Journal of the European Academy of Dermatology and Venereology

ELSEVIER 8 (1997) l-11

Continual medical education

Chemical peeling: How, when, why?

I. Ghersetich a, P. Teofoll ‘, M. Gantchevab, M. Ribuffo ‘, P. Puddu ’
a Department of Dermatology, University of Florence, Via Alfani 37, 50121 Florence, Italy
b Department of Dermatology, Medical Faculty, University of Sofia, Sofia, Bulgaria
’ Department of Immunodermatology, IDI, IRCCS, Rome, Italy

Abstract

General description Chemical peeling is a procedure frequently used to treat unaesthetic cutaneous
alterations such as photoageing, actinic keratosis, chloasma,senile lentigo, and post-acneicscarsas well those of
a non-strictly aesthetic nature such as seborrhoeic keratosis and flat warts. Several chemical agents are used
depending on the depth of peeling to be obtained. The most commonly used agents are: alpha-hydroxy-acids,
resorcinol, Jessner’ssolution, and trichloroacetic acid. In the present study the characteristicsof the individual
substances,technical procedure, and applications are taken into consideration. Finally, the main risks and
side-effects,depending on the depth of peeling, are considered.
Learning objective The reader will have learned what a chemical peeling is, what chemical agents are
available, and how to perform chemical peeling in the office. The mechanism of action of different chemical
agents, expectations from this procedure, potential risks and complications are also reviewed with insight into
criteria for selecting patients.

Keywords: Chemical peeling; Technical approach; Complications

1. Introduction skin according to the depth of the wound through the

Chemical peeling consists of the application on
the skin of one or more exfoliating agents to obtain
first destruction and then regeneration of part of the
epidermis and/or dermis. This technique produces a
controlled wound determining cutaneous renewal
with reduction or disappearanceof actinic keratosis,
pigmentary dyschromia, wrinkles and superficial de-
pressedscars.
Chemical peeling induces a modification of the
following mechanisms:
1. Epidermal growth stimulation following the re-
moval of the stratum corneum.
2. Specific destruction of the damaged cutaneous
layers and further regeneration of “normal” tis-
sue, which is mandatory in some cutaneousalter-
ations, such as actinic keratoses or pigmentary
dyschromias.
3. Induction of an inflammatory reaction in the
deeper skin layers. In this case, the release of

