BJD

R E V I E W A RT I C L E British Journal of Dermatology

Chemical peeling in ethnic skin: an update

A. Salam,1 O.E. Dadzie2 and H. Galadari3
1
Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, U.K.
2
Department of Dermatology and Histopathology, The North West London Hospitals NHS Trust, Northwick Park Hospital, Watford Road, Harrow, HA1 3UJ,
UK.
3
College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates

Summary

Correspondence With the growth of cosmetic dermatology worldwide, treatments that are effec-
Hassan Galadari. tive against skin diseases and augment beauty without prolonged recovery peri-
E-mail: hgaladari@uaeu.ac.ae
ods, or exposing patients to the risks of surgery, are increasing in popularity.
Accepted for publication Chemical peels are a commonly used, fast, safe and effective clinic room treat-
21 April 2013 ment that may be used for cosmetic purposes, such as for fine lines and photo-
ageing, but also as primary or adjunct therapies for acne, pigmentary disorders
Funding sources and scarring. Clinicians are faced with specific challenges when using peels on
This supplement was kindly sponsored by L’Oreal ethnic skin (skin of colour). The higher risk of postinflammatory dyschromias
Research & Innovation and Beiersdorf.
and abnormal scarring makes peels potentially disfiguring. Clinicians should
Conflicts of interest therefore have a sound knowledge of the various peels available and their safety
None declared. in ethnic skin. This article aims to review the background, classification, various
preparations, indications, patient assessment and complications of using chemical
DOI 10.1111/bjd.12535 peels in ethnic skin.

What’s already known about this topic?

• Chemical peels are efficacious therapeutic interventions for many skin disorders.
• Many peels exist; however, not all are safe for use in ethnic skin.
• Darker skin types have an increased risk of adverse events from chemical peeling
such as pigmentary disorders.

What does this study add?

• This is an up-to-date review of the various peeling agents and their indications for
use in ethnic skin.
• It provides a summary of newer peeling agents.
• It gives practical tips on performing chemical peeling safely and effectively in eth-
nic skin.
• Prevention and management of complications of chemical peeling in this cohort
are discussed.

The ethnic makeup of the world is rapidly changing. Of the
1
5 billion people the world is predicted to have gained by
2020, the majority will be from Asia (56%) and Africa
(16%).1 The U.S.A. is predicted to have close to 50% of its
population comprising people with skin of colour by 2050
(U.S. 2000 census),2 and the U.K. has seen the proportion of
Black Africans double between 2001 and 2011.3
Despite turbulent economic climates, cosmetic procedures
are at an all-time high with over 13 million procedures per-
formed in the U.S.A. in 2011 (5% increase from 2010). Mini-
mally invasive procedures, such as chemical peels, have
increased by 123% since 2000, in comparison to surgical pro-
cedures, which have increased by only 17%.4
Given the simultaneous growth of people with skin of col-
our and the demand for cosmetic procedures, dermatologists
must appreciate the challenges of cosmetic procedures in those
with darker skin types. On top of this, dermatologists must
also appreciate the facial anatomy, ageing patterns and cultural

82 British Journal of Dermatology (2013) 169 (Suppl. 3), pp82–90 © 2013 The Authors
BJD © 2013 British Association of Dermatologists

