Phenol Peel: Miracle Cure or Risky Procedure?

The power of social media’s influence on beauty trends is unmatched. Videos of the dramatic results of the phenol peel seen on TikTok and across skincare forums have boosted a sudden interest in the once-outdated procedure. The potential of smoothing out decades' worth of wrinkles and erasing acne scars to reveal unblemished skin may seem tempting, but is it worth the risk of severe side effects? Let’s discuss what phenol peels are, how they work, and what the associated risks are.

What are phenol peels?

Phenol peels are deep chemical peels that use phenol and croton oil combined with water and soap-based mixing agents. Chemical peels are a type of skin resurfacing procedure that works by causing controlled damage to the skin through a chemical burn, to which the body responds by promoting skin healing and regeneration.

The skin has three main layers — the epidermis, the dermis, and the hypodermis. Chemical peels affect the skin at different sublayers of the epidermis and dermis. Deep chemical peels penetrate the reticular and papillary layers of the dermis, with phenol peels reaching the furthest.

Phenol, also known as carbolic acid, is an organic compound extracted from petroleum that is corrosive when in direct contact with skin. Croton oil comes from the seed of a small shrub that causes irritation and increases inflammation when in contact with the skin.

Phenol has been used in peels since the early 1900s, but it was in the 1960s when a formulation, the Baker-Gordon formula, was standardized. At the time, phenol was accepted as the main active compound responsible for the results. However, in the 1990s, studies showed that Croton oil allowed the mixture to penetrate the dermis deeper and, in higher concentrations, caused more damage. Based on these studies, different phenol and croton oil concentrations have been used to create formulations targeting different parts of the face and minimize side effects.

Some clinics also create proprietary formulations and protocols combining phenol peels with trichloroacetic acid or perform peels over two days to prevent further side effects. As these are newer techniques and do not have a lot of clinical data available, the method and peel being used should be explained in detail by the physician providing the service.

Pros and cons of a phenol peel

Here are some of the known advantages and side effects to account for when considering a phenol peel:

What are the benefits of phenol peels?

Changes to the skin that occur through aging, skin damage, trauma, and acne can affect different layers of the epidermis and dermis. As phenol peels exfoliate into the dermal layer of the skin, it can remove much of the previously aged and damaged skin, making it a potentially effective option for several skin concerns.

Wrinkle reduction

Connective tissue within the dermis is made of collagen, elastin, and other proteins. It provides a structural framework for the rest of the skin. As we age, the production of these cells decreases. With the addition of sun and other environmental damage, there is a significant decline in this supportive structure. In addition, the aging epidermis stops holding onto hydration and does not bind to the dermis as well as it used to.

All these factors cause the skin to thin and start sagging, leading to the formation of wrinkles. The reduction in wrinkles by phenol peels is well established. Improvement of fine lines occurs through new layers replacing the exfoliated skin. An increase in collagen and elastin production in the dermis after the peel helps decrease the deeper, more prominent wrinkles.

Balancing skin tone

Hyperpigmentation, or darkening of the skin tone, can be caused by many factors, such as sun damage, inflammation from acne, and hormonal changes during pregnancy (melasma). Melanocytes, the cells of our skin creating the pigment melanin, are found in the deepest layer of the epidermis. Examining the skin samples under the microscope after treatment with phenol peels has shown that phenol impairs melanin production.

On the other hand, inflammation caused by phenol and croton oil may stimulate increased melanin production and result in post-inflammatory hyperpigmentation. According to a study comparing different peels for melasma, TCA showed superiority in decreasing the severity of melasma. However, the concentration of the phenol used in the study was below what is usually clinically used. Pigmentation changes are a common side effect of phenol peels. When used for other indications, the peel may improve the appearance of pigmentation but may also worsen it.

Softening acne scars

While we are used to seeing the superficial effects of acne on the upper layer of the skin, prolonged or severe inflammation from the lesion can extend the damage into the dermis, creating deep ice-pick scars. Superficial peels and other acne treatments can help post-inflammatory hyperpigmentation and damage to the upper layer of the skin but are often unable to heal deep scars.

Most research on acne scarring focuses on treatment with lasers and surgical procedures, as the risk of side effects and complications is limited. One study comparing the impact of CO2 lasers versus phenol peel showed that the phenol peel could lead to greater production of collagen in the dermis. This is likely why we see the impressive results of phenol peels on acne scarring in before-and-after pictures. More evidence is needed to support its comparative safety with other treatment modalities.

Reversing sun damage

Prolonged exposure to UV rays without sun protection leads to damage throughout the skin, such as the breakdown of connective tissue, increased oxidative stress, and damage to the DNA. This damage leads to wrinkle formation, sagging skin, dilation of small blood vessels, dark spots, and an increased risk of skin cancer.

In addition to improving wrinkles and pigmentation issues, phenol peels may prevent skin cancer by removing sun-damaged tissues and precancerous lesions like actinic keratosis and Bowen’s disease. However, more research is needed to show long-term efficacy and safety.

What do phenol peels involve?

