Overview

Chemical peelings represent accelerated exfoliation or skin damage induced by caustic agents that cause controlled damage, followed by the release of cytokines and inflammatory mediators, resulting in thickening of the epidermis, deposition of collagen, reorganization of structural elements, and increases in dermal volume. This process decreases solar elastosis and replaces and reorients the new dermal connective tissue. The result is an improved clinical appearance of the skin, with fewer rhytides and decreased pigmentary dyschromia. Since the days of ancient Egypt, people have been using chemexfoliation methods, also known as chemical peeling, to re uvenate skin. The original chemexfoliant was lactic acid, an active ingredient of sour milk that was used topically by the nobles as part of an ancient skin re uvenation regimen. !n the "iddle #ges, old wine with tartaric acid as its active ingredient was used for the same purpose. Today, these historical chemexfoliants are known to contain alpha hydroxy acids, which are the active ingredients responsible for the skin exfoliation. "odern day chemical peeling originally was promoted by dermatologists, such as $.%. &nna, who first described the properties of salicylic acid, resorcinol, phenol, and trichloroacetic acid 'TC#(. Slowly, the early practitioners of chemical peels began to develop other peeling agents for varying depths of penetration. !n the )*+,s, -aker and %ordon developed a deep peeling agent, which was able to smooth deeper furrows, especially around the mouth. .rom the )*/,s to the present, an explosion has occurred in the mass of research on this sub ect, with the elucidation of many different types of peels, each for a specific range of problems.

General process of performing a chemical peel

#n evaluation of the patient by the clinician is necessary to determine the appropriate treatment based on the dermal defect. 0hen evaluating the patient before the peel, an extensive history should be taken. !f it is determined that a chemical peel is warranted, the appropriate agent is selected based on the patient1s .itzpatrick skin type and %logau photoaging group, as well as other variables that may affect peel penetration. Evaluation of the skin should also refer to skin thickness and oiliness. Sebaceous skin usually re2uires priming with topical retinoids or3and alpha hydroxy acids and thorough skin defatting before the procedure to assure even penetration of the peeling solution. The patient must be educated concerning the chemical peel process and give signed consent is advised if performing a medium or deep peel. The patient has to be 2uestioned about their general health status, medications 'eg, oral isotretinoin(, smoking, previous cosmetic procedures 'eg, surgical lifts, fluid silicone in ections(, recurrent herpetic outbreaks, and keloid formation. The skin should be defatted properly with acetone. 4elicate areas that need to be protected should have petroleum elly applied, including the lips, inside the nose, and optionally in the nasolabial fold, medial canthus, and lateral canthus. The correct peeling agent then is applied for the appropriate amount of time. 0hen performing a combination peel, pouring one agent at a time is advisable because of the ease in which the agents may be confused when poured into similar cups. Then, the peeled area should be neutralized, and the patient should be sent home with proper instructions along with advice to call should any complications arise. Skin preparation with bleaching creams and early reintroduction of these products in the immediate postpeel period are crucial to avoid postinflammatory hyperpigmentation in dark phenotypes. The images below depict a patient during and after a salicylic acid peel.

"en also re2uest chemical peeling. This 5+6year6old man is in the

process of a salicylic acid peel. a successful chemical peeling.

Same patient as shown above following

Indications
Pigmentary disorders
"elasma $ostinflammatory hyperpigmentation .reckles 7entigines .acial melanoses Superficial acne scars $ostacne pigmentation Comedonal acne8;: #cne excori<e #cne vulgaris 6 "ild to moderately severe acne $hotoaging .ine superficial wrinkling 4ilated pores Superficial scars

Acne 8), 9:

Aesthetic 8=, ):

Epidermal growths
Seborrheic keratoses #ctinic keratoses

0arts "ilia Sebaceous hyperplasia 4ermatosis papulosa nigra

&pper epidermal defects, such as melasma, can be treated with superficial peels, while deeper defects, such as deep wrinkles, may re2uire a deep peeling agent.85: "edium6depth 'superficial dermis( defects, such as mild dermatoheliosis, re2uire a medium6depth peel. 4eep perioral rhytides may re2uire a deep peel, such as the -aker %ordon solution.

