Ophthalmol Clin N Am 18 (2005) 227 235

An Ophthalmologists Guide to Chemical Peels

Marian Cantisano-Zilkha, MD*
Edificio Colegio Brasileiro de Cirurgioes, Rua: Visconde de Silva, 52, 5 Andar CEP 22271-090, Botafogo,
Rio de Janeiro, Brazil

Chemical peels are an effective and noninvasive

therapeutic option for reversing photoaging of the
skin. They are simple to perform, inexpensive,
and require minimum healing time. These procedures are well suited for the delicate eyelid and periorbital structures.
The very fine eyelid skin is part of the ophthalmic and periorbital anatomic complex. It should be
evaluated, treated, and maintained by the ophthalmic surgeon. When the eyelid is properly positioned
against the globe and its skin texture, elasticity, and
youthful contours are preserved, it can perform its
primary functions of protecting the globe and serving esthetically as a frame for the eyes.
Home care regimens using sophisticated topical
eye serums and lotions, including antioxidants,
moisturizers, and eye-tested sun screens, as well as
the in-office application of a variety of chemical
peeling agents and various laser and radiofrequency
technologies will optimize skin quality, reverse photodamage, and rejuvenate the periorbital area.
This article discusses the use of different chemical peels in the authors practicevery superficial,
superficial, and medium depth. Once ophthalmologists understand the value and indications of this

therapy, learn the techniques of application, and feel

comfortable and confident with these methods, they
should be able to treat the entire face.
Superficial peels are recommended to treat the
following superficial epidermal and dermal conditions (Figs. 1A,B and 2A,B):






Mild actinic damage

Superficial wrinkling
Dyschromia
Actinic keratoses
Active acne

A series of peels is recommended, because the

effect is cumulative. Adverse reactions or complications are rarely observed in any skin type. Peels
work in synergy with other noninvasive therapies,
such as intense pulsed light (IPL), injectables (fat
transfer, hyaluronic acid fillers, neuromodulation
[Botox]), nonablative lasers, and radiofrequency therapy (Thermage).
Medium depth peels are used primarily to treat
the following conditions (Fig. 3A E):
 Moderate to severe photoaged skin
 Moderate to severe rhytidosis where epidermis

is atrophic and stratum corneum is thickened

 Moderate to severe skin laxity
 Moderate to severe dyschromia
 Actinic keratoses
* Bosniak + Zilkha, 135 East 74th Street, New York,
NY 10021.
E-mail address: mzilkah@rcn.com

Severe photoaging should be addressed with

deeper chemical peels or a combination of chemical
peels and ablative resurfacing with the CO2 laser.

0896-1549/05/$ see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.ohc.2005.03.006

ophthalmology.theclinics.com

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Fig. 1. (A) Before and (B) after photographs of a patient with moderate dyschromia and texture irregularity treated with a series
of six AHA peels and two sessions of the Cool Touch II (dynamically cooled Nd:YAG laser).

Other noninvasive therapies can also be useful and

can maximize the results (see Fig. 2A,B).

How to select a chemical peeling agent

Selecting the ideal chemical peel agent will depend primarily on the patient and the perceived objectives. Patient selection depends on the following:











Fitzpatrick skin type classification

Age (younger patients respond better)
Lifestyle (sun exposure, alcohol, drugs, smoking)
Current skin care regimen
Previous skin care treatments (including other
chemical peels and other technologies)
Previous cosmetic surgeries
Current medical history (illness, medication,
allergies, herpetic history)
Nutritional supplementation
Patient expectation
Available healing time

Once the patient and physician fully understand all

of the different points to be addressed and have
achieved a common ground, the physician can
make a recommendation about the depth of the peel
to recommend.
Patients requesting subtle changes who have mild
actinic or environmental epidermal changes and no
availability of downtime receive a series of superficial peels at regular intervals (weekly basis). The
results become apparent gradually and are limited to
the surface of the skin. As described previously,