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2 I. Ghersetich et al. /J. Eur. Acad. Dermutol. Venereal. 8 (1997) I-l 1
mediators of inflammation may induce new colla-
gen synthesis and extracellular matrix deposition
in the dermis.
2. Classification of chemical peeling agents
Chemical peeling is generally classified according
to the depth obtained by exfoliation [l], which is
usually related to the chemical agent used, its con-
centration, and the duration of application.
Table 1 shows the most used classification of
main chemical peeling agents [2]. It is obvious that
the deeperthe wound, the better the results obtained,
but with a higher risk of side-effectsand the need for
increasedprecautions to be taken.
3. Alpha-hydroxy-acid peel
The alpha-hydroxy-acids (AHAs) are a group of
organic acids of vegetable derivation representedby
glycolic acid (which is surely the most common)
citric acid, lactic acid, malic acid, and pyruvic acid.
Different from other substanceswith a keratolytic
effect, such as salicylic acid, urea, and lithium salts
Table 1
Classification of chemical peeling agents
Very superficial (stratum granulosum)
30-50% glycolic acid (or other alpha-hydroxy-acids
with comparableeffect)
Jessner’ssolution (l-3 coats)
Resorcinol at low concentration(20-30%),
apphed only for a few minutes
Superficial (down to the papillary derma)
Glycolic acid (50-70%)
Jessner’ssolution (4-10 coats)
Resorcinol(40-50%, applied for 60 min)
TCA (10% to 30%)
Medium depth (down to the superficial reticular derma)
Glycolic acid 70% (application varying from 3 to 30 min)
TCA (35-70%)
Combined peeling (TCA 35% + CO,,
Jessner’ssolution+ TCA 35%,
glycolic acid 70% + TCA 35%)
Deep (down to the to the medium reticular dermis)
Baker and Gordon’s phenol formula
which act at more superficial levels, the alpha-hy-
droxy-acids seemto act at the lowest stratumcomeum
[3-61.
The alpha-hydroxy-acids are used in dermatology
to treat numerous clinical conditions, such as cuta-
neous xerosis, ichthyosis, seborrhoeic keratosis, ac-
tinic keratosis, warts, and acne [3]. The excellent
results achieved with alpha-hydroxy-acids imply that
their mechanism of action goes beyond mere cohe-
sion reduction of the keratinized cells, and they
presumably play a fundamental role in the healing
processand preventing cutaneousageing.
Recent studies have demonstratedincreased epi-
dermal thickness and a greater amount of hyaluronic
acids in the dermis following treatment with alpha-
hydroxy-acids [7-91.
A clinical (histological and ultrastructural) pilot
study on the effects of alpha-hydroxy-acids on pho-
toageing has documented an increase of epidermal
and dermal thickness, increasesin mucopolysaccha-
ride acids and collagen density, and an improvement
in the quality of elastic fibres after 6-months of
application with a lotion containing a mixture of
25% alpha-hydrox-acids [lo].
An in vivo preliminary study by our group showed
an increase in epidermal Langerhans cells in 3 pa-
tients who underwent 1 month treatment with gly-
colic acid (peeling with 70% concentration weekly,
and done at home, daily therapy with a 10% concen-
tration lotion) (Fig. 1) [11,12].
Interestingly, all these effects occurred without
any real inflammatory effects. This supports the
hypothesis that the mechanism of action of the al-
pha-hydroxy-acids and their related substancesis a
specific direct effect on the skin which goes beyond
the irritating effect.
4. Glycolic acid peel
4.1. General characteristics of glycolic acid
Formula 70% glycolic acid solution (Glypure-
DuPont). The solutions are formulated with water, or
combinations of water, alcohol and propylene glycol.
Stability Non-sensible to light. Very stable (more
than 2 years). Easy evaporation (the bottle must be
kept well closed).
 I. Ghersetich et al. /J. Eur. Acad. Dermatol. Venereol. 8 (1997) 1-11

Fig. 1

Fig. 2
Fig. 1. Increased CDla+ cells in the epidermis after glycolic acid tre:atment.

Fig. 2. Post-acne scarring: a major indication for TCA peel.

