Traditionally phenol peels components are:
• propylene glycol
• oil that accelerates carbolic acid absorption into epidermis
• distilled water
There are 3 types of peel formulation depending on the concentration of phenol:
• light-medium depth peel (3% carbolic acid)
• medium depth peel (25% carbolic acid)
• deep peel (over 35% carbolic acid)
Phenol peel is a high toxic chemical peel that is considered to be a serious dermatologic surgery procedure requiring sound medical judgment including kidney, liver and cardiovascular system examination. The procedure should be performed under intravenous anesthesia by a highly experienced physician under the supervision of an anesthetist with continuous cardiac monitoring.
Deep chemical peels affect all layers of the epidermis down to papillary layer resulting in prolonged recovery time (up to 12 months in some cases) requiring careful attention and special care.
Despite general recognition as “gold standard” of aesthetic medicine and radical non-surgical method of wrinkle removal, phenol peels are recommended only for a local application on affected skin areas with serious defects. According to recommendations of the scientific community, other skin areas should be peeled with milder exfoliation solutions.
Phenol peel is not recommended to be used for cosmetic purposes with the exception of certain cases when there is no alternative. For example by absolute contraindications for laser treatment and dermabrasion by patients with serious cosmetic defects that significantly affect quality of life.
Indications for phenol peel:
• significant age-related skin changes such as deep wrinkles and skin folds
• tissue scarring
• need for recovery after surgical treatment by lumpy scars
• loose skin
• severe demodicosis
• severe acne
Contraindications for phenol peel:
• age under 18
• burned skin
• acute phase of herpes
• cardiovascular diseases
• IV–VI skin phototype (Fitzpatrick skin type)
• individual intolarence to any ingredients of peel formulation
• oncological diseases
• skin diseases (eczema, psoriasis, atopic dermatitis)
• increased body temperature of any origin
• infectious diseases
• mental disorders
• thyroid disease
• periods of intense sun exposure
• personal meteosensitivity
• Isotretinoin need for 6 months before the procedure
• kidney and liver diseases
• fungal diseases
• violation of skin integrity
• skin damage on the treated skin area
• multiple nevuses
• keloid prone skin
• violation of skin sensitivity
Relative contraindication for phenol peel is age over 60 due to decreased function of the liver’s enzyme system by older people.
Compared to other peels, phenol peel has its advantages and disadvantages.
Advantages of phenol peel:
• controlled application of the peel solution
• visible anti-aging and curative effect
• long-term effect maintenance (7-10 years)
• the procedure requires only a single performance
Disadvantages of phenol peel:
• extensive list of contraindications
• prolonged recovery time (about 2 weeks after superficial exfoliation and up to 12 months after deep exfoliation)
• careful medical examination prior to the procedure required
• special pre-peel skin preparation required
• stress for cardiovascular and excretory system
• pain and discomfort during the procedure
• sedation required (local anesthesia by superficial exfoliation, intravenous anesthesia by deep exfoliation)
• continuous cardiac monitoring during the procedure performance required
• risk of developing severe complications
Properties of the active ingredient
Phenol (also known as hydroxybenzene or carbolic acid) is a simple volatile aromatic compound. In case of contact with skin phenol provides its exfoliation stimulating glycosaminoglycan synthesis and protein production improving skin elasticity. Carbolic acid also significantly helps to even out skin texture and skin tone. These processes lead to general skin improvement making it look younger, smoother and firmer.
Phenol is considered to be a very toxic substance that penetrates the skin rapidly entering the body by intestinal absorption. In a few minutes after absorption it starts to affect brain tissue causing disruption of the central nervous system, mucous membrane and respiratory tract irritation, convulsions, cyanosis and cognitive dysfunction. At the same time, phenol does not show any carcinogenic effects.
When absorbed by the intestine, carbolic acid enters the liver where it is dissolved by the enzymes into harmless soluble metabolites excreted by the kidneys. Such mechanism of phenol excretion prevents late toxicity. However, phenolic compounds are also produced by the human body by tyrosine decomposition indicating the ability of the organism to neutralize and excrete phenol by itself.
In as much as liver and kidneys are responsible for phenol excretion, a careful medical examination of these organs is required prior to the procedure. Moreover, carbolic acid can cause cardiac arrhythmia which means continuous cardiac monitoring is required by deep phenol peel.
Phenol peel policy and standards have been developed upon a scientifically based research carried out in 1979 by two biochemists – Truppman and Ellenby – who have proven dependency between degree of carbolic acid toxicity, its concentration, size of the treated skin area and speed of the application of the peel composition.
In particular, experience has shown that by slow application of peel composition to small skin areas phenol has no significant toxic effect due to the liver’s ability to neutralize certain amount of substance by slow exposure. Although rapid application of only 2% carbolic acid to the whole body skin surface can cause death.
It should be noted that certain medications may enhance the toxic effects of phenol peel. For example aspirin is neutralized by the same liver enzymes that neutralize carbolic acid. Therefore drug intake can affect liver slowing down phenol metabolism and should be avoided for this reason to prevent severe intoxication.
