Continuing medical education
Advanced chemical peels: Phenol-croton oil peel

https://doi.org/10.1016/j.jaad.2018.11.060Get rights and content

Once considered the standard for deep facial resurfacing, the classical Baker-Gordon phenol-croton oil peel has largely been replaced by formulas with lower concentrations of phenol and croton oil. The improved safety profile of deep peels has ushered in a new era in chemical peeling. Wrinkles can be improved and skin can be tightened with more subtle and natural results. No longer does a deep peel denote “alabaster white” facial depigmentation with complete effacement of wrinkles. Gregory Hetter's research showed that the strength and corresponding depth of penetration of the phenol-croton oil peel can be modified by varying the concentration of croton oil. This second article in this continuing medical education series focuses on the main historical, scientific, and procedural considerations in phenol-croton oil peels.

Section snippets

Background

Key points

  1. •

    Brown described a phenol-croton oil formula in 1959

  2. •

    Baker-Gordon's formula (2.1% croton oil) was the standard from 1962 to 2000

  3. •

    Hetter's formulas (≤1.6% croton oil) became the standard after 2000

  4. •

    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

  1. •

    Deep peels produce mid-reticular dermal injury with marked collagen formation and organization of elastic fibers

  2. •

    These changes persist for over a decade

  3. •

    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

  1. •

    Phenol-croton oil offers the ability to treat multiple degrees of photoaging by strength gradation

  2. •

    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

  1. •

    Cardiac monitoring is required for full-face deep peels

  2. •

    The therapeutic effect is increased with more strokes, volume, pressure, and concentration of croton oil

  3. •

    Waiting 10 to 15 minutes between each cosmetic unit minimizes cardiotoxicity

  4. •

    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

  1. •

    Seven percent of patients will exhibit transient intraoperative cardiac arrhythmias

  2. •

    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)

  • J.R. Dmytryshyn

    Phenol peels and toxic shock syndrome

    J Am Acad Dermatol

    (1983)
  • T.M. Bertolini

    Is the phenol-croton oil peel safe?

    Plast Reconstr Surg

    (2002)
  • G.P. Hetter

    An examination of the phenol-croton oil peel: part II. The lay peelers and their croton oil formulas

    Plast Reconstr Surg

    (2000)
  • A.M. Brown

    Skin treating method and composition

  • C. Litton

    Chemical face lifting

    Plast Reconstr Surg Transplant Bull

    (1962)
  • T.J. Baker

    The ablation of rhitides by chemical means. A preliminary report

    J Fla Med Assoc

    (1961)
  • C.G. Wambier et al.

    Comments: hemiface comparative study of two phenol peels (Baker-Gordon and Hetter formulas) for the correction of facial rhytids

    Surg Cosmet Dermatol

    (2017)
  • T.J. Baker

    Chemical face peeling and rhytidectomy. A combined approach for facial rejuvenation

    Plast Reconstr Surg Transplant Bull

    (1962)
  • G.P. Hetter

    An examination of the phenol-croton oil peel: part III. The plastic surgeons' role

    Plast Reconstr Surg

    (2000)
  • I. Neitzke et al.

    Randomized controlled trial on the use of Septisol and Johnson's baby shampoo in a phenol-croton oil peel formula.

  • G.P. Hetter

    An examination of the phenol-croton oil peel: part IV. Face peel results with different concentrations of phenol and croton oil

    Plast Reconstr Surg

    (2000)
  • G.P. Hetter

    An examination of the phenol-croton oil peel: part I. Dissecting the formula

    Plast Reconstr Surg

    (2000)
  • T.J. Baker et al.

    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

    (2000)
  • F. Behin et al.

    Comparative histological study of mini pig skin after chemical peel and dermabrasion

    Arch Otolaryngol

    (1977)
  • A.M. Kligman et al.

    Long-term histologic follow-up of phenol face peels

    Plast Reconstr Surg

    (1985)
  • S.Y. Giese et al.

    The effect of chemosurgical peels and dermabrasion on dermal elastic tissue

    Plast Reconstr Surg

    (1997)
  • R.E. Fitzpatrick et al.

    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

    (1996)
  • S.J. Stegman

    A comparative histologic study of the effects of three peeling agents and dermabrasion on normal and sundamaged skin

    Aesthetic Plast Surg

    (1982)
  • T.J. Baker et al.

    Long-term histological study of skin after chemical face peeling

    Plast Reconstr Surg

    (1974)

    • Date of release: August 2019

    Expiration date: August 2022

    Funding sources: None.

    Conflicts of interest: None disclosed.

    View full text
    Published by Elsevier on behalf of the American Academy of Dermatology, Inc.