4 I. Ghersetich et al. /J. Eur. Acad. Dennatol. Venereol. 8 (1997) I-l 1
Physical characteristics Clear and transparentso-
lution; may be produced in gel by the addition of a
gelling agent (the gel may appearyellow-coloured or
turbid).
4.2. Skin preparation for peeling
Before using any exfoliating agent for chemical
peeling, a 2-week preparation is necessaryinvolving
application of cream containing retinoic acid and/or
alpha-hydroxy-acids associated with a cutaneous
bleaching agent, depending on the type of skin and
the specific problem of the patient.
4.3. Degreasing
Degreasing is effected with alcohol or acetone
and allows a deeperand more homogeneouspenetra-
tion of the exfoliating agent.
4.4. Application
The application of the acid may be performed
with a special brush, a Q-tip or a gauze. Once the
acid has been applied to the whole area to be treated,
it is necessaryto wait for the patient’s reaction to see
if there is erythema or “frosting”. The latter may
occur with glycolic acid peel as a spotted-like pattern
indicating epidermolysis which consists of detach-
ment of the epidermis from the papillary dermis [13].
Generally, glycolic acid peeling is done to obtain
slight exfoliation without side-effects to make the
skin smoother. Therefore, the acid must be immedi-
ately neutralized if frosting occurs [ 131.The duration
of application is extremely variable from patient to
patient and is unpredictable. It is advisable to ob-
serve the patient carefully during application and to
establish the duration of application according to
personal experience.
4.5. Neutralization
It is extremely important to neutralize the acid in
order to avoid the “overpeel” phenomenon due to
too deep penetration [ 131.
The neutralizing process is achieved with any
alkaline solution; generally a solution of sodium
bicarbonate (815%) is used, which allows the per-
ception of effervescencedue to the releaseof carbo-
nium dioxide acid that terminates only at the end of
neutralization.
4.4. Post-peel care
Following peeling, it is recommended that no
cream containing alpha-hydroxy-acids be used for 2
or 3 days. If the patient does not show any sign of
irritation, erythema or abrasion, no specific post-peel
care is necessary.
Two or 3 days application of topical non-
halogenated steroids should be prescribed for sub-
jects presenting significant erythema [13]. In the
event of an overpeel phenomenon with abrasions,
application of an antibiotic cream for at least 1 week
is necessary.
5. Resorcinol peel
Resorcinol (m-dihydroxybenzene), structurally
and chemically related to phenol, soluble in water,
alcohol, and ether, acts as a potent reducing agent. In
fact, it is able to break the weak bonds of the keratin
to the hydrogen [14]. In some casescontact allergy
has been observed 1151.This substance is used in
creamy formulations at concentrations ranging from
10 to 30% basedon Unna’s 18th century formulation
later modified by Letessier [ 161.
Currently the formula most used is:
Resorcinol 40 g
Zinc oxide 10 g
Benzoated sugna 28 g
Kaolin 2g
Normally this cream is applied with a spatula on the
area to be treated and left there for 60- 120 min.
Following this application the patient shows a
reaction similar to a first-degree bum with further
exfoliation which generally continues for 1 week to
10 days. The post-peel care foresees the use of
antibiotic creams and corticosteroids for about 1
week and l-month complete protection against UV
radiation. This type of peeling is quite easy to man-
age and has a low risk of side-effects,mainly tempo-
rary hyperpigmentation. Resorcinol peel is especially
recommendedin patients with acne, including come-
 I. Ghersetich et al. /J. Eur. Acad. Dermatol. Venereol. 8 (1997) I-l 1
donic acne, with good success in the clearing of
pigmented lesions and very superficial scars.
6. Jessner’s solution peel
In addition to the creamy formulation of resorci-
no1there is also a liquid formulation called “Jessner’s
solution” [ 171.
Formulation of Jessner’s solution
Salicylic acid 14 g
Resorcinol 14 g
Lactic acid (85%) 14 g
Ethanol up to 1OOml
Stability Light- and air-sensible; must be stored in
a dark-coloured container. Can be kept for up to 2
years.
Physical characteristics Slightly amber-coloured
clear solution, which becomes darker with age and
exposure to light.
Jessner’s solution peel rarely causes “overpeel”
and therefore the risk of complications is very low
[18]. The main disadvantagesare related to the great
variability of manufacturing since the formula con-
tains 3 active substances,to possible intense exfolia-
tion which is sometimesburdensomefor the patient,
and to an intense burning sensation,generally greater
than with glycolic acid [ 181.
The application technique is similar to that of
glycolic acid, but the effect on the skin is different.
During the first phaseerythema will appearfollowed
by a dust-like white “powder” all over the skin
which, however, is not comparableto “frosting” but
is only due to precipitation onto the skin of the
chemical compounds in the solution. This “whiten-
ing” is easily removed with water or simply by
rubbing with a finger.
During the following days exfoliation occurs, sim-
ilar to that produced with the creamy resorcinol peel,
and lasts for 8-10 days; post-peel care is similar to
that used with the creamy formulation. Jessner’s
solution is best for dyschromic changes and all the
other indications referring to alpha-hydroxy-acids.
Although Jessner’s solution peel has the advantage
of producing more uniform peeling, it is less ac-
cepted by patients because it induces more evident
exfoliation [ 181.
5
7. Trichloroacetic acid (TCA) peel
The most efficient peeling method for wrinkles
and scars is definitely the TCA peel. It can be
applied at different concentrations and therefore can
be used to cause peeling at different depths. In all
casesthe peeling is easy to control and predictable,
although the risk of scarring seems to be more
frequent only for concentrations over 40%.
Histological and ultrastructural studies have
demonstrated that TCA peeling is able to reduce
some typical aspects of photoageing (Fig. 3) by
inducing renovation of epidermal polarity, reduction
of epidermal intracytoplasmic bodies, increase in
fibroblasts, increasein collagen type I deposit, reduc-
tion of elastic fibres [ 191.Generally, these effects are
visible 1 month after peeling [20].
The indications for TCA peeling are above all
photoageing.with sun elastosis, slight wrinkles, and
actinic keratosis. Deep and perioral wrinkles respond
only moderately to this treatment. Other indications
include pigmentary changes (lentigo simplex,
melasma or post-inflammatory hyperpigmentation).
Although precautions must be taken, the results are
variable and the possibility of worsening has to be
considered. TCA peeling, at concentrations ranging
from 35 to 50% [21], gives excellent results in
post-acneic scars, especially in cases of moderate
scarring (Fig. 2). In the literature, there are reports
that also acne rosacea, seborrhoeic dermatitis and
dilated pores can be treated with TCA, but in our
experience the results are not satisfactory.
7.1. TCA peeling technique
7.1.1. General characteristics of trichloroacetic acid
Formula Crystal trichloroacetic acid at 20-50%,
in water solution.
Stability Not light-sensible. No refrigeration nec-
essary. Stable for at least 23 weeks.
Physical characteristics Clear and transparent.
Without precipitates.
7.1.2. Preparation of the skin for peeling
Skin priming is particularly important in TCA
peeling. Priming is necessaryto allow more uniform
penetration of the exfoliating agent, to reduce the
re-epithelization phase, to minimize the risk of post-
 1. Ghersetich et al. /J. Eur. Acad. Dennatol. Venereal. 8 (1997) l-l 1

