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DONALD J. CAPUANO, M.D.
Plastic Surgeon

HISTORY
A "chemical peel" is a procedure during which chemicals are put on the skin, causing it to "peel" in many cases. The application of chemicals actually produces a burn of the skin.

Chemical "peels" are not new. The ancient peoples of Egypt described a method of treating the skin with ground rocks and chemicals; therefore, we know that chemical treatments have been around for at least four thousand years.

Chemical peels were used by cosmeticians in the early 1900's. The Gypsies of Europe used peeling agents, and German dermatologists brought the formulas to the States. During the 1960's, Drs. Baker and Gordon in Miami and Dr. Linton in Washington did studies to establish the effects and safety of the "phenol" peel.

Over the past few decades, other methods of "chemical peels" have been developed. In today's day and age, peeling agents are available that have fewer potential side effects than the "phenol" peel. Today there is an increasing number of peeling agents that are safer and give a result which is in many cases as good as or better than the potentially toxic chemicals used in the past. Many chemical peels are done using chemicals normally found in the human body.

Since people who are getting older are the ones seeking improvement by a chemical peel, the use of less toxic chemicals is certainly a welcome situation.

SKIN CHANGES
Improvement after a chemical peel takes the form of a tightening and smoothing of the skin. Studies of treated skin have shown that the peel affects the fibers within the skin. Treatment by peeling tightens the elastic fibers of the skin which were like a bunch of dropped pickup sticks. These elastic fibers become aligned into a pattern, causing a general tightening of the skin.

This tightening changes the way the skin looks. It looks better when it is examined under the microscope. The realignment of the skin fibers gives the skin the appearance of that found in younger people.

After a peel there is a thickening of the "dermal" layer of the skin. This is the layer that usually thins with age and/or severe sun damage. This is the layer that is mainly responsible for wrinkling.

Generally, the degree of change in the skin depends on the chemicals used, the concentration, additives, the type of skin, the process of healing, the depth of the peel, etc.

Depending upon the type of peel and the patient and doctor's preference along with the extent, the peel may be performed under sedation in the hospital outpatient department, in the office using no anesthesia, or rarely under general anesthesia.

You can get an idea of what a 'peel' is like if you compare it to a severe sunburn or a steam burn. As you know, the skin at first is swollen and red. Crusts may form. Blisters may be present. The scab makes the skin look dark. The outer dark layer 'peels' off revealing the underlying skin. The skin is usually red and this redness may last for weeks and even months to some degree. Some patients have reported the area to darken, but this is temporary. You should be aware that in the few days after the procedure this may be noted.

Rarely the skin will remain red. Such cases have been associated with the drug ACCUTANE. This drug is used for acne therapy. If you have taken Accutane and are interested in a chemical peel, YOU MUST MAKE US AWARE OF THIS FACT.

As in severe sunburns or steam burns, blisters can result. Fluid may drain and crusting can occur. It is not unusual to have a minor infection in the crusts. Deep or extensive infections are rare.

The use of antibiotics, the application of compresses, and personal care of the skin minimize the chances of severe infection.

AFTER CARE
On the evening of the day of the peel, and depending on the areas and the type of the peel, you will be asked to begin showering or using compresses 6 to 8 times a day, and to apply certain creams and ointments. The face should be kept moist at all times. Once the crusts separate and healed skin is present, moisturizing creams or ointments such as Vaseline or A&D cream or ointment should be applied to healed areas.

Compresses may be needed if infection begins. A compress is a wet piece of gauze that is put on the areas of crusting and/or infection. Water is boiled, cooled, and stored in a clean container in the refrigerator. This can be warmed as needed. (A microwave is quite convenient for this.) The gauze is moistened and put on the crusts. The gauze may be remoistened if it dries out.

Antibiotics may be prescribed in some cases.

HEALING AND CHANGES
A change in skin color is seen. The outer layer of skin is shed similar to the "peeling" from a sunburn. There may be a lightening of the skin. With deep chemical peels, very light skin can result. If for example, the lip alone is treated, the area can be lighter in color than the surrounding skin. On the other hand, light skin may turn darker. Blotchy skin usually smooths out to some degree. Over time, the color of the skin usually evens out. Remember that skin color on different portions of the face and are not even to begin with.

After healing, you should be prepared to use cosmetics and makeup if the color difference is very noticeable. Medications, including steroids (Kenalog or Hydrocortisone), bleaching agents (such as Hydroquinones), or tape containing medications also may have to be applied for several weeks in some cases. Over a few months the difference in color can blend back in, resulting in a more normal appearance. However, with deep peels, such as the phenol peel, permanent lightening can occur and is common. With the TCA peel used in our practice, the chances of permanent significant lightening is quite low.

As you know after a bad sunburn you don't go into the sun again until the skin is healed and is not tender or red. After a chemical peel, direct sun should be avoided until the skin is well healed. The use of sun blocks with at least a 45 factor is recommended thereafter. We recommend sun screen for everyone, regardless of whether or not you undergo a chemical peel.

Wind burns, such as those incurred while skiing, should be avoided.

If you have taken the drug Accutane for acne treatment in the past, you should be aware that your skin may be prone to thickened scars following a chemical peel. You must inform the Doctor if you have ever been treated with Accutane. Even without having taken Accutane, thick scars could occur.

There is no sure way of predicting who will develop thick scars. Individuals with American Indian, African, or Asian blood seem to have an increased chance of developing such scars. They have, however, occurred in all peoples. Please notify the doctor if you or members of your family have developed thick scars. Please show the doctor scars that may concern you.

Other factors influence healing. Smoking is a significant deterrent to good healing. Those who smoke would have to accept the increased possibility of infection, thickened scars, etc.

<<** If you have a history of "COLD SORES" (herpes labialis), you should inform the doctor before the peel.**> > Treatment with Zovirax (a medicine that controls herpes) may be needed.

Other conditions such as diabetes, light sensitivities, and diseases such as scleroderma can cause unexpected consequences. If you have any skin problems or diseases, let us know.

Because of the many factors that influence the final result, there is no sure way of determining the exact outcome of a chemical peel. Results do differ.

Other factors affecting results include the type of peeling agent, the pre-treatment condition of the skin, the thickness of the skin, the depth of wrinkling, the health of the skin, the presence of oils in the skin, and the "turn over" rate of the skin. Diabetes, medications, smoking, ethnic background, environment, etc., also can affect the results.

Severe problems, while rare, can occur. Thick scars which cannot be improved and deep infections have been reported, but have not been seen by Dr. Capuano. Great caution is used in treating the eyelids.

If there is a major question as to how your skin might react to a peel, a test area could be done in an area hidden by hair. Color changes that result from the treatment can be watched. The way your skin heals can be observed. Anesthetic risks are a possibility but no severe problems have been encountered.

SUMMARY
Improvement in the texture of the skin can be anticipated after a chemical peel. Unfortunately no guarantee, promises or assurances can be given you as to the results.

Chemical peels are at one time simple but complex. We expect that you might have questions, and we strongly encourage you to ask them.

 

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