Popularity of the peel: Chemical ablation retains place in derm armamentarium

Atlanta - Despite an explosion of skin-resurfacing options, including devices highly promoted to consumers by manufacturers, the tried-and-true chemical peel remains one of the most performed cosmetic surgeries on women.

The rate of popularity growth for the chemical peel is not what it was in the 1990s, but unrivaled dramatic results and a good safety profile keep peels on dermatologists’ and patients’ radars, explains Harold J. Brody, M.D., clinical professor of dermatology, Emory University, Atlanta.

Derm domain

Medium-depth and deep peels are very much in the dermatologist’s domain, according to Dr. Brody.

"Dermatologists are the experts in recognizing dermal depth and dermal pigment, which are crucial in judging the type of peels for different areas of the face," Dr. Brody says. "Other specialties (physicians and nonphysicians) do not understand which areas of the skin are thicker and can withstand more moderate or deeper peels, as opposed to superficial peeling, which is acceptable for all areas of the face."

Peel pros and cons

Peels offer two important advantages over other skin resurfacing options, Dr. Brody says.

"Peeling solutions cost pennies compared to devices," he says. "And if you stick with using peels that are histologically substantiated, peeling is safe (complications, when they occur, are manageable) and predictable."

However, nonphysicians and physicians who do not understand the true definition of chemical peeling, according to Dr. Brody, are attempting to redefine the procedure for marketing purposes. Many do not understand which combinations of peeling agents cause skin tightening and which do not. Because of these misleading claims, chemical peels are becoming known as treatments rather than surgery or medicine.

"This creates misconceptions about the effectiveness of the peel," he says. "For example, some are talking about salicylic acid, glycolic acid and 20 percent TCA - none of which pass beyond the epidermis - and calling them superficial, medium and deep peels.

"Certainly, a medium-depth peel, properly done, has to penetrate through the papillary dermis. If it does not penetrate entirely through the papillar dermis, you will not get wrinkle removal and skin tightening, and you will not get the true definition of a medium-depth peel."

Another negative trend, he says, is that within dermatology there is general ignorance of very effective techniques, including deep, or phenol peeling, and chemabrasion, which involves applying a chemical peel solution on the skin then dermabrading the surface.

"Instead, people are leaning on devices which may or may not work," Dr. Brody says. "I always say that what is new is not always the best. Secondly, everything that is now obsolete was once new."

Indications evolve

Indications for chemical peels have evolved throughout the last 20 years, Dr. Brody says.

"We still use chemical peeling for actinic keratoses, wrinkles, scarring, pigmentary problems and to produce skin smoothness," he says.

However, because there are so many options today, there are times when chemical peeling might not be the answer. Dermatologists can treat actinic keratoses, for example, with topical chemotherapy, photodynamic therapy and cryosurgery, in addition to chemical peeling.

"Some of these options might be more cost-effective, depending on how many actinic keratoses there are and the patient’s skin type. So, chemical peeling is usually used for more severe actinic keratoses," he explains.

Many devices work well for mild wrinkling, but nothing works better for severe wrinkling than deep chemical peeling, Dr. Brody adds.

Chemical peeling tends to not be as effective for the treatment of scars as other solutions, according Dr. Brody. But the C.R.O.S.S. technique, which is the chemical reconstruction of skin scars done with a chemical peeling wound agent is cost-effective and good. The C.R.O.S.S. technique uses 100 percent TCA.

"With melasma and pigmentation many different modalities work, but peeling is still good, if not better than, lasers for melasma.

"In post-inflammation pigmentation, almost anything will work, and with very light skin melasma almost anything will work: lasers, IPL, peeling, fractional resurfacing. The challenge is what will work in darker skin, and peeling is still extremely competitive, if not the best," he says.

A place for peels

Dermatologic chemical peeling will continue to have a place in the treatment of photoaging and scarring.

The key, according to Dr. Brody, is understanding which peels will truly tighten the skin and selecting the proper peel for the amount of photodamage on the proper cosmetic unit on the face.

DT

Disclosures: Dr. Brody reprots no relevant financial interests.