Contraindications
Relative contraindications
>elative contraindications are determined by the skin type of the patient and the defect being treated. To optimize the procedure, some classifications are very useful, such as the .itzpatrick and the %logau photoaging classifications. .itzpatrick skin typing is graded from )6+, with the first ; skin types being white skin with progressively more active responses to tanning. Type = is light6brown skin, and type 5 is dark brown skin. Type + skin never tans and is essentially black skin with an e2uivalent sun protective factor 'S$.( of /. .itzpatrick skin types 5 and + are usually not ideal candidates for medium and deep peels. The best candidates are the light skin types, ), 9, and ;, which are at less risk of complications such as pigment dyschromia and scarring. #lthough skin types 5 and + are not ideal for peels, they can be peeled using superficial agents such as salicylic acid or glycolic acid. The %logau photoaging classification is a visual grading system used to 2uantify photodamage. $atients with photoaging type ! are not good candidates for deep peeling because the peel may be more damaging than beneficial, while a superficial peel would be more efficacious. $atients with type !? photodamage may benefit from deep peeling, while a superficial peel may not make much of a difference. $atients with skin types !! and !!! ordinarily benefit from superficial or medium6depth peels, depending on the exact circumstances of the patient. @ther variables also should be considered, including the .itzpatrick skin type, when determining which peeling agent to use. !n type !, the patient, usually is in the second or third decade of life, shows mild early photoaging that consists of mild pigmentary changes, does not have keratoses, and has minimal wrinkles. The patient re2uires minimal or no makeup. !n type !!, the patient has wrinkles that appear when he or she makes facial gestures or other dynamic facial muscle activity 'ie, Awrinkles in motionA(. Early6to6moderate photoaging is recognized by early senile lentigines, keratoses that are palpable but not visible, and the emergence of parallel smile lines. The patient is usually in the third or fourth decade of life. .emale patients usually wear some foundation. !n type !!!, the patient has wrinkles not dependent on facial movement 'ie, Awrinkles at restA(. #dvanced photoaging is recognized by obvious dyschromia, telangiectasias, visible keratoses, and wrinkles at rest. The patient is usually aged 5, years or older, and female patients almost always wear heavy foundation. !n type !?, the patient has only wrinkles, and nearly no smooth skin. Severe photoaging is characterized by yellow6gray coloration of the skin, prior history of skin malignancies, and skin

that is thoroughly wrinkled. The patient is usually in the sixth or seventh decade of life. !n addition, the patient cannot wear makeup because it cakes and cracks in the wrinkles.

Absolute contraindications
#ctive bacterial, viral, fungal, or herpetic infection @pen wounds Bistory of drugs with photosensitizing potential $reexisting inflammatory dermatoses 'eg, psoriasis, atopic dermatitis( &ncooperative patient 'patient is careless about sun exposure or application of medicine( $atient with unrealistic expectations .or medium6depth and deep peels, history of abnormal scarring, keloids, atrophic skin, or isotretinoin use in the last + months