definitions of beauty when approaching the cosmetic treat-
ment of ethnic skin.5 It is through exploring the patient’s
desired outcomes, and having an appreciation for the cross-
cultural definitions of beauty, that allows the dermatologist to
set realistic objectives for treatment.
Even through the diverse cross-cultural definitions of
beauty, some factors remain universal. These include having
smooth skin, an even distribution of pigmentation and a lack
of wrinkles. It is this unspoken consensus that has led to the
increasing popularity of chemical peels.
The classification of skin types using the internationally rec-
ognized Fitzpatrick skin phototype (SPT) classification6 is
widely accepted but criticized as it does not define race, cul-
ture or reaction to various treatments. For the purposes of this
review we shall discuss patients with ‘ethnic skin’ or ‘skin of
colour’ or ‘noncaucasian skin’, which traditionally includes
SPT IV–VI.
Background
Chemical peels were first reported on records describing
ancient Egyptian medicine. The Egyptians would bathe in
sour milk, which contains lactic acid, to smooth their skin.7
Today, chemical peels are a fast, safe and effective clinic
room treatment. The mechanism of action lies in the elimi-
nation of the damaged skin, with subsequent regeneration
of a new epidermal layer, and remodelling of the dermal
layer.
The indications for chemical peels can be broadly classified
under pigmentary abnormalities, photodamage and textural
concerns. Unlike SPT I and II skin, where peels are mostly
used to treat skin changes associated with photoageing, SPT
IV–VI peels are used mostly for mottled dyschromia, acne
vulgaris, postinflammatory hyperpigmentation (PIH), melasma
and pseudofolliculitis barbae.8
Clinicians are faced with specific challenges when using
peels on ethnic skin. Although darker skin confers the
advantage of added photoprotection, it is the often unpre-
dictable response of melanocytes to injury that can cause
disfiguring postinflammatory pigmentary changes. It is pri-
marily this risk that makes chemical peels potentially disfig-
uring.
A broad range of chemical peels exist and a familiarity with
the various agents is essential. Peels can be broadly classified
according to their target skin depth (Table 19). However,
newer ways of peeling are frequently emerging either as novel
peeling agents, novel combinations of peels or varying
strengths of peels.
This may create difficulties in choosing a peel, but the prin-
ciples of treatment remain the same. A thorough assessment
of the patient is essential for success.
Chemical peeling agents
Broadly speaking, superficial peels are well tolerated in all skin
types, medium-depth peels may be used in ethnic skin, but
© 2013 The Authors
BJD © 2013 British Association of Dermatologists
Chemical peeling in ethnic skin, A. Salam et al. 83
deep peels should generally be avoided due to the very high
risk of dyschromia and scarring.10 Deep peels will not be dis-
cussed in this article.
Salicylic acid
Salicylic acid (ortho-hydroxybenzoic acid) is a naturally occur-
ring b-hydroxy acid derived from the bark of the willow tree.
It is a lipophilic agent, which produces desquamation of the
upper, lipophilic layers of the stratum corneum, providing sal-
icylic acid with its comedolytic effect in acne vulgaris. At con-
centrations of 3–5% it functions as a keratolytic agent, yet
ethanol solutions of 20–30% salicylic acid function as a peel
(Fig. 1a, b) that is widely considered to be the safest in the
ethnic skin population as demonstrated by work from
Grimes11 and Bari et al.12
Salicylic acid and acne
Studies conducted by Lee and Kim,13 Ahn and Kim14 and
Hashimoto et al.15 reported a reduction of both inflammatory
and noninflammatory acne lesions, in addition to demonstrat-
ing the lightening effect of salicylic acid. However, when used
for the treatment of melasma, the agent fell behind when
compared with 4% hydroquinone.16
Salicylic acid and postinflammatory hyperpigmentation
Salicylic acid may be effective in treating PIH, but
this requires further study using objective outcome
measures.17
Glycolic acid
Glycolic acid belongs to a family of a-hydroxy acids, which
are naturally occurring acids that include lactic acid (in sour
milk), malic acid (in apples), citric acid (in oranges and other
fruits) and tartaric acid (in grapes). This family of chemicals
functions as peels by causing epidermolysis within a few min-
utes of application, followed by desquamation and the disper-
sion of epidermal melanin.
Glycolic acid is a readily available peeling agent, and comes
in many preparations. Concentrations of 10–70% are popular
and effective in dark-skinned patients.18 Glycolic acid must be
neutralized with normal saline or sodium bicarbonate, other-
wise epidermolysis will continue.19
Glycolic acid and acne
Glycolic acid has recently been shown to be bactericidal
against Propionibacterium acnes, having an anti-inflammatory effect
on acne lesions.20
Wang et al.21 treated 40 East Asian patients with acne vulga-
ris with four series of 35% and 50% glycolic acid peels.
Patients also used 15% glycolic acid home care products for
the study period. Wang reported significant resolution of
British Journal of Dermatology (2013) 169 (Suppl. 3), pp82–90
84 Chemical peeling in ethnic skin, A. Salam et al.

