Accepted: 1 February 2017

DOI: 10.1111/jocd.12329

REVIEW ARTICLE

Review in peeling complications

Izelda Maria Carvalho Costa MD, PhD | Patrick Silva Damasceno MD |

Mariana Carvalho Costa MD | Keila Gabrielle Pati Gomes MD

Department of Dermatology, HUB,

University of Brasilia, Brasilia, Brazil Summary
Chemical peeling, a procedure wherein a chemical agent is applied to the skin to
Correspondence
Patrick Silva Damasceno, Department of cause controlled destruction followed by regeneration and remodeling, is a dynamic
Dermatology, HUB, University of Brasilia, tool for the treatment of acne, pigmentation issues, and photoaging [Journal of
Brasilia, Brazil.
Email: Patrickdamasceno@gmail.com cutaneous and aesthetic surgery vol. 5 (2012) 254–260]. The results and complica-
tions are related to the depth of the procedure, with deeper peels producing more
marked results and higher rates of complications. Complications are more likely with
darker skin types, certain peeling agents, and sun exposure after treatment [Journal
of cutaneous and aesthetic surgery vol. 5 (2012) 254–260]. They can range from
minor irritations and uneven pigmentation to permanent scarring. In extremely
uncommon cases, the complications can be life-threatening. This knowledge is
essential to prevent, reduce, and eliminate the occurrence of complications [Cirurgia

gica em consulto
dermatolo
rio. S~
ao Paulo: Atheneu; 2009]. Swelling, pain, persistent
erythema, pruritus, allergic reactions, folliculitis/acne, infection, herpes recurrence,
hypopigmentation and hyperpigmentation, demarcation lines, and scarring are some
of the complications that will be discussed in this article. The first step in preventing
complications is to identify the patients at risk. By doing so, complications can be
anticipated, prevented, and, if they still occur, treated as early as possible.

KEYWORDS
chemical peel, complications, erythema, peels, pigmentation, scar

1 | INTRODUCTION pigmentary disorders. Deep peels, affecting the reticular dermis, may
be used for severe photoaging, deep wrinkles, or scars.4 A peeling pro-
Chemical peeling is a procedure wherein a chemical agent of a cedure will take into account the depth of the targeted structure and
defined strength is applied to the skin, which causes a controlled the skin condition of the patient to carefully select among the vari-
destruction of the skin layers followed by regeneration and ables such as chemical class of the peeling agent, concentration, fre-
remodeling, with improvement of texture and surface abnormalities.1 quency, and pressure of the application.5 The results and level of
Over the past 40 years, it has become established as an effective complication of the peel are related to the depth of the injury.
outpatient method for skin rejuvenation as well as a treatment for a Although the best results are obtained with deep-depth peels, the use
variety of skin conditions.2 Chemical peels are classified as superfi- of a medium-depth peel provides excellent results without the danger-
cial, medium, and deep according to the depth of the peeling solu- ous side effects of deep peels.6 Prior to introducing peels as a routine
3
tion penetration. Superficial peels, which penetrate only the procedure in your practice, it is important to understand that, like all
epidermis, can be used to enhance treatment for a variety of condi- medical procedures, chemical peeling has many potential side effects.
tions, including acne, melasma, dyschromias, and photodamage. Med- Complications of chemical resurfacing may occur even when a
ium-depth peels, penetrating to the papillary dermis, may be used controlled chemical wound has been induced. The physician must be
for dyschromia, multiple solar keratoses, superficial scars, and entirely familiar with the types of peels and the management of

J Cosmet Dermatol. 2017;1–8. wileyonlinelibrary.com/journal/jocd © 2017 Wiley Periodicals, Inc. | 1

2 | COSTA ET AL.

