Indications and Technique for Phenol-Croton Oil Peels



Indications and Technique for Phenol-Croton Oil Peels


Gehaan D’Souza

James E. Zins





DEFINITION



  • Intermediate and deep chemical peeling imparts injury to the epidermis and varying depths of the dermis in a controlled manner in efforts to stimulate epidermal regrowth. Peeling has been shown to rejuvenate facial skin and has been used to treat acne, rhytides, and photodamage.1


  • Chemical peels are available in a variety of formulas, which produce superficial, medium, and deep wounds.



    • Superficial peeling techniques are limited to epidermal injury only.1,2 Intermediate and deep chemical peels most commonly involve trichloroacetic acid (TCA) and phenol-croton oil. Both TCA and phenol-croton oil depth can be varied by changing the concentration, number of applications, and the amount of peeling agent applied.


    • Deeper peels, such as the conventional phenol-croton oil formula, are the most effective in resurfacing skin but are also associated with more severe complications and may not be appropriate for certain patients.


  • The use of phenol-based chemical peels declined with the advent of laser technologies.



    • There has been renewed interest in the use of this technique in recent years with the realization that reducing the concentration and application methods can reduce complications while maintaining results.3,4


    • The phenol-croton oil formulas use varying concentrations of phenol, croton oil, Septisol, and water.3


  • Full facial phenol peels require deep sedation or general anesthesia and cardiac monitoring. Because of the potential for cardiac arrhythmias, full facial chemical peeling should be done based on anatomic units over a relatively prolonged period of time (1-1.5 hours).


  • Additionally, these peels pose risk for renal failure and hepatotoxicity.3,5


  • Adjusting croton oil concentration allows for variation in phenol-croton oil peel depth and achievement of more uniform results on different thicknesses of skin.3



    • Phenol-croton oil peels are increasingly being used as a medium-depth peeling modality and can be performed on a spectrum of ages and skin conditions.4


ANATOMY



  • Phenol-croton oil, while most commonly recognized as a deep peeling technique, can also be used as a superficial or medium-depth peeling modality (FIG 1).6


  • Chemical peels are divided into three categories based on the degree of injury caused by the treatment7:



    • Superficial peels—cause epidermal injury and do not penetrate below the basal layer


    • Medium-depth peels—ablate the epidermis and varying degrees of the dermis


    • Deep peels—remove the epidermis, papillary dermis, and generally extend to the midreticular dermis


  • Indications for phenol-croton oil peels include4,6,8



    • Rhytides


    • Melasma


    • Acne


PATHOGENESIS



  • Factors such as environmental damage, actinic damage, smoking, and radiation.9,10,11


  • Rhytides form for a variety of reasons. The contraction of the musculature and attachments of the retinaculum cutis that attaches to the skin acts on the skin to create a wrinkle with animation.


  • Strategies for preventing rhytides include sun avoidance, smoking cessation, and treatment of skin with retinoids.11



    • Once rhytides are present in the perioral area at rest, they are difficult to treat.


PATIENT HISTORY AND PHYSICAL FINDINGS



  • Medical and surgical history, as well as physical examination should address general health or risks from current medications (eg, isotretinoin, birth control pills, or immunosuppressants), possibility of pregnancy, liver disease, history of herpes simplex virus, history of hypertrophic or keloid scars, history or risk of hepatitis or HIV, history of radiation exposure, and history of cutaneous disease at the peel site (eg, rosacea, seborrheic dermatitis, atopic dermatitis, psoriasis, and vitiligo).


  • Previous injury to the reticular dermis including previous peeling, laser, or even electrolysis will affect how aggressive one is with peeling depth.


  • Gender differences in perioral wrinkling have been described.



    • Women have a lower ratio of blood vessels to connective tissue than do men.12 This can also be explained by the differences of follicles, sebaceous glands, and androgen-dependent hair.13


  • The patient’s skin type using a Fitzpatrick classification is important in determining the need for suppression of melanin and prevention of hyperpigmentation.


  • The Glogau photoaging scale determines the depth of the peel.14,15


  • Indications for chemical resurfacing:



    • Photoaging of the skin and rhytides


    • Preneoplastic or neoplastic lesions such as actinic keratosis and lentigines







      FIG 1 • Review of basic skin anatomy as it relates to peel depth.


    • Acne or other underlying skin diseases


    • Pigmentary dyschromias


    • Demarcation lines secondary to other resurfacing procedures


  • Contraindications to chemical resurfacing:

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Nov 12, 2019 | Posted by in Aesthetic plastic surgery | Comments Off on Indications and Technique for Phenol-Croton Oil Peels

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