Fig. 3

Fig. 4
Fig. 3. Lentigo senilis in a photo-aged skin.

Fig. 4. Frosting of the skin during a TCA peel.

inflam matory pigmentation, and to evaluate patient 7.1.3. Degreasing

compl iance in advance and thus avoid treating unre-
liable subjects [23]. Retinoic acid 0.1% is the best
pliIlliIl lg agent when used daily for at least 15 days.
Alpha. -hydrox: f-acids, hydroquinone, and kojic acid
can al ways be: used together with a total sunscreen.
As for the other peels, the d<:gre asiw agents
mostly used are alcohol and acetone
7.1.4. Application
TCA can be applied with a Q-tip 01 wi th a2
cm X 2 cm gauze. A first applicatio a is dlone on the
 I. Ghersetich et al/J. Eur. Acad. Dermatol. Venereol. 8 (1997) 1-11
area to be treated, allowing the substanceto pene-
trate for a few seconds,and then a second applica-
tion is made, followed by another one until frosting
appears (whitening due to the coagulation of the
protein in the epidermis), indicating that the acid has
penetrateddown to the papillary dermis (Fig. 4) [23].
At this point the process is stopped by sprinkling
water at room temperature on the treated area. It is
not necessaryto neutralize TCA and its dilution is
sufficient to limit and terminate the effect [23].
The following aspects must be considered when
performing a TCA peel.
1. Peeling is painful; generally the discomfort lasts
only until dilution of the acid. Treatment takes
about lo-15 min and is well tolerated by most
patients. If necessary,in some particularly sensi-
tive patients EMLA pre-anaesthesiacan be done.
However, one must consider that local anaesthet-
its cause vasoconstriction, thus increasing the
depth of peeling. ‘Therefore,when anaesthesiais
required, one should consider using a lower TCA
concentration. In any case, for particularly sensi-
tive patients a sedative or a systematically admin-
istered analgesic is recommended.
2. Several TCA coats obtain an increasein the depth
of peeling; therefore, if higher concentrations
(50%) are used, only 1 or 2 coats are advisable.
3. When the patient requires treatment of a limited
area, we recommend performing light peeling all
over the face in order to avoid dyschromia.
7.1.5. Post-peeling care
The immediate postoperative treatment foresees
the use of an antibiotic, sometimesassociatedwith a
hydrogel dressing. Patients should be warned to ex-
pect various modifications, in particular:
1. itching sensations,
2. marked hyperpigmentation possibly associated
with oedema,and that
3. exfoliation is never the sameall over the face but
generally starts at the periorbital and perioral
(more movable) area and ends at the forehead. It
is important in this phase not to remove the skin
to avoid post-inflammatory hyperpigmentation.
Generally, in the days following treatment it is
sufficient to avoid the use of soapsand detergents,to
apply an antibiotic cream twice a day and to use total
sun block. The patient is recommendedto avoid UV
7
radiation for 4-5 months. For 2 or 3 weeks after
exfoliation the skin may maintain a pinkish colour;
in such casesa light corticosteroid or a cream con-
taining zinc oxide may hasten the return of normal
skin colouring.
8. Phenol peel
The phenol peel, using the Baker-Gordon for-
mula, is the deepest peeling method; the peeling
agent penetrates down through the reticular derma
[24,25]. Since the chemical agent may be absorbed
and could cause cardiac, hepatic or renal toxicity as
well as other local and systemic side-effects,peeling
must be performed only in an operating theatre with
the assistanceof an anaesthetistto monitor eventual
cardiac arrhythmia [26].
9. Complications of chemical peeling
Obviously, the deeper the peeling, the greater the
possibility of complications. The most frequent com-
plications are:
9.1. Pigmentary modifcations
It is possible to see a difference in colour with
evident boundary lines between the exfoliated and
the non-treated area. Generally, this inconvenience is
temporary, and within l-2 months uniform colour-
ing will be observed.
The most feared complication following chemical
peeling is hyperpigmentation [27]. Quite often this is
due to even minimal sun exposure, although some-
times it may depend on other factors. In the latter