attention to lifestyle, nutrition, and sun protection

will enhance the result.
Patients with moderate and severe actinic and
textural changes extended to the superficial dermis
receive medium depth peels. The results are more
dramatic, but there is a postpeel recovery time of at
least 5 days. Additionally, postpeel home care is
necessary. The same principles on lifestyle, nutrition,
and sun protection apply to this modality.
When possible, before the chemical peels, patients
should engage in at least a 2-week home care regimen
with topical and systemic antioxidants, retinoids,
alpha-hydroxyl acid (AHA) lotions and serums,
bleaching agents, and sun protection. This regimen
is important not only to prepare the skin for therapy
but also to focus the patients attention to following
instructions. The goal of chemical peels is to achieve
a thinner stratum corneum, a thicker epidermis with
less cellular atypia and more evenly distributed
melanin, and increased distribution of new collagen
and glycosaminoglycans in the dermal matrix.
Light peeling agents induce a faster sloughing
of cells in the stratum corneum, whereas a deeper
peeling creates necrosis and inflammation in the
epidermis, papillary dermis, and reticular dermis. The
destruction of specific layers of damaged skin leads
to the creation of new skin with normal tissue. The
induction of an inflammatory reaction deeper in the
tissue than the necrosis activates a mechanism of
mediators of inflammation that generates new collagen and matrix for the dermis.
When one takes into consideration that the deeper
the peel the more risk of complications and the longer
the recovery time, the key to success is to repeat the

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229

Fig. 2. (A) Before and (B) after photographs of a patient with a generalized dull skin texture with mild dyschromia and
telangiectasia treated with eight AHA peels and three IPL sessions.

superficial and medium depth peels more often to

create as little necrosis as possible while inducing
as much new tissue formation as possible [1 5].

Superficial peels
Alpha-hydroxyl acids are the most frequently
used superficial peel agents (Fig. 5). They are also
called fruit acids and are derived from a group of
natural substances found in food and fruits (glycolic
acid in sugarcane, malic acid in apples, and citric
acid in citrus fruit). Of this group, the most commonly used AHA is glycolic acid. Because it is a
small molecule, it has an easier penetration in the
skin than the other acids. The AHAs are recommended in a variety of skin conditions, particularly
those with a thickened stratum corneum (hyperkeratinization), with fine wrinkling, and those associated with photodamage and acne. Although the
mechanism of action is not completely understood,
AHAs are thought to disrupt keratocyte cohesion,
creating a thinner stratum corneum with less wrinkles, better texture, and more uniform coloration.
They also facilitate the absorption of nutrients and
other topical agents through the skin, increasing the
hydration and synthesis of cellular matrix substances
such as collagen and glycosaminoglycans.
Alpha-hydroxyl acids are available in different
concentrations as solutions or gels and are used
in concentrations of 15% to 30% by estheticians and
concentrations of 50% to 70% by physicians. They
are systemically safe and nontoxic and produce
instant gratification and few complications. They
can be neutralized easily with water or with other
neutralizing solutions. The depth of penetration of a

glycolic peel depends on the concentration, method

of application, pretreatment of the skin, and the time
that the agent is in contact with the skin.
Other superficial peels are trichloroacetic acid
(TCA) in concentrations 10% to 20%, salicylic acid
50%, and Jessners solution (resorcinol, 14 g; salicylic acid, 14 g; lactic acid, 14 g; and ethanol (95%)
in 100 mL). Because resorcinol and salicylic acid
can potentially be toxic, the author rarely chooses
these agents.
Steps of application
Skin preparation
When possible, patients should be started on a
topical and systemic skin care regimen at least
2 weeks before the peel to enhance the results and
accelerate healing time.
Room and material
The room where the procedure is performed should
have a sink with running water and a tray with the
following items (Fig. 4): small flat brush, different size
swabs, gauze, timer, small cup, headband, small fan,
saline solution, alcohol or acetone, or any other preparation solution of the physicians choice.
Patient preparation
The patient should remove his or her contact
lenses and thoroughly remove all make-up.
Cleansing
Headbands should be used to keep the hair away
from the face. The skin should be cleaned thoroughly
with make-up remover and then with toner to remove
any remaining make-up debris. To facilitate the

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Fig. 3. (A) This patient presented with moderate generalized facial laxity and rhytidosis. She was first treated with facial
Thermage. One week later, she was treated with a 35% TCA peel. (B) During the application of the 35% TCA peel, the various
levels of frosting are noted. (C) A moderate brown crusting and erythema are noted on the first postpeel day. (D) One week
following the peel, a mild generalized erythema is still apparent. (E) One month following the peel, a significant improvement in
skin texture and pigmentation is noted. The patient has also begun micropigmentation of her lips.

penetration of the peel, the skin is degreased with

acetone or alcohol applied with a folded 4 by 4 gauze
pad or large cotton swab. Care should be taken so
that the degreasing solution or the fumes of the
alcohol or acetone do not irritate the eyes. Hyperpigmented or hyperkeratotic areas of the face that
need more attention are prepared with additional
passes and pressure. The delicate eyelid skin is prepared with a small cotton tip applicator.