Table 1 The classification of chemical peels by depth

Type of peel Target depth Commercially available peels
Superficial: light Stratum spinosum Glycolic acid 20–50%
Salicylic acid 20–30%
Superficial: deeper Up to entire TCA 10–30%
epidermis Jessner’s solution
Glycolic acid 70%
Medium depth Upper reticular TCA 35–40%
dermis Phenol 88%
Brady’s combination
(solid CO2 + 35% TCA)
Monheit’s combination
(Jessner’s + 35% TCA)
Coleman’s combination
(70% glycolic acid
+ 35% TCA)
Deep Mid-reticular Baker–Gordon formula
dermis (phenol 88% + tap water
+ liquid soap + croton oil)
Indications for use
Melasma, solar lentigines, acne, PIH,
photoageing, fine lines/wrinkles
Actinic keratoses, solar
lentigines, acne,
photoageing, melasma, PIH
Melasma, moderate
photoageing, scars,
actinic keratosis, lentigines, PIH
Severe photoageing, dermal-type
melasma, deep acne scarring,
PIH, actinic keratoses
Considerations
Safe in all SPT; may do
series of peels; PIH is
rare; erythema/scaling
may last 1–3 days;
salicylic acid particularly
suits SPT IV–VI
Caution advised in darker
skin types; higher
risk of dyschromia
Erythema/scaling
typically lasts 8–10 days
but up to 30 days;
not as suitable as
superficial peels for
acne vulgaris/rosacea;
can use hydroquinone
for PIH
Best for SPT I and II and
should be avoided in
SPT IV–VI; erythema
/scaling for 14 days
but up to 60; risk of
prolonged erythema
and hypopigmentation;
poorly efficacious at
eradication of wrinkles
at vermillion border;
may see lines
of demarcation

TCA, trichloroacetic acid; PIH, postinflammatory hyperpigmentation; SPT, Fitzpatrick skin type. Adapted from Ferguson et al.9 with permis-
sion from Wiley-Blackwell.

(a) (b) Glycolic acid and postinflammatory hyperpigmentation

Burns et al.22 assessed 19 patients (SPT IV–VI) with PIH who

were randomized to either of two groups. The control group
was managed with 2% hydroquinone/10% glycolic acid gel
twice daily, with 0
05% tretinoin at night. The treatment
group received the above plus six serial glycolic acid peels
(68% maximum concentration). The treatment group experi-
enced greater, and more rapid improvement, with lightening
of the skin.

Glycolic acid and melasma

Fig 1. Pre- (a) and post- (b) 30% salicylic acid peels (four sessions)
for melasma in a woman with Fitzpatrick skin type IV.
comedones, papules and pustules, as well as ‘brighter and
lighter looking skin’ with only 5% of patients developing
side-effects.
Chemical peels are generally used to treat only the epidermal
and mixed forms of melasma, as an attempt to treat the dee-
per variant often leads to unwanted complications like hyper-
trophic scarring and permanent depigmentation.23
Grover and Reddu24 used 10–30% glycolic acid peels in 41
Indian patients (SPT III–V) with various disorders (39% acne,
36
5% melasma, 12% PIH and 12% superficial scarring of var-
ied aetiology) treated with 3–5-min applications fortnightly,
and were assessed at 16 weeks. The peel was effective

British Journal of Dermatology (2013) 169 (Suppl. 3), pp82–90 © 2013 The Authors
BJD © 2013 British Association of Dermatologists
 Chemical peeling in ethnic skin, A. Salam et al. 85

especially in superficial scarring and melasma, moderately suc- (a)

cessful in patients with acne and unsuccessful (no response)
in dermal pigmentation. Eleven of the 15 patients with mel-
asma treated with glycolic acid experienced skin irritation,
two of 15 experienced PIH, one of 15 herpes labialis and one
of 15 hypopigmentation.
In a letter, Godse and Sakhia25 described the use of 55%
glycolic acid peels with a triple combination cream (2%
hydroquinone, 0
05% tretinoin and 0
01% fluocinolone aceto-
nide) in 20 Indian patients (SPT IV and V) with melasma. The
triple cream was applied every night, and the peel was applied
(b)
for 2–6 min, every 3 weeks, for a total of four peels. Half the
patients experienced >50% improvement in their skin condi-
tion, but hyperpigmentation and irritation occurred in one
patient. This study demonstrated that glycolic acid peels can
enhance the efficacy of topical regimens. This enhanced effi-
cacy had previously been observed with the combined use of
glycolic acid peels and modified Kligman’s formula (hydro-
quinone 5%, tretinoin 0
05% and hydrocortisone acetate 1%
in a cream)26 as well as with glycolic acid peels and 4%
hydroquinone combination.27