case there is a major risk in dark-skinned people
[28]. According to Fitzpatrick, peeling is imprudent
in any seasonand in any subject with phototype V.
Hyperpigmentation can be treated with any bleach-
ing agent with generally good results; sometimesit
disappears spontaneously after some months. It is
more difficult to treat hypopigmentation due to de-
struction of melanocytes[29]; this may be permanent
and can occur with potent peeling with a 50% TCA
or phenol.
8 1. Ghersetich et al./ J. Eur. Acad. Dermatol. Venereol. 8 (1997) l-11
9.2. Infections
Infection associated with peeling is rare. Nor-
mally, the frequency of this type of complication
increases with the depth of peeling and is more
pronounced when crusting occurs [30]. The most
common pathogensare Streptococcusand Staphylo-
coccus; infection due to Pseudomonasis much rarer.
An herpes simplex infection may be reactivated by
peeling at any depth [31]. A suitable local and/or
systemic antibiotic therapy should be administered
quickly to treat bacterial infection.
9.3. Acne-like eruptions
A small percentage of patients show acne-like
eruptions during or immediately after the exfoliation
phase [29]. The reason for this side-effect is un-
known, and the phenomenon generally disappears
within 5 or 6 days with application of topical clin-
damycin or erythromycin.
9.4. Allergic reactions
Allergic reactions occur most frequently with re-
sorcinol peel, while with other types of peel they are
very rare [32]. The problem of allergic reaction is
often difficult to diagnose since the symptoms may
be similar to the sensationsinduced by the peeling
itself (erythema or oedema).Identification and ther-
apy of this complication are very important since it
greatly increasesthe possibility of side-effects such
as hyperpigmentation and scarring.
9.5. Persistent erytherna
Persisting erythema lasting for 2 or 3 weeks
following a peel is considered normal, especially
after a TCA peel. Erythema persisting for more than
3 weeks may indicate hypertrophic scarring and
should be treated with a potent topical cortocos-
teroid, silastic plasters, or pulsating dye laser.
9.6. Scars
Fortunately, scarring is quite rare, but this is
certainly the most feared complication in cases of
chemical peeling [33]. The major risks are in patients
subjectedto deeperpeeling (which may occur due to
the performance of superficial peels), in subjects
with keloids or hypertrophic scars, in patients who
have undergone recent Accutane therapy, and in
patients with infections or allergic post-peeling reac-
tions [32].
Different scarring reactions may result: flat, hy-
popigmented, depressed atrophic areas, and thick-
ened, elevated areas and keloids. Scar treatment
differs according to the type of scar and may require
the use of intralesional steroids, silastic plasters,
laser therapy, and cryotherapy, including excision
and revision of the scar.
10. Written informed consent to chemical peeling
All patients who are to undergo a procedure that
has a minimum risk of complications must sign an
informed consent. It is recommendedthat the patient
be given written information concerning side-effects
and complications, discomfort and temporary skin
changes that may occur during and following the
treatment.
The following may be considered a draft of written
informed consent:
Written informed consent to chemical peeling
The undersigned, . . . . . . . . . . . . . . . . . . . . . . . .. here-
with gives formal consent to the chemical peeling
treatment at . . . . . . . . . . . . . . . ..
The treatment has been explained to me and I had
the opportunity to make questions. This procedure
will determine a modification in the treated area of
my face (or in the treated area) which might be
unpleasant. My face will become red and succes-
sively will darken as if sunburned. Then exfoliation
will begin lasting around 10 days, and erythema may
persist for 15-20 days. I was informed that a mini-
mum risk of side-effects exists, such as hyperpig-
mentation and scarring (very rarely). Furthermore, I
do approve to be photographed.
Date and patient’s signature (or parents or
guardian if the patient is a minor).
 I. Ghersetichet al. /J. Eur. Acad. Dermatol. Venereol.8 (1997) I-II 9

