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Chances are that cost-effective chemical peels will always be at the front of the dermatologist's facial rejuvenation bag of tricks. But these peels should no longer be viewed in a vacuum, according to Harold J. Brody, M.D., clinical professor of dermatology, Emory University, Atlanta.
"Chemical peeling is still probably the most cost-effective way to resurface the skin," Dr. Brody says. "It is excellent for removal of wrinkles, precancers, splotchy pigmentation and, in certain cases, scarring. There are many other methods of resurfacing that can be used in combination with peeling."
Three levels of peel Chemical peels come in three categories: superficial, medium-depth and deep peels.
"We do not use 50 percent TCA anymore," Dr. Brody says.
And deep peeling involves phenol formulas.
"Phenol formulas for deep peeling ought to be going through a resurgence because laser resurfacing is performed so much less today because of the pigmentary problems associated with it," Dr. Brody tells Dermatology Times. "The loss of pigment with phenol formulas is not greater and probably even less than some of the deeper laser resurfacings that were done in the late 1990s. I think that anybody who has considerable wrinkles and requires a deep peel is going to have some loss of pigment. But they are not going to have porcelain, alabaster skin."
According to Dr. Brody, older phenol solutions and inappropriate technique were to blame for the undesirable results from deep peels done in the 1960s and '70s. The phenol formulas that came out in the last few years do not lighten the skin as much. Doctors are also less likely to apply phenol to isolated segments of the face without treating the full face. In the past, doctors did not choose their patients appropriately; they applied the phenol too thickly or used post-surgery dressings that caused too much phenol absorption or deeper wounds, he says.
No escaping downtime, yet While dermatologists might get acceptable results using nonablative procedures alone to address mild sun damage, they generally need to resort to ablative procedures, such as medium-depth or deep peels, to noticeably improve wrinkles, precancers and scarring.
All those options require downtime - usually at least seven days, according to Dr. Brody.
"You have to have downtime in order to have enough collagen production after the procedure to make it worthwhile," he explains.
Good in combination "Chemical peeling cannot be considered in a vacuum, and that is the key," he says. "It works in concert with a lot of the newer entities. I do dermabrasion, laser resurfacing and chemical peeling, and would very easily combine dermabrasion or laser resurfacing or chemical peeling together on the same face."
Dermatologists should evaluate initial indications, such as scarring, splotching and precancers, then decide based on the treatment for all of those which combination is best for the patient, based on patient preferences regarding downtime and cost.
Words of peel wisdom Dr. Brody does not use any TCA peel higher than 50 percent and would use 50 percent only on local applications. He uses the combinations of medium-depth chemical peels, but says the Jessner's solution followed by TCA is the most popular.
Applying dry ice followed by TCA is more technique-sensitive and provides a deeper peel, while the combination of glycolic acid followed by TCA is roughly equivalent to the Jessner's solution followed by TCA, according to Dr. Brody.
When using any of the combination medium-depth peeling regimens, dermatologists should stick to the way these procedures were described by their innovators because the complication rate is less than 1 percent of scarring for all of these if they follow the original prescriptions, Dr. Brody explains.