods to reverse this relentless and inexorable deterioration. The desire for rejuvenation via chemical peeling is in fact an ancient yearning stretching back to antiquity. The Ebers Papyrus,’ written 3500 years ago, notes the earli- est recorded dermatologic prescriptions for applying caustic and peeling chemicals to the skin.

Contemporary chemical peeling, first documented in medical litera- ture in the 194Os, had been vogue for several decades. Joseph J. Eller and Shirley Wolff in 19412 listed a multitude of formulas, some of which included phenol, used in the treatment of cosmetic defects and diseases of the skin. They noted the importance of degreasing, emphasized hydration to reduce systemic toxicity, and stated that the phenol solution should be applied over a l-hour period. Their solutions were freshly mixed prior to application; powdered talcum was applied to dry the skin, and the patients were sedated before peeling. Finally, it was observed that dilution of phenol with water could result in rapid absorption and possible systemic toxicity. They screened patients prior to treatment for possible kidney disease, which would enhance the toxicity of phenol.

In 1946, Joseph Urkov stated “the production of exfoliation . . . is of course a time honor practice in dermatology.“3 Urkov describes several peeling procedures that include the use of phenol occluded by tape for treatment of wrinkles. George Mackee had been using liquified phenol for acne scarring since 1903, but it was not until 1952 that he revealed his formula or technique in the Journal of the American Medical Associaticm.4

A lay operator, Antoinette LaGasse, practiced in the Los Angeles area during the 1930s and 1940s using a technique of phenol peeling that she had brought with her from Europe.5 Mrs. LaGasse’s father was a World War I French physician who treated soldiers for powder burns of the face with phenol solutions, a not uncommon treatment at the time. He noted that an unattractive area of skin on a patient treated with phenol solution and then covered with adhesive tape healed with cosmetic improvement. He refined the formula and technique in his practice. Working as a nurse in his office, she brought the formula

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58 P. S. Collins

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and technique with her when she immigrated to the United States.

In the 196Os, Samuel Ayres III6 published his experience with chemical peeling. He found both phenol and trichloroacetic acid (TCA) effective for treatment of actinic changes of the skin and for the eradication of wrinkles. Phenol toxicity was a concern, and thus he stated his preference for utilizing TCA.

Also in 1960, Adolph Brown, Lee Kaplan, and Marthe Brown7 described their phenol formula, the resultant histologic skin changes, and potential toxicity of phenol. The death of an individual from overzealous applications of phenol was attributed to a lay operator.

From the multitude of phenol formulas described in the 194Os, 195Os, and 1960s emerged two specific solutions: a nonsaponized formula utilized by Clyde Litton and a saponized formula described by Thomas Baker. Clyde Lit- ton in 19618@ presented his formula, consisting of phenol, glycerin, croton oil, and water utilized in a series of 50 facial peels. Thomas Bak- er’s published formula’0 was similar, except that septisol was substituted for glycerin, resulting in a saponized phenol formula.

Over the last decade, progress has been made in determining the depth of penetration of different peeling solutions along with the histologic changes produced.11-18 Samuel Stegman16 compared the depth of penetration and the histologic changes seen with applications of TCA, phenol, and Baker’s formula (both nonoccluded and occluded) on the skin of a guinea pig. Phenol toxicity of the myocardium was again re-emphasized in the late 1970s1g-22 with new standards of care delineated for patient safety.

Definition

Chemical peeling is the application of an irri- tant chemical solution onto the skin, resulting in either keratolysis or keratocoagulation7 with the subsequent destruction of the epidermis and the upper dermis, followed by replacement with new epidermis and dermal connective tissues. The final product is rejuvenation of the skin as evidenced by disappearance of rhytides, lentigoes, actinic keratoses, superficial skin

cancers, and actinic dermatitis with a tightening and smoothing of the skin. Numerous appellations describe the procedure: chemexfoliation, skin peeling, chemical face lifting, phenol chemosurgery, facial rejuvenation, surface surgery, dermapeel, and chemosurgery. I have used the term chemical peel in this chapter because it is simplistic and implicit.

Formulas

Chemical peeling can be accomplished by using either TCA or phenol in an assortment of dilutions and formulations. The multitude of formulas, the techniques of application, and the physical characteristics of the skin treated make standardization of results difficult. As noted, Joseph Eller and Shirley Wolff in 19412 listed a variety of peeling pastes and lotions that produced a spectrum of inflammatory reactions from mild peeling t.41 intense inflam- mation with marked edema. The chemicals used were salicylic acid, acetone, resorcinol, solution of formaldehyde, phenol, betanaph- thol, glacial acetic acid, mercurial salts, sulfur, and carbon dioxide.

Two phenol lotions are described: 1. Salicylic acid . . . . . . . . . . . . . . 6 gm or cc

Phenol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Alcohol (95%) . . . . . , . . . . . . . . . . . . . . . . 64

2. Salicylic acid . . . . . . . . . . . . . . . . . . . . . . 3 Mercury bichloride . . . . . . . . . . . . . 1.50 Phenol . . . . . . . . . . . . . . . . . . . . . . . . . 22.50 Alcohol (95%) . . . . . . . . . . . . . . . . . . . 22.50

Both formulas produce an intense reaction with deep peeling.

Richard B. Aronsohn29 uses the following to peel the dorsal hand:

Salicylic acid powder USP . . . . . . . 50% Methyl salycylate . . . . . . . . . . . . . . . 16 gtt Aguaphor qs . . . . . . . . . . . . . . . . . . . . 4 oz.

If excessive freckles are present, he adds croton oil . . . 2 gtt.

Samuel Ayers, III” in 1960 was using either liquified phenol (88% solution) or a combination of phenol (33-l/3%), TCA (33-l/3%), and alcohol (33-l/3%) for facial peels.

Brown et al.7 gave still another combination:

October-December 1987 Volume 5 Number 4 The Chemical Peel 59

Phenol . . . . . . . . . . . . . . . . . . . . . . . 60-95% Saponated solution of cresol . . . . . . 0.3% Olive oil or sesame oil . . . . . . . . . . . 0.25% Distilled water qs . , . . 100% by volume

Gross and Mascheka in 1980 listed nine separate phenol formulas including their own. They believe all the formulas listed were adequate in the treatment of wrinkling and actinic damage of the face.

