Chemical Peels of the Eyelids and Face

From EyeWiki


Epidemiology/Incidence

Formally known as chemoexfoliation, chemical peeling is a procedure that enables targeted skin removal through application of caustic agents with subsequent wound healing, skin rejuvenation, and improvement in the clinical appearance of the skin1. Dating as far back as 1871, it was first described by British dermatologist William Fox who documented 20% phenol solution as capable of lightening the skin1. Now, in the United States, chemical peeling is the most common procedure for facial rejuvenation, with a 20% increase in its number from 2000 to 20182.


Types of Chemical Peels & Mechanism of Action for Intended Use

Currently, there are three classifications of chemical peels that are distinguished by the depth of the wound created by the peel: superficial chemical peeling, medium-depth chemical peeling, and deep chemical peeling. The depth of penetration by a chemical peel is dictated by the selected caustic agent, its concentration, and its pH, with the targeted anatomical location, skin integrity, and target skin thickness as additional elements to consider when applying the chemical peel3. For each of these peels, there are specific acidic agents whose concentrations are modified to appropriately target the desired skin layer.


Superficial chemical peeling

Through decreasing corneocyte adhesion and promoting dermal collagen, superficial chemical peels only penetrate the epidermis, and full epidermal regeneration can be expected within three to 5 days days.1,3 Example caustic agents include 10-30% salicylic acid, 20-70% glycolic acid, Jessner solution (14% salicyclic acid, 14% lactic acid, and 14% resorcinol in 95% ethanol), solid carbon dioxide slush, and <20% trichloroacetic acid (TCA).3,4

Superficial chemical peels are often utilized for treating mild photoaging, acne vulgaris, acne scarring, pigmentary disorders such as melasma, and post-inflammatory hyperpigmentation.3


Medium-depth chemical peeling

Medium-depth peels ablate to the upper reticular dermis. They precipitate proteins and cause coagulative necrosis of the epidermal cells, along with collagen necrosis of the papillary dermis and reticular dermis.5 The result is dermal edema, homogenization of the mid-reticular dermis with later re-epithelization.5 As expected, there is a longer healing process, up to one week, with required skin protection from the sun for several weeks.6,7 For these peels, TCA 35-50% is typically used and can be supplemented with 70% glycolic acid, Jessner solution, or solid carbon dioxide.3

Medium-depth chemical peeling is indicated for moderate photoaging, actinic keratoses, rhytides (commonly known as wrinkles), pigmentary disorders including moderate dyschromia (abnormal pigmentation), seborrheic keratosis, and superficial atrophic scars.3


Deep chemical peeling

Deep chemical peels reach the mid-reticular dermis, and they denature surface keratin and other proteins in the dermis layer, maximizing the regeneration of collagen.7 Despite epidermal regeneration beginning within 5 to 10 days, the healing time from a deep chemical peel can be two months or more.1,7 TCA with concentrations greater than 50% and Baker-Gordon formula (3 mL phenol, 2 mL water, 48.5% phenol and 2.2% croton oil) are the common agents of choice.3,8 Phenol peeling is another common solution used for deep peeling that can penetrate to the mid-reticular layer and maximize the production of collagen.7

Deep chemical peeling is used for severe photoaging, pigmentary disorders, and premalignant skin tumors.3


Chemical Peel Treatment for the Eyelid and the Periorbital Area

For the eyelid and periorbital area, from an aesthetic standpoint, this is usually the first part of the face to reflect the aging process, and treating crow’s feet and tear troughs are common requests among patients.9 Superficial peels can be effective for these areas if there is only mild sun damage and fine wrinkling in the periorbital area.10 Along with providing longer-lasting effect for treating mild sun damage and mild wrinkling, there are medium-depth periorbital peels that can tighten the anterior lamella for patients not yet seeking surgical interventions.9,10 For this form of eyelid rejuvenation, TCA 35% alone (or supplemented with other agents) can be used and repeated every 12 weeks if necessary for the desired clinical improvement.9 If warranted, deep chemical peeling for the eyelids can be done as part of a full-face peeling process, and Baker-Gordon formula has been a successful agent for this.8

General Procedure Steps

Dr. Soleymani and his colleagues outlined the following general steps as an ideal algorithm for the chemical peel procedure1: 1. Preparation of the Skin a. Gentle cleanser to remove any dirt, oil, or makeup, followed by further degreasing with either acetone or alcohol 2. Position the Patient 3. Application of the Chemical Peel a. Careful, uniform application of the caustic agent, with number of application layers being determined by the desired depth of keratocoagulation 4. Termination of Chemoexfoliation a. Neutralizing the agent with a dilute sodium bicarbonate solution or use of cool saline compresses, once the depth of chemoexfoliation is attained 5. Immediate Postoperative Care a. Continued application of cold compresses, along with generous application of sunscreen