Selection of the peel strength

Different strengths of peeling solutions can be
used on different areas of the face. The author
chooses from the following solutions (in increasing
order of strength): a 70% buffered peel solution, a
30% unbuffered solution, a 50% unbuffered solution,
or a 70% unbuffered solution. The strength of the
peel is determined not only by the concentration but
also by the buffering. For instance, a 70% buffered

guide to chemical peels

231

as the patient builds tolerance to the peel. A maximum application time of 10 minutes is allowed.
Care should be taken with Fitzpatrick skin types V
and VI because it can be difficult to gauge the level of
erythema and to decide when to terminate the peel.
Excessive irritation may cause secondary pigmentary
disturbances. The home care use of retinoids and
AHAs can make patients more sensitive to the peels,
tolerating shorter times after application.

Fig. 4. The tray set-up for an AHA peel contains a timer,

peel solution, cups, an applicator or brush (not shown), and
a hand fan.

peel is less potent than a 30% unbuffered AHA peel.

For eyelids, I typically use a 70% buffered solution
or a 30% unbuffered solution. After the application
of the peel, the skin is observed for erythema. The
length of time that the peeling solution is left on the
skin before neutralization is limited by the appearance of erythema. This time will gradually increase

Application
After starting the timer, the solution or gel is
applied to the face with a large cotton tip applicator, a
brush, or a 4 by 4 gauze square folded into a triangle.
For the eyelids, a small cotton tip applicator is best.
The patient should be seated with his or her head in
an upright position, and the solution should be
applied to the entire face in about 15 seconds, starting
on the forehead, with strong smooth fluid strokes
until the entire area is covered. The eyelids and
nasolabial folds should be the last areas treated. Areas
with minor wounds or inflammation are covered with
petroleum jelly (Vaseline). Patients should start feeling a minor tingling or burning sensation; a hand fan
can make the sensation more pleasant. After a
maximum of 10 minutes, patients can experience
mild erythema, and the peel should be neutralized
with water.

Fig. 5. AHA peel consent form. (From Bosniak S, Cantisano-Zilkha M. Minimally invasive techniques of oculo-facial
rejuvenation. New York: Thieme; 2005. p. 26; with permission.)

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Neutralization
Patients can rinse their own face with water, with
special care for the eyes, until all the peeling solution
is washed off. Even though AHA peeling agents are
neutralized by water, if any of the solution gets into
the eyes, patients are advised to rinse them thoroughly and to be aware that a mild keratoconjunctivitis can follow.
Postpeel care
Often, patients will comment that their skin feels
tight and clean. At this point, a mild moisturizer and
sun block is applied. If the patient wishes and there is
no disruption of the integrity of the skin, the patient
can use make-up immediately following the peel.
Moisturizer should be used two or three times a day.
If there is no further irritation of the skin, patients
can resume their home care routine with AHAs and
retinoids the following day. If redness persists, 1%
hydrocortisone cream is recommended. In more severe cases, Aristocort 0.25% can be prescribed, and
a follow-up visit is scheduled in 1 week.
Complications and management of complications
Complications are rare and are often related to
the depth of the peel.
Herpes simplex
Patients with a previous history of herpes simplex
should be pretreated with Zovirax or Famvir for about
a week before the peeling.
Erythema
High concentrations of unbuffered AHA solution
may leave patients temporarily erythematous. Certain
areas of the face, such as the nasolabial folds and
eyelids, are more sensitive to the peels and sometimes
should be neutralized earlier. The use of retinoids can
also sensitize the skin and will make it erythematous
earlier. In these cases, topical corticosteroid cream
is advised.
Pigmentary changes
Hyperpigmentation can be secondary to an inflammatory response in dark skinned patients. In
severe cases, hypopigmentation can result.
Crusting
In inflamed areas where epidermolysis has occurred,
topical antibiotics and zinc oxide are recommended.