Other considerations
4egree of photoaging damage $atients with either severely damaged skin or excellent skin may not be good candidates for chemical peels. Sun6damaged skin shows epidermal changes, elastosis, and collagen distortion in the midreticular dermis. To eradicate photodamage, deep peels are re2uired. "ore superficial peels, even when performed in repetitive fashion, do not reach the affected histological level and therefore have a minimal effect on photodamaged skin. Smoking $atients must understand the necessity for smoking cessation. The dynamic action of puffing can worsen perioral rhytides, and the chemicals in the smoke can cause enzymatic reactions that weaken the skin and cause further wrinkling around the mouth and eyes. $rior cosmetic surgery 0aiting several months following surgery that involves the face is recommended. %ive the skin time to heal prior to sub ecting it to chemexfoliation. Compliance with prepeel and postpeel treatment must be assured. The patient must be motivated enough to adhere to a daily regimen for a few weeks before and after the procedure. %eneral health 0ith phenol peels, the patient should be in good general health because phenols can cause arrhythmias. $henol is directly toxic to myocardium. Cardiac arrhythmias have been recorded in up to 9;C of patients when a full6face peel was performed in less than ;, minutes. These arrhythmias have included tachycardia, premature ventricular beats, bigeminy, atrial tachycardia, and ventricular tachycardia. #de2uate patient management reduces this complication rate to less than DC. %ood kidney and liver function are necessary for ade2uate excretion and detoxification. # screening blood chemistry that includes blood urea nitrogen, creatinine, and liver function is wise. EC% monitoring is necessary during the peeling process. Eo hepatorenal or central nervous system toxicities have been reported in the literature with properly performed chemical peels. "ental health

$atients who are mentally unstable may be overly self6conscious and may not be prepared for their aesthetic appearance immediately following the peel. "edications # thorough medical and drug history is very important. "edical conditions such as cardiac, hepatic, or renal disease may influence treatment decisions and the choice of peeling agents. Exogenous estrogens, oral contraceptives, and other medications may be photosensitizing and predispose patients to pigmentation complications after chemical peeling and worsening the skin discoloration that the chemical peel was intended to eradicate. $atients taking blood thinners, such as warfarin, should avoid deep peels because of the possibility of blood oozing from the peel site. $atients taking aspirin usually do not have complications, but, if the medication is not necessary, advise them to stop taking it ) week prior to a deep peel. Berpes # history of herpes simplex re2uires antiviral prophylaxis from the immediate prepeel period until reepithelialization is complete. #cyclovir '=,, mg( should be started 9 days prior to the peel and continued for 5 days after the peel to reduce the risk of recurrent herpes infection. Some dermatologists advise prophylaxis in all patients to avoid the risks of a herpetic outbreak. #ny existing lesion must heal completely before undergoing a chemical peel. Bistory of scarring $atients need to be asked if they have a history of hypertrophic scarring. "any people who have hypertrophic scarring can develop keloids. This usually is found in patients with .itzpatrick skin types 5 and + but can develop in patients with skin types ), 9, ;, and =. "edium and deep peels penetrate into the superficial and deep dermis, which may stimulate keloidal development in patients who are inclined to develop keloids. 0eak superficial peels can be considered in patients with skin types = and 5 because the penetration is only into the epidermis. $atients with a history of scarring are not candidates for ma or skin resurfacing, such as laser or medium3deep peels. Expectations # discussion between the physician and patient is necessary prior to a chemical peel, especially a deep peel. Examples of before6and6after results should be shown, and the possibility of complications must be explained to the patient. .ollicle unit density $revious use of isotretinoin must be noted. $atients should wait until + months after the last dose of isotretinoin to reduce the risk of scarring. $atients who have had recent radiation treatment need to have a skin biopsy performed to ascertain the existence of hair follicle units, because these follicle units are where the reepithelialization occurs.

