Anatomy of a deep chemical peel

April 1, 2007

Washington - Chemical peels have become a mainstay in cosmetic dermatology practices.

They alleviate deep wrinkles that sometimes result from excessive sun exposure. Skin wrinkling around the lips and chin area are corrected with chemical peels, as well as general skin imperfections in sun-damaged, unevenly pigmented or coarsely wrinkled facial areas. Harold J. Brody M.D., clinical professor of dermatology, Emory University School of Medicine, Atlanta, offered his tips to foster best results in the use of deep chemical peels at the 65th Annual Meeting of the American Academy of Dermatology, here.

"It is important for cosmetic dermatologists and dermsurgeons to understand that phenol is not an uncontrollable protoplasmic toxin producing an all-or-none effect, and that a stronger concentration does not produce deeper results in phenol formulas," Dr. Brody says.

Following the application of phenol, the ensuing frosting will be light white, white or gray-white.

A full-face deep chemical peel with phenol takes approximately two hours to perform, but is increasingly unnecessary due to better skincare and other peeling agents.

Other, more limited applications, such as treating the severe wrinkling of the upper lip, may take 30 minutes or less. Dr. Brody says the positive aesthetic effects of a phenol/croton oil chemical peel can last for many years, and the improvements in the patient's skin are often pleasingly quite dramatic.

When performing a deep peel or Baker/Gordon peel, Dr. Brody uses phenol with croton oil (an epidermolytic vesicant) to increase the desired inflammation and depth of the peel. According to Dr. Brody, the croton oil may act to enhance the absorption of the phenol in the skin and may be responsible for spectacular results.

"Depigmentation is one of the possible side effects of deep chemical peels, but it is important to understand that this is not the rule. Hypopigmentation can occur with excessive quantities of croton oil and phenol, the use of occlusive taping or thymol iodine powder, as well as with a miscalculation in the skin type of the patient," Dr. Brody says.

Less used, still popular

Many formulas derived from lay peelers are used less today but are still popular among some physicians.

These formulas include Venner-Kellson (Lysol, olive oil, croton oil, water), Maschek-Truppman (glycerin, croton oil, water) and Grande I, II, III or Stone (glycerin, croton oil, olive oil, water).

Dr. Brody says that in a phenol/croton oil peeling, the phenol concentration is not the important variable. Using a higher concentration of croton oil makes it possible to use a weaker strength of phenol in the formula, thereby reducing the systemic effects of phenol toxicity. Hetter's work demonstrated that an addition of 0.2 percent of croton oil increases the phenol peel by 20 percent. When performing a perioral peel for moderate wrinkling, Dr. Brody likes to use Hetter's 1.2 percent croton oil.

For the cheek and forehead, temples and upper nose and eyelids and neck, he usually uses 0.8 percent, 0.4 percent and 0.1 percent to 0.2 percent croton oil, respectively. Care must be given, though, to concentrations more than 1 percent croton oil, as there may be an increased risk of hypopigmentation.

Complications, formulations

Complications of a deep peel include scarring, delayed healing, erythema, infection, acne and milia, textural changes and contact dermatitis.

For the perioral region or very wrinkled skin requiring a heavy peel, Dr. Brody advocates the original Baker/Gordon formula consisting of 3 cc phenol USP 88 percent, 2 cc tap water, 8 drops of septisol liquid soap and 3 drops of croton oil (2.1 percent croton oil if 1 gutta = 27 drops/cc). He first adds the croton oil to the phenol, then water, followed by the septisol. When performing a medium to heavy peel (not eyes or temple), he uses 4 cc of phenol (33 percent), 6 cc water, 16 drops of septisol and 2 drops of 0.7 percent croton oil.

Medium to light peel

Dr. Brody tells Dermatology Times a common peel that can be used by physicians is the medium-to-light peel, consisting of 4 cc phenol (33 percent), 6 cc water, 16 drops septisol and 1 drop of 0.35 percent croton oil.

A very light peel - for example, for the eyes and neck region - consists of 3 cc of a medium-light formula with the addition of 2 cc of phenol (27.5 percent) and 5 cc of water.

"Deep peeling is the most cost-effective method to remove moderate-to-severe wrinkles with a minimum of complications under normal and customary circumstances. Yes, there are novel devices that have improved to treat mild-to-moderate wrinkles. It is important to remember, though, that everything that is now obsolete was once new, but what is new is not necessarily always the best," Dr. Brody says.