Chemical peels still have role

New Orleans - Although laser cosmetic procedures have captured popular attention, chemical peels continue to be appropriate for many patients, according to Suzan Obagi, M.D., at the annual cosmetic surgery symposium of the American College of Oral and Maxillofacial Surgeons.

"The results are gratifying, and they're inexpensive to use. Peels are becoming a lost art, and there is so much you can do with them, if you do them correctly."

A thorough intake involving patients' current medications may also show that the patient is taking agents that can impair wound healing. These include prednisone and D-penicilamine. The dermatologist should also know whether the patient has diabetes, has had a transplant or is immunocompromised in any other way.

The patient's skin type will influence the type of peel used, she says.

"The darker they are, the more you want to think about aggressive skin conditioning to avoid pigmentation problems," she says. "Agents such as tretinoin (Retin-A), hydroquinone and alpha-hydroxy acid can be used before peeling in various skin types. These agents prepare the skin for the peel and help it to heal faster. They are particularly helpful for darker patients, who have a tendency (toward) hyperpigmentation. These agents will suppress or curtail the hyperpigmentation response."

The thickness of the patient's skin will also affect the depth of the peel, she says.

"If the patient has thick skin, you'll have to take the peel deeper to get a clinical result," she says. "Conversely, if the patient has thin skin, you'll need to exercise caution to avoid scarring. However, thin-skinned patients are better candidates for peels than other resurfacing. The peel can cause the collagen to build up with less risk of injury to deeper tissues and less risk of complications, than with other resurfacing procedures."

Patients with oily skin will need to pre-treat, because excessive oil can interfere with the penetration of the peeling agent. Agents such as low-dose isotretinoin (Accutane, Roche) can help reduce oil production and help patients get better results with their skincare products as well as with the chemical peel, she says. The depth of the targeted lesions will also determine the depth of peels, she says.

Superficial peels Superficial peeling agents consist of salicylic acid, glycolic acid, low-dose trichloroacetic acid (TCA) and Jessner's solution.

"These peels can be used to create two or three days of exfoliation and to help with fine freckles and acne," Dr. Obagi says. "However, they will not affect deeper lesions such as wrinkling and deep-seated melasma."

For melasma, the dermatologist may want to use Jessner's solution but increase the TCA concentration in the solution.

"Don't go above 30 percent concentration or you can get too deep too quickly," she cautions.

Another strategy may be combining two peels in one session. Some combinations will get a faster peel, while some are designed to slow down the peeling depth and create a more uniform peel such as the Obagi Blue Peel. (Dr. Obagi has no affiliation with Obagi medical products.)