postoperative wound care based on the skin type of the patient.7 days to resolve.12 Typically, the edema is fairly mild, but it can be
Complications are more likely with darker skin types, certain peeling large enough to cause the eyes to shut. With the knowledge that
agents, and sun exposure after the procedure.8 They can range from this can happen, advising the patient can help alleviate his/her con-
minor irritations and uneven pigmentation to permanent scarring. In cerns if this occurs. Ice, antihistamines (loratadine 10 mg, hydrox-
extremely uncommon cases, complications can be life-threatening. yzine 25 mg, diphenhydramine 25-75 mg at night), and proper
This knowledge is essential to prevent, reduce, and eliminate the wound care are ways to avoid severe swelling.12 Systemic steroids,
occurrence of complications. Neither the physician nor the patient such as prednisone or methylprednisolone, should be used in
should be surprised by an unpleasant outcome. patients who develop severe edema, but some physicians choose to
The first step in preventing complications is to identify patients at use it preventively, which can lead to poor healing.12
risk, so that complications can be anticipated and prevented, and if
they still happen, treated as early as possible. These patients include
2.2 | Pain and Burning
those with darker skin types with a tendency to develop postinflam-
matory hyperpigmentation; with sensitive skin or history of atopic der- Pain is an expected and very ordinary outcome of medium-depth
matitis; with dry skin and a reddish hue; with outdoor occupations; and deep peels. The intensity of pain varies from patient to patient,
with a history of photosensitivity or postinflammatory hyperpigmenta- and it can vary from low to very high intensity. In medium-depth
tion; on photosensitizing drugs; with a history of keloids, with poor peels, the pain lasts for only a few minutes after the application of
wound healing or herpes infection; who have recently received isotre- the product, and it is rarely necessary to prescribe pain medication
tinoin; with unrealistic expectations; those who are uncooperative and to patients.12 During the procedure, 2.5% lidocaine+2.5% prilocaine
1
difficult; and those who are psychologically disturbed. Selecting the or 4% lidocaine can be used to reduce the pain without affecting
appropriate technique relies on a critical analysis of the skin defect bal- the peel penetration.12 Deep peels usually generate more pain, and
anced against the risks of treatment. The final protocol should be indi- it tends to increase hours after the procedure, lasting a maximum of
vidualized to the needs of each patient.9 Although complications can 8-12 hours.12 Prolonged sun exposure, deficient applications of sun-
occur, the procedure is still valuable for certain skin conditions that screen, or using topical retinoid or glycolic acid immediately after
cannot be managed successfully by standard surgical procedures.10 peels can prompt this complication.8 Uncommonly, in a few patients,
To avoid unpleasant situations in the future, a detailed, signed con- sunscreens have caused contact sensitization or irritant dermatitis.13
sent form should be obtained from every patient, and prepeel photog- Pain and burning is typically experienced during a peel procedure in
raphy under proper lighting is advised in all cases.1 Additionally, it is sensitive skin.
always advisable to instruct the patient not to schedule an important Immediate ice application reduces pain and burning sensa-
11
event or vacation for at least 5 days after a superficial peel , 20 days tions.8 When applying deep peels, the use of potent analgesics
after a medium-depth peel and 30 days after a deep-depth peel. may be necessary. Additionally, topical calamine lotion can be
The most noteworthy complications are displayed in Table 1 used to sooth the skin. Topical steroids such as hydrocortisone or
below. fluticasone are used to reduce inflammation; emollients moisturize
the skin; and sunscreens can help prevent postinflammatory
hyperpigmentation.8
2 | COMPLICATIONS IN PEELS OF ALL
TYPES
2.3 | Persistent erythema
2.1 | Swelling
Erythema is common after all types of peels, but persistent erythema
All of the agents used in peels can possibly cause swelling, although results from angiogenic factors stimulating vasodilation, which indi-
it occurs more often in deeper peels. Edema is expected and appears cates that the phase of fibroplasia is being stimulated for a pro-
between 24 to 72 hours after a procedure, and it may take several longed period of time. Consequently, it can lead to skin thickening
and scarring.8
T A B L E 1 Common complications in all peel types
Medium and deeper peels lead to more prominent and long-last-
Swelling Herpes recurrence ing erythema. Erythema usually vanishes in 3-5 days in superficial
Pain and burning Ecchymosis peels, 15-30 days in medium peels, and 60-90 days in deep peels.14
Persistent erythema Hypopigmentation If it continues after the time expected, it should be evaluated since
Pruritus Hyperpigmentation there is a possibility of scar formation.
Ocular injuries Telangiectasia Some known causes of persistent erythema are the use of topi-

