Preprocedure Rejuvenation Regimen

Several different prepeel regimens have been described in the literature. Multiple combinations exist with a few key players such as topical tretinoin, hydroquinone, alpha-hydroxyl acids, kojic acid, and low-potency steroids. It is also important to counsel patients to minimize sun exposure, utilize sun blocks with UVA/UVB protection, and to avoid smoking.

There is evidence that pretreatment with 2–4% hydroquinone twice daily and topical tretinoin (0.05% and 0.1%) or retinoic acid nightly 1 month prior to the peeling reduces dyschromias and promotes faster healing in the immediate postpeel period. The use of tretinoin prior to chemical peeling speeds epidermal healing and enhances the effects of the procedure [12]. These agents act by priming the skin. They help to achieve a more uniform penetration of peeling agents by reducing sebum and thinning the stratum corneum. They also accelerate re-epithelization, reduce wound healing time, and have a lightening effect by enhancing dispersion of melanin granules [13]. Hydroquinone blocks the enzyme tyrosinase from developing melanin precursors for the production of new pigment in the epidermis during the healing phase.


Another approach to patients with pigment dyschromias is to start a prepeel regimen that consists of using 4% hydroquinone twice daily 2–4 weeks prior to the peel and to resume using the 4% hydroquinone 2 days postpeel. The combination of the peel and twice-daily application of 4% hydroquinone produced substantial decreases in the intensity of hyperpigmentation and lesional area for both PIH and melasma [14]. Of note, prolonged use of high concentrations of hydroquinone (6–10%) may paradoxically produce ochronosis, especially in patients with Fitzpatrick types V and VI skin.

Combinations of hydroquinone, topical steroids, and tretinoin have also been reported for the treatment of melasma and used in combination with glycolic acid peels in darkerskinned patients [15], the best-known combination being Kligman’s formula (tretinoin 0.1%, hydroquinone 5%, and dexamethasone 1% in hydrophilic ointment) used daily [16]. There are other variations of Kligman’s formula, which have been adapted using lower concentrations of hydroquinone and lower potency steroids. Additional adjunct to topical therapy include AHAs, which are incorporated into many skin care maintenance regimens. The use of AHA has been shown to reverse histologic signs of photoaging by increasing epidermal thickness, reversing basal cell atypia, dispersing melanin pigmentation, and normalizing the rete pattern of the dermoepidermal junction. There are multiple combinations that can be used, such as 2% hydroquinone/10% glycolic acid gel twice daily and 0.05% tretinoin cream at night. Kojic acid is another topical agent that can be used in the preprocedure rejuvenation regimen. Kojic acid, like hydroquinone, can be combined with chemical peels to utilize its bleaching effects. It is an antibiotic produced by many fungal species such as Aspergillus and Penicillium in an aerobic process from a wide range of carbon sources [17]. Its mechanism of action is likely due to competitive inhibition of the catecholase activity of tyrosinase [18].

The combinations of prepeel rejuvenation regimens are endless.Many studies have shown that the combination of the prepeel regimens with superficial peels provides additional benefits with minimal adverse effects in patients of all skin types. Typically, the prepeel regimen is begun 2–4 weeks prior to the peel, stopped 2–3 days before the peel, and resumed postoperatively after complete re-epithelialization has occurred.