Trichloroacetic acid
(c)
Trichloroacetic acid (TCA) (Fig. 2a–c) is a crystalline inor-
ganic compound, which causes coagulative necrosis of cells
through extensive protein denaturation and resultant structural
cell death. The degree of necrosis depends on the concentra-
tion of solution applied.28 As a peel it is self-neutralizing, typ-
ically creating a white frost on the skin, which is not desired
in SPT IV–VI due to the risk of dyschromias and scarring.8
Chun et al.29 evaluated the use of varying concentrations of
TCA (10–65%) pressed firmly and focally onto a range of
benign pigmentary disorders (65% TCA for seborrhoeic kera-
tosis, 50–65% TCA for solar lentigines and freckles and
10–50% TCA for melasma) in 106 patients with SPT IV and
V. No significant complications were observed, and patient
Fig 2. Pre- (a) and post (b, c) trichloroacetic acid peel (X1 session)
satisfaction rates ranged from 55% for melasma to 86% for
for acanthosis nigricans in a man with Fitzpatrick skin type IV.
seborrhoeic keratosis.

Trichloroacetic acid and melasma

Both Kalla et al.30 and Kumari and Thappa31 found that the
improvement in pigmentation with 10–20% TCA was more
rapid than with 20–75% glycolic acid, with chronic pigmenta-
tion responding better to TCA. Glycolic acid, however, caused
fewer side-effects than TCA.
Jessner’s solution
Jessner’s solution is a combination of three synergistic kerato-
lytic agents with additional skin-lightening properties: salicylic
acid (14 g), resorcinol (14 g) and lactic acid (85%) in etha-
nol (95%).32
Although it may be used alone, studies by Safoury et al.33
and Kim et al.34 for the treatment of acne, have shown that
Jessner’s solution is most effective when combined with other
peels. It is these authors’ experience that Jessner’s should
therefore not be used alone for the treatment of pigmentary
changes, acne or scarring.
Lactic acid
Lactic acid is an a-hydroxy acid shown to inhibit tyrosinase
enzyme activity directly in a dose-dependent manner.35
Work by Sachdeva36 has shown that lactic acid may
be used for the treatment of acne scarring with minimal
risk of any adverse events. In addition, Sharquie et al.37
reported improvements in the Melasma Area and Severity
Index (MASI) and results were comparable to that of
Jessner’s solution.