On post-operative day 1, the patient should use a dilute acetic acid solution to cleanse the treated areas as antibacterial and antifungal prophylaxis, along with generous application of an unscented moisturizer.1 On post-operative day 2, a gentle cleanser can be used with subsequent application of the moisturizer.1 In the interim, the patient is also educated on use of hats and avoiding sun exposure as much as possible.1 Whether or not a patient has a follow-up appointment depends on the depth of the selected chemical peel treatment. For superficial peels, follow-up appointments are not usually needed, while deep chemical peels require a follow-up visit the very next day.11 Medium-depth chemical peels require follow-up but not as immediately as a deep chemical peel would.11


Side Effects, Complications, and Contraindications

Side effects of the chemical peel include itching, crusting, and erythema. Itching and crusting that is not well controlled and presents worse than anticipated should be evaluated for possible fungal, bacterial, or viral infection.12 Post-inflammatory hyperpigmentation, hypopigmentation, acne and milia are complications that arise in the first few weeks after the chemical peel is complete.12 While the chance of recovering pigment is small for hypopigmentation, hyperpigmentation can be addressed with lightening agents, and milia and acne can either be manually extracted or treated with antibiotics, respectively.12 Scarring can occur with a chemical peel and depending on the type of scarring, can be managed with either intralesional injections of Kenalog or 5-fluorouracil, laser treatment, or pulsed light therapy.12


Contraindications to chemical peels include active skin infection and allergy to any of the peel ingredients.9 Relative contraindications include smoking, regular indoor or outdoor tanning, history of post-inflammatory hyperpigmentation, history of poor wound healing or high-dose iatrogenic immunosuppression, active inflammatory dermatoses, and habitual excoriation.9 Specifically for phenol peels, absolute contraindications include a history of hypertrophic scarring or keloid formation, Fitzpatrick skin type VI, and recent surgical rhytidectomy.9 For phenol peels, a type of deep chemical peel, caution must be exercised in patients with a history of hepatic, cardiac, or renal disease, for phenol is directly toxic to myocardium and is known to impact hepatic and renal functioning.13 Our literature search revealed no solutions to avoiding hepatic and renal complications aside from avoiding use of phenol peels altogether. However, for cardiac complications, they can be avoided with slow, careful application of the peel with concurrent cardiac monitoring for any arrhythmias.13


Ocular Complications

Throughout the years, case reports involving chemical peels in the eyelid and periorbital region have documented lower eyelid cicatricial ectropion, corneal ulceration after periorbital application, and superficial punctate keratitis secondary to TCA coming into direct contact with the eye.14-17 To avoid ectropion, evaluate whether the patient has senile lid laxity, weak skin, or a history of transcutaneous blepharoplasty.14 If ectropion occurs, however, conservative management with massaging the lid skin, using artificial tears, and taping the lids at night is usually done with eventual self-resolution.14 Having a syringe filled with saline as part of the necessary procedural equipment, utilizing dry swabs to absorb tears that could expose the eye to the peeling agent, and application of petroleum jelly to the inner canthus of the eye are ways to protect the eye from caustic damage.18


Special Considerations: Fitzpatrick Skin Types and Ethnic Skin

By the year 2020, the Central Intelligence Agency in the United States predicted that, of the 1.5 billion people gained by the world at this point, 56% of them will be from Asia and 16% from Africa.9,19 With this in mind, it is important to consider how different extents of skin pigmentation can react with varying chemical peels. If patient populations with greater skin pigmentation are not evaluated properly before a chemical peel is applied, these skin types may be at risk of attaining possibly disfiguring dyschromias and abnormal scarring.9,19 For the purposes of discussing pigmentation, we will be referencing the Fitzpatrick skin type classification system, with a focus on Fitzpatrick skin types IV (light brown skin) to VI (dark brown or black skin).9,19 Some examples of superficial chemical peeling agents with a noted safety profile for Fitzpatrick skin types IV to VI include TCA 10-35%, glycolic acid solution 30-50%, and Jessner solution.20 Medium-depth peeling agents for these skin types include TCA 50%, 70% glycolic acid, and TCA 25% combined with 70% glycolic acid gel.20 Despite the skin phenotype upon presentation, it is still important to inquire about ethnic background because those with Middle Eastern heritage and lower Fitzpatrick skin types with lesser skin pigmentation may exhibit skin characteristics and reactions to chemical peels that are similar to higher Fitzpatrick-skin types.19 Thus, it is important to fully explain expectations to patients about chemical peel outcomes and clarify the impact their ethnic background can have on their skin’s reaction to particular chemical peels.


