Complications

As with any other treatment, complications may occur that are highly undesirable for both patient and doctor. The truth is that everyone who works with chemical peels has, at some point, had their share of unexpected surprises and problems. As skilled and trained as the practitioner may be, side-effects can always arise and patient selection is paramount to keep them to a minimum.

Being full-facial procedures, the possible occurrence of side-effects is particularly important, and more worrying to some extent, when compared to localised procedures such as soft tissue fillers. Complications may develop generally in the whole face or in one specific area alone. Problems are more likely to occur in increasingly deeper peels, while medium peels show relatively lower complication rates.

The most fearsome complication of a deep peel is cardiotoxicity, with the possibility of arrhythmia and extrasystoles taking place during the procedure. However, these can be controlled by the anaesthetist. Many patients referred to this kind of procedure are of a certain age and naturally suffer from compromised heart and vascular functions. A previous detailed analytical and imagiologic study should be mandatory. In the patient selection process, the author has turned down patients who present a minimum risk for the procedure.

Another of the more concerning complications is post‑inflammatory hyperpigmentation (PIH). It may occur in any patient, with any type of peeling. It is fair to say that PIH is more likely to appear in deep peels and high phototypes; however, it is also true that there is no possible objective way of anticipating which patient may develop such a condition. Special caution must be taken when conditions are present that may favour the production of melanin, as well as in the presence of hormonal disorders, gynaecological pathologies, photosensitising medication, and a keloid-related background, among others. The author makes a point in providing careful preparation before and ensuring comprehensive follow-up care after the procedure.

Hypopigmentation occurs less often than PIH, but it may still take place if the procedure is too aggressive and irreversibly damages the melanocyte. In the case of medium TCA peels, hypopigmentation may be a problem if serial peels are performed too frequently.

Scarring is another possible side-effect, particularly with deep peels if they are too aggressive and if the protocol described above has not been complied with. Delayed healing processes can cause them to form and special caution is advised in patients prone to keloid formation.

Infection may also be an issue in deep peels, mainly during the first week; therefore, the patient must be continuously monitored for any alarming signs and preventive measures must be taken at the minimum suspicion.

Both milia and acneiform eruptions are complications that may arise more than 5–7 days after peeling. Cosmetic intolerance, pruritus, and textural changes may be late appearing signs, occurring within weeks or even months after the procedure. Their underlying reasons are an ill-known phenomena, related to an individual’s sensitivity.

Herpes is a possibility for people with a history. A previous preventive treatment may be advised for patients with frequent herpetic outbreaks. If herpes is suspected to have appeared in the days following the peel, immediate action must be taken. Following a herpetic outbreak, treatment cannot be considered until 1 month after it has resolved.

In patients with a history of facial herpes zoster, the use of a chemical peel must be questioned and discussed. If the periocular area has been affected and/or if the condition has been resistant to treatment, the patient should not be considered as eligible for this kind of procedure. In all the other uncomplicated cases, a minimum period of 6 months must be completed after the cure before carrying out the peel.

Furthermore, it should not go unmentioned that any one of these procedures may trigger a herpes zoster outbreak which, although rare, is more likely to occur in elderly patients.

Erythema is a normal occurrence that will gradually disappear during the following months. However, in some patients, it may be particularly resistant or appear under the form of facial flushing triggered by solar exposure, anxiety, physical activity or certain cosmetics.

Demarcation lines may also jeopardise the final outcome. These are transition areas which become too visible, separating treated from non-treated areas and spreading around natural orifices, particularly the eyes, as well as in the transition from the face to the neck. This is why a deep peel must always cover up to 1–2 cm below the jaw line.

Almost all the complications described above are based on the author’s experience, and are treatable or at least manageable.

Conclusions

Chemical peels are versatile treatments adapted to a wide variety of patients. They provide reliably reproducible results and offer a good cost-to-benefit ratio.

Wrinkles can be effectively reduced using medium‑depth and deep peels. Deep peels are the most powerful and effective, but they do take a long time to master and their downtime must be taken into serious consideration.

Side-effects can never be completely ruled out; however, thorough patient selection and adequate follow-up care will help turn the procedure into a rewarding experience for both the patient and the doctor.