Phenol peels are a significant undertaking involving steps that must be planned for several months before and after the peel. Phenol peels require time and commitment to ensure successful treatment and reduce the risk of side effects.

Preparing for a phenol peel

Common pre-peel recommendations include:

• Stop isotretinoin for 12–24 months before peel to ensure proper healing.
• Avoid doing a phenol peel six months before or after pregnancy, as increased estrogen levels increase the risk of hyperpigmentation.
• Stop smoking at least a month before peel, as it can slow down the healing process.
• Broad-spectrum sun protection starting at least three months before the peel.
• Avoid microdermabrasion, waxing, and electrolysis for 3–4 weeks prior to the peel.
• Use the medications prescribed by your doctor to help prime your skin for uniform penetration and decrease the risk of hyperpigmentation.
• Proper hydration prior to the procedure.

As phenol peels function by creating a severe burn, there is significant swelling after the procedure, and you may not be able to open your eyes fully. A competent caregiver is necessary during the recovery period after the peel to assist with transportation and basic needs. Some clinics provide an option to stay at an associated recovery center or can recommend external nursing services. Speak with your treating doctor about the options and if a package deal is available to help reduce costs.

Phenol peel application

Phenol peels may be absorbed into the blood, leading to toxicity of other organs. Cardiac monitoring is required during the procedure as there is a rare but serious risk of developing an arrhythmia (abnormal heart rhythm). There may also be significant pain due to the depth of the tissue being exfoliated right after the procedure. IV hydration, different levels of anesthesia (local or general), and post-operative pain management are offered depending on how much skin is being treated.

Due to the potential for serious side effects and the required level of monitoring, phenol peels are performed in appropriately equipped offices or surgical centers by board-certified dermatologists and plastic surgeons who have received additional experience performing deep peels. Phenol peels are not safe to be performed at home. All chemical peels should be performed appropriately to avoid complications.

Once the patient is ready, the steps of phenol peel application include:

1. Cleansing of the face with soap and acetone.
2. Application of different concentrations of the peel to the face, one section at a time. The physician may rub the peel into the areas where the skin is thicker and stretch out areas of deep wrinkles to ensure the peel is applied evenly.
3. The peel may be covered by an ointment or bandages.

What to expect after a phenol peel?

The visit for the procedure usually takes 2–3 hours, which includes some time for observation of immediate side effects.

Medications for pain management are usually provided. While in some cases, the pain subsides after several hours, it is not uncommon to experience recurring pain.

The first follow-up visit is the day after the peel is completed to remove the bandages and apply a yellow powder that forms a mask to help protect the skin for 7–14 days. Additional follow-up visits may be needed to assess the healing.

After removing the powder mask, the skin may look red for a month or more. Using make-up after two weeks is usually safe as the skin has regenerated completely. However, your skin may be more sensitive, and any product causing irritation should be avoided. You should discuss any products you are unsure of with your doctor before restarting use.

The results of the phenol peel may take six months or more to be noticeable, but many see a difference soon after the procedure.

Post-treatment recommendations

Common post-peel recommendations usually include:

• Avoid direct sunlight for at least seven days, after which use of sun protection is recommended. Avoid other UV light sources, such as tanning beds, for at least 12 weeks.
• Avoid smoking for at least six months after the peel.
• Avoid pregnancy and taking birth control pills for six months after treatment.
• Remain well hydrated.
• Do not pick peeling skin.
• Wash with a gentle cleanser using a patting motion. Pat dry the skin as well to avoid forceful rubbing of the skin.
• Use prescribed medications and skincare to help regenerate healthy, new skin.

It is vital to follow the instructions given by your provider to ensure your skin heals well and does not experience any complications.

Who is a good candidate for a phenol peel?

Historically, the ideal patients for phenol peels have been people of Northern European descent with light hair and eyes. Some physicians are now treating a broader spectrum of patients using proprietary protocols they have developed. However, changes in pigmentation remain a significant risk of phenol peels, especially in people with skin tones more prone to tanning than burning (type 4 or higher on the Fitzpatrick Scale).

Patients who may not be considered for phenol peels may also include those with:

• Abnormal heart rhythms
• Kidney or liver disease
• Uncontrolled diabetes
• Recent sunburn, active infection, or unhealed wounds in the target area
• Active or frequent oral herpes recurrences
• Personal or family history of developing hypertrophic scars (keloids)
• Allergies to peel ingredients

You may be asked to do some blood tests during or before the introductory visit to ensure you are a suitable candidate.

Phenol peel complications

Complications of phenol peels may include:

If you experience any unusual symptoms after your peel, make sure to call the treatment center to be assessed as soon as possible.

Phenol peels can produce considerable results by breaking down and removing skin previously marred by scarring and wrinkles, allowing the body to form new layers. A single peel has helped patients achieve smoother, younger-looking skin after failing other treatment modalities. However, not everyone is a good candidate, especially those with certain medical conditions and deeper skin tones. Physicians trained in this procedure tend to recommend phenol peels to the patients best suited for it. As phenol peels can have serious side effects, it is imperative to seek treatment with a physician who has significant experience in the field and can make the best treatment recommendations for your concerns while minimizing the risks to your health.