Chemical peels remain mainstay in dermatologic surgery armamentarium

Key Points

"According to the American Society of Plastic Surgeons interdisciplinary survey, chemical peeling placed second among the top five minimally invasive cosmetic procedures in 2006, with 1.1 million peels performed. Like all treatments, its place is in a state of evolution and flux. However, with its histologically-substantiated efficacy, cost-effectiveness, predictability and safety when properly performed, chemical peeling will never be eclipsed entirely," says Dr. Brody, clinical professor of dermatology, Emory University, Atlanta.

Providing an update on the state of chemical peeling in 2007, Dr. Brody reviewed its indications and placed its role in perspective relative to alternative treatment options.

Management of actinic keratosis (AK) continues to be a use for chemical peels, although in this indication, chemical peeling is generally reserved for very severe or residual AKs rather than being a first-line alternative.

"In patients who have multiple, recurrent AKs, chemical peeling can reset the clock and allow them to go back and use other modalities easier," Dr. Brody says.

Wrinkles

For the treatment of wrinkles, only dermabrasion and resurfacing laser treatment can match the penetration achieved with a phenol peel. However, dermabrasion is no longer used extensively and the resurfacing lasers also have a limited role due to the associated risk of complications.

Intense pulsed light treatment (IPL) is not an option for wrinkle improvement, because it produces no skin contraction at all. Treatment with radiofrequency and light emitting diode devices yields only a modest effect, and better results are anticipated for a second generation, 1550-nm erbium fractionated laser or CO₂ fractionated laser. However, that is a promise yet to be fulfilled.

"There are many ablative and nonablative devices on the market for fractional resurfacing. They all require multiple treatments under local anesthetic and involve downtime of three days or longer. Better wrinkle improvement seems to be achieved with newer technologies, but none gives results as good as a phenol peel in the treatment of severe photoaging," Dr. Brody tells Dermatology Times.

Acne scarring

Use of chemical peeling for acne scarring varies according to scar type. A permanent filler such as silicone, with or without dermabrasion, is best for deep, depressed scars. However, for atrophic scars, a medium-depth chemical peel may be used in combination with sandpaper abrasion. According to one report, the fractionated laser may also have a role in reducing atrophic scarring, although there is no information about it in the peer-reviewed literature.

For severe mixed scarring, dermabrasion is the treatment of choice, although fractionated laser treatment can provide some improvement. Chemical peeling with 35 percent to 50 percent trichloroacetic acid (TCA) along with a variety of lasers and other resurfacing modalities can improve the appearance of superficial shallow scars.

However, chemical peeling using a new CROSS technique stands out for its efficacy in the treatment of icepick scars. The procedure is performed using a toothpick or a very fine applicator to apply 100 percent TCA directly into the scar, avoiding contact with surrounding skin. The number of treatments necessary may vary from one to six.

"This is one of the best techniques to emerge in the spectrum of chemical peeling in a long time," Dr. Brody says.

Hyperpigmentation

For melasma, chemical peeling using a technique of multiple superficial repetitive and increasing strength peels provides an effective method for removing the hyperpigmentation, especially in darker skin patients. The procedure begins using a superficial peel. If it is effective in removing the hyperpigmentation, the patient may be maintained on 6 percent hydroquinone. Otherwise, the peel is repeated with a higher strength solution, progressing to a medium and deep level of peeling as needed on a specific cosmetic unit to treat sites of resistant melasma.