Conclusions

With this overview of the types of chemical peels, their application steps, and anticipated side effects, along with ocular complications and a call for awareness of ethnicity’s impact on peel outcomes, one should be more familiar with the options, relative contraindications, and indications for their utilization. With this knowledge, an ophthalmologist should be better equipped to counsel their patient about clinical expectations for their periorbital and eyelid improvement through chemical peeling, along with knowing how to treat ocular complications and coordinating care with dermatology.

References

1. Soleymani T, Lanoue J, Rahman Z. A Practical Approach to Chemical Peels: A Review of Fundamentals and Step-by-step Algorithmic Protocol for Treatment. J Clin Aesthet Dermatol. 2018;11(8):21-28.

2. Borelli C, Ursin F, Steger F. The rise of Chemical Peeling in 19th-century European Dermatology: emergence of agents, formulations and treatments. J Eur Acad Dermatol Venereol. 2020;34(9):1890-1899.

3. O'Connor AA, Lowe PM, Shumack S, Lim AC. Chemical peels: A review of current practice. Australas J Dermatol. 2018;59(3):171-181.

4. Pinto JMN, Delorenze LM, Vasques W, Issa MC. Jessner’s Peel. In: Issa MCA, Tamura B, eds. Chemical and Physical Peelings. Cham: Springer International Publishing; 2016:1-6.

5. Camacho FM. Medium-depth and deep chemical peels. Journal of Cosmetic Dermatology. 2005;4(2):117-128.

6. Lynch SA, Schwarz KA. Chapter 83 - Chemical Peeling and Dermabrasion. In: Weinzweig J, ed. Plastic Surgery Secrets Plus (Second Edition). Philadelphia: Mosby; 2010:549-553.

7. Rendon MI, Berson DS, Cohen JL, Roberts WE, Starker I, Wang B. Evidence and considerations in the application of chemical peels in skin disorders and aesthetic resurfacing. J Clin Aesthet Dermatol. 2010;3(7):32-43.

8. Stone P. Phenol Peeling. In: Rebecca C. Tung MGR, ed. Chemical Peels. 2nd ed. Philadelphia, PA: Elsevier/Saunders; 2011:71-72.

9. Reserva J, Champlain A, Soon SL, Tung R. Chemical Peels: Indications and Special Considerations for the Male Patient. Dermatol Surg. 2017;43 Suppl 2:S163-s173.

10. Periorbital Chemical Peels. Plastic Surgery Key Web site. https://plasticsurgerykey.com/periorbital-chemical-peels/. Published 2016. Accessed April 30 2022.

11. Chemical Peels: FAQs. American Academy of Dermatology. https://www.aad.org/public/cosmetic/younger-looking/chemical-peels-faqs. Accessed April 30, 2022.

12. Vanaman M FS, Carruthers J. Complications in the Cosmetic Dermatology Patient: A Review and Our Experience (Part 2). Dermatologic Surgery. 2016;42(1):12-20.

13. Myint SA EJ. Periorbital Chemical Peels. In: Nonsurgical Peri-Orbital Rejuvenation. New York, NY: Springer US; 2014:25-38.

14. Costa IMC, Damasceno PS, Costa MC, Gomes KGP. Review in peeling complications. J Cosmet Dermatol. 2017;16(3):319-326.

15. Fung JF, Sengelmann RD, Kenneally CZ. Chemical Injury to the Eye from Trichloroacetic Acid. Dermatologic Surgery. 2002;28(7):609-610.

16. Ozturk MB, Ozkaya O, Karahangil M, Cekic O, Oreroğlu AR, Akan IM. Ocular complication after trichloroacetic acid peeling: a case report. Aesthetic Plast Surg. 2013;37(1):56-59.

17. Wojno T, Tenzel RR. Lower eyelid ectropion following chemical face peeling. Ophthalmic Surg. 1984;15(7):596-597.

18. Anitha B. Prevention of complications in chemical peeling. J Cutan Aesthet Surg. 2010;3(3):186-188.

19. Salam A, Dadzie OE, Galadari H. Chemical peeling in ethnic skin: an update. Br J Dermatol. 2013;169 Suppl 3:82-90.

20. Roberts WE. Chemical peeling in ethnic/dark skin. Dermatol Ther. 2004;17(2):196-205.

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