"(Clinicians) need the best bang for their buck, and often they cannot afford a $140,000 laser right out of school," says Cherie Ditre, M.D., director, Cosmetic Dermatology & Skin Enhancement Center, University of Pennsylvania School of Medicine, Philadelphia. "Patients with sun damage have actinic keratoses, rhytids and lentigines — a whole sundry of problems. Often (physicians) cannot buy three different lasers to treat each problem. Chemical peels can treat pre-skin cancers, photodamaged skin, acne and melasma — allowing for the ability to treat a number of different problems without any special equipment." Peel vs. laser data While the chemical peel has never left many practitioners' arsenal, the laser is often the preferred treatment tool. Yet, recent research underscores the efficacy of chemical peels. Dr. Ditre has found the combined use of 5 percent fluorouracil and glycolic acid peels to be very effective in treating actinic keratoses and improving the overall cosmetic appearance of the skin, yielding a dual benefit for the patient: both medical and cosmetic.Even with laser's powerful presence in the aesthetic medical discipline, the chemical peel continues to make strides against newer technology. When studying facial resurfacing for the treatment of actinic keratoses, a 30 percent solution of trichloroacetic acid edged out the use of 5 percent fluorouracil and laser removal (Basil Hantash et al. "Facial resurfacing for nonmelanoma skin cancer prophylaxis." Arch Dermatol. 2006; 142:976-982). Each treatment significantly reduced the mean lesion count at three months compared with the control group; however, the study reported a nearly 40-fold lower rate of subsequent nonmelanoma skin cancers in the trichloroacetic acid arm compared with the control population. Improved patient compliance in the trichloroacetic acid arm, ease of performance in the outpatient setting and subjective measures of better tolerance for this procedure make it an attractive alternative to repeated courses with topical agents or laser resurfacing, the study's authors concluded. Brush boost With evidence supporting the fundamental approach to chemical peeling, many clinicians are looking for ways to build on established principles. Beyond their use in combination with laser therapy, some practitioners are exploring pre-peel cleansing procedures and patient-applied topical creams to enhance peel effectiveness. In her current study comparing 20 percent and 30 percent glycolic solutions, Dr. Ditre is using the Clarisonic face brush (Clarisonic, Pacific Bioscience Laboratories) to augment the peel's strength. Based on sonic technology that works with the natural elasticity of the skin, the Clarisonic's brush oscillates at more than 300 movements per second, with bristles traversing facial lines, pores and scars. The motion of the brush also aids in dislodging debris, similar to the action of sonic surgical instrument cleansers. "The brush method is showing a significantly enhanced penetration of the glycolic peel by giving the best possible cleansing prior to the treatment," says Dr. Ditre, whose results are to be presented at the American Society of Cosmetic Dermatology & Aesthetic Surgery meeting at the end of November. "When using this method, I tend to stay with lower concentrations of glycolics — in the 20 to 30 percent range — because the brush results in an approximate 70 percent augmentation." An additional breakthrough from Dr. Ditre's practice is the use of fluorouracil (Efudex, Valeant Pharmaceuticals) one to two weeks prior to a 70 percent glycolic peel. By building on the topical drug's ability to specifically isolate pre-skin cancers and then using the glycolic acid peel as the "smart bomb" to chemolyze the actinic keratosis and thereby slough them from the superficial layers of skin, the glycolic peel's impact is enhanced. "We are getting very good results (with the use of fluorouracil prior to glycolics), including further decrease of pre-skin cancers, such as actinic keratoses," Dr. Ditre says. |