Infection
Secondary infection can be the consequence of
crusting and poor wound care.
Scarring
Although its occurrence is rare, scarring can result
from crusting, poor wound care, and secondary infection. In the authors practice, when AHA peels
are performed in a very superficial fashion, a series of
at least five or six AHA peels is recommended on
a weekly basis. At the end of the series of peels, if the
patient shows little or no textural, color, or rhytid
improvement and the quality of the skin is largely
unchanged, he or she is re-evaluated and a more aggressive therapy considered.

Medium depth peels

Trichloroacetic is the authors agent of choice for
this effective peel modality. It is very controlled,
penetrating the basal layer of the epidermis, papillary
dermis, and even extending to the upper reticular
dermis. The concentration of the peel, the number
of coats applied, the pressure during application, and
the preparation of the skin will affect the depth and
the final result.
Concentrations of 10% to 20% function as superficial peels and are recommended as mild exfoliants
to treat mild actinic changes or when patients cannot
spare any downtime. The neck and hands are areas
treated with these lower concentrations. Concentrations of 30% to 40% are considered medium depth
peels and will affect the papillary dermis.

Preparation
Patients with a history of herpes simplex should
be pretreated with acyclovir, 400 mg four times daily,
beginning 24 hours before the peel and continuing
after the peel for about a week. When possible, a
home care regimen of topical AHAs, retinoids,
bleaching agents, and sunscreen should be started at
least 2 weeks before the peel.

Steps of application
Cleansing
The skin should be well cleansed with make-up
remover, wiped with toner to remove remaining
debris, and then degreased with alcohol or acetone.

guide to chemical peels

233

other eyelid, the other cheek, and, finally, the perioral

area. After a few minutes, frosting should become
apparent, and one can assess where to apply additional TCA. For the eyelids, a single small cotton
tip applicator is used (Figs. 6 and 7A,B).

Fig. 6. Irregular frosting during a 20% TCA peel for

improvement of lower eyelid dyspigmentation and texture.
Vaseline limits the borders of the peel.

Care should be taken with these aromatic liquids in

the periocular area.
Patient preparation
Owing to the nature of this peel, a mild analgesic is recommended 30 minutes before the treatment.
The patient should wear loose fitting clothing, and
a headband should be used to keep the hair away
from the face. Tetracaine eye drops are applied, and
a petrolatum base lubricant is applied to the skin to
delineate the limit of the peel, avoiding dripping of
the solution down the neck, into the ear, or in other
unwanted areas. The patients head remains elevated
throughout the procedure.
Application
With a folded 4 by 4 gauze pad or three small
cotton-tipped applicators grasped in one hand, application is started on the forehead from the midline to
the side, the other side, down the nose, the eyelid
(2 mm below the lower lid margin), the cheek, the

Pearls about the application

 The skin should be stretched tightly to allow
the chemical to treat the depth of the wrinkle
and to prevent it from staying on the shoulders
of the rhytid.
 The applied coats of the peel should not be
overlapped. One should assess the completeness
of the frosting and the length of time for the
frost to appear before applying additional coats.
The more homogeneous the frosting, the more
rapidly the frost appears and the more profound
the depth of the peel.
 To avoid a demarcation line, the peel should
be extended into the hairline and beyond the
jawline. If one plans to use two coats of the
TCA solution on the face, one coat should
be applied 1 cm beyond the jaw for blending purposes.
 One should be consistent about the pressure
applied during the application of the peel. The
peels are very technique dependent.
 One should consider the preparation of the
skin. Patients who have been using retinoids
or who have been prepared with keratolytic
solutions should be observed carefully to
avoid overtreatment.

Depth of the peel

The degree of frosting of the skin reveals the
desired level of penetration of a TCA peel. Frosting

Fig. 7. (A) Photographs before and (B) 1 week after a laser-assisted lateral canthal plication and lower eyelid 20% TCA peel. A
significant improvement in lid level and contour is noted; mild erythema and hyperpigmentation are still evident. This
appearance cleared by the second postoperative week.