© 2013 The Authors British Journal of Dermatology (2013) 169 (Suppl. 3), pp82–90
BJD © 2013 British Association of Dermatologists
86 Chemical peeling in ethnic skin, A. Salam et al.
Lactic acid and acne
Sachdeva36 described the use of full strength (92%, pH 2
0)
lactic acid applied fortnightly to a maximum of four peels to
treat acne scarring in seven Indian patients (SPT III and IV). At
3 months post-treatment, moderate to significant improve-
ments in texture, pigmentation, general appearance and scar
lightening were seen in six out of seven patients.
Lactic acid and melasma
Sharquie et al.38 studied 20 Iraqi patients (SPT IV) with mel-
asma treated with pure lactic acid (92%, pH 3
5) every
3 weeks until the desired response was achieved (range two
to six sessions). All 12 patients who completed the study
showed a statistically significant improvement in MASI (by
56%) with no side-effects reported.
The following year, Sharquie et al.37 compared full-strength
lactic acid (92%, pH 3
5) with Jessner’s solution, applied
every 3 weeks until the desired response was achieved (range
two to five sessions), in a split-face trial of 30 Iraqi patients
with melasma (mostly SPT IV). In the 24 patients who com-
pleted the study, both treatments showed statistically signifi-
cant improvements in MASI, with equal effectiveness when
comparing both groups, and no side-effects reported.
Although these studies demonstrate the potential for lactic
acid to be an effective routine peeling agent, especially in the
treatment of melasma, further studies, involving greater
patient numbers, are required.
Tretinoin
Tretinoin (all-trans retinoic acid) is a synthetic vitamin A ana-
logue used as topical therapy for many skin diseases. It has
been shown to promote wound healing and collagen synthe-
sis,39 as well as improving pigmentary abnormalities.40,41 It
can be used alone or as part of Kligman’s formula for treating
melasma.
Khunger et al.42 compared 1% tretinoin peel applied on one
side of the face vs. conventional 70% glycolic acid peel
applied to the other side at weekly intervals for 12 weeks in
the treatment of melasma in SPT III–V. Both groups were
comparable in the reduction of modified MASI score.
In Brazil, tretinoin is applied in much higher concentrations
of 9% as a mask for a period of 8 h. This allows for a gentle
peel that lasts for 3–4 days and helps reduce pigmentary dis-
orders and acne.
Further studies are needed to assess the effectiveness of tret-
inoin as a chemical peel.
Combination peels
Combination peels allow clinicians to utilize lower concentra-
tions of individual peels, while combining the agents’ syner-
gistic effects to achieving a deeper peel. The most commonly
studied combination peel is Jessner’s solution plus TCA. Work
British Journal of Dermatology (2013) 169 (Suppl. 3), pp82–90
by Al-Waiz and Al-Sharqi43 has shown a decrease in acne scar-
ring when Jessner’s was combined with 35% TCA. Safoury
et al.33 reported significantly greater improvement in MASI
score with Jessner’s plus 15% TCA in comparison with 15%
TCA alone.
Newer peels
Pyruvic acid
Pyruvic acid has diverse keratolytic, antimicrobial and sebo-
static properties, with the ability to stimulate the production
of new collagen and elastic fibres. It is effective for treating
acne, photodamage, superficial scarring and pigmentary disor-
ders in light-skinned patients.23 Further testing in darker skin
types is required, but it shows promise.
b-Lipohydroxy acid
b-Lipohydroxy acid is a derivative of salicylic acid with an
additional fatty acid chain creating increased lipophilicity com-
pared with salicylic acid, and therefore a greater keratolytic
effect.44 It has a pH similar to normal skin (5
5), without the
need for neutralization, and with a very tolerable side-effect
profile.13 It is available at concentrations of up to 10% provid-
ing a superficial peel with antibacterial, anti-inflammatory,
antifungal and anticomedogenic properties.45
Favourable results have been reported in treating acne,46
but comparison with other peels is required, especially in eth-
nic skin.
Salicylic–mandelic acid
Mandelic acid is one of the largest a-hydroxy acids, providing
a slow and uniform penetration of the epidermis and dermis.
It is combined with salicylic acid, which penetrates quickly,
and this combination has been shown to be effective in the
treatment of acne, acne scarring and pigmentary disorders
such as melasma.23,47
Amino fruit acids
Amino fruit acids are slightly alkaline chemicals, with a close
to physiological pH. They are well tolerated, especially in
those with dry and sensitive skin.48 Amino fruit acids have
been shown to be effective in the treatment of melasma and
acne but further study in dark skin is required.
Evaluation of the patient with ethnic skin for
peeling
A thorough assessment of the patient is essential to determine
the most suitable peel, avoid complications and explore their
expectations. A patient who is uncooperative with unrealistic
expectations is unlikely to have a good outcome, especially as
the pre-peel and post-peel regimens require excellent compli-
© 2013 The Authors
BJD © 2013 British Association of Dermatologists
 Chemical peeling in ethnic skin, A. Salam et al. 87

Table 2 Assessment of the patient with ethnic skin for chemical peeling

Further details
Aspect of assessment
1 Viral infection
2 Abnormal scarring
3 Inflammatory disorders
4 Systemic disease
5 Radiotherapy/surgery
6 Smoking
7 Drug history
Examination
8 Nonsun-exposed skin
9 Reaction to trauma
10 Photographs
Elicit history of HSV infection and consider prophylactic valaciclovir (1 g every 6 h) treatment starting
2 days before treatment until 10–14 days after the treatment54
Immunocompromised patients, such as patients with HIV infection should not routinely receive
treatment due to post-treatment infection risks
Enquire about previous keloid/hypertrophic scarring, or any family history of either
Coexistent inflammatory skin disease may make patients more susceptible to hypersensitivity
Patients with psoriasis may develop the Koebner phenomenon after a peel
A history of systemic disease, especially renal/liver/cardiac, is relevant when considering deep peels in
case of systemic toxicity
Recent radiotherapy or surgery to the skin should be considered relative contraindications as they may
interfere with collagen remodelling
Smoking slows the healing process in response to any injury, including peels
Patients on oral isotretinoin should have peels delayed until 6–12 months after completing treatment
Topical retinoids may be discontinued 1 week before if applicable
Identify any photosensitizers, e.g. minocycline, amiodarone, thiazides, tricyclic antidepressants
Systemic therapies that may cause hyperpigmentation such as oral contraceptives and hormonal
treatments
Carefully examine nonsun-exposed skin in order to assess accurately skin type and degree of
photoageing
Examine any previous burns to appreciate individual reaction type
Photographic documentation prior to peel is essential including full face and the specific area of interest

