What is Optimal Time Between Chemical Peels for Acne Scarring?

Our treatments use combination therapy to improve the epidermis and dermis for most deep scars. The options available for acne scars depend on the character of your scars, in terms of topography and contour. We see atrophic and hypertrophic acne scars, as well as scars that have hypo and hyperpigmentation. We begin each scar evaluation with an assessment of scar quality and subtype. Our main concern is rebuilding collagen and that is why we use a HIDEF protocol that includes combination therapy. Morpheus 8, scar subcision, fibrous release, fractional laser, CO2 laser, Thulium laser, PDL Vbeam laser, and fractional resurfacing can be used in addition to TCA Cross and chemical peels to further improve skin. Patients should start Melarase AM and Melarase PM for active hyperpigmentation. Always begin with a consultation to decide whether early subcision should be started.

Best,
Dr. Karamanoukian
Realself100 Surgeon

Chemical peels have been a reliable mainstays of the cosmetic physician's toolbox for well over a century. Trichloroacetic acid (TCA), Jessner's solution, salicyclic acid, glycolic acid and phenol have all been used in varying concentrations and protocols for treating acne scarring for many decades before lasers came on the scene. Since acne scars tend to be deeper within the dermis, superficial chemical peels, even when performed in a series, tend to produce little benefit in my experience. Deeper peels, on the other hand, such as those employing TCA in concentrations of 50% or higher or the Baker's Phenol Peel, while offering more dramatic results, entail a risk of scarring, irreversible loss of pigmentation or permanent hyperpigmenation. For this reason, despite its efficacy, deep peeling fell in considerable disfavor in the last twenty years.

If a deeper peel is needed, such as for acne scars, I prefer to perform the "Punctuated Phenol Peel"--a very recent advance in chemical peeling technique, and one that is sure to put chemical peeling squarely back on the map and in competition with the more expensive, more heavily hyped laser and light-based therapies currently intensively marketed to consumers.

The procedure is simple, requires no sedation, and has little or no downtime. Using 88% plain phenol, the scars are treated in punctuated (i.e. fractionated or pixelated)  fashion. Using a very finely pointed applicator, the chemical is applied in a serial spot fashion with each spot separated from surrounding treatment spots by approximately one-quarter inch. The use of serial spot coverage, rather than coverage of whole areas, allows for rapid recovery as healing takes place from the intervening non-treated areas. It is precisely the same rational for the use of fractional lasers.

The "Punctuated Phenol Peel" technique is a novel approach to rejuvenation that limits the overall potential for toxicity and downtime of traditional deep peels while constituting focal spots of more intense peeling. Treatment sessions can be repeated at monthly intervals if necessary until the desired result is obtained. 

(As a sidebar, I have found the CROSS technique, which utilizes 100% TCA, to be an effective approach for improving pit scars. In this technique, the highly concentrated acid is placed deeply within the pit with a fine needle or very sharp end of a toothpick. The irritation that results ultimately leads to permanent sealing of the pit and improves its appearance. One treatment is often enough.)

Consultation with and treatment by an aesthetic physician experienced in chemical peeling is an absolute must for determining  the appropriateness of these approaches for any particular situation.

I prefer dermabrasion under sedation as the best and most effective treatment for acne scar.  No laser nor chemical peel could match its results for the scarring.  I have been performing this procedures for years.  The right chemical peel is excellent for controlling acne and hyperpigmentation under the hands of an experienced dermatologist familiar and experienced with the wide variety of chemicals available for peeling and their indications.

A series of weekly, bi weekly, or even monthly glycolic acid peel can help treat acne, hyperpigmenation from acne or fine lines but these peels do little for atrophic (depressed) acne scars.  Consider modified Jessner's peels, TCA peels or laser treatment for true acne scarring.  These generally require a 2-4 week interval or longer if the peel is deeper.

Because glycolic acid peels only work on the outer layer of skin, they are more effective at exfoliation, reducing pigmentation & temporarily improving appearance of pores than at actually making a difference with acne scarring.  They can be done as often as every one to two weeks, if low enough concentration, but glycolic acid peels don't stimulate collagen remodeling because they don't reach the dermis where the scar tissue is.  We use either stronger peels or fractionated  lasers to more effectively treat acne scarring, keeping in mind the patient's skin type.  Consultation with an experienced cosmetic dermatologist is logical.