For treatment of photoaging, valid arguments abound for peels, lasers

Key Points

National report - Both chemical peels and lasers represent safe and effective methods for treating signs of photoaging. Each technique has its pros and cons, and whether the balance weighs in favor of chemical peeling or a laser procedure can be argued either way.

To underscore this point, Gary Monheit, M.D., speaks in support of chemical peels, while Kimberly Butterwick, M.D., is a proponent of laser treatment.

Chemical peels

"Chemical peels have a long history of safe use and can produce reliable results in a broad range of indications, including for the treatment of keratoses, lentigines, ephelides, dyschromias, fine lines and scars," says Dr. Monheit, clinical associate professor, departments of dermatology and ophthalmology, University of Alabama at Birmingham. "In contrast, there is no one laser that is suitable for addressing all of these problems."

Dr. Monheit points out that experience with chemical peels dates back more than 75 years, and even in 2009, it ranked as the second-most popular cosmetic procedure, according to data from the American Society of Dermatologic Surgery and the American Society of Plastic Surgeons.

Chemical peeling also requires a minimal financial investment for the physician, and it is a relatively low-cost procedure for patients. Considering the peel solutions and necessary equipment, start-up costs can be less than $100 for chemical peeling, versus $100,000 or more for a laser. Preparation time is generally the same for peels and laser procedures, but a peel procedure also involves less operative time and requires fewer staff members than laser surgery, Dr. Monheit says.

Peels are very versatile, as the aggressiveness can be tailored to meet the patient's cosmetic needs and desired downtime. Depending on the chemical used, a superficial peel can be inflammatory, inducing dermal thickening and improving the appearance of fine lines and wrinkles, or it can be noninflammatory, to treat dyschromias.

"In contrast to laser-resurfacing procedures for the latter indication, a salicylic acid chemical peel can be used with better safety in darker skin types, because it does not have a risk of causing postinflammatory hyperpigmentation," Dr. Monheit says.

In a medium-depth chemical peel using Jessner's solution and 35 percent trichloroacetic acid (TCA) to remove the epidermis and inflame the upper dermis, dermatologic surgeons can achieve more complete skin rejuvenation, addressing epidermal dyschromias and lesions along with fine textural changes in a procedure that takes just 20 minutes and involves five to seven days of recovery time, he says.

Dr. Monheit acknowledges that the achieved depth of a chemical peel depends on a number of factors. In addition to the chemical used, operator dependency plays a role, since the method of skin preparation and application technique are both important. However, the surgeon can maintain good control of the outcome using TCA as the peeling solution, he says.

"TCA application results in various tones of white frosting, depending on the achieved depth of the peel, and this physiologic response can be used to gauge the desired endpoint of the procedure. With a laser, there is no such visible marker that can be followed to tailor the procedure to the patient's needs," Dr. Monheit says.

Dr. Monheit acknowledges that fractionated laser procedures have a greater effect on improving deeper wrinkles and folds, because they remove portions of the dermis and stimulate more tissue contraction. Nevertheless, if full-face resurfacing is indicated, a medium-depth chemical peel may still be preferred, as it simultaneously addresses more superficial skin lesions and fine wrinkles. Areas with deeper wrinkles can be targeted with the addition of localized manual dermasanding, Dr. Monheit says.

Fractionated resurfacing

Regarding fractionated CO₂ laser resurfacing, Dr. Butterwick compares it with medium-depth chemical peels. Acknowledging that peels are a less-expensive option, she highlights points to support her premise that the laser procedure is well worth its increased cost.

Among the advantages of fractionated CO₂ laser resurfacing is that when it is performed with a short pulse duration (<0.8 milliseconds), the laser procedure is less painful than chemical peeling, and it is associated with a faster recovery time.

"There is no need for patients to be premedicated for the laser procedure. They can drive themselves to and from the procedure, can function well while at home, and are able to return to work sooner. These differences translate into economic advantages favoring the laser procedure," says Dr. Butterwick, who is in private practice in La Jolla, Calif.

"Even with its greater depth, the fractionated laser procedure is still very safe, without the risk of scarring or other complications that can occur with conventional CO₂ laser resurfacing or using chemical peels to try to achieve the same depth," Dr. Butterwick says.

"However, surgeons must still be careful in selecting appropriate parameters and avoid being overly aggressive when performing fractionated CO₂ laser resurfacing," she says.

Additionally, a fractionated CO₂ laser procedure is likely to stimulate more neocollagenesis, since it can induce fibroblast activity via a thermal effect and because it removes damaged extracellular matrix.

Dr. Butterwick suggests that better accuracy and predictability are features of the laser procedure; the operator controls depth of penetration and the amount of collateral damage via the energy and density settings, respectively.

"By modifying the laser parameters, one can adjust the treatment for patients with different skin types and for treatments on extrafacial skin, whereas chemical peeling involves more of a standard protocol," she says.

Furthermore, there are more uncontrollable variables that can impact outcomes of chemical peeling and lead to unpredictable results, including the concentration of the peeling solution, the integrity of the epidermal barrier, the method of preparation and the treatment technique.

The laser procedure also affords greater versatility in performing concomitant procedures, since treatments with other types of lasers as well as fat transfer, filler injections, punch excision or even facelifts can all be performed safely at the same session as fractionated CO₂ laser resurfacing, Dr. Butterwick says.

As a high-tech tool of the 21st century, the laser also represents a marketing asset for the practice, and since laser surgery is an exciting and dynamic field, surgeons who become involved will reap professional and intellectual rewards, she says. In addition, surgeons who wish to add or enhance their skills in rejuvenation will find many more educational opportunities in the area of laser surgery.

"At the 2009 meeting of the American Academy of Dermatology, there were 31 lectures relating to laser procedures, but only three sessions on chemical peeling," Dr. Butterwick says. "I recently conducted an ASDS (American Society for Dermatologic Surgery)-sponsored workshop on lasers, but the society has not featured a workshop on chemical peels for over a decade."

Disclosures: Drs. Monheit and Butterwick report no relevant financial interests.