Fig. 1
Phenol-croton oil peeling. Edema is stable after 24 h. Vesication is noted on temples and nasal areas
Fig. 2
Phenol-croton oil peeling. Extreme edema is seen after 24 h. Skin is kept moist and occluded with deliberate use of petroleum jelly
Fig. 3
Phenol-croton oil peeling. Yellow/brown crusts associated with fibrin formation after 72 h. Edema has regressed substantially
Fig. 4
Phenol-croton oil peeling. Erythema is pronounced on the seventh day
The higher the concentration of croton oil and/or phenol, the stronger the peeling will be (Hetter 2000a). In treated sites, if erythema is not seen, after 7–10 days, the skin can be retouched, with the same or stronger solution, during the wound care visits in the first 2 weeks, or be planned as a new peeling session, after 2–6 months, when it is possible to switch intervention by combining LASER resurfacing, if residual lines with partial results are mild.
For after-peel care, facial shower or bathing should be avoided for at least 2 days. During this critical period, patients are allowed to wash with cold sterile saline or saline compresses , and should be instructed to apply as much pure petroleum jelly (Vaseline™) as required to maintain crusts always soft. Proper petrolatum occlusion in the first days helps to protect against irritants and allows the dermatologist to examine the healing skin daily. Some dermatologists use adhesive tape for occlusion (Stuzin et al. 1989) which causes greater damage during its removal. After improving from the extreme edema, patient is allowed to shower with hypoallergenic baby shampoo or cleanser lotion. Patients should be warned not to pick, scratch, nor pull crusts. Patients may be instructed to cut any hanging crusts with scissors. Daily office appointments to check for infections and general wound care are recommended. After 48 h, wound crusts and fibrin must be gently debrided washing with sterile saline jets, after at least 15 min of soaked sterile saline compresses. Wet cotton-tip applicators may be used for gentle lift and debride crusts and fibrin. Delicate sterile surgical instruments such as scissors and atraumatic tissue forceps may be used do debride necrotic skin, crusts, and fibrin.
During such visits, it is not uncommon to start oral and topical antibiotics due to purulent exudates, increased odor, and erythema. Routine use of prophylactic antibiotics should be avoided. Valaciclovir for herpes prophylaxis must be prescribed to all patients, 500 mg 2 times a day during the first 7 days, previous herpes history is irrelevant. For pain management, immediate after-peel application of 4% lidocaine cream before applying petroleum jelly, and previous prescription of codeine 30 mg every 4 h, starting 2 h before peeling. If severe pain is experienced during the first postoperative day, patients are instructed to double the dose of codeine. Stronger opioids, such as oxycodone 10mg can be prescribed for better pain control, taken 3h before the peel and repeated 2 hours after the end of the peel, then, every 8 hours, as needed. Tramadol 100mg every 8h is also an effective alternative. Both oxycodone and tramadol may cause nausea, which is usually controlled with sublingual ondansetron 4mg.
Topical and systemic retinoids and steroids are avoided for at least 6 months. Erythema and hyperpigmentation are best managed with hypoallergenic cosmeceuticals , such as topical vitamin C , E, nicotinamide, and topical hyaluronic acid .
Strengths and Preparation of Phenol-croton oil Formulas
There is a variety of possible phenol-croton oil formulas . The strongest formula is the stock solution by itself, which contains one drop of croton oil per ml of liquid 88% phenol (Hetter 2000b). This formula contains completely solubilized 4% croton oil in 85% phenol; presents a uniform, monophasic, yellowish hue; provokes very deep peeling; and is currently used by the author to repair incomplete earlobe cleft and treat actinic cheilitis (Fig. 5), xanthelasma, icepick, and boxcar acne scars by chemical reconstruction of scars (CROSS) . The author has baptized this full strength solution “capeta ” (devil), as a reminder for the novice on chemical peels to be extremely cautious when using this dangerous and extremely strong formula. To prepare this stock solution, add 1 ml of croton oil to 24 ml of pure 88% liquefied phenol (Hetter 2000b). For smaller volume, mix 0.5 ml of croton oil into 12 ml of 88% phenol.