Allergic reactions Skin textural changes cal tretinoin immediately before and after the procedure, oral isotre-
tinoin administration preceding the peel, alcoholic beverage
Blistering Milia
consumption,15 contact dermatitis, contact sensitization, and some
Folliculitis/Acne Demarcation lines
preexisting skin conditions (rosacea, atopic dermatitis, lupus
Infection Scarring
erythematosus).
COSTA ET AL. | 3

As soon as it is diagnosed, long-lasting erythema must be treated

2.6 | Allergic reactions
with potent topical steroids for 1-2 weeks, hats and sunscreens and
continued emollients.12 Occasionally, cosmetic camouflage can be Allergic contact dermatitis is more common with resorcinol, salicylic
used to minimize erythema during treatment. Intralesional, oral, or acid, kojic acid, and lactic acid.8 Any peel can cause irritant dermati-
intramuscular steroids can be used in cases with no response. Persis- tis, especially when used with high frequency, inappropriately high
tent erythema responds well to intense pulsed light or pulsed dye concentrations or in cases of vigorous skin preparation using acetone
laser devices.12 or other degreasing solutions.
Setting expectations before a procedure is essential, as patients The allergic reaction typically caused by resorcinol is an urticar-
will appreciate being aware of what to expect in the postpeel period ial-type eruption. Agents such as trichloroacetic acid (TCA) or gly-
(Figure 1).16 colic acid have no reports of true allergic reactions, but the TCA can
cause cholinergic urticaria.12 If an allergic reaction occurs, it can be
resolved with the use of antihistamines. The challenge is to differen-
2.4 | Pruritus
tiate an allergic reaction from erythema and swelling expected from
Pruritus occurs due to reepithelialization and typically begins in the the peel, but if the patient has a history of an allergic reaction to
first two weeks after treatment and continues for approximately one any peeling agent, he/she should be given antihistamines
month. It is more common after medium and deep chemical peels. If prophylactically.
it occurs with increased erythema or pustules, beware of a possible
contact allergy to the cream used in wound care.12 Some patients
2.7 | Blistering
can be very bothered by the pruritus and should be given oral anti-
histamines and topical hydrocortisone creams. To avoid atrophy or Blistering typically occurs in younger patients with loose periorbital
telangiectasia, fluorinated steroids must be used with care. skin and around the eyes. Deeper peels, particularly using alpha-
hydroxy acids, can cause epidermolysis, vesiculation, and blistering,
especially in delicate areas, such as the nasolabial fold and perioral
2.5 | Ocular injuries
range. Trichloroacetic acid 50% and glycolic acid 70% can cause blis-
Inadvertent spillage of any chemical peel agent in the eyes can lead tering. To prevent this complication, the nasolabial folds, internal
to corneal harm, so it is important for the physician to be very care- canthus of the eye, and corners of the mouth should be protected
ful when peeling around the eye. One way to avoid this is to pre- with petroleum jelly.8
pare a cotton-tipped applicator to immediately remove tears near
the lashes and a syringe filled with saline in case of an accident with
2.8 | Folliculitis and acne
the acid solution inside the eyes.12
If an inadvertent spillage occurs, the eyes should be rinsed with In susceptible patients, chemical peels can lead to an outbreak of fol-
saline to minimize corneal harm. If a phenol peel is being utilized, liculitis or acne. Soon after a peel, mostly due to emollient creams
8
flushing should be performed with mineral oil rather than saline. An used in this period, numerous erythematous tender papules can
ophthalmologist should be consulted in these cases. appear, and the treatment is not easy since most topical acne agents
Cases of cicatricial ectropion have been reported in phenol- are irritating to recovering skin. Oral antibiotics (tetracycline 500 mg
peeled patients, and lower eyelid ectropion has reportedly occurred bid/minocycline 100 mg bid) can be used in these cases, and the
in patients undergoing a deep eyelid peel in conjunction with a ble- eruptions usually vanish within a week.12
17
pharoplasty. The predisposing characteristics for these conditions
are older patients with senile lid laxity, patients who have experi- 2.9 | Infection
enced previous transcutaneous blepharoplasty, and patients with
2.9.1 | Bacterial
weak skin.8 In most cases, this complication is self-limited and does
not need specific treatment, just conservative care (massaging of The occurrence of infection after chemical peels is unusual since the
lower lid skin, adequate taping of the eyelid especially at night and agents used in the procedure are bactericidal, but predisposing fac-
protection of the globe with artificial tears).18 tors for infection are prolonged application of thick occlusive

