Optimizing Chemical Peels in Aesthetic Practice

Chemical peeling is an effective and well-documented approach to skin resurfacing that has remained popular over several decades. In fact, chemical peels were among the first aesthetically-directed procedures to be widely adopted into modern dermatology practice. Recent developments in the formulation of peels have led to clinical endpoint-directed predictability and reductions in the risk profile of chemical peels.¹ Despite their versatility and the fact that they can be integrated into practice with minimal investment, peels are not as widely performed as neuromulators or fillers. Admittedly, injectables have different mechanisms of action and effects from peels, but in many cases, peels may be complementary to these procedures. Practices and patients may benefit from expanded use of peels.

Effects of Chemical Peels

Chemical peels can mediate cell turnover, epidermal thickening, skin lightening, and new collagen formation, and the specific effects depend on the depth of the peel. Deeper peels present greater risk for undesirable effects like dyspigmentation or hypertrophic or keloid scarring; the risk for these is enhanced in patients with Fitzpatrick skin types IV to VI. However, these patients may respond well to superficial and medium-depth chemical peels.²

Chemical peels rely—as their name suggests—on the use of acidic chemicals to induce cell turnover and resurface the skin. Several different agents can be used, including phenol, trichloroacetic acid (TCA), salicylic acid, resorcinol, and alpha hydroxy acids, alone or in combination. These acids peel to differing depths; some are self-limiting in terms of duration of action on the skin. Acids used for skin peeling are available to physicians generically, however, several brands have developed specific formulations with features intended to enhance safety and convenience.

Chemical peels are a great way to deeply renew and rejuvenate the skin. Chemical peels can be used for general improvement in signs of photodamage, including skin texture and wrinkling and mild pigmentary irregularities or “sunspots.” Medically directed peels are a great option for several specific indications. When properly matched to the patient’s needs and skin type, peels may be used to address melasma, post-inflammatory hyperpigmentation, acne, and pre-cancerous actinic keratosis.

Because light, medium, and deep peels have very different treatment purposes and recovery times, it is important that those performing the peel adhere to the highest standards of care with patience and caution to achieve best results. Patients should be counseled that in many cases best results can be achieved with a series of peels provided at intervals. In some instances, a series of light peels may provide similar effects to a single deeper peel but with reduced risk of unwanted effects.

Supportive skincare

Supportive prescription and/or cosmeceutical skincare can be used to prepare the skin in the weeks before a peel and to optimize healing and maintain results post-procedure. Ideally, the physician will create a regimen based on the specific peel to be used. Generally, the products recommended for pre- and post-peel care will vary depending on patient skin type and the intended results of treatment. It may be necessary to avoid certain products just before and the first few days after a peel.

Pre-procedure. For many patients, peels are intended to target fine lines, brown spots, and skin texture concerns. For these patients, I generally recommend prescription agents, including a four-to-six-week course of hydroquinone and a retinoic acid. Retinoic acid is discontinued one week prior to the chemical peel for optimal results.

Patients with acne, hyperpigmentation, or other medical concerns typically use a topical prescription and skincare regimen targeted to their disease.

Post-procedure. Because chemical peels increase skin sensitivity to sunlight, I generally recommend these treatments in the early fall and winter months, when patients typically have less exposure to the sun. Nonetheless, sunscreen is essential post-peel. The other key product for use post-peel is an optimal moisturizer. Aside from these two products—a sunscreen and a moisturizer—patients should use no other leave-on skincare products for approximately two weeks after undergoing a peel. It makes good sense to recommend sunscreen use in the pre-peel period (and really all year-round) so that patients are in the habit post-peel. Skin cleansing can be accomplished with a gentle, hydrating cleanser.

Sunscreens for post-peel use should be effective and gentle to avoid irritating exfoliated skin. Generally, inert physical blockers are preferred for reduced risk of skin reactivity. I frequently recommend EltaMD and SkinCeuticals sunscreens to my patients based on their preferences for formulation type (lotion, cream, etc.). In addition to using sunscreen, patients should avoid sun exposure for the first two weeks after a peel.

Ointments can be a great option following a chemical peel. Ointments are thicker than lotion or cream and are multi-purpose; they protect and soothe the skin when it is extremely dry. (Ointments are a go-to for chapped lips, cracked skin on the hands and feet, and many other types of skin irritations, too.) Ointments tend to have fewer ingredients relative to lotions or creams, and are therefore sting-free—a plus for sensitive post-peel skin.

Peels in Combination with Other Procedures

Peels are great to use as a comprehensive approach to skin health. For patients with acne, salicylic acid peels are great during acne treatment to help address active acne and associated post-inflammatory hyperpigmentation. Some patients will present for peels at set intervals—several months or annual—to maintain results. In terms of primarily aesthetic indications, I am very much an advocate of customized combination therapies. Peels are quite effective when performed by board-certified core aesthetic specialists who know the depth and the specific solution to use to optimize results. Peels also can be used safely in patients undergoing injectables and other aesthetic treatments. Aesthetic injectables generally do not exert significant effects on skin texture and do not address pigmentation. Therefore, peels can be a great adjunctive treatment to fillers and neurotoxin treatments to address more superficial skin concerns. In terms of the decision whether to use peels or energy-based interventions for resurfacing, the physician and patient should weigh multiple factors.

Both chemical peels and laser treatments are used for resurfacing, and each has unique advantages. Skin resurfacing procedures work predominantly on the top layer of the skin so that the healthy skin underneath can be shown. The top-most layer of skin is most susceptible to photodamage and barrier function issues.

Laser resurfacing uses energy to penetrate the skin to exert its effects. Chemical peels can have similar resurfacing power compared to lasers, depending on the strength of the solution used. Peels may require several sessions, again depending on what is being treated.

Versatility and Efficacy

Perhaps taken for granted by physicians and patients alike, chemical peels are a versatile tool for skin resurfacing with a track record of safety and efficacy. Peels can be used alongside popular aesthetic interventions like injectable neuromodulators and fillers. They may be an alternative to energy-based procedures for certain patients. They also provide efficacy for a number of medical concerns—many of which are associated with aesthetic concerns for patients.

1. Pathak A, Mohan R, Rohrich RJ. Chemical Peels: Role of Chemical Peels in Facial Rejuvenation Today. Plast Reconstr Surg. 2020 Jan;145(1):58e-66e.

2. Jackson A. Chemical peels. Facial Plast Surg. 2014 Feb;30(1):26-34.