Using chemical peels
Dr. Levine: How do you use chemical peels in melasma?
Dr. Desai: Chemical peels have really become a huge part of my practice for several reasons:
- They are very easy and efficient to do in the office — they take very little time;
- Patients experience very little downtime;
- The cost isn’t that high — you don’t have to charge patients an arm and a leg for these treatments.
I tell patients who have melasma that they need to do, on average, at least three chemical peels to really start noticing any improvement; however, the ideal is a series of five peels. I usually space those every two to three weeks apart.
For a brand new patient who comes in with melasma, I will prescribe a combination lightening agent, retinoid, and steroid along with a physical blocker sunscreen. I also have an extensive conversation about photoprotection. After a month, I check in with the patient to see how the therapy is going, and then I often start the chemical peel treatments.
My go-to chemical peel for a new melasma patient are either 30% glycolic acid or 30% salicylic acid. The only time I choose salicylic over glycolic is if the patient is extremely oily and had large prominent sebaceous pores, or if the patient has acne with melasma. The salicylic will help the comedonal and cystic lesions as well as the pigmentation.
There is no reason you can’t do salicylic acid peeling on a patient with no acne, the point is to stimulate collagen growth and help desquamate the epidermis and those keratinocytes. But glycolic tends to work well and the studies do favor glycolic for melasma.
The preparation is very easy. I use acetone or alcohol to remove the debris on the skin. I then apply the acid solution, allow it to penetrate for about two to three minutes, and then apply a neutralizing agent as well as a good emollient and sunscreen. The key is to make sure the patient has stopped the prescribed retinoid or the combination five to seven days before the peel.
I have patients sign a consent form that goes over the risks and benefits of chemical peels, just like any other procedure. In this case, they also initial that they have discontinued the retinoid at least five to seven days before the procedure.
Two to three weeks later, the patient returns for the next peel. The patient can reinstitute the topical regimen in between the peels. I have had great success with this, and patients like it because it’s not very expensive.