Picking the best peel

Dr. RullanPeels successfully treat a variety of cases of melasma, acne scars and sun-damaged skin, dermatologist Dr. Peter Rullan told colleagues, but he says it's crucial to select the right peel for the right patient. And in some cases, he says, lasers can offer better results, either in conjunction with peels or alone.

Rullan, M.D., has a private practice in Chula Vista, Calif., and is a volunteer clinical professor of dermatology at the University of California at San Diego. He described his recommendations at the 2016 CalDerm Symposium, a continuing education seminar offered by the California Society of Dermatology & Dermatologic Surgery.

Active Acne

For active acne Dr. Rullan recommends 30% salicylic, Jessner’s and VI peels.

"I routinely do 30% salicylic on patients on low-to-medium doses of isotretinoin," he says. "For isotretinoin, I like 20 mg/day initially, and based on tolerance and need, I slowly titrate upward."

Dr. Rullan adds monthly Vbeam Perfecta pulsed dye laser for red acne scars, even while the patient is on low-dose isotretinoin.

"I use 10-msec and 8 joules, 7 mm spot size, followed immediately by a 30% salicylic peel or wash if the patient has active acne lesions," he says. "The red marks from recent acne lesions respond very well to the laser, and acne lesions such as comedones and papules dry out or exfoliate with the salicylic peel."

Dr. Rullan offers several cautions: "Buffered glycolic works well for comedonal acne but cannot be done while using topical or systemic retinoids because it can cause blisters," he says. "And although they're effective, Jessner’s peels can cause post-inflammatory hyperpigmentation (PIH) in skin types 4-6."

Boxcar Acne Scars

For small boxcar or ice pick acne scars Dr. Rullan likes to mix a TCA peel with laser.

"I do CROSS – Chemical Reconstruction of Skin Scars – with 30% TCA for thin skin, 60% for medium, and 100% for thick-skinned patients. It must be applied with a toothpick to avoid spillage onto the shoulders of the scars," he says. "It can be done in all skin types with minimal risk of PIH, but if done incorrectly it can widen the scars temporarily."

"If I see rolling scars, then I do Nokor 18-gauge needle subcision before I do the CROSS with TCA," he adds.

If appropriate, Dr. Rullan follows CROSS immediately with either fractional Erbium or CO² laser based on available downtime or severity of scars. He cautions that "Combining CROSS with ablative lasers is better than just lasers alone, since lasers cannot ablate the lateral walls of box or ice pick scars. Many of the patients that come to me have been very disappointed with the results and the cost of their CO² laser peels for scars."

Other treatment approaches, he says, can include dermabrasion, 2-day phenol chemabrasion for spot or full-face scarring, excision, punch elevation and punch grafting.

Next: Melasma

Melasma

"Melasma cannot be cured with any peel," Dr. Rullan states, but a 30% salicylic peel can be appropriate. He describes it as the "safest peel," one that provides a "very superficial" level of penetration.

Dr. Rullan also recommends 70% glycolic acid peels – another kind of peel considered very superficial – and 20% salicylic plus mandelic acid peels. He points to a recent study of 90 patients in India with melasma [Dermatol Surg. 2016 Mar;42(3):384-91]. Patients were randomly assigned to peels with glycolic acid 35%, 20% salicylic plus mandelic acid and phytic combination. Patient skin was most tolerant of salicylic plus mandelic acid, the researchers reported.

The also found that 35% glycolic acid and salicylic plus mandelic acid peels were more efficacious than the phytic combination. After 12 weeks, the melasma area and severity index scores in the patients decreased by 62%, 61% and 45%, respectively.

In addition, a variety of other treatments can be appropriate for melasma, Dr. Rullan says, including, but not limited to, protection from heat and sun, hydroquinone 2%-6%, retinoids, glutathione 500 mg BID, and anti-inflammatory medications.

Photoaging

Dr. Rullan prefers pre-packaged peel kits for treatment of photo aging.

"Commercial kits provide a well-defined procedure and post-op care that helps the physician and the staff gain confidence in chemical peels," he says.

For mild photoaging, Dr. Rullan prefers a “superficial” level of penetration. He points to ZO 3-step stimulation peel (10% TCA, 17% salicylic acid, 5% lactic acid and 6% retinol cream), VI Peel Precision (30% phenol, 7% TCA plus salicylic and tretinoin acid, but no croton oil) and Jessner's 15-20% TCA.

For moderate photoaging, he prefers "medium depth" peels via Jessner's 25% TCA and TCA peels assisted by blue dye.

"These peels actually improve fine wrinkles and lentigos but do not provide the amount of skin tightness and lifting that a croton oil/phenol peel can do, especially for deep wrinkles in the mouth region."

"They help the patients get a fresher, more even complexion that appears more glowing and with only a five-day turnaround,” Dr. Rullan says. “For example, you do the peel on Wednesday, they look pink and dry for two days, and then exfoliate for two or three days max during the weekend."

Things to Watch Out For

Dr. Rullan cautions about post-inflammatory hyperpigmentation from ablative lasers, intense pulse light and strong chemical peels.

"If the patient has oily skin and acne scars and is skin type 4 or darker, you will get PIH when doing medium and deep chemical or CO2 laser peels," he says. "No pre-op regimen with hydroquinone or tretinoin will prevent it. I find it more effective to start them on very low-dose isotretinoin – when qualified – if you start seeing PIH after the peel has healed. I use doses like 10-20 mg daily for 30 days."

Getting an Education in Peels

"Learning peels is difficult because the residency and fellowship programs do not teach them in workshops," Dr. Rullan says. "I teach them in residency programs, and for some third-year residents this is the first time they have ever been taught peels."

To gain experience and feel more comfortable Dr. Rullan suggests they join the International Peeling Society and attend workshops or courses.

"Commercial kits provide a well-defined procedure and post-op care that helps the physician and the staff gain confidence in chemical peels," he says. “They should feel safe doing the 30% salicylic on acne and melasma patients. And I suggest applying 35% TCA on individual AKs – actinic keratosis -- to learn the wounding and healing process."

Disclosures: Dr. Rullan reports that he is a medical consultant for Vitality Institute, where he helps develop safer peeling protocols, and on the faculty at ZO Skin Health.