The most common acid and acid formulas used today are various concentrations of TCA, phenol (88%), Litton’s formula introduced in 1961, and Baker’s formula.

Clyde Litton’s formula9 cannot be quickly formulated and is usually compounded and stored in brown glass bottles in a cool area:

Liquefy 1 pound of phenol crystals by heating in warm water until melted, and adding 8 cc of distilled water and 8 cc of glycerin.

stir well

Take 4 oz of liquefied phenol and add to 1 cc of croton oil. Stir well. Into 8 oz bottle, place 4 oz of distilled water, and then add phenol and croton oil mixture.

shake well before applying Thomas Baker’s formula is probably the most

widely used phenol formula because it can be mixed readily by the physician prior to application.

Phenol(USP) . . . . . . . . . . . . . . . . . . . . . . 3cc Distilles water . . . . . . . . . . . . . . . . . . . . . . 2 cc

Croton oil . . . . . . . . . . . . . . . . . . . . . . 3 drops Liquid soap (septisol) . . . . . . . . . . . . . 8 drops

TCA is utilized in various dilutions ranging from 20%z4 (which causes mild exfoliation of the upper epidermis) to 50% and as high as 70% for deep peels.z4-z~130 Seldom is TCA combined with other chemicals” other than its dilution by water. The standard formula for a 50% TCA solution28 is:

TCA USP (crystals) . . . . . . . . . . . . . . . . . 50 g Distilled water qs a.d. . . . . . . . . . . . . . . 100 cc

I use phenol 20%, phenol 88%, Baker’s and Litton’s phenol formulas, and TCA in dilutions from 20%~50%. Patient selection and the cutaneous condition to be treated will determine the acid selected.

Histology of Peels

Penetration of the epidermis by the various acids and acid formulas is determined by a multitude of factors. Resultingly histologic findings and clinical results may vary. The major factors that determine depth of penetra-

tion are concentration of acid; peeling formula; skin preparation prior to peeling: degreasing, washing, abrasion, or topical retinoic acid: sebaceous gland density; cutaneous area; occlusion by taping; method of application; neutralization; repetition and frequency of peel: and storage and age of peeling solution.

It appears that neither the thickness of the skin nor the degree of actinic damage present determines the ability of the skin to regenerate from a chemical peel. The type of skin, ie, the density of adnexal glands present, and the chemical used determine the ability of the skin to regenerate. Eyelid skin can tolerate Baker”s formula even under occlusion, yet the thicker skin of the neck and upper chest often scar in response to an unoccluded Baker’s formula application.

TCA is a chemical cauterant that coagulates the proteins of the skin. As the concentration increases, the depth of dermal damage, as evidenced by edema, cellular infiltration, and necrosis, also increases. Concentrations above 50% may induce extensive necrosis and inabil- ity for normal tissue regeneration. Conversely, some cutaneous tissue can tolerate very high TCA concentrations when applied to small areas (xanthelasma of the eyelids treated with 80% TCA).

Phenol in its pure state exists as a crystal. Liquefied phenon (phenol liquefaction USP) is chemically 88% phenol and 12% water. Phenol 88% is a keratocoagulant and, when applied, becomes a barrier to further penetration of the phenol into the dermis and systemic absorption.417 As the concentration is lowered to approximately 50%, phenol becomes a keratolytic agent, causing proteins to be denatured without being coagulated. Hence, lowering the concentration actually increases the penetration of phenol into the dermis and subsequently increases systemic absorption.’ TCA, a keratocoagulant, is more caustic than phenol, and this property limits its effectiveness. Phenol’s keratolytic property allows greater dermal penetration without inducing scar production.

Baker’s and Litton’s formulas are the two most commonly used phenol formulaszl Both employ liquefied phenol (phenol 88% USP) di- luted to a 50-55% concentration by the addition

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60 P. S. Collins Dermatology

of distilled water, which converts the phenol reaction from keratocoagulation to keratolysis with increased penetration depth. Croton oil, derived from seed of croton tiglium, causes vesiculation and sloughin@ and, by disrupting the epidermis, enhances penetration of the phenol. Baker’s formula contains septisol, a soap. Septisol acts to decrease surface tension and allows uniform penetration. Glycerol is miscible with water. This dilutes the phenol and helps keep the formula in the solution.

Skin preparation is an important part of the procedure. Removal of debris, loosely adherent keratin, and oils allows uniform penetration of the peeling solution. Degreasing with acetone or ether is mandatory, as even small amounts of skin oil will maintain surface tension and decrease penetration.8 Washing with septisol removes surface oils. Vigorous scrubbing, while degreasing, produces a superficial abrasion that clears the skin of loosely adherent debris and keratin.

Topical retinoic acid applied qd or qod for l-2 weeks prior to chemical peeling promotes early shedding of corneocytes, a thinner stra- tum corneum, enhanced fibroplasia, and early wound repair.31

It has been my experience, as well as that of others,32 that patients with thick, oily skin do not respond as favorably to peels. Sebaceous hyperplasia and sebaceous hypersecretion with the associated high cutaneous oil content is often seen in patients with thick, oily skin and is more common in men. Since skin oil increases surface tension and decreases penetration of acids, this is the reason some authors32note that men are not favorable candidates for chemical peels.

Occlusion of phenol or TCA produces greater tissue necrosis.13~16~17 No explanation for this phenomenon other than increased maceration can be stated.

Chemical peeling is not an all-or-none phe- nomena. Vigorous rubbing of the acid solution into the skin produces deeper penetration than a light application.16 TCA that is not neutralized with alcohol or water produces a greater chemical burn.

Repetition of a dilute peeling solution (20% or 25% TCA) applied at frequent intervals (every

7-14 days) can produce a deeper peel without the additional risk of scarring.33 This is of importance when peeling the neck, chest, hands, or back. I took serial biopsy specimens from the neckof a patient being peeled every 14 days with TCA 25%. Each subsequent speci- men showed a progression in the development of a cellular infiltrate and in the appearance of new pink collagen. Although conclusions can not be drawn from a single case, it appears that serial peeling may produce some of the dermal changes seen with deeper peels without sub- jecting the skin to higher concentrations of acid and the potential for scarring.