• Medical examination of liver, kidneys and cardiovascular system.
• Skin treatment with bleaching agents (weak acid solutions) for 5-7 weeks. This stage of pre-peel skin preparation is required to avoid deep skin damage during the procedure and hyperpigmentation after it.
• Angioprotectors and antioxidant preparations intake during 2-3 weeks.
• Withdrawal of aromatic retinoids (externally and internally) 6 months prior to the peel procedure. These preparations increase skin exfoliation providing deeper penetration of phenol into skin layers causing skin burn and hyperpigmentation.
• Any procedures that may cause skin injury such as epilation, mechanical skin cleansing or shaving should be avoided 10 days prior to the peel procedure.
• Laser skin treatments, mechanical dermabrasion as well as mid-grade peels should be avoided 6 months prior to the procedure.
• The physician performing the peel procedure should be informed about constantly taking medications.
• Sun exposure as well as solarium should be avoided 3 months prior to the peel procedure.
Since phenol vapors are toxic, all procedures using this substance should be performed in a well-ventilated place with a hood. Due to the high toxicity of the active ingredient phenol peel is usually applied to small skin areas most affected by deep wrinkles, acne, stretch marks and scars, while other skin areas are treated with a mid-grade peel solution. Carbolic acid is never used on keloid-prone skin areas such as arms, chest, neck and inner thighs.
Phenol peel stages:
• Anesthetist makes intravenous or local anesthesia depending on the peel depth. Local anesthesia is usually performed with 2% lidocaine. It should be noted that anesthetic dose escalation can increase phenol toxicity as soon as both substances are transformed by the same liver enzymes. It can cause severe complications such as AV block (impairment of the conduction between the atria and ventricles of the heart) and respiratory arrest.
• Make-up removal using a hard sponge followed by careful drying of skin surface.
• Skin cleansing using alcohol to remove contaminations and excess skin oil.
• The peel solution is applied with uniform layers with slow smooth movements. The interval between treatments of different skin areas should be longer than 5 minutes.
• Carbolic acid neutralization using special peel-off mask and neutralizer which is applied over the mask once it dried.
• Sunscreen application.
The procedure takes 40-120 minutes depending on individual skin features.
Phenol Peel. Photos before and after procedure
Post-peel skin care
After the peel procedure patients usually feel significant skin burning on treated areas. It is a normal skin reaction, but in case of severe pain anesthetics are recommended.
On the first day after the treatment contact with water should be avoided as it provides phenol penetration into deeper skin layers increasing risk of uncontrolled skin burn. For that reason the patient should avoid tooth brushing and drink only through a straw.
On the second day the mask is peeled off with dead skin cells revealing ruby red surface of rejuvenated skin. Contact with water should still be avoided.
At this stage a crust forms on the treated skin areas requiring external application of panthenol spray. Scratching and decrustration should be avoided to prevent scars and hyperpigmentation.
Complete recovery after superficial peel and partial skin rejuvenation after deep phenol peel usually appears after 10-14 days after the procedure. At this stage the patient can go back to his social life keeping using panthenol. Skin redness disappears in 2 months, however healing processes will be completed in full only in 7-12 months.
Application of foundations is allowed in 3 weeks after the peel procedure.
Sun exposure as well as solarium should be avoided during the next year.
For post-peel skin treatment physicians usually prescribe following products:
• bleaching agents
• sunscreens with SPF 50+
• moisturizers with hyaluronic acid
• intake of vitamins A and C to amplify the effect of bleaching agents
This post-peel skin care should be carried out for at least the next 6 months after the procedure.
Potential complications after phenol peel:
• high risk of developing of cardiac arrhythmia, hepatic and renal failure
• third degree burn requiring skin protection from UV-radiation for the rest of the life
• acute herpes
• reduced immunity
• infectious, fungal and viral diseases
• demarcation line between the treated skin area and the skin area that wasn’t treated (typical for dark skin)
• hyperpigmentation as a result of liver and kidneys function abnormality as well as by oily skin
• miliums (whiteheads)
• keloid scars
• loss of ability to produce skin pigment. It should be noted that freckles will never appear again. The skin requires continuous protection from UV-radiation for the rest of the life to avoid hyperpigmentation and prevent skin cancer.
• pathological increase in skin sensitivity
• persistent skin swelling (last longer than 72 hours)
• acute skin diseases such as acne, seborrheic dermatitis and rosacea
• skin atrophy
• persistent erythema
• depigmentation of skin areas
• enlarged pores
Effect of phenol peel
Positive visual effect after the peel procedure remains for the next 10 years. Advantages of phenol peel are:
• normalization of skin function
• visible skin rejuvenation (makes skin look 5-15 years younger)
• significantly improves skin texture making it smooth, firm, soft and light
• pigmentation spots removal
• deep wrinkles and scars removal
• expression wrinkles and fine lines removal
• skin tone improvement
• human organism systems activation at the microcircular, neural and humoral levels.
Phenol peels vary in price depending on the area treated as well as the depth treated. Cost may vary between $1000-$6000.