Fig. 5
Treatment of actinic cheilitis with full-strength phenol-croton oil peeling on lower lip. Croton oil concentration of 4% (one drop per ml of 88% liquefied phenol)
The most traditional formula is the Baker Gordon solution , which contains about 2.1% croton oil in 50% phenol (Baker et al. 1966). This formula causes diffused melanocyte toxicity and requires at least 60 min to peel the whole face with adequate room air exhaustion, due to higher cardiotoxic risk. Extreme acne scars (in association with CROSS technique using “capeta”) or extreme facial elastosis on phototype I-II are best managed with this formula. The author does not recommend this peeling for lower eyelids due to increased risk of ectropion. To prepare this super potent formula, mix 3 ml of 88% phenol with three drops of croton oil. Then, add eight drops of Septisol and 2 ml of water and mix well before use, because this and all the next formulas are biphasic .
Hetter’s formulas are the most versatile; croton oil concentration varies from 0.4% to 1.6% in 35% phenol, although 50% phenol can also be prepared (Hetter 2000b). To prepare the formulas, the final volume will always be 10 ml. First, add 1, 2, 3, or 4 ml of the stock solution to 3, 2, 1, or “0” ml of 88% phenol, to prepare 0.4% croton oil (mild), 0.8% (medium), 1.2% (potent), and 1.6% (very potent) formulas, respectively. Observe that the sum of ml of the stock solution plus phenol should always be 4 ml in order to obtain 35% phenol solution. Then, add 5.5 ml of water mixed with 0.5 ml of Septisol (remaining 6 ml). To prepare 50% phenol formulas, the volume of phenol may be increased to 5.5 ml, with decrease of water volume to 4 ml. In order to prepare a solution very similar to Baker Gordon formula with this volumetric technique, mix 5.5 ml of the stock solution to 0.5 ml of Septisol dissolved in 4 ml of water (2.2% croton oil in 50% phenol), or mix 5 ml of the stock solution, plus 0.5 ml of 88% phenol into 0.5 ml of Septisol dissolved in 4 ml of water (2% croton oil in 50% phenol).
The mildest formula is 0.105% croton oil in 27.5% phenol (Orra et al. 2015), which is a very safe and tolerable formula with mild edema during healing time, with faint desquamation. To prepare this formula, which was named by Hetter as a “very light peel” of his 1996 Heretic Formulas, mix 4 ml of phenol 88% with 1 drop of croton oil, 16 drops of Septisol, and 6 ml of water. Take 3 ml of this mixture and add 2 ml of phenol 88% and 5 ml of water (Hetter 2000b). Alternatively, a very similar formula may be prepared by mixing 0.3 ml of stock solution with 3 ml of 88% phenol, and add 6.5 ml of water and 0.6 ml of Septisol. That will produce a 0.12% croton oil with 27.5% phenol formula, which can be safely used to attenuate fine wrinkles in lax eyelids.
The decision to which strength to be used is crucial for adequate treatment of each condition. The author considers formulas stronger than 0.4% croton oil in 35% phenol deep chemical peels and more diluted formulas mid to superficial peelings.
Combining with Other Chemical Peel
The traditional combination treatment for phenol-croton oil peels is to apply a milder peel in the remaining facial skin, such as depicted in Fig. 6, in a case that was combined with Monheit’s Jessner + TCA 35% (Monheit 2001) in the same procedure.
Fig. 6
Combination treatment of periocular phenol 35% and croton oil 0.4% with Monheit’s medium-depth peeling in the remaining facial skin. (Jessner’s solution followed by 35% trichloroacetic acid). Left: pretreatment. Right: after 30 days
When using a very strong phenol-croton oil formula, such as Baker Gordon formula on mid upper eyelids, in the area that would be excised during a upper blepharoplasty, good results are achieved by the application of plain liquefied phenol 88% in the remaining eyelid skin and periorbital area, plus a milder medium-depth chemical peel in the rest of the face, such as 35% TCA in the remaining aesthetic units of the face (Parada et al. 2008).
Gregory Hetter revolutionized phenol-croton oil peeling by suggesting milder formulas of phenol-croton oil peels to be used in the same procedure, without the need to combine with different chemicals, reducing the risk of demarcation marks between aesthetic units. Hetter suggests that stronger formulas are better used in the perioral area, whereas weaker formulas are used in the eyelids and neck, with excellent results (Hetter 2000b). Nowadays, it is preferable to seize skin tone uniformity with different phenol-croton oil formulas or milder application techniques (less friction, feathering), than to use other chemical agents. When using a different chemical agent, it is recommendable to delay the second peel until full epidermal recovery from phenol-croton oil peel is seen (as seen in Figs. 7 and 8).