Equipment
uperficial peeling agents
Trichloroacetic acid8+, D: Trichloroacetic acid 'TC#( can be used to create a superficial, medium, or deep peel. #part from variables such as patient skin type, ade2uacy of skin priming, layers of acid applied, and techni2ue of application, the most important factor affecting the depth of the peel is the concentration of TC# used. Concentrations of ),695C are used for intraepidermal peels, whereas ;,6=,C are used for papillary dermal peeling. TC# is most commonly used for medium6depth peels, especially to treat pigmentation disorders and early facial rhytides. TC# '),6;5C( has been used for many years and is safe to use at lower concentrations. #t higher concentrations, such as 5,C and greater, TC# has a tendency to scar and is less manageable than other agents used for superficial peels. TC# is found in several proprietary peels at varying concentrations, and some kits have instructions and buffering agents so the peel can be diluted as deemed necessary. The end point is frosting for TC# peels, which are neutralized either with a neutralizing agent or cold water, starting from the eyelids and then proceeding to the entire face. Fessner solution Fessner peel solution is a combination of salicylic acid )=C, lactic acid )=C, and resorcinol )=C in alcohol. This agent is easy to use, with no timing necessary. #pply the agent, wait for a light frost, and then neutralize with water. The solution is applied to the skin with a soft applicator in patients with thin, sensitive skin or is rubbed in with gauze s2uares in patients with thick sebaceous skin. The depth of the peel depends on the number of coats of solution applied. # very superficial Fessner peel results in faint erythema, which may be associated with a light powdery6looking whitening of the skin surface. Salicylic acid Salicylic acid has been used for several decades and is found in medications such as 0hitfield1s ointment at =C and Trans6?er6Sal at )DC concentrations. #dverse effects, usually only found with high6dose oral ingestion, include headache, nausea, and ringing of the ears, each of which may be resolved with a few glasses of water and rest. These have never been reported with a peel procedure. .or salicylic acid peels, the end point is the pseudofrost formed when the salicylic acid crystalizes. This type of agent is very safe, and patients generally tolerate the procedure well. Salicylic acid is lipid solubleG therefore, it is a good peeling agent for comedonal acne. The salicylic acid is able to penetrate the comedones better than other acids. The anti6 inflammatory and anesthetic effects of the salicylate result in a decrease in the amount of erythema and discomfort that generally is associated with chemical peels. The most common concentration used today is 9,6;,C and can be purchased in easy6to6use kits. # newly introduced agent, beta6lipohydroxy acid, is a salicylic acid derivative and has properties that could possibly expand the clinical use of peels.8/, *: Carbon dioxide Carbon dioxide peels use a solid block of carbon dioxide ice dipped in an acetone6 alcohol mixture, which is then applied to the skin for 56)5 seconds, depending upon the desired depth.

 Carbon dioxide is easier to use, and the depth of the peel can be controlled more easily than with li2uid nitrogenG carbon dioxide is at 6D/HC, while li2uid nitrogen is at 6)*+HC. #lpha hydroxy acid8),, +: #lpha hydroxy acid peels include lactic acid, glycolic acid, tartaric acid, and malic acid that are synthesized chemically for use in peels. ?arious concentrations can be purchased, with ),6D,C concentration used for facial peels, most commonly 5,C or D,C. #lpha hydroxy acids are weak acids that induce their re uvenation activity by either metabolic or caustic effect. #t low concentration 'I ;,C(, they reduce sulfate and phosphate groups from the surface of corneocytes. -y decreasing corneocyte cohesion, they induce exfoliation of the epidermis. #t higher concentration, their effect is mainly destructive. -ecause of the low acidity of alpha hydroxy acids, they do not induce enough coagulation of the skin proteins and therefore cannot neutralize themselves and must be neutralized using water or a weak buffer. $yruvic acid $yruvic acid is used in superficial peeling and if difficulty is encountered controlling peel depth. # product currently is being developed that uses ethyl pyruvate and has a higher pB and greater buffering ability than other related products. !edium"depth peels 8)): Three combination peels currently being used are carbon dioxide and TC# ;5C, Fessner solution and TC# ;5C, and glycolic and TC# ;5C. These peels are as effective as the other medium6depth peels, with less chance of scarring and pigment dyschromia. #n endless number of combinations are possible, more than can be covered in this overview. TC# 5,C is seldom used because of a higher risk of scarring and the availability of the combination peels. .ull6strength phenol '//C( is a very caustic agent that causes immediate keratin agglutination, preventing further penetration of the agent deeper into the dermis. #gain, the increased risk of scarring and pigment dyschromia makes this agent less attractive to the practitioner. !f diluted and mixed with other complementary chemicals, this agent can be used effectively as a deep peeling agent. #eep peels 8)9: -aker6%ordon peel produces the most dramatic results and is the most effective peeling agent currently used. The phenol produces a new zone of collagen that is thicker than that produced by laser. This solution is very effective in smoothing wrinkles related to aging and sun damage. This advantage is countered by several disadvantages. The agent may produce premature ventricular contractions or more serious arrhythmia. # long healing time is re2uired, with erythema occasionally lasting as long as + months. !n addition, the potential for pigmentary changes, scarring, and infection are high with this peel. 4espite the problems that may be encountered, a properly administered phenol peel is unmatched by the other peeling agents, and, for perioral wrinkles, the phenol peel even surpasses laser resurfacing. #lthough dramatic results can be achieved with the phenol peel, the risks and benefits should be weighed carefully before proceeding. @nly experienced clinicians should attempt a phenol agentJbased peel. The -aker6%ordon solution is made of phenol //C, 9 m7 distilled water, / drops Septisol, and ; drops croton oil. This formula penetrates into the middle reticular dermis and re2uires special monitoring devices, such as an EC% monitor and pulse oximeter, because of the potential of the phenol to cause arrhythmias. The -aker6%ordon formula is not often used in current practice