F I G U R E 1 Evolution of persistent
erythema. Before, 2 months after, and
6 months after periocular deep-depth peel
(phenol)
4 | COSTA ET AL.

ointments, poor wound care, or even the patient’s fear of taking care
2.10 | Herpes recurrence
of his/her wounds, causing the accumulation of necrotic debris and
leading to secondary impetiginization. These factors can contribute A herpes recurrence can occur after the trauma induced by a chemi-
to the growth of microorganisms such as Streptococcus, Staphylococ- cal peel, so the patient must be screened for a history of herpes sim-
cus, or Pseudomonas.8,12,16 The clinical features of infections are plex outbreaks. The onset of herpes eruptions may vary in duration
postponed wound healing, folliculitis, ulceration, and crusting (Fig- from 5 to 12 days after the procedure.21 Since there is not a fully
ure 2). formed epidermis due to the peel, the herpes lesions are not vesicu-
To reduce the risk of infection, patients must be instructed to lar, but they appear as exulcerations and often ulcerations, 2 to
clear the crusted or necrotic skin using a compress of 0.5% acetic 3 mm in size, round shaped, isolated or in areas with extensive con-
acid soak three times a day until the crust disappears or using intra- fluent erythema on the base. The treatment is acyclovir (400 mg 4-
nasal topical antibiotic ointments if the patient is susceptible.12 If an 59/day) or valacyclovir (500 mg 39/day).12 The prophylactic treat-
infection occurs in the postpeel period, it must be monitored closely ment is oral acyclovir (200-400 mg 39/day) or valacyclovir (500 mg
because of the risk of scarring, and the appropriate treatment with 29/day) starting 2-3 days before the procedure and ending 14 days
broad-spectrum antibiotics must be applied. Additionally, bacterial after it.8,12 The treatment aim is to prevent scarring, although herpes
cultures and gram stains should be performed before initiating the infections usually resolve without scarring.12,21 Lasting lesions should
treatment to help select the appropriate antibiotics. be cultured and treated with broad-spectrum antibiotics since it is
If patients develop a fever, syncopal hypotension, vomiting, or difficult to distinguish impetigo and herpetic infection during the
diarrhea 2-3 days after a peel followed by scarlatiniform rash and healing period of a peel.
desquamation, a physician should be alerted to screen for toxic The most common infectious complications are listed in Table 2.
shock syndrome. Other symptoms of toxic shock syndrome could
include myalgia, mucosal hyperemia, and hepatorenal, hematological
2.11 | Ecchymosis
or central nervous system involvement. Large volumes of parenteral
fluid with beta-lactamase-resistant antibiotics should be given to Ecchymosis typically occurs in the infraorbital area of some patients
prevent vascular collapse.19,20 as a rare complication of chemical peels. It is strongly associated
with severe edema after peels, with cutaneous atrophy or with acti-
nic damage.12 It resolves spontaneously, and the most effective pre-
2.9.2 | Candidal
vention is to treat the swelling before ecchymosis appears. It is
Candida infections can occur and are very difficult to distinguish recommended that at-risk patients be informed of the possibility of
because the skin is eroded. Superficial pustules often occur in candi- this complication.
dal diseases.8
Predisposing factors for candida infections include recent intake
2.12 | Hypopigmentation
of oral antibiotics, immunocompromised state or diabetes, and pro-
longed topical steroid use. It is important to remember that candidal A slight hypopigmentation is expected after a peel since the agents
infections are typically not observed in phenol peeling.12 used in the procedure cause exfoliation. It is usually noticed in the
Treatment can be managed with topical clotrimazole 1% or sys- jaw-neck region where untreated skin on the neck appears different
temic antifungals (fluconazole 50 mg/day). from the newly rejuvenated skin from the face. As the cells are
removed, the amount of melanin in the epidermis will decrease. In epi-
dermal peels, hypopigmentation is expected but temporarily.12 If the
entire epidermis is removed, melanocytes are also removed, and it
takes time for new melanocytes to migrate into the new epidermis.
Permanent hypopigmentation, however, is a feared complication of
the procedure, occurring more often in dark-skinned patients.12 It
occurs more frequently when there is an uneven penetration of the
peel and appears in a haphazard distribution that is fairly noticeable.