HSV, herpes simplex virus; HIV, human immunodeficiency virus. Adapted from Ferguson et al,9 with permission from Wiley-Blackwell.

Table 3 A pretreatment priming regimen for chemical skin peels in (a)

ethnic skin starting 2–4 weeks prior to peeling

Photoprotection: sunscreen UVA and UVB SPF 30

Gentle cleansing agent
Hydroquinone: topical 4% compound applied twice daily
Stop topical retinoids 7 days prior to peel (unless priming
for deeper peel in special circumstances)

UV, ultraviolet; SPF, sun protection factor.

(b)

ance. The occupation of the patient is important to consider,

especially those with outdoor jobs being treated over the sum-
mer period. This consultation is also an excellent time to dis-
cuss the risks and benefits to gain informed consent.49 Table 2
summarizes the important aspects of assessing a patient with
ethnic skin for chemical peeling.
Fig 3. Complications of chemical peeling in Fitzpatrick skin type VI.
Agent used in both cases was 70% glycolic acid. (a) Postinflammatory
Pre and post-peel regimens hyperpigmentation; (b) irritant dermatitis.

A peel date needs to be decided to plan the pretreatment prep-
aration and priming regimen. This is usually initiated 2–
4 weeks prior to peeling, and discontinued 3 days before
(Table 3).50 Patients should be instructed not to bleach, wax,
scrub, massage, use depilators or schedule an important event
1 week before the peel.51
Pre-peel priming with 2–5% hydroquinone is effective in
reducing the risk of PIH. Nanda et al.52 compared the priming
effects of hydroquinone with those of tretinoin. Although
similar improvements were seen at 12 weeks, the hydroqui-
none group showed a statistically superior reduction in post-
peel reactive hyperpigmentation by 6 months.
Patients should be aware of the risks of skin dryness, irrita-
tion and erythema. Photoprotection may also reduce the risk
of PIH. Patient education is essential to reduce the risk of
complications.

© 2013 The Authors British Journal of Dermatology (2013) 169 (Suppl. 3), pp82–90
BJD © 2013 British Association of Dermatologists
88 Chemical peeling in ethnic skin, A. Salam et al.

Table 4 The stepwise approach to chemical peeling in ethnic skin

Step Procedure
Pre-peeling
1 Prime face as described in Table 3 2–4 weeks before treatment
Discontinue 1 week before treatment
Peeling
2 Choose peel according to patient characteristics and desired depth
Acne prone/oily skin: consider salicylic acid
Dry skin: consider glycolic acid
3 Defatting to remove excess oils
Cleanse/wash immediately before with gentle syndet cleanser and/or apply degreaser such as acetone
4 Remove hair from face, apply occlusive ointment to lips and protect ear canal
Adapt technique to the desired depth of peel
Volume of agent used
Amount of pressure applied to skin
Contact time with skin
 Neutralization of peel
Apply test peel to postauricular region
Apply to treatment area starting with low concentration and titrate to tolerability, spacing peels 4–6 weeks apart
Both the strength of peel and time to neutralization can be increased with each subsequent peel
Post-peeling
5 Commence with photoprotection and bland emollients immediately post-peel
6 1 week post-peel restart hydroquinone and topical retinoid therapy

Syndet, synthetic detergent. Adapted from Ferguson et al,9 with permission from Wiley-Blackwell.