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denotes coagulation of protein. Clues to the depth of

penetration as determined by the level of frosting
are as follows (see Fig. 3B D):
No frosting or minimum frosting occurs in a very
superficial peel limited to the stratum corneum.
Minimum frosting in a scattered pattern with
mild erythema occurs in a superficial epidermal peel.
Mild frosting with erythema showing through
occurs in a full epidermal peel.
With total frosting (homogeneous), the peel
penetrates from the epidermis to the papillary
dermis. If the skin acquires a grayish appearance, the peel has penetrated the reticular
dermis and can lead to scarring.
To prevent complications or overcoating, the physician should observe the frosting time. The time
between the application of the peel and frosting is
about 40 to 90 seconds. One should wait until the
frosting is completely evident, denoting which level
or depth has been achieved, before applying another coat.

Time to change from frosting to erythema

How fast the skin changes from frosting to
erythema denotes the depth of the peel:
In a superficial peel to the basal layer of the
epidermis, the frosting fades in 15 minutes.
In a medium depth peel to the papillary dermis,
the frosting fades in 30 minutes.
In a deeper peel to the reticular dermis, the
frosting fades in 60 minutes.
The application of cold compresses immediately
following application of the TCA can reduce the
symptoms of burning and discomfort but will not
neutralize the peel. Moist compresses can dilute any
excess TCA that remains on the skin.

Postpeel care
Healing time depends on the depth of the peel. In
a superficial peel, the healing time is 1 to 2 days. A
gentle cleanser and bland moisturizer are required. A
normal skin care routine can be resumed in 4 to
5 days. A medium depth peel requires a longer
healing time. The skin will turn from light to dark
brown in 72 hours. It will start peeling off around
the mouth, eyes, and finally on the forehead. In 5 to

6 days, most of the crusting will have peeled off, and

a radiant glowing skin will be apparent. In the early
postpeel period, only bland moisturizers such as
Aquaphor, Vaseline, or CU3 copper peptide cream
should be used.
In the early postpeel period, sun avoidance, with
use of hats and sunglasses, is of paramount importance. After the first week, patients should begin to
use transparent zinc oxide sunscreens.

Complications and management of complications

Hyperpigmentation
Patients with skin types II, III, and IV should be
very aware of this transient complication (Fig. 8). It
can be ameliorated or prevented with extreme sun
avoidance. Once it occurs, the use of Retin-A with
bleaching agents (hydroquinone, kojic acid) is highly
recommended. Care should be taken not to overtreat
and create an additional inflammatory response with
secondary hyperpigmentation.

Hypopigmentation
The occurrence of hypopigmentation is proportional to the depth of the peel. Once destroyed by the
chemical agent, the melanocytes cannot recover.

Herpes simplex
Patients with a previous history are prophylatically treated with antiviral agents starting the day
before the peel and continued for 1 week. If there is
an active lesion on the face, the peel should not
be performed.

Scarring
Scarring is rare. It is secondary to the depth of
the peel or to infection or trauma. Patients who have
undergone treatment with Accutane within 1 year
before the peel are not good candidates for chemical
peels because re-epithelialization is compromised.
Patients who undergo chemical peels should be
carefully monitored. When early signs of infection,
such as persistent crusting and erythema that does not
resolve with mild cleansing, or hypertrophic healing
are observed, a more aggressive treatment regimen
with topical and systemic antibiotics and topical
steroids can be instituted.
Chemical peels are a minimally invasive modality of skin rejuvenation and an effective addition
to the arsenal of skin therapies. The learning curve is

guide to chemical peels

235

Fig. 8. TCA peel consent form. (From Bosniak S, Cantisano-Zilkha M. Minimally invasive techniques of oculo-facial
rejuvenation. New York; Thieme; 2005. p. 29; with permission.)

not steep, the cost is low, and patient satisfaction

is high.

References
[1] Cantisano-Zilkha M. Chemical peels. In: Bosniak S,
Zilkha M, editors. Minimally invasive techniques of
oculo-facial rejuvenation. New York7 Thieme Medical
Publishers; 2005. p. 22 9.

[2] Matarasso A. Nonoperative techniques for facial rejuvenation. Part I. Clin Plast Surg 2000;27(4):501 2.
[3] Pugliese P. Physiology of the skin II. Lancaster (PA)7
Allured Publishing; 2001. p. 300 2.
[4] Thomas J, James M, Baker TM. Facial skin resurfacing. Boston7 Quality Medical Publishing; 1998 [Chapters 4,5].
[5] Rubin MG. Manual of chemical peels: superficial and
medium depth. Philadelphia7 JB Lippincott; 1995
[Chapters 4,7,8].