Microscopic findings have been extensively studied”-18comparing the following modalities of treatments: dermabrasion, TCA (40% and 60%), phenol 88%, and Baker’s and Litton’s formulas with and without occlusion. All produce dermal injury with necrosis, cellular infiltrate, edema, and disorganization of collagen. The depth of acute dermal injury ranged from the lower papillary dermis and upper reticular dermis with 40% TCA to the deep reticular dermis with Baker’s and Litton’s formulas under occlusion. It is apparent from the studies that Baker’s and Litton’s formulas produced the greatest histologic changes, especially when occluded.

These changes can still be obvious 20 years after peeling. Upon healing, a new band of thin, compact, parallel collagen bundles arranged horizontally to the surface replaces the upper elastotic dermis. Fine elastic fibers are also randomly arranged through this band. Sharply demarcated and below this band is an elastotic mass representing old unpeeled dermis. Telan- giectatic vessels were confined to this deeper elastotic dermis.14jl*

The epidermis becomes more orderly with a basal layer of columnar cells without cytologic iregularities. The PAS basement membrane is more uniform in thickness and staining quality than untreated skin.18 Thus deep chemical peels, especially Baker’s and Litton’s peels with occlusion, result in dramatic epidermal and dermal changes that persist for decades. There is a reversal of actinic changes and several authors observed a decrease rate of appearance of new neoplasms.11~18~32


lndlcations

Chemical peeling may be utilized both for therapeutic and cosmetic treatment of the skin. Therapeutic applications include the following:

1. 2.

3.

4. 5. 6. 7. 8. 9.

10.

11. 12. 13. 14. 15. 16. 17.

Multiple actinic keratoses Widespread actinic dermatitis (elastotic dermatosis) and actinic changes Multiple superficial squamous cell carcinoma in situ Superficial epitheliomata Lentigo maligna Actinic cheilitis Lentigines Melasma Hyperpigmentation Postinflammatory scarring including postacne scarring Xanthelasma Seborrheic keratoses Verruca plana Acne rosacea Damage from previous radiation34 Acne vulgaris Seborrheic dermatitis

Cosmetic indications for chemical peeling are:

1. Rhytides of the aged face 2. Rhytides of the upper lip 3. Rhytides of the lower eyelid and orbital area 4. Postblepharoplasty, lower eyelid rhytides

Technique

Trichloroacetic Acid Peels

Two methods are used in TCA peeling-the light superficial peel with weekly, biweekly, or monthly cauterant application, and a deep chemical peel (Figs. 1-4).24y26p33

The light superficial repetitive peel (TCA-S) is performed with concentrations ranging from 20-35% for “refreshing” the skin. This aids in the removal of fine, subtle lines, softening in the appearance of enlarged pores, silkiness of the skin surface, improvement of skin texture, and lightening of hyperpigmentary disorders. It can be used in individuals with dark complexion.

As with all peeling procedures, the skin surface must be adequately prepared. After washing to remove superficial oils and make-up, the

skin is vigorously scrubbed with an acetone moistened gauze pad. The TCA is applied with

two cotton-topped applicators (Q-tips@, Chese- brough-Ponds, Inc., Greenwich, CT). The TCA is rubbed into the skin with the forehead initially treated. Neutralization of the acid by alcohol sponge occurs when blanching or frosting is seen, or if the patient notes burning and stinging. If the acid is not neutralized, frosting will become more prominent and the patient will experience a greater chemical burn. A new set of TCA-dampened cotton applicators are used with each facial unit (forehead, each cheek, nasal, and perioral). The extent of frosting obtained can be determined by TCA concentration, how briskly the applicators are rubbed into the skin, and how quickly neutralization occurs after application. The frosting (white blanching) disappears in a few minutes and is replaced by erythema. In 2 or 3 days, the skin becomes dry and cracked (if moisturizers or make-up is applied, the process is slowed). Wet-to-dry soaks enhance sloughing of the dry skin in 4-10 days.

Deep TCA peeling (TCA-D) can also be used in patients with dark-pigmented skin although optimal results are in fair-skinned individuals. TCA is not absorbed and produces no systemic symptoms other than transient pain upon application. It can be used in patients with myocardial, hepatic, or renal disease without monitoring.

TCA-D of the face can be performed with TCA concentrations of 35-50% in the same way TCA-S was applied. The patient is instructed not to apply cosmetics the day of the peel. Again, meticulous skin preparation and cleansing are necessary. All rhytides are stretched out to ensure acid penetrates into the folds. The acid is applied onto the vermillion; earlobes and brow and feathered into the hairline. Frosting occurs quickly and neutralization is often not performed, thus allowing a deep burn to develop. Neutralization of the acid with the onset of frosting is necessary to limit the depth of the burn on the neck. Neutralization must occur within 15-30 seconds after application to be effective.

Different concentrations may be used during peeling: TCA 50% to the forehead and cheeks,

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FIG. l.A (topleft). Multipleactinic keratoses with elastoticdermatosisof theforeheadandscalp. B (topright).

Nine months postoperatively following 45% TCA, there isdisappearance of actinic keratoses with smoothing of

skin texture.

FIG. 2. A (bottom left). Multiple lentigoes and actinic keratoses of the hand. 8 Six months postoperatively. Each lesion was treated twice with 25% and 35% TCA (keratotic lesions treated with 35% TCA) followed by 20%

TCA to the entire hand. C (bottom right). Nine months postoperatively after treatment of only one hand by 35%

TCA to lesions and 25% TCA to entire hand. Usually, only one hand is treated to minimize maceration from washing. Here the patient could not return for completion until 9 months later.

FIG. 3. A (facing page, fop left). Multiple actinic keratoses, lentigoes, and actinic dermatitis of the neck and

chest. i3 (facing page, top right). Results from 35% TCA peeling. Note that the hypopigmented scar from electrodesiccation of an actinic keratosis did not improve.

FIG. 4. A (facing page, middle left). Multiple actinic keratoses of the scalp and forehead. B (facing page, middle right). Marked improvement 12 months after asingle treatment with 45% TCA. A second treatment would remove the few remaining lesions.