because of resurfacing laser technologyG however, a deep peel works well on deep perioral rhytides. 4eep peels can be occluded or nonoccluded. The occluded method uses zinc oxide tape or another artificial barrier product to prevent evaporation of the phenol from the skin, thus enabling the solution to penetrate deeper. Two variants of the -aker6%ordon peel are 7itton1s formula, which replaces Septisol with glycerin, and the -eeson6"cCollough formula, which uses aggressive defatting and a heavier application of -aker6%ordon solution.

Pearls
-efore the appropriateness of chemical peeling is determined, the patient has to be 2uestioned about their general health status, medications 'eg, oral isotretinoin(, smoking, previous cosmetic procedures 'eg, surgical lifts, fluid silicone in ections(, recurrent herpetic outbreaks, and keloid formation. 0hen performing a combination peel, pouring one agent at a time is advisable because of the ease in which the agents may be confused when poured into similar cups.

Complications
Pigmentary change
$igmentary change is not an uncommon complication, especially with the deeper peeling agents. !n some cases, the peeled area remains stark white. Taking proper precautions 'as described earlier( can help prevent undesirable pigmentary changes. &sually, patients with lighter complexions have a lower risk of hyperpigmentation, but genetic factors play an important role, and, sometimes, light6skinned patients with Adark genesA hyperpigment unexpectedly. Skin priming using a combination of hydro2uinone and tretinoin cream 'Kligman formulation( before a superficial or medium6depth peel and early introduction of this preparation after deep peels reduces the rate of this complication.

carring
Scarring remains the most dreaded complication of chemical peels. The contributing factors are not well understood. -y matching the patient and peeling agent properly, the risk of scarring can be decreased. !n addition, to further decrease the risk of scarring, the patient should be advised to refrain from picking at the healing skin. $atients with a history of keloids should not undergo medium or deep peels because of the risk of scarring. "edium and deep peels penetrate to the superficial and reticular dermis and, thus, may stimulate keloids. 0eaker superficial peels that only exfoliate the stratum corneum or superficial epidermis can be used.

Infection
-y using bacitracin for the medium and deep peels and cleaning the face with a povidone wash, the risk of infection is decreased. Cold sores can be prevented with acyclovir '=,, mg $@ bid(, beginning 9 days prior to the peel

and continuing D days after the peel. Candidiasis infection also can develop, for which a short course of fluconazole can be used. Cultures need to be taken, and appropriate antibiotics should be administered. Toxic shock syndrome has been reported after a chemical peel.8)=:

Prolonged erythema
$atients usually do not report erythema because it generally subsides in ;,6*, days, but sometimes erythema continues. $rolonged erythema is usually not permanent, and topical hydrocortisone can be used to speed the healing process.