11. Conclusions 4) What is most suitable for neutralizing glycolic

acid?
Chemical peeling representsa successfuland safe a. Any alkaline solution
approach to treat selectedcutaneousproblems of an b. A buffered solution
aesthetic nature. In order to avoid any undesired c. Normal saline solution
side-effects, it is suitably performed by specialists 5) What is chemical peel classi@ation generally
according to a procedure which should be, if possi- based on?
ble, standardized[34]. a. Level of depth obtained through exfoliation
Apart from the well-known chemical exfoliating b. Concentration of the chemical agents
effect, several studies exist describing the stimula- c. Chemical agent used.
tory activity of some of these chemical agents on 6) Chemical peel level of depth depends on:
fibroblasts (glycolic acid and trichloroacetic acid). a. Number of coats
For this reason the use of these substancesin pho- b. Chemical agents used
toageing is advisable and offers the opportunity for c. Chemical agents concentration
use also in other skin lesions. It is definitely neces- d. All of the above
sary to investigate further the exact molecular mech- e. Type of applicator used
anism inducing fibroblast activation and subsequent 7) What is skin priming for?
extracellular matrix synthesis. Several studies docu- a. To shorten the re-epithelization phase
ment the benefits of associating chemical peeling b. To minimize the post-inflammatory hyperpigmen-
with topical tretinoine, but comparative studies on tation risk
the use of topical tretinoine or chemical peeling, c. To allow a deeper penetration of the chemical
mostly with glycolic acid, are not satisfactory. In any agent used
case, the most successfulchemical peel seemsto be d. All of the above
the TCA peel which may be used for superficial, 8) What is generally suggested for skin priming?
medium and deep peels. Depth of penetration is a. Retinoic acid cream
easily noticed by frosting, neutralization is not b. Alpha-hydrohxy-acid preparation
needed,and systemic toxicity does not occur. c. Both separatelyor in association.
9) What is most used as skin degreasing agent?
a. Alcohol
b. Acetone
Appendix - CME questions on chemical peelings c. Liquid soap
d. Cetaphil
1) What is it suitable to achieve when performing a e. Both a. and b.
chemical peel? 10) Which of the following chemical agents induces
a. A controlled wound for skin renewal the most stinging and burning sensation when ap-
b. Controlled abrasion plied on the skin?
c. Predictable inflammatory outcome a. TCA
d. Light exfoliation b. Resorcinol
2) Which is one of the most freqent complications of c. Glycolic acid
chemical peel? 11) What is skin degreasing for?
a. Folliculitis a. To eliminate skin debris
b. Hyperpigmentation b. To prevent infection
c. Scarring c. To allow a deeper and more uniform penetration
3) Which of the following chemical agents needs to of the chemical agent
be neutralized when used to perform a chemical d. Both a. and c.
peel? e. To remove make-up
a. TCA 12) What instrument do you use to pet$orm a TCA
b. Glycolic acid peel?
c. Resorcinol a. A spatula
10 I. Ghersetich et al. /J. Eur. Acad. Dematol. Venereal. 8 (1997) l-l 1

b. Cotton tip References

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