TCA 35% to the eyelids, and TCA 25% to the Taping will cause a deeper chemical burn by neck. This results in differential depth of peel- maceration of the wound and thus increase the ing and is based on the ability to regenerate development of new dermal collagen. Depend- without scarring in that cutaneous region. ing on the preference of the physician, any


FIG. 10. A (bottom left). and B (bottom right). Dramatic perioral rhytid improvement with Baker’s phenol formula.

number of hypoallergenic surgical or paper are usually taped. The tape is removed in tapes may be used. I prefer Blendermm (3M, St. approximately 48 hours, exposing pink, edem- Paul, MN) tape because of its adherent proper- atous skin. Lubricating creams are applied to ties. The forehead, cheeks, nose, and upper lip prevent drying and fissuring of the skin. Lotions

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are initially avoided because of their high alcohol content, which can be irritating and desic- cating to the newly formed epidermis. Any area exhibiting pun&ate bleeding after removal of the tape is treated with a topical steroid ointment. This promotes healing and limits the potential for scarring and postinflammatory hyperpigmentation. The skin is initially ery- thematous and swollen. The redness and swelling disappear rather swiftly compared with phenol peels. Flaking may continue for several weeks after the initial shedding of skin.

TCA-D peeling produces a refreshing of the skin and does not eliminate deep rhytides. The sallow complexion of actinic damage is replaced by a ruddy, smooth appearance. It is important the patient understands this concept prior to peeling. A woman will find that cosmetics can be applied easily and uniformly. A pleasant, healthy, facial “glow” that brightens the skin is the object. Postoperatively all patients are placed on a nightly dose of hydroxyzine 25-50 mg for several weeks. This decreases the occa- sional post-peel pruritus and reduces dermographism with its flushing or burning sensation.

Repeated peeling every 3-4 weeks by TCA-D may be effective for stubborn, deeper rhytides such as those found on the upper lip. The lim- itation of TCA-D versus phenol formulas becomes obvious when treating upper lip rhytides. Often Baker’s formula will eradicate the major- ity of rhytides in a single, nonoccluded treatment.40 TCA-D may soften the appearance but will not eradicate deep upper lip rhytides with a single treatment. Even repetitive TCA-D peels (35-45% applied every 3-4 weeks for a total of three treatments) will leave residual rhytides. Intradermal “fillers”such as Zyderm@ (Collagen Corporation, Palo Alto, CA) or sil- icone may be needed as adjunctive treatment.

TCA-D peels are especially useful in the treatment of multiple, widespread facial superficial squamous cell carcinomas in situ, epithe- liomas, actinic keratoses and actinic dermatitis. Phenol may be contraindicated in the elderly because of its myocardial toxicity, whereas TCA can be used safely. Regional peels can be performed to further minimize discomfort. The pain, burning, and stinging from application of TCA lasts only 5-15 minutes, unlike

those from phenol, which can last for hours and rarely several days. Single-application peeling requires a TCA concentration of 35% or greater to be effective. Even actinically acquired baso- philic degeneration of collagen (elastotic dermatosis) can be corrected or dramatically im- proved. Inadequate TCA-D peels may be repeated 2-8 weeks with second peels left untaped when using concentrations of 45% or greater. It should be noted that when repeating a peel for inadequate treatment, one may lower the concentration to 25% and still obtain adequate results if performed 2-4 weeks after the initial treatment.

Keratotic lesions should be removed, curet- ted, or shaved flat prior to peeling to permit optimal penetration. Acid, however, should not be directly applied to ulcerated or bleeding skin, as obviously the depth of the chemical burn will be greater and scarring may result. Therefore, keratotic lesions should be treated and allowed to heal for l-2 weeks before peeling. Retinoic acid applied qd or qod for 2-3 weeks prior to peeling will enhance wound healing and remove or soften keratotic lesions, allowing adequate penetration.

TCA peeling of the neck, V of the chest, or the hands requires patience on behalf of the physician. He or she often has to resort to repetitive peels utilizing weaker concentrations to prevent scarring.33 Specific lesions such as actinic keratoses, lentigoes, or lentigines are treated first with either 25% or 35% TCA solution. The following week, the lesions are again treated if the initial treatment appears inadequate. When adequate treatment of the specific lesions has been obtained, the entire anatomic area is treated with a 25% or 35% solution. This results in rejuvenation of the surrounding skin, prevents pigmentary “halos” around the treated lesions, and produces a uniform erythema of the skin. Acid should never be reapplied to skin ulcers or wounds not re-epithelialized. It is far wiser to apply a weaker concentration that may produce an inadequate peel than an acid concentration that will not allow normal healing. Repetitive TCA peeling can produce adequate results with minimal potential for scarring. Neck peeling is uncomfortable during healing as movement may produce superficial abra-

October-December 198 7 Volume 5 Number 4 The Chemical Peel 65

sions along the neck folds. These should be treated with a topical steroid ointment to minimize crusting and irritation.

Usually, no sedation is administered for regional peels. Many patients can tolerate full- face TCA-D peels without sedation. Although temporary, however, the burning and stinging can be unpleasant to some individuals. I have used the following premeditation for TCA-D peels and phenol peels in selected patients: the night before surgery secobarbital 100 mg PO qhs and hydroxyzine pamoate 50 mg PO qhs; 1 hour prior to arriving at office: trimethoben- zamide HCl 250 mg PO; and preoperatively (30-45 minutes prior to surgery): meperidine 50-100 mg IM, hydroxyzine pamoate 50 mg IM, promethazine HCl 50 mg IM, and diazepam 10 mg SL.

Patients undergoing TCA-D untaped are told to apply wet-to-dry soaks postoperatively. This enhances the peeling of treated skin, as evidenced by the development of dryness, scal- ing, and fissures. At this stage, the treated area becomes uncomfortable. Warm-water com- presses followed by lubricating ointments quickly relieve the uncomfortable tight feeling and enhance shedding of the peeled skin. The loose adherent skin must not be plucked by the patient as this often leaves denuded bleeding areas. Pulling or tearing shedding skin may result in scarring and pigmentary changes. Topical steroid ointment is applied to any denuded skin.

Phenol Formula Peels

Given the ideal skin color, there is no one procedure that can produce the astounding results of a full-face phenol formula peel. Years appear to melt away as facial skin tightens, lifts, smooths, and unwrinkles. It is not a substi- tute for rhytidectomy, blepharoplasty, or a forehead lift. Baggy eyes, sagging face, and ptotic brows are specific problems requiring specific procedures. The peel will help tighten the face, but there is a limit to its correction of redundant sagging skin that is best served by other surgical procedures. In the fair-skinned individual with multiple rhytidesof the perioral

and periorbital region, actinic dermatitis with widespread actinic keratoses, lentigoes and lentigines, mottled pigmentation from actinic damage, sallow skin with multiple furrows, or the facial features associated with cigarette smoking, the benefits gained from phenol formula peels truly astound both the physician and the patient (Figs. 5-10).