T A B L E 2 Infectious complications
Bacterial Viral Mycotic
Staphylococcus Herpes simplex Candidiasis
Streptococcus
F I G U R E 2 Bacterial infection after medium-depth peel Pseudomonas
(Jessner+TCA 35%). The patient was treated with cephalexin for
Toxic shock syndrome
1 week. The second image shows the result 1 week posttreatment
COSTA ET AL. | 5

Additionally, infection and scarring can cause hypopigmentation,

which can be very evident in patients with type III or darker skin tones.
A porcelain appearance, also known as an “alabaster statue” look, can
only be observed after erythema fades and is characteristic of phenol
peels because of the direct melanotoxic effect of phenol.12

2.13 | Hyperpigmentation
Hyperpigmentation can occur any time after a peel, but it usually
occurs between four days and two months after a procedure.21 It is
the most common complication of trichloroacetic acid peeling, and it
can persist if treated inadequately (Figure 3). It is also important to
determine the level of pigmentation using a Wood lamp examination.
In superficial peels, complications are usually transient hyperpigmen- F I G U R E 3 Hyperchromic stains and spots 15 days after medium-
tation or dyschromia, particularly in dark-skinned patients.21 Tempo- depth peel application (Jessner+TCA 35%)

rary highlighting of lentigines and nevi might occur since the existing
sun damage near these lesions has been cleared. Warning patients of this possibility prevents surprise, and if they
Factors leading to a high risk of hyperpigmentation include skin become disconcerted about it, intense pulsed light, electrosurgery or
types III-VI, skin types I and II following intense sun exposure and vascular lasers can be used to clear the telangiectasia.12
tanning, use of photosensitizing agents, early exposure to sunlight Patients with prior telangiectasias may notice worsening after
without adequate broad-spectrum sunscreens and use of estrogen- phenol peeling.21
containing medication, such as oral contraceptives and hormone
replacement therapy.8 In patients with a history of hyperpigmenta-
2.15 | Skin textural changes
tion from other skin lesions, there is a greater risk of developing
postinflammatory hyperpigmentation, and a test spot area must be Because of the removal of stratum corneum, the temporary appear-
performed prior to full-face procedures in these individuals. ance of enlarged pores can occur after the procedure.
Patients who become pregnant within 6 months after a peel also Cosmetic products such as oils and other agents should be com-
have increased risk of hyperpigmentation, even when sun avoidance is pletely removed before the procedure because they can limit the
practiced. Pregnant women with darker skin may be treated to avoid peel’s penetration and lead to variations in peel depth, leading to
postinflammatory hyperpigmentation for up to 1 year postoperatively.12 poor results that can present as visible textural changes in the skin.
Hydroquinone 4%-6% is the most used treatment for hyperpig- Additionally, skin textural changes can be due to inappropriate tech-
mentation, and it can be associated with tretinoin to increase bleach- nique or a patient’s response to the peeling agent. Patients should
12
ing effects when the skin is healed. If the patient is allergic to be instructed not to apply oily products for days following the pro-
hydroquinone, other options for treatment are vitamin C, kojic acid, cedure. The physician must apply the peel agent equally on the skin
and azelaic acid. In some cases, a superficial peel (glycolic acid, 30%- to prevent deeper penetrations in some areas. If a deeper penetra-
40%) is used to expedite the result. If preexisting hyperpigmentation tion occurs, microdermabrasion or repeeling of the affected areas
exists, adequate priming of the skin for at least 2-4 weeks prior to may help solve the problem.12
the peel and discontinuing the priming 3-5 days before the proce-
dure is of vital importance.12,16 Priming is performed by applying a
2.16 | Milia
depigmentation agent such as hydroquinone or retinoic acid.
For long-lasting results, a good skin care regimen is necessary Potential resulting milia after reepithelialization occurs one to three
since studies have shown that peeled skin returns to its baseline sta- months after the procedure.21 Milia, inclusion cysts that appear as a
tus within 2-6 months without maintenance therapy. The patient part of the healing process, have been reported in up to 20% of
should use broad-spectrum (ultraviolet A and B) sunscreens before patients after chemical peels16 and typically emerge during the first
and indefinitely after the peels and practice strict sun avoidance. few weeks of the recovery period. They can also be caused by post-
The cessation of birth control pills during the peri-peel period is peel care of deeper peeling because of occlusion of the upper pilose-
important to avoid pigmentary changes. baceous units with ointment.8
The use of retinoic acids before and after a procedure can
reduce the appearance of milia.12 Because it complicates wound
2.14 | Telangiectasia
healing and can cause irritation, the acid should only be used after
Superficial telangiectasia can be effectively managed with chemical erythema has decreased. Milia generally regresses spontaneously and
peels, but most of them become deeper and more noticeable after a should only be treated if the patient requests it. Inclusion cysts
peel since it removes circumjacent actinic changes and pigmentation. should be extracted by needle or lancet or electrodessication.
6 | COSTA ET AL.

