NEW YORK — When attempting to improve the appearance of the skin, the risk of chemical peels in all skin types is excessive penetration of the chemical solution that produces complications, but the heightened risk for hyperpigmentation in skin of color places a particular emphasis on proceeding conservatively, according to an expert.

Most peels for skin of color patients work best in a series, typically administered about 4 weeks apart, to achieve an optimal result at a low risk, Heather Woolery-Lloyd, MD, director of the Skin of Color Division in the Department of Dermatology at the University of Miami Miller School of Medicine, Miami, said at the Skin of Color Update (SOCU) 2025.

At this pace, good or excellent cosmetic results can be achieved, but it can be an issue when patients are expecting an immediate transformative result.

One Peel Is Rarely Sufficient

“Patients often think their skin will peel like a snake’s and every imperfection will be gone after a single treatment,” Woolery-Lloyd cautioned. Of the points she made during the presentation, she called managing patient expectations the most important.

As an example, she pointed to patients who come to the office for a chemical peel with near-perfect skin. When there is little room for improvement, “you need to ask them about their end goal,” said Woolery-Lloyd. Even if they have a specific issue for which there are treatment options, a chemical peel might not necessarily be the best choice to achieve the result they are pursuing.

Chemical peels are a valuable option for many skin conditions for patients with lighter and darker skin types, including hyperpigmentation, melasma, acne and acne scars, keratosis pilaris, actinic damage, and photoaging, Woolery-Lloyd said. But this is an area of treatment that is evolving continuously with newly available products and evolving strategies, she noted.

For superficial peels — the type Woolery-Lloyd most commonly performs — she uses glycolic acid 20% or 30% most often, but salicylic acid 20%-30%, tretinoin, and Jessner’s solution are the ones she employs most often for patients with skin of color. She acknowledged that there are others, including combinations, that continue to expand the options.

“Mandelic acid is a new emerging peeling agent for acne vulgaris due to its antibacterial and anti-inflammatory properties,” she said, offering one example. Patients now sometimes request this product, according to Woolery-Lloyd. She cited a comparative study of patients in India with mild-to-moderate acne, which found that mandelic acid was more effective and better tolerated for inflammatory lesions, while salicylic acid was more effective for noninflammatory lesions, although efficacy was considered comparable.

The range of chemical peels is helpful across the mix of conditions for which they are used, but Woolery-Lloyd recommended developing comfort with a limited number of products. The potential differences between combination products illustrate the point. She cautioned that even different products with the same mix of agents at the same concentrations are not necessarily interchangeable.

More Acidic Peels Produce Deeper Peels

“The depth of injury is dependent on the proportion of free acid solution,” she explained. “That means that if you have two different 20% glycolic acid peels, the one with the lower pH will have the largest amount of free acid in the solution, so you will have a deeper peel,” she added.

“This is important if you start to switch brands,” and variations might be even greater when more than one peeling agent is included in a combination, she warned. “I try to stick with one brand because of the potential for these variations.”

For melasma, one of the most common indications for chemical peels among patients with skin of color, Woolery-Lloyd had several specific recommendations. In addition to starting with a low concentration and titrating up slowly while advising patients that four or more peels 4 weeks apart will be needed, she emphasized that patients should stop using retinoids 7 days prior to the peel and should be asked about other risks for excess penetration.

As an example, and a clinical pearl, Woolery-Lloyd suggested caution on the upper lip, where patients might have undergone depilation. Asking patients about specific risks from excessive peel penetration is not enough.

As a precaution before starting, “I have the neutralizer and cleanser on the tray and ready” in case a problem develops during the procedure, she said. Patients may not intentionally be misleading when they fail to mention that they didn’t stop their retinoid as requested or that they have another risk for deep penetration of the chemical solution; “they just forget.”

Salicylic crystal deposition after salicylic acid solution used for the peel dries is normal but should be removed with a soap-free cleaner. However, frosting prior to drying or after the peel has been removed is not normal, and Woolery-Lloyd advised that this might be the first sign that penetration, often the result of not stopping retinoids for a full 7 days prior to the treatment, is too deep, whether it occurs with or without stinging.

In such cases, “remove the peel immediately, and apply a mid-potency steroid cream in the office to reduce the inflammation,” Woolery-Lloyd advised. She also sends these patients home with the topical steroid to apply at home for 2-3 days, advising them to practice strict sun avoidance, which, when possible, is safer than using sun protection, and to never pick at peeling skin. She considers a history of picking at skin or being noncompliant with sun protection or avoidance as characteristics of patients who are poor candidates for peels.

Expectations Are Important to Clinical Experience

The beneficial effect of chemical peels for most indications in patients with skin of color appears gradually, which underlines the importance of managing expectations, said Woolery-Lloyd, who recommends taking photographs at every treatment to document change.

While chemical peels are effective in darker skin types for an array of indications, Cheryl M. Burgess, MD, medical director of the Center for Dermatology and Dermatologic Surgery and an assistant clinical professor in the Department of Dermatology, George Washington University, Washington, DC, seconded the concept of a conservative approach.

Asked specifically by Medscape Dermatology if she would also move slowly on new products in order to develop comfort in optimizing benefits and minimizing risks, she reiterated the idea that clinicians stick with a limited number of products.

“It aligns well with the principles of safe aesthetic practice in patients with richly pigmented skin,” she said. “Mastering a few formulations, such as glycolic acid, lactic acid, salicylic acid, and low-strength TCA [trichloroacetic acid], allows one to anticipate outcomes, titrate appropriately, and recognize early signs of irritation of dyschromia, which is critical for maintaining safety in skin of color.”

Also asked to comment on the use of chemical peels in patients with skin of color, dermatologist Caroline Robinson, MD, told Medscape Dermatology that “because post-inflammatory hyperpigmentation (PIH) risk increases with chemical peel depth and when peel actives are combined, I emphasize an intentional approach to pre-care, procedure technique, and post-care in patients with darker skin who are already at higher risk — prioritizing skin hydration, heat control, and strict photoprotection.”

Robinson, who practices in Chicago, added that she also recommends “performing a spot test off face when there is a strong history of PIH or recent inflammation and when using a new combination formula.”

With the broad and evolving array of options, Woolery-Lloyd recommended a chapter on chemical peels in skin of color written by Pearl E. Grimes, MD, Grimes Center for Medical and Aesthetic Dermatology, Los Angeles, in Cosmetic Procedures in Skin of Color, published in 2024.

Woolery-Llyod reported having financial relationships with AbbVie, Allergan, Arcutis, AVITA, Beiersdorf, Eirion, Estée Lauder, Galderma, Incyte, Johnson & Johnson, Kenvue, L’Oréal, Ortho, Pfizer, Procter & Gamble, Regeneron, Teoxane, and Unilever. Burgess reported having financial relationships with AbbVie, Aerolase, Allergan, L’Oréal, Merz, Prollenium Medical Technologies, and Teoxane.