Poor patient selection, inadequate facial preparation, inconsistent technique, nonmeticu- lous application to rhytides, and deviations in the chemical formula may result in inconsistent and disappointing results. The ideal patient is a thin-skinned woman with fair complexion and fine rhytides. In selecting patients, consid- eration should be given to their activities and cosmetic preferences.32 Patients who cannot curtail excessive sun exposure will likely develop postpeel mottled hyperpigmentation and be unhappy. Those patients who wear no make- up and have a deep tan may complain of the lack of “color” afterwards. Olive or dark complexion results in inconsistent pigmentary changes, ie, mottled, hypopigmented, or hyper- pigmented, especially at the borders.

I have excellent results in men. Although the peel does not produce as dramatic a result, the male patient desires improvement of skin texture and not necessarily eradication of all rhytides. Rhytides are lines of expression in men but age lines in women. In the man, the solution is applied onto the bearded portion of the neck. There should be no sharp line of demarcation but rather a haphazard, feathered, zig-zag line that reaches the lower bearded neck. Selection is even more important in men as they are unwilling to utilize make-up for blending. Fair complexion, dense neck beard and minimal sebaceous hyperplasia, and the presence of actinic changes (actinic keratoses, actinic dermatitis, lentogoes and elastotic dermatitis) are important criteria for optimal results. Individ- uals with multiple sebaceous hyperplasia should have the individual lesions treated first by electrodestruction and then later undergo a phenol-formula peel. Another option in these individuals is a dermabrasion combined with a chemical peel.

Photography is mandatory. All nevi, scars, telangiectasia, prominent pores, and pigmen-

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FIG. 5. A. Multiple deep rhy-

tides of forehead, chin, and peri-

oral area with advanced actinic

changes. B. Baker’s formula peel

taped. Note improvement of the

deep rhytides. There is also a

generalized tightening of facial

skin around the eyes and oral

area.

tary abnormalities should be demonstrated to third group who endure pain for several days.35 the patient, photographed, and charted. It is The last group may associate their postpeel best that all cutaneous blemishes be unmasked grotesque appearance with pain, thus decreas- prior to the peel. ing their pain threshold. .

Consultation must include discussion of possible complications as well as the grotesque appearance that is expected postoperatively. The patient should be prepared for discomfort. Pain is variable, with some noting mild discomfort for only several hours; others, severe pain, but again, for only several hours; and a

Patients should be screened for myocardial, renal, or hepatic disease. Systemic absorption of phenol can occur through the skin or via the respiratory tract. An inadequately ventilated room will increase pulmonary absorption of phenolic vapors. Once absorbed, 25% is meta- bolized to carbon dioxide and water and 75% is

FIG. 6. A. Close-up of oral area demonstrating the perioral and chin rhytides. 6. Results from a taped Baker’s formula phenol peel. Deep rhytides such as these seem to respond best to taping.


FIG. 7.A. Actinic keratoses, len-

tigoes, and actinic changes involv-

ing the face and neck. Treatment of the face only would result in

noticeable contrast. B. The face

was treated with Baker’s phenol

formula untaped and the neck

was 35% TCA. Taping was not

performed because the rhytides

were relatively superficial.

excreted by the kidneys either unchanged in the urine or conjugated with glycuronic or sul- furic acid. The liver also participates by detoxi- fying a portion of the phenol to hydroquinone and pyrocatechol.36+5

Phenol is a myocardial toxin. Arrhythmias can occur even in patients with normal preoperative electrocardiograms.20+ Patients with renal, myocardial, or hepatic disease may be poor candidates for full-face phenol-formula peels. They, however, may undergo regional

peels performed on separate days, as their exposure to phenol and systemic absorption will be minimized.‘0,2’

Cardiac and blood pressure monitoring and an intravenous line should be established for the above reasons in all patients undergoing full-face phenol-formula peels or in patients with systemic disease. The patient receives approximately 500 ml of Ringer’s lactate prior to the procedure and an additional 500-1000 ml during and after the peel. This ensures ade-

FIG. 8. A. Typical actinic skin changesseen in a fair-skinned woman. 8. Litton’s phenol formula applied to face and upper neck. At this time, I was taping all phenol formula peels.

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FIG. 9. A and 5. Results of Bak-

er’s phenol formula peel. Notice

the improvement of the facial sag-

ging.

quate hydration and enhances excretion of any absorbed phenol.37 These precautions are not mandatory when performing a regional peel in healthy individuals. Blood pressure and pulse rate should be noted preoperatively and during the procedure, however.

Preoperative sedation is as outlined under deep TCA peels. Full-face phenol peels can be very painful, and intravenous sedation is necessary. Diazepam or midazolam and meperidine will control the pain during the application and immediate postoperative period.

Elimination of rhytides may be disappointing if adequate skin preparation is not performed. The rhytides must be stretched out and vigorously scrubbed to remove all debris, oils, keratin, and any residual cosmetics. This step should be repeated at least once and preferably twice with an acetone- or diethyl ether-dampened cotton gauze.

The phenol formula bottle is shaken to mix the solution, which is then poured into a glass beaker placed on a tray. The height of the tray should be lower than the patient’s head. This prevents accidental splashing of the phenol solution onto the patient. Two types of applicators are utilized in the procedure-a large cotton applicator (Scopettes, Jr.,@ Brichwood Lab- oratories, Inc., Eden Prairie, MN) and a smaller cotton applicator (Q-tips@, Chesebrough-Ponds,

Greenwich, CT). The large applicator is used on flat surfaces for uniform application. The smaller cotton applicator is used for meticulous application, ie, rhytides, around orifices, in the hairline, and on the eyelids.

Phenol solution will separate quickly and must be mixed constantly to stay in solution. The applicator is stirred in the beaker, then rolled along the glass walls to eliminate any excess solution from dripping off the cotton tip. The applicator is brought to the side of the face and never over it, preventing accidental spillage onto the patient.

