Adverse Effects

Complications and risks of medium-depth peel are fewer with the advent of the combination peel, but they still exist. The most common complication following a TCA peel is hyperpigmentation, and the most common factor responsible is early sun exposure [52]. Patients are routinely instructed to avoid significant sun exposure in the weeks leading up to and following a medium-depth peel. A sunscreen with a UVA/UVB block is to be worn faithfully, and some doctors recommend their patients abstain from oral contraceptives (2 months before and after peeling) because their use may incite pigmentary changes [52, 44]. Pretreatment with retinoic acid and hydroquinone can reduce the risk of postoperative hyperpigmentation, but those with darker skin types and or those being treated for pigment problems are at even greater risks. If it arises, postpeel hyperpigmentation can be managed with retinoic acid, hydroquinone products, midpotency topical steroids, and follow-up peels (approximately 3–6 months later) until a lightening effect is achieved [44, 52]. Postpeel hypopigmentation is less frequently a problem,but its treatment options are few and less reliable. Although previously thought only to be a complication of deep peels, hypopigmentation has been reported following blanching with 20% TCA and 35% TCA chemical peels [44]. In darker skin types, this potentially permanent side effect can be devastating.


Hypertrophic scarring is a rare but is a disastrous complication of TCA peels. Those at increase risk include patients who have undergone facial plastic surgery, including a rhytidectomy, blepharoplasty, and deep-plane face lift in close proximity to peeling. Resnik et al. recommend a 6-month waiting period after these procedures before attempting a dermal peel.Additionally, patients who have taken isotretinoin should wait a minimum of 1 year before having a medium-depth peel although many clinicians prefer to wait 18–24 months [44]. Obagi et al., however, conducted a large controlled study and reported that hypertrophic scarring did not result from past, current, or postoperative use of isotretinoin as long as the peel depth did not extend beyond the papillary dermis [62]. Misplacement of the chemical and the depth of penetration in excess of the operator’s expectation are features of peeling that might be avoidable. Special care in not allowing the agent to drip or be drawn into unwanted areas is of critical importance. Maintaining a container with water and 10% sodium bicarbonate close at hand to neutralize glycolic acid and TCA, respectively, can tighten the control one has over how long and where the agent contacts the skin.Conditions that predispose to delayed healing may also be responsible for the development of hypertrophic scarring in certain patients. Chronic medical illnesses, prior radiation, chemical or thermal burns, and medication known to delay wound healing may all play a role in predisposing to scarring. The areas most vulnerable to this disfiguring effect are the jaw line, skin overlying the zygomatic arch, and the perioral perimeter. Treatment options include massage, compression bandages, topical/ intralesional steroids, and silicone gel sheeting [44, 63, 64].

Herpes simplex infection reactivation is a risk of any skin-resurfacing procedure.Because the consequences of a herpes outbreak following a medium-depth peel can be diffuse facial dissemination and scarring, patients are routinely prophylaxed with antiviral medication. The regimen may include any of the accepted oral antiherpetic medications beginning from 2 days before the peel (or started on the day of) and continued until re-epithelialization is complete (postoperative days 7–10). If an acute infection erupts in spite of prophylaxis, the medication is usually continued but at a higher dose. With early intervention, scarring is frequently avoided [52]. The risk of bacterial infection is reduced by the frequent acetic acid soaks (1 tablespoon of white vinegar/1 pint of water) recommended following the peel, which is not only antimicrobial against pseudomonas and other gram-negative organisms but acts as a debridement. Candidal infection may result from prophylactic antibiotics [47].

Less serious but more common side effects reported include milia, acne flares, and cyst formation [47] and keratoacanthomas [62] following chemical peeling. The use of occlusive ointments following the peeling process has been implicated as a possible cause. Bland emollients are a necessity in order to protect the newly laid epithelium and promote would healing. Persistent erythema beyond the accepted 60 days may indicate an incipient scar, contact dermatitis, or infection, and warrants careful proactive management in most cases [47].