excessive actinic damage or is undergoing a deep peel into the retic-

2.17 | Demarcation lines
ular dermis. The skin of the neck, dorsal hands, and chest cannot
Demarcation lines are transition areas with pigmentary changes undergo peeling without a risk of scarring because these areas do
where peeled and unpeeled skin meet, and they most commonly not have enough follicular structures.12 Physicians must be careful to
occur below the mandible, near the eyes and periorally. They are not not repeel an area that has been peeled recently and has not had
a complication in themselves; they merely show the difference adequate time to heal.
between the treated and untreated skin. However, they are not aes- The use of isotretinoin is linked to delayed wound healing and
21
thetically pleasing when very evident. To avoid these lines when greater incidence of scarring. A patient using this treatment should
performing medium and deep peels, especially in darker skins, a peel- wait at least 6 months to undergo a medium or deep chemical peel.12
ing agent with lower concentration should be feathered at the edges Other predisposing factors for scarring are history of smoking,
to merge with the surrounding normal skin.8 The doctor should also recent facial surgery, recent ablative resurfacing procedures (includ-
be careful to avoid application irregularities. ing dermabrasion or laser within 6 months of the procedure),22 mul-
For a smooth result around the eyes, peels must be performed tiple applications of TCA, medium-depth peels on areas such as the
directly below the lashes of the lower lids and to the supratarsal crease mandible, neck, and chest which are areas susceptible to scarring.
on the upper lids. In the perioral area, peels must be performed into Because TCA is more likely to penetrate deep into the reticular der-
the nasolabial folds but should not go onto the cheeks, leaving possi- mis, thin-skinned patients are more prone to scarring. Some authors
ble demarcation lines on the nasolabial folds instead of on the cheeks. have theorized that patients who have been recently treated for hair
With the hairline and the mandible, the peel should be feathered into removal with lasers may have trouble healing after medium or deep-
the hairline and extend below the angle of the jaw and onto the depth peels since reepithelialization occurs from adnexal structures.8
neck.12 It is important to note that patients who undergo procedures The first signs of scarring are persistent erythema, pruritus, and
such as a facelift can have these demarcation lines up to their face. delayed healing (taking more than 2 weeks to reepithelialize). If scar-
If demarcation lines due to peeling are important, the rest of the ring occurs, the patient should receive immediate treatment with
face can be treated with a medium or deep peel. The neck has less high potency topical steroids, with the knowledge that atrophy and
pilosebaceous units, which are important to reepithelialization. telangiectasias are risks of the prolonged use of steroids. If the skin
Because of this fact, the lines between the face and neck have takes more than 2 weeks to reepithelialize, a more aggressive inter-