The face is divided into peeling units: forehead, right and left cheek, perioral, nose, and periorbital areas. The mandibular margin is outlined. The rhytides in each unit are carefully spread and acid applied with the small cotton tipped applicator. At completion, the entire unit is treated with the scopette-dampened applicator. The physician can be assured each rhytide was treated and there was uniform application to the surface by following this sequence.

A lo-16 minute time lapse before treating the next unit will lengthen the duration of the entire procedure to more than 60 minutes and minimize phenol-induced arrhythmiasZ++ The solution is rubbed into the hairline and brows (it will not affect hair growth or color)


for blending at the hairlines. The nasal alar and columnella are also treated. Phenol is absorbed through the respiratory tract. Ade- quate ventilation of the operating room will minimize inhalation of the vapors by the physician and patient. The solution is carefully applied into all perioral rhytides (a wooden applicator may be more effective here) and onto the vermilion.

Extreme caution must be taken when treating the eyelids. Phenol spilled into the eye will cloud the cornea. Ophthalmic irrigating solution should be available on the tray. The patient must keep the eyes closed. An assistant must constantly remove all tear formation with a cotton gauze sponge that is immediately dis- carded after a single use. By eliminating any tearing, retrograde flow of phenol into the eyes will be prevented. The upper lids are peeled to the level of the superior margin of the tarsal plate but not to the lid margin. On the lower lid, solution is applied to within 2 mm of the ciliary border.

The mandibular margin as marked determines the lower edge of taping. Solution is feathered (applied lightly and without vigorous rubbing) onto the neck to the level of the hyoid in women. In men, the solution is applied to the low neck beard area. The neck is not taped. The solution is applied to the earlobes but not the ear. For blending purposes, the solution is applied to the postauricular area immediately adjacent to the earlobe. In individuals with prominent actinic changes or multiple rhytides of the neck, 25% or 35% TCA may be applied to the entire lower neck. Do not overlap the phenol-treated area when applying TCA.

As each unit is treated, a white frost appears immediately upon application. This is soon replaced by a rubor, dusky color, edema, and even vesiculation, which appear within minutes after this. At the completion of the procedure, swelling may be noticeable.

Postoperative Care of Phenol-Formula Peels

The postpeel management differs consider-

ably from author to author. The common techniques include:

1. Occlusion, thymol iodide powder, moisturizer$Q 2. Occlusion, moisturizers 3. Moisturizers with no occlusion45

I have used all three methods with full-face phenol-formula peels. I no longer apply thymol iodide powder. The resulting crust is uncomfortable and moist wounds heal quicker. Appli- cation of antibiotic ointments (bacitracin) and frequent cleansing with water will minimize bacterial overgrowth.

Does occlusion produce better results? It has been determined that occlusion, with all other factors being equal, produces a deeper chemical burn.16 The technique of peeling is variable,39 however, and as a result, some authors can obtain similar results without occlusion by meticulous skin preparation and vigorous application of the solution into the skin.32 Removal of the tape at 24-48 hours has not, in my experience, required sedation or narcotics and thus is not a factor in the decision against occlusion. Indeed, it has been my impression that patients undergoing full-face phenol-formula peels that are not occluded are likely to experience greater pain. Skin burns are more painful when exposed than when covered with a dressing. Con- versely, McCollough feels that occlusion is less likely to result in a porcelain or colorless complexion devoid of its typical pinkness (personal communication).

I use occlusion in patients with deep rhytides and extensive advanced actinic dermatitis and elastotic dermatosis. The added penetration with occlusion appears to be important in obtaining a more uniform result when the skin is not thin and rhytides are very deep.

An assortment of agents has been used to moisturize the skin. Ointments provide better occlusion and prevent desiccation. Bacitracin ointment is excellent but more expensive than an ointment such as Vaseline Dermatologic Formula@ ointment (Chesebrough-Ponds, Inc., Greenwich, CT). Crisco@ (Procter and Gamble, Cincinnati, OH) has also been used with suc- cess.

Once the skin has ceased oozing, a cream can be substituted for the ointment. Topical steroids certainly can decrease erythema but may

70 P. S. Collins

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enhance the presence of telangiectasia. Areas of persistent erythema, ie, after the second week, may indicate incipient scar formation. It is appropriate to treat these topically with a fluorinated steroid cream or, if necessary, systemic steroids.

Pruritus and dermographism are common postpeel. To minimize the itching and burning, hydroxyzine 25-50 mg PO is given routinely at night for 2 weeks postpeel. Diphenylhydram- ine 25 mg PO can be given in addition if itching is not adequately controlled.

Steroids are not administered at the time of the peel as they inhibit the dermal inflammatory infiltrate and possibly decrease the ulti- mate result. They may be administered after the fifth postoperative day to hasten the resolution of the postinflammatory erythema.

Sequelae of Chemical Peels

According to Webster’s dictionary, a sequela is something that follows, or is the result or consequence; a complication is a condition occurring during another disease and aggra- vating it. When discussing chemical peels, the patient should be informed of the sequelae as well as the possible complications.

The more common sequelae of chemical peels include the following:

1. Pigmentary Alterations A. Demarcation lines 6. Hyperpigmentation C. Hypopigmentation D. Phenol bleaching E. Blotchy or streaking pigmentation F. Darkening of existing nevi

2. Enhanced Solar Sensitivity 3. Erythema 4. Pruritus 5. Dermographism 6. Telangiectasia 7. Prominence of Skin Pores 8. Milia

PigmerLary alterations commonly occur. Pa- tients with lighter complexions will have fewer pigmentary irregularities. Phenol formulas are more apt to produce demarcation lines, which are most noticeable along the angle of the jaw.38 Feathering in a zig-zag pattern will diminish the obvious skin color and texture changes. When peeling the upper lip, the solution should be applied to the nasolabial fold and slightly

beyond (approximately 0.5 cm). The lower eyelids are peeled inferiorly to the orbital rims to minimize demarcation and laterally onto the temple to eradicate rhytides.

Hypopigmentation and hyperpigmentation may occur singly or jointly, thus producing a blotchy, streaking pigmentation. Hyperpig- mentation is more common with TCA peels and occurs on the upper cheek area, usually as a consequence to solar sensitivity. Application of the following formula as soon as hyperpigmentation is noted often resolves this sequela:

Mix and Dispense: Tretinoin cream 0.1% . . . . . . . . . . . 15 gr Eldopaque Forte@ (Elder Pharmaceu- ticals, Inc., Bryon, OH) 48% . . . . . 15 gr Triamcinolone cream 0.1% . . . . . . 15 gr

Apply b.i.d.

