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    Picking the best peel

    Dermatologist shares favorites for acne and more

    Peter Rullan, M.D.Dr. RullanPeels successfully treat a variety of cases of melasma, acne scars and sun-damaged skin, dermatologist Dr. Peter Rullan told colleagues, but he says it's crucial to select the right peel for the right patient. And in some cases, he says, lasers can offer better results, either in conjunction with peels or alone.

    Rullan, M.D., has a private practice in Chula Vista, Calif., and is a volunteer clinical professor of dermatology at the University of California at San Diego. He described his recommendations at the 2016 CalDerm Symposium, a continuing education seminar offered by the California Society of Dermatology & Dermatologic Surgery.

    Active Acne

    For active acne Dr. Rullan recommends 30% salicylic, Jessner’s and VI peels.

    "I routinely do 30% salicylic on patients on low-to-medium doses of isotretinoin," he says. "For isotretinoin, I like 20 mg/day initially, and based on tolerance and need, I slowly titrate upward."

    Dr. Rullan adds monthly Vbeam Perfecta pulsed dye laser for red acne scars, even while the patient is on low-dose isotretinoin.

    "I use 10-msec and 8 joules, 7 mm spot size, followed immediately by a 30% salicylic peel or wash if the patient has active acne lesions," he says. "The red marks from recent acne lesions respond very well to the laser, and acne lesions such as comedones and papules dry out or exfoliate with the salicylic peel."

    Dr. Rullan offers several cautions: "Buffered glycolic works well for comedonal acne but cannot be done while using topical or systemic retinoids because it can cause blisters," he says. "And although they're effective, Jessner’s peels can cause post-inflammatory hyperpigmentation (PIH) in skin types 4-6."

    Boxcar Acne Scars

    For small boxcar or ice pick acne scars Dr. Rullan likes to mix a TCA peel with laser.

    "I do CROSS – Chemical Reconstruction of Skin Scars – with 30% TCA for thin skin, 60% for medium, and 100% for thick-skinned patients. It must be applied with a toothpick to avoid spillage onto the shoulders of the scars," he says. "It can be done in all skin types with minimal risk of PIH, but if done incorrectly it can widen the scars temporarily."

    "If I see rolling scars, then I do Nokor 18-gauge needle subcision before I do the CROSS with TCA," he adds.

    If appropriate, Dr. Rullan follows CROSS immediately with either fractional Erbium or CO2 laser based on available downtime or severity of scars. He cautions that "Combining CROSS with ablative lasers is better than just lasers alone, since lasers cannot ablate the lateral walls of box or ice pick scars. Many of the patients that come to me have been very disappointed with the results and the cost of their CO2 laser peels for scars."

    Other treatment approaches, he says, can include dermabrasion, 2-day phenol chemabrasion for spot or full-face scarring, excision, punch elevation and punch grafting.

    Next: Melasma

    Randy Dotinga
    Randy Dotinga is a medical writer based in San Diego, Calif.

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