The policy was developed with a literature search of the MEDLINE database through July 2010. There were several review articles that discussed possible applications of chemical peels and two small published studies.

 

A key issue for the policy is the determination of whether the treatment is primarily cosmetic in nature. Regarding actinic keratoses, these are premalignant lesions, and the medical necessity for their destruction/removal is considered appropriate, although watchful waiting may also be an option. Review articles suggested that chemical peels might be appropriate when there are numerous lesions (i.e. 10 or more), making treatment of the individual lesions impractical and when the treatment constitutes a full-thickness necrosis of the epidermis which is considered curative (Morganroth, 1993) (Brodland, 1988). Photodynamic therapy is another option for the treatment of patients with multiple actinic keratoses.

 

Review articles also suggested that chemical peels may be appropriate for treatment