When Peels Beat Lasers for Acne Scarring, Other Conditions

An expert takes a look at both modalities in treating acne scarring, wrinkles, pigmentation issues, and actinic keratoses.

“There are no head-to-head studies comparing peeling with lasers,” said Harold Brody, MD, FAAD, who is clinical professor of dermatology at Emory University School of Medicine in Atlanta, Georgia, and past president of the International Peeling Society-USA(IPL), based in Rolling Meadows, Illinois in a presentation at the American Academy of Dermatology 2022 Annual Meeting.1 He also noted that procedures vary among individual dermatologists. “However, trichloroacetic acid (TCA) chemical reconstitution of skin scars(CROSS) is superior to any laser treatment for pitted scars because it penetrates more deeply,” Brody told Dermatology Times®.

“Many dermatologists who practice medical dermatology are unaware of the advances in peeling in the last 15 years, and both some patients and some dermatologists might be ‘brainwashed’ by industry laser advertising,” Brody told Dermatology Times® in a follow up interview. In his presentation, he noted that peeling is more cost-effective than laser treatment and results can be “competitively comparable” if performed by doctors well-versed in the modality being used. He also noted that radio frequency (RF) microneedling was not considered in his talk due to his focus, but that its efficacy is evolving.

Brody supported this overview with a detailed breakdown of lasers and peels for treating four different issues.

Acne Scarring

Brody stated that treating scarring requires using a physical modality with peeling: dry ice followed by TCA or a Jessner peel (JS) followed by TCA with sandpaper or the CROSS technique for pitted scars. “The goal is to convert rigid scars to distensible scars and then to elevate them with long lasting fillers,” he added. Ablative fractional lasers, according to Brody, can provide variable improvement.

Wrinkles

“Peels are underused for wrinkles but phenol-croton oil formulas are “superb”. New formulas require no EKG and IV hydration or analgesia in segmental peeling,” Brody told Dermatology Times®. He noted that peeling can eliminate photoaging III and IV in 1 treatment using 1 of these new formulas. Lasers can achieve those single-treatment results for photoaging III but photoaging IV is more challenging to eliminate in 1 treatment, he said. Fully ablative erbium lasers can approximate those results, but prolonged healing can dampen its viability.

Pigmentation

Brody noted that both lasers and peels are useful in treating melasma, but that both may have variable success. He feels both modalities can improve quality of life for patients, although both may necessitate multiple treatments. For post-inflammatory hyperpigmentation, Brody told Dermatology Times® that here, too, he sees a role for superficial peels and non-ablative fractional lasers to help bleaches penetrate “faster and better”.

Actinic Keratoses (AKs)

AKs can be removed with properly performed medium-depth peeling in 1 treatment, resulting in a 75% to 90% reduction (in lesions). The 927 Fractionated Thulium Laser can do the same but needs up to 4 treatments at 2- to 6-week intervals. Brody noted that peels are usually best for single-treatment improvement, while lasers work better across multiple treatments but the upside for the patient is that they may require less downtime. He added both may need follow ups for small recurrences.

Considerations for Patients of Color

“For patients of color, peels are superb but both peels and lasers should be gentler,” Brody told Dermatology Times®. He added that dermatologists need to be aware of when to tell patients of color to stop pre-regimens: several days before for people with darker Fitzpatrick skin types but the day of the procedure for those with lighter skin types.

Disclosures

Brody listed the following relevant disclosures: Allergan, Inc., Galderma Laboratories and Merz Aesthetics

Reference

Brody H and Ibrahami O. Do lasers have better outcome than chemical peels? Presented at: American Academy of Dermatology 2022 Annual Meeting; March 25-29, 2022; Boston, MA.