Hyperpigmentation has been reported after phenol peels and can be due to estrogens or phenothiazines. These medications may need to be stopped before the hyperpigmentation will resolve or respond to therapy (application of depigmentary formula or a second peel).

Hypopigmentation is to be expected with the utilization of phenol and, if extreme, produces phenol bleaching. Kligman, Baker, and Gor- danI demonstrated that, contrary to popular belief, phenol produces hypopigmentation and not depigmentation of the skin. Melanocytes were not found to be decreased in number. Premature excessive solar exposure will height- en the pigmentary contrast. Less noticeable bleaching occurs with lighter complexions.

Blotchy or streaked pigmentation may be due to faulty technique, failure to properly cleanse the skin, inadequate mixture of the phenol formula, nonuniform application of the solution, or an unevenly applied tape mask. All produce differences in the depth of peel. Cor- rection consists of repeeling the involved areas with full-strength phenol (88%) or phenol formula untaped 3-4 months following the initial peel. Pigmentary abnormalities after a TCA peel are treated similarly. Application of the depigmentary formula and/or repetition of the TCA peel often solves or significantly improves this problem. Reflected light can stimulate irregularities in pigmentation. Patients must be forewarned of reflected light while driving


in an automobile. Complications Nevi may appear darker following a peel.

This may be the result of hypopigmentation of the surrounding skin. Each nevus on the face should be noted and the possibility of darkening explained. Excision of an objectionable or potentially objectionable nevus should be done prior to the peel. Shave excision may be inadequate to remove the entire nevus. A postpeel darker nevus may be lightened by the application of liquid nitrogen.

Complications may occur despite meticulous technique and precautions. Rapid recognition and expeditious treatment may be necessary to mollify the outcome in some instances. The following are complications associated with chemical peeling:

1. Cardiac arrhythmias

Erythema can be persistent and disturbing. Some individuals will have bright erythema for as long as 20 weeks. Typically, it disappears in 4-8 weeks. Erythema can be associated with dermographism and pruritus. Hydroxyzine 25-50 mg qhs and, if needed, the addition of diphenylhydramine 25 mg qhs will control these problems. Patients are routinely placed on hydroxyzine 25-50 mg qhs to mollify these sequalae. Resolution of both erythema and pruritus may be hastened by administration of systemic steroids, with my preference being 1.5 ml IM of Celestone Soluspan@ (Schering Corporation, Kenilworth, NJ). Topical steroids are effective but might accentuate or produce telangiectasia. Postpeel pruritus can be severe and if not controlled, excoriation with possible scarring can occur. Facial erythema is effectively masked by application of a green color tone make-up such as Pantheon Products’ Con- cealer@ (Pantheon Products, Inc., Odessa, TX).

2. Accidental spillage of solution 3. Herpes simplex infection 4. Bacterial infections 5. Scars

A. Hypertrophied scars 5. Scar contracture C. Skin ulceration D. Full-thickness sloughs

6. Laryngeal edema 7. Psychological disturbances

The presence of telangiectasia and prominence of skin pores should be demonstrated to the patient prior to peeling. Awareness of their presence can be a rude awakening and a source of discontent to the patient postpeel. Electro- coagulation (with an insulated platinum nee- dle) of prominent telangiectasia is effective. Enlarged pores are more difficult to deal with. They may even occur after dermabrasion.

Milia or inclusion cysts appear at 4-6 weeks. Moisturizing ointments often occlude the ori- fice of the pilosebaceous unit and induce these retention cyts. Spontaneous resolution may be hastened by gentle abrasion (Buf Puf@, 3M, St. Paul, MN), gentle sharp incision, or application of retinoic acid. Retinoic acid applied several weeks prior to peeling can reduce the occurrence of milia.

Cardiac arrythmia is the most serious potential complication of systemic absorption of phenol. In contrast, TCA is not absorbed and produces no known systemic toxicity. Systemic toxicity of phenol has been recognized for decades.3F4 Although Clyde Litton reported in 197319 the occurrence of cardiac arrhythmias, it was Truppman and Ellenby in 1978 who “sounded the alarm.” Cardiac arrhythmias, which included premature ventricular contrac- tions, bigeminy, paroxysmal atria1 tachycardia, and ventricular tachycardia, occurred in 10 of 43 consecutive phenol face peels. Nine of the 10 had normal preoperative electrocardiograms. Gross reported22 that 10 of 17 patients with a previous history or a current problem of cardiac disease developed cardiac arrhythmias during phenol-formula peels. He also noted 11 of 37 patients with no history of cardiac disease or electrocardiogram abnormalities developed arrhythmias. No author could relate the appearance of cardiac arrhythmias with either sex, age, phenol serum levels, administration of oxygen, or use of either saponated or nonsapo- nated phenol formula. A normal preoperative electrocardiogram in addition to a negative history of cardiac disease did not preclude the possible development of arrhythmias.

Cutaneous absorption and cardiac arrhythmias are related to (1) duration of procedure and (2) the size of the area covered by the phenol solution. The extent of phenol solution

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depends more upon the total area of skin exposed than upon the concentration of the solution used.36 Once absorbed, the kidneys excrete 75% in the urine, while 25% is metabo- lized to carbon dioxide and water. The liver participates in detoxification by converting phenol to hydroquinone and pyrocatechol.36y45 Therefore, all candidates for phenol peels should also be screened for renal or hepatic disease, which may enhance systemic toxicity.

Application of the phenol formula to small individual facial units (forehead, each cheek, perioral, nose, and periorbital regions) while allowing a lo-15-minute time lapse between treatment of each unit increases the duration of the procedure to 60 minutes or greater. This will significantly reduce the probability of cardiac arrhythmias.20~22~37+5 Greater caution should be observed in the presence of cardiac, renal, or hepatic disease. Here it may be advisable to peel a few units in any one day, thus limiting the area exposed to phenol. No arrhythmias were noted in any patients who had less than 50% of the face peeled.

Induced diuresis during and immediately following application of phenol20 reduces the incidence of ventricular tachycardia in adult rabbits.37 All patients should have an intravenous line established should treatment of severe arrhythmias become necessary. Hydration pri- or to peeling with 500 ml of Ringer’s lactate and an additional 1000 ml during peel and recovery stage promotes diuresis.