greater risk of scarring and contractures. It is recommended to avoid vention with biologic dressings and antibiotics is necessary.12 If scars
Baker’s formula in the neck. In this area of the face, less deep for- appear, the most effective treatment is intralesional injections of
mulas are recommended.21 steroids (triamcinolone 10-40 mg/cc). To help soften firm scars, mas-
sage, silicone gel sheets, compression over time and steroid impreg-
nated tape can be applied. Intense pulse light and pulsed dye laser
2.18 | Scarring
devices are helpful to ameliorate red scars. Surgical corrections can
Scars are the most dreaded complication, and physicians must warn be made only after a minimum period of six months.21
patients of their possibility before the procedure and should also be
aware of patients at higher risk for scarring. Scarring usually develops
two to three months after a peel.21 Although it is an unusual complica- 3 | COMPLICATIONS WITH SPECIFIC
tion of chemical peels, it is the hardest one to treat. Fortunately, scars PEELING AGENTS
with some degree of hypertrophy are more common than keloids, con-
tractures, atrophy, and necrosis.21 Hypertrophic scars and contractures Although rare, toxicity may occur with resorcinol, salicylic acid, and
affect the function and movement of the face, and surgical interven- phenol.23
tions with multiple treatments to minimize the problem are often nec-
essary. Persistent erythema can predict early scarring. The risk of
3.1 | Phenol toxicity
hypertrophic scarring from medium-depth peels is not common, but if it
occurs, it is usually observed in the mandibular line, periorally, or on the Phenol has hepatic metabolism and renal excretion and is toxic when
cheekbones, chin, inner corner of the eyelids, and areas of excessive used in high doses. Between 20 and 25% of the amount absorbed
movement of the face.21 In the lower third of the face, scarring most by the liver is conjugated to glucuronic acid and sulfuric acid and
frequently occurs in areas related to movement for speaking and eating, then excreted. Seventy to 80% of phenol absorbed is excreted via
and this area is also associated with the highest frequency of interven- urine within 15 to 20 minutes after its application. Therefore, when
tion. Remember that the neck, suprasternal, and submental regions are using a phenol peel, the face is divided into at least five regions, and
prone to the formation of hypertrophic scars.21 Atrophy is uncommon the product is applied to each region with 15-minute time intervals,
in phenol peeling, and trichloroacetic acid (TCA) is more likely to pro- allowing the concentration absorbed to be eliminated via urine with-
duce scarring than phenol because it is more caustic (Figure 4). out causing cardiac problems.24,25 To maximize phenol elimination
A patient is more likely to develop scars if she/he has a history and minimize systemic complications, patients are hydrated with
of poor wound healing, keloid, or hypertrophic scar formation or intravenous fluids and followed with cardiac monitoring.26
COSTA ET AL. | 7