Acne
Some patients develop acne after a chemical peel. This usually occurs between days ;6*. Cultures should be taken, and an antibiotic that covers gram6positive bacteria should be prescribed. !f it is a true acne occurrence, then the appropriate topical treatment also should be started. !f severe enough, isotretinoin may be initiated.

!ilia
Small inclusion cysts, sometimes called milia, can appear in the healing process after a chemical peel. These usually appear about 96; weeks after reepithelialization and may be aggravated by ointments, owing to occlusion of the sebaceous glands.

tages of $ound %ealing After Cheme&foliation

Coagulation and inflammation
The healing process after a chemical peel must be as rapid as possible to avoid infections that may deepen the wounds, extending the peel from superficial to deep, with increased risks of scaring. 4eep peels may be prophylactically treated with antimicrobials, but superficial and medium6deep peels are simply kept moist with the application of petrolatum6based products. #fter reepithelialization, and when skin appearance is back to normal, a regimen of alpha hydroxy acids, retinoic acid, bleaching creams, moisturizers, and sunscreens should be restarted. Sun exposure must be avoided for + weeks after the peel to minimize the risks of postinflammatory hyperpigmentation. $roduction of controlled chemical burns of the epidermis and3or dermis results in exfoliation. The first phases of this process must be understood well to control the depth of penetration of chemical peelings. $hases are as followsL The development of diffuse homogeneous erythema indicates epidermal penetration. The development of white frost indicates coagulative necrosis of the papillary dermis. The development of gray6white frost indicates coagulative necrosis of the reticular dermis. !n all these events, clotting factors are activated, as are monophages and lymphocytes. !nflammatory mediators are activated, such as C5a, leukotriene -=, and kallikrein.

Reepitheliali'ation
$reventing scab formation is important for faster and more even healing. -iosynthetic occlusive dressings can be used to hasten the healing process for deep peels.

Granulation tissue
%ranulation tissue usually appears the second day and consists of fibroblasts, inflammatory cells, fibronectin, glycosaminoglycans, and collagen. >eepithelialization occurs subse2uent to this process.

Angiogenesis
This process begins with endothelial cell migration to the wound site and is essential for wound healing. The erythema following a chemical peel primarily is caused by the new capillary growth in the area.

Collagen remodeling
Collagen remodeling is the main reason that chemical peels are able to reduce wrinkles. The process of remodeling involves a reorientation of the collagen in a parallel fashion and begins as collagen is formed following the peel. 4eposition of glycosaminoglycans in the dermis correlates with the efficacy of the peeling procedure. ). >endon "!, -erson 4S, Cohen F7, >oberts 0E, Starker !, 0ang -. Evidence and considerations in the application of chemical peels in skin disorders and aesthetic resurfacing. J Clin Aesthet Dermatol. Ful 9,),G;'D(L;96=;. 8"edline:. 8.ull Text:. 9. Kim >B, #rmstrong #0. Current state of acne treatmentL highlighting lasers, photodynamic therapy, and chemical peels. Dermatol Online J. "ar )5 9,))G)D';(L9. 8"edline:. ;. 7eves2ue #, Bamzavi !, Seite S, >ougier #, -issonnette >. >andomized trial comparing a chemical peel containing a lipophilic hydroxy acid derivative of salicylic acid with a salicylic acid peel in sub ects with comedonal acne. J Cosmet Dermatol. Sep 9,))G),';(L)D=6/. 8"edline:. =. %oldman #, 0ollina &. .acial re uvenation for middle6aged womenL a combined approach with minimally invasive procedures. Clin Interv Aging. Sep 9; 9,),G5L9*;6*. 8"edline:. 8.ull Text:. 5. Kumari >, Thappa 4". Comparative study of trichloroacetic acid versus glycolic acid chemical peels in the treatment of melasma. Indian J Dermatol Venereol Leprol. Ful6#ug 9,),GD+'=(L==D. 8"edline:. +. 4uffy 4". #lpha hydroxy acids3trichloroacetic acids risk3benefit, strategies. # photographic review. Dermatol Surg. .eb )**/G9='9(L)/)6*G 2uiz )*,6). 8"edline:. D. %logau >%, "atarasso S7. Chemical peels. Trichloroacetic acid and phenol. Dermatol Clin. #pr )**5G);'9(L9+;6D+. 8"edline:. /. -erson 4S, Cohen F7, >endon "!, >oberts 0E, Starker !, 0ang -. Clinical role and application of superficial chemical peels in today1s practice. J Drugs Dermatol. Sep 9,,*G/'*(L/,;6)). 8"edline:. *. .ischer TC, $erosino E, $oli ., ?iera "S, 4reno -. Chemical peels in aesthetic dermatologyL an