Continuous cardiac monitoring with the appropriate cardiopulmonary resuscitative capa- bilities should be available.20~22~36~45 The patient is monitored for an additional 30 minutes at the conclusion of the procedure. The appearance of any arrhythmia after this time is unlikely.22 The appearance of a cardiac arrhythmia de- mands immediate cessation of the application of phenol. The persistence, severity, and type of arrhythmia will determine the course of action. Nasal oxygen with either intravenous administration of lidocaine for ventricular arrhythmias or propranolol for supraventricular arrhythmias will effectively correct the arrhythmia. Some mild arrhythmias will spontaneously revert before treatment can be administered; others may persist for days.22

Once the arrhythmia has been corrected, the physician must determine if continuation of the procedure is appropriate. Development of the arrhythmia early in the procedure may indicate cardiac hypersensitivity to phenol. Com- pletion of peeling may be advisable on a second day. Apparently, most patients who developed arrhythmias were still able to complete the entire procedure the same day.20y22

Accidental spillage of the solution must be quickly neutralized by olive oil or soap and water to minimize the chemical burn. Contam- ination of the eyes requires irrigation with co- pious tap water or an ophthalmic irrigating solution. Ophthalmic consultation may be wise.

Facial herpes simplex may be activated by peeling. Patients with a history of frequent recurrence can be prophylactively treated with a tid dosage of acyclovir capsules 24 hours prior to and for 4-5 days after the peel. Active herpes can be controlled also with acyclovir capsules (five capsules a day for 5-7 days).

Significant bacterial infection is unusual. TCA and phenol are bactericidal.41 Folliculitis or pustulosis may occur several weeks after the peel, the result of application of occlusive ointments. Washing with antibacterial soaps (Hi- biclens, Stuart Pharmaceuticals, Wilmington, DE) and administration of an antibiotic (tetra- cycline 500 mg bid) will control this.

In spite of all precautions, scarring may result following chemical peeling. Indeed, in a questionnaire of complications evaluated by Litton and Trinidad, 21% of the 588 United States plastic surgeons using phenol reported scarring.21 The most frequent sites were the lips, chin, and perioral region. Appearance is usually within the first 3 months.42 Fortu- nately, most scars are small and isolated. TCA is more caustic than phenol and at high concentration more apt to produce scarring. Ayres43 states scarring is unpredictable with TCA, with the area of the neck and on and beneath the chin carrying the greatest risk. Intrale- sional steroids are the treatment of choice for hypertrophic or contactural scars. Patients should not have a permanent or dyes placed in their hair the week prior to a peel. The combination of the hair chemicals and peeling solution, especially the phenol-peel formula, may


induce a reaction resulting in a skin ulceration or skin slough at the hairline.

Full-thickness skin sloughs are associated with compromised cutaneous circulation as seen postrhytidectomy. It is advisable to wait 2 months between procedures. When a slough occurs, it is often better to allow the wound to heal spontaneously and then perform any necessary surgical revision.42 Laryngeal edema with respiratory stridor, hoarseness, and tachypnea can develop within 24 hours of phenol peeling.44 All three cases resolved within 48 hours with just observation and application of warm mist therapy. No subsequent episodes occurred since the patients were placed on antihistamines prior to peeling.

Psychologic disturbances in many instances can be prevented with adequate preoperative counseling. A properly informed patient is much easier to manage, making the procedure easier for the patient and the physician. There- fore, it is essential that the patient thoroughly understand the entire procedure.38 Even the thoroughly informed patient may find the facial appearance frightening and unnerving the first few days postoperatively. Certainly not a few physicians, unfamiliar with the procedure, have experienced shock and apprehension when confronting a face peeled with phenol formula.

Summary

The spectrum of chemical peeling encom- passes a diverse group of peeling agents with the ability to produce a wide range of cutaneous burns. The most spectacular peels are produced by the phenol formulas. The physician, however, is restricted in the number of potential candidates as determined by skin color and potential toxicity.

While not as impressive, trichloroacetic acid peels are an excellent modality for treatment of actinic keratoses, actinic dermatitis and lentigoes. Improvement of rhytides, skin tone, and texture can be impressive. Utilization of TCA may require repetitive peeling to obtain the desired result.

With the alarming increase in the incidence of severe facial solar radiation as manifested by multiple premalignant and in situ malignant

lesions, therapeutic chemical peeling has become an increasingly important procedure. The dermatologic surgeon can not only eradicate the multitude of facial lesions present but also markedly diminish the incidence of new lesions.

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Stegman SJ. A study of dermabrasion and chemical peels in an animal model. J Drrmatul Sin-g Oncol 1980:6:490-497.

Stegman SJ. A comparative histologic study of the effects of three peeling agents & dermabrasion on normal Rr sun damaged skin. Aesth Plast Surg 1982:6: 123-135.

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20. Truppman ES, Ellenby JD. Major electrocardiographic changes during chemical face peeling. Plast Reconstr Surg 1979;63:44-48.

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23. Fredericks S. Symposium on problems and compiica- tions in aesthetic plastic surgery of the face (Chapter 23). In: Kaye BL, Gradinger GP, eds. Chemical Peel. St. Louis: CV Mosby. 1984;341-359.

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Koopman CF. Phenol toxicity during face peels. Otola- ryngoi Head Neck Surgery 1982;90:383-384.

Wexier MR, Halon DA, Teitelbaum A, et al. The preven- tion of cardia arrhythmias produced in an animal model by the topical application of a phenol preparation in common use for face peeling. Plast Reconstr Surg 1984;73:595-598.

Baker TJ, Gordon HL, Mosienko P. Chemical peel, aesthetic surgery: trouble, how to avoid it and how to treat it. In: Court& EH, ed. Chemical Peel. St. Louis: CV Moeby, 1978145-150.

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Baker TJ, Gordon HL. Chemical peeling as a practical method for removingrhytidesof the upper lip. Ann Plast Surg 197%2:2&l-212.

Ah TH. Complications of chemical peeling easily avoided by careful administration. Dermatology Times 1981: (Nov):l, 16.

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Address for correspondence: Paul S. Collins, MD, 527 West Esplanade Avenue #303, Kenner, LA 70065.

the chemical peel

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