Chemical peels

Superficial peels are the mildest of the chemical peels and are mainly used to improve skin texture and reduce roughness. They mainly remove stratum coneum (dead skin surface cells) and sometimes the upper epidermis. They might improve discolorations, especially if the peeling solution includes a bleaching agent. Some types of superficial peels (such as salicylic acid peel) may help improve acne but that is not well researched.

Superficial peels are generally repeated at regular intervals to maintain results. Improvements with superficial peels are usually short-lived - hence superficial peels are often used repeatedly. Some people get cumulative improvement with repeated superficial peels; others simply maintain initial improvement; yet others see little or no improvement.

Superficial peels require no downtime but it is common to have a brief period of redness, flaking and/or skin sensitivity after a peel. However, peels should not be repeated so often as to create a state of chronic skin irritation and hypersensitivity. Otherwise, your skin will actually end up aging faster.

The most common agents used for superficial peels are alpha hydroxy acids (e.g. glycolic acid, lactic acid) and beta hydroxy acids (salicylic acid). Sometimes additional bleeching agents (e.g. hydroquinone, kojic acid) or other modifiers are added to customize the effects.

Superficial peels, such as 30% alpha or beta hydroxy acid peels, are not considered medical procedures by the FDA and are often performed by estheticians rather than doctors.

Medium peels

Medium peels impact the epidermis and upper dermis. The damage caused by the peeling agent induces a healing response and leads to a mild-to-moderate skin remodeling. As a result, medium chemical peel usually improves not only skin texture, but also fine lines and small wrinkles. Deeper wrinkles remain mostly unaffected. Blemishes and discolorations may also improve.

Medium peels may needed to be repeated two or more times to obtain the desired result. They would usually be spaced out over several months.

The most common agent for medium peels is trichloroacetic acid (TCA). It is a medium-strength acid, which produces damage by breaking up connections between cells, denaturing proteins in cells and skin matrix and so forth. After TCA treatment the skin surface becomes crusty and mild-to-moderate swelling would generally develop. You will need about 7-10 days of downtime to heal sufficiently to return to work and other normal activities. It is best to avoid sun exposure or at least use heavy UVA+UVB protection for at least a few more weeks. The improvements after medium peel are more lasting compared to superficial peel but fall short of the results delivered by deep peels.

Deep peels

Deep peels affect both epidermis and dermis and are both more effective and more risky than superficial or medium peels. It is mainly used to improve medium-to-deep wrinkles, severe skin roughness and other advanced signs of skin aging. The most common agent used in deep peels is phenol, which produces tissue necrosis by denaturing biological polymers.

Some call deep chemical peel a poor man's laser resurfacing. This is inaccurate because deep peels are not that much cheaper than ablative resurfacing. However, the degree of skin ablation, typical results, downtime and side effects of a deep peel are comparable to those of ablative laser resurfacing.

Based on relatively limited research comparing the two methods, deep peels remain a viable alternative to ablative laser resurfacing. For example, Dr. Langsdon and colleagues from Facial Plastic Surgery Clinic, Germantown TN, concluded that:

"Phenol CP [chemical peel] is as effective as the laser in diminishing rhytids [wrinkles] in the thin-skinned areas of the face. The laser produces improved results in the thick, glandular areas of the face, but also produces more intense hypopigmentation, longer periods of patient discomfort, and longer periods of postoperative erythema [redness]. Both phenol CP and laser resurfacing remain useful clinical tools."

In another study, Dr Moss and coworkers found some advantage of phenol peel versus ablative laser in relation to rebuilding collagen. In particular, they concluded that:

"The initial biopsies demonstrated that the CO2 lasers ablate more superficial skin than the peels, but the 3-month biopsy specimens showed that the zone of new collagen formation was thicker as a result of the phenol peel. ...With the parameters used in this study, phenol peels resulted in the formation of a thicker zone of collagen despite the deeper ablation depth of the laser."

While phenol peel produces greater and longer-lasting results, it is far less common than medium or superficial peel. One reason is that phenol peel requires 2-4 weeks of downtime during which a rather uncomfortable healing process takes place. (After all, like ablative resurfacing, phenol peel creates a large open wound.) Second, there is a substantial risk of both short- and long-term side effects. (Sort-term: infection, edema; long-term: loss of pigmentation, sun sensitivity, scarring.) In fact, pigmentation changes after a phenol peel (and, incidentally, after ablative laser too) are so common that dark skin color is considered a contraindication.

Deep peels should be performed by a certified, experienced surgeon. As opposed to superficial and medium peels, which are often repeated to enhance or maintain results, deep peel is performed once.

Costs

Chemical peels tend to be somewhat cheaper than some newer alternatives, such as lasers. After all, the peeling chemicals are dirt cheap compared to laser equipment. However, the price differential is less than it may seem because superficial and medium peels are generally performed in series (so you pay for multiple peels, not one) and deep peels are almost as expensive as laser resurfacing because most of its cost is patient care.

To be specific, superficial peels range between $150 and $300 each; medium peels range between $1000 and $2,000 each; while a deep peel starts at about $2,500 but may run as high as $5000 or more, depending on the costs of anesthesia, medication, postoperative care, and so forth.