T A B L E 3 Systemic and cutaneous complications

Cutaneous

Systemic Pigmentary Scarring Structural

Cardiac Hypopigmentation Keloids Ectropion
Hyperpigmentation
Renal Line of demarcation Hypertrophic scarring Eclabium
Hepatic Accentuation of nevi Atrophic scarring
Persistent erythema Necrosis
Persistent flushing

concentration of this agent in the peel because its overapplication can

lead to systemic toxicity that can present as different degrees of nausea,
vomiting, diarrhea, pallor, cold sweats, tremors, dizziness, drowsiness,
headaches, bradycardia, paralysis, shortness of breath, diaphoresis, and
nervousness.12 Continuous application of resorcinol can cause myxe-
dema because of its antithyroid activity. Repeated applications should be
performed with caution in patients with low body weight.8
F I G U R E 4 Scars after 40 days of medium-depth peel
(Jessner+TCA 35%)
3.3 | Salicylism
Cardiotoxicity is the most observed systemic effect caused by
phenol peeling, and more systemic effects are likely to appear with If a large amount of salicylic acid is absorbed, it can lead to toxic
higher doses.12 Phenol can produce arrhythmias even if normal heart effects such as tinnitus, nausea, vomiting, deep and rapid breathing,
function was present before. The occurrence of arrhythmias is unre- gastrointestinal irritation, and even stroke. Since it is present in Jess-
lated to age, sex, or the use of saponified or nonsaponified formula- ner’s and Combe’s formulas, which are used regularly, patients
tions. Thirty minutes after a phenol peel, a patient can experience should be warned of the symptoms and advised to not take too
tachycardia followed by premature ventricular contractions, bige- much aspirin because it can have synergistic effects.12
8
miny, paroxysmal atrial tachycardia, and ventricular tachycardia.
Some of these symptoms progress to atrial fibrillation.27,28 To avoid
complications, phenol peels should not be applied widely. Phenol 4 | CONCLUSION
peels associated with a medium depth applied regionally are safer
than applying phenol to the entire face. Gaining knowledge on the use of chemical peeling is essential to
Landau et al. observed that the incidence of cardiac complica- understand and prevent not only the major complications but also the
tions in appropriately performed deep chemical peels was lower than most common ones. If complications occur, you must be able to
previously estimated. From a total of 181 patients who were treated address them in the best possible manner to avoid an unfavorable out-
during the study period, cardiac arrhythmia during the procedure come. By covering important information to consider when performing
was recorded in 12 patients (6.6%). Cardiac arrhythmia was more chemical peels, this review was designed to help professionals become
common in patients with diabetes, hypertension, and depression more skilled at applying this procedure. Never forget to inform the
29
according to this study. patient of the potential complications and always establish a good bal-
Symptoms of stridor, hoarseness, and tachypnea could develop ance between the patient’s expectations and reality.33 For profession-
within 24 hours after a peeling and should subside within another als who are new to the use of chemical peels, use common sense, do
24 hours after initiating inhalation therapy with heated aerosol not seek quick results, and use the correct indications. A dissatisfied
30
mist. These symptoms could arise due to a hypersensitivity reac- patient with a partial result that can be easily resolved with a new
tion in the larynx and must be promptly treated. A chronically irri- application is better than a dissatisfied patient with complications,
tated larynx due to cigarette smoke is more likely to develop this such as the development of deep scars, requiring difficult treatment.
complication but may be prevented by the use of antihistamines
prior to the procedure.8 ACKNOWLEDGMENTS
The complications found in phenol peeling are summarized in
Table 3.31,32 The authors have taken efforts in this project. However, it would
not have been possible without the kind support and help of many
individuals and organizations. The authors would like to express their
3.2 | Resorcinism
gratitude toward family and friends for their kind cooperation and
Resorcinol has ¼ of the potency of phenol and should not be applied to encouragement, which helped in completion of this project. Finally,
large areas such as the patient’s back.12 The physician should limit the their appreciation also goes to their patients, for agreeing to
8 | COSTA ET AL.

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19. Dmytryshyn JR, Gribble MJ, Kassen BO. Chemical face peel compli-
be completed.
cated by toxic shock syndrome. A case report. Arch Otolaryngol.
1983;109:170-171.
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