update 9,,*. J Eur Acad Dermatol Venereol. Sep / 9,,*G8"edline:. ),.-riden "E. #lpha6hydroxyacid chemical peeling agentsL case studies and rationale for safe and effective use. Cutis. .eb 9,,=GD;'9 Suppl(L)/69=. 8"edline:. )).Balaas M$. "edium depth peels. Facial Plast Surg Clin North Am. #ug 9,,=G)9';(L9*D6;,;, v. 8"edline:. )9.7andau ". #dvances in deep chemical peels. Dermatol Nurs. 4ec 9,,5G)D'+(L=;/6=). 8"edline:. );."angat 4S, Tansavatdi K, %arlich $. Current chemical peels and other resurfacing techni2ues. Facial Plast Surg. .eb 9,))G9D')(L;56=*. 8"edline:. )=.Bolm C, "Nhlbauer 0. Toxic shock syndrome in plastic surgery patientsL case report and review of the literature. Aesthetic Plast Surg. "ay6Fun )**/G99';(L)/,6=. 8"edline:. )5.8%uideline: de -erker 4, "c%regor F", Bughes ->. %uidelines for the management of actinic keratoses. r J Dermatol. .eb 9,,DG)5+'9(L9996;,. 8"edline:. )+.8%uideline: Strauss FS, Krowchuk 4$, 7eyden FF, et al. %uidelines of care for acne vulgaris management. J Am Acad Dermatol. #pr 9,,DG5+'=(L+5)6+;. 8"edline:. )D.#. Tosti, $. E. %rimes, ". $. 4e $adova. %licolic #cid. !nL Springer!Verlag erlin "eidel#erg$ Color Atlas o% chemical peels$ &erman'. 9,,+LChapter 9G pages );69). )/.-rody BF. Chemical Peeling and (esur%acing. 9nd ed. St. 7ouis, "oL "osby6Mear -ookG )**D. )*.7andau ". Cardiac complications in deep chemical peels. Dermatol Surg. .eb 9,,DG;;'9(L)*,6 ;G discussion )*;. 8"edline:. 9,."onheit %4. Chemical peels. S)in *herap' Lett. .eb 9,,=G*'9(L+6)). 8"edline:. 9).>endon "!. &tilizing combination therapy to optimize melasma outcomes. J Drugs Dermatol. Sep6@ct 9,,=G;'5 Suppl(LS9D6;=. 8"edline:. 99.>esnik SS, >esnik -!. Complications of chemical peeling. Dermatol Clin. #pr )**5G);'9(L;,*6 )9. 8"edline:. 9;.Truppman ., Ellenbery F. The ma or electrocardiographic changes during chemical face peeling. Plast (econstr Surg. )*D*G+;L==. 9=.Tse M, @stad #, 7ee BS, et al. # clinical and histologic evaluation of two medium6depth peels. %lycolic acid versus Fessner1s trichloroacetic acid. Dermatol Surg. Sep )**+G99'*(LD/)6+. 8"edline:.