Continuing medical educationAdvanced chemical peels: Phenol-croton oil peel
Section snippets
Background
Key points Brown described a phenol-croton oil formula in 1959 Baker-Gordon's formula (2.1% croton oil) was the standard from 1962 to 2000 Hetter's formulas (≤1.6% croton oil) became the standard after 2000 Croton oil is the active ingredient
Croton oil is obtained from the seeds of Croton tiglium, a vegetal matrix of phorbol esters. These compounds display a broad range of biologic activities over several proteins/enzymes.1 The activation of protein kinase C causes extreme inflammatory and promoter effects.2
Histology
Key points Deep peels produce mid-reticular dermal injury with marked collagen formation and organization of elastic fibers These changes persist for over a decade More strokes with peel agents increase wound depth
The most important histologic observation is a dense, dermal neocollagenesis zone (Fig 1) that increases until 16 weeks.19 Organized elastic fibers replace the elastosis.20 Melanin granules decrease despite the presence of melanocytes.21, 22, 23, 24, 25, 26
Occlusion increases the depth of effects
Clinical indications for phenol-croton oil
Key points Phenol-croton oil offers the ability to treat multiple degrees of photoaging by strength gradation Phenol-croton oil can be used on the face and the front of the neck
Deep peels (Fig 2) are traditionally indicated for the treatment of severe rhytides (Glogau classification of photoaging IV) and severe acne scars. The indications have broadened since Hetter's work on strength gradation, with new indications such as moderate photodamage (Glogau classification of photoaging III). Other indications
Application technique
Key points Cardiac monitoring is required for full-face deep peels The therapeutic effect is increased with more strokes, volume, pressure, and concentration of croton oil Waiting 10 to 15 minutes between each cosmetic unit minimizes cardiotoxicity Petrolatum jelly or tape can be used for occlusion
The first step is to mix croton oil with 88% phenol into a solution, followed by the addition of soap and water (Table III). This preparation separates after 1 minute into 2 phases (Supplementary Video 1, available
Adverse effects
Key points Seven percent of patients will exhibit transient intraoperative cardiac arrhythmias Prolonged erythema is an expected side effect
Transient rate-corrected QT interval prolongation may occur during phenol-croton oil peels51; therefore, a baseline electrocardiogram is needed for full-face peeling, and drugs known to prolong the rate-corrected QT interval should be discontinued. Approximately 7% of patients undergoing full-face peels will exhibit transient intraoperative cardiac arrhythmias, which
References (58)
- et al.
Comment on “Anti-aging effects of ingenol mebutate for patients with actinic keratosis” and phenol-croton oil peelings
J Am Acad Dermatol
(2019) Observations on the employment of croton oil
Lancet
(1833)- et al.
Phenol-croton oil peel: establishing an animal model for scientific investigation
Aesthet Surg J
(2009) Phenol-croton oil peel: an update
Aesthet Surg J
(2005)- et al.
Modified phenol chemical face peels: recognizing the role of application technique
Clin Plast Surg
(2001) Croton oil peels
Aesthet Surg J
(2008)- et al.
Chemical face peeling and dermabrasion
Surg Clin North Am
(1971) - et al.
Augmentation and eversion of lips without injections: the lip peel
J Am Acad Dermatol
(2019) - et al.
Comment on “Surgical smoke: Risk assessment and mitigation strategies” and chemical adsorption by activated carbon N95 masks
J Am Acad Dermatol
(2019) - et al.
Prolongation of rate-corrected QT interval during phenol-croton oil peels
J Am Acad Dermatol
(2018)
Phenol peels and toxic shock syndrome
J Am Acad Dermatol
Is the phenol-croton oil peel safe?
Plast Reconstr Surg
An examination of the phenol-croton oil peel: part II. The lay peelers and their croton oil formulas
Plast Reconstr Surg
Skin treating method and composition
Chemical face lifting
Plast Reconstr Surg Transplant Bull
The ablation of rhitides by chemical means. A preliminary report
J Fla Med Assoc
Comments: hemiface comparative study of two phenol peels (Baker-Gordon and Hetter formulas) for the correction of facial rhytids
Surg Cosmet Dermatol
Chemical face peeling and rhytidectomy. A combined approach for facial rejuvenation
Plast Reconstr Surg Transplant Bull
An examination of the phenol-croton oil peel: part III. The plastic surgeons' role
Plast Reconstr Surg
Randomized controlled trial on the use of Septisol and Johnson's baby shampoo in a phenol-croton oil peel formula.
An examination of the phenol-croton oil peel: part IV. Face peel results with different concentrations of phenol and croton oil
Plast Reconstr Surg
An examination of the phenol-croton oil peel: part I. Dissecting the formula
Plast Reconstr Surg
An examination of the phenol-croton oil peel: part IV. Face peel results with different concentrations of phenol and croton oil by Gregory P. Hetter, MD
Plast Reconstr Surg
Comparative histological study of mini pig skin after chemical peel and dermabrasion
Arch Otolaryngol
Long-term histologic follow-up of phenol face peels
Plast Reconstr Surg
The effect of chemosurgical peels and dermabrasion on dermal elastic tissue
Plast Reconstr Surg
Pulsed carbon dioxide laser, trichloroacetic acid, Baker-Gordon phenol, and dermabrasion: a comparative clinical and histologic study of cutaneous resurfacing in a porcine model
Arch Dermatol
A comparative histologic study of the effects of three peeling agents and dermabrasion on normal and sundamaged skin
Aesthetic Plast Surg
Long-term histological study of skin after chemical face peeling
Plast Reconstr Surg
Cited by (35)
Cosmetic Dermatology Concerns in Older Adults
2024, Clinics in Geriatric MedicineUpdate on Chemical Peels
2024, Dermatologic ClinicsSkin of color repigmentation after phenol-croton oil chemical peel
2023, Journal of the American Academy of DermatologyStatic glabellar lines can be treated using a superlocalized phenol-croton peel
2023, JAAD InternationalEfficacy and Safety of Phenol and Trichloroacetic Acid Combination Peel for the Management of Dark Circles
2022, Actas Dermo-SifiliograficasThe effects of 35% trichloroacetic acid-Croton oil and 35% glycolic acid-Croton oil compared to 35% phenol-Croton oil Hetter's very heavy formula for deep chemical peel
2022, Journal of the American Academy of Dermatology
Date of release: August 2019
Expiration date: August 2022
Funding sources: None.
Conflicts of interest: None disclosed.