After thorough cleansing of the face with alcohol and acetone, two or three coats of salicylic acid (20 or 30%) are applied to the entire face with a 2 x 2 wedge sponge, 2 x 2 gauze sponges, or cotton tipped applicators for 3-5 min. Typically, the cheeks are treated first, applying the peel from medial to lateral areas, followed by application to the chin and forehead. Most patients experience some mild burning and stinging during the procedure. Some patients experience a sensation of peel-related facial anesthesia. Portable hand-held fanning during the procedure substantially mitigates the sensation of burning and stinging.
A white precipitate which represents crystallization of the salicylic acid begins to form at 30 s to 1 min following peel application. This should not be confused with frosting or whitening of the skin, which represents protein agglutination. After 3-5 min the face is thoroughly rinsed with tap water to remove salicylic acid crystals. The face is gently blotted to remove excess water. When treating hyperpigmentation, TCA 10 or 15% is then applied to the areas of hyperpigmentation with a cotton-tipped swab for 2-3 min, producing minimal (Level 1) or no (Level 0) frosting. The face is again rinsed with tap water. If treating photodamage, acne, or tex-turally rough skin, TCA is applied to the entire face. This protocol usually involves a regimen of two or three combination peels performed at 2- to 4-week intervals.
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