Table 5 The prevention and management of the common complications of chemical peels

Complication Prevention Management

Immediate (minutes to hours)
Skin irritation, itching or burning
Persistent erythema, oedema
Ocular complications
Late (days to weeks)
Reaction to chemical agent:
(1) acneiform eruption;
(2) allergic reaction; (3) toxicity
Infection:
(1) bacterial;
(2) candidal;
(3) herpetic
Problematic wound healing:
(1) hypertrophic scarring;
(2) keloid;
(3) scarring;
(4) delayed healing;
(5) milia; (6) textural changes
Pigmentary changes:
(1) hyperpigmentation;
(2) hypopigmentation;
(3) demarcation lines
Avoid excess peel concentrations
Stop photosensitizers, avoid sun
exposure, apply photoprotection
Eye protection, cautious application of
peel, petroleum jelly around eyes
Postauricular test peel (2)
Avoid rubbing, itching, peeling,
scratching (All)
Assess for immunodeficiency states (1 + 2)
Prophylactic antiviral therapy for those
with history of herpetic infection (3)
Avoid rubbing, itching, peeling, scratching (All)
Personal or family history of
abnormal scarring (1 + 2)
Vigilance and early neutralization
of peel if necessary (3)
Smoking and diabetes history (4)
Avoidance of deep peels in dark skin
Adequate priming
Photoprotection
Emollients
Topical steroids if persists to avoid dyschromia
Saline irrigation of eye for TCA or glycolic
acid spillage, referral to ophthalmology
Topical or oral antibiotics, topical azelaic
acid, low-dose intralesional corticosteroids
or low-dose isotretinoin51(1)
May require cardiopulmonary monitoring (3)
Topical or systemic antibiotics (1)
Topical or systemic antifungals (2)
Oral antiviral therapy (3)
Occlusive covers (e.g. silicone gel),
intralesional triamcinolone, laser
therapy, radiation, surgical excision
or topical imiquimod55(1–3)
Electrodessication or surgical extraction56(5)
308-nm xenon chloride excimer laser
to hypopigmented patches may be useful56(2)

TCA, trichloroacetic acid.

British Journal of Dermatology (2013) 169 (Suppl. 3), pp82–90 © 2013 The Authors
BJD © 2013 British Association of Dermatologists

Post-peel instructions should be given to the patient in
writing. Photoprotection and bland emollients should be
started immediately after the peel, and wetting the area should
be avoided for 24 h, followed by a return to normal cleansing
activities.8 One week after the peel, hydroquinone and topical
retinoid therapy may be restarted.
Complications
It is well recognized that the complications (Fig. 3a, b) of
chemical peels occur more commonly in those with darker
skin and with medium-to-deep peels.12,53 Therefore, the
risk of complications can be significantly reduced with
meticulous patient selection, peel selection (volume, combi-
nation, concentration and technique of application), patient
education, adequate priming, and good intra-peel and post-
peel care.51
PIH is most likely in patients with SPT IV–VI, with med-
ium-depth peels posing a greater risk than superficial peels.
Deep peels in darker skin types must always be avoided. If
a deeper peel is required, consider combining superficial
peels to increase efficacy without increasing risk.53 Although
temporary PIH can occur in all skin types, long-standing
PIH is more common in darker skin. Careful post-treatment
monitoring is essential to identify and treat prolonged ery-
thema with topical corticosteroids, thus reducing the risk of
PIH. It is prudent to start with a low-potency peel and
titrate up, as underpeeling is better than overpeeling.
Table 4 summarizes a stepwise approach to safe chemical
peeling in ethnic skin, while Table 5 summarizes the com-
monly encountered complications, as well as their preven-
tion and management.
Conclusions
Many chemical peeling agents currently exist, with newer
agents constantly emerging. These agents are highly effective
treatments for a plethora of skin disorders seen in ethnic skin,
and offer the advantages of being cheap, fast and safe. How-
ever, the use of chemical peels on ethnic skin should not be
taken lightly due to the increased risk of disfiguring dyschro-
mias and abnormal scarring. Clinicians must therefore be cog-
nizant of the strengths, limitations and safety of the peeling
agents they are utilizing.
More comparative research is required to develop a hierar-
chy of peel effectiveness for various ethnic skin disorders in
various skin types. This would provide clinicians with a pool
of evidence on which they can objectively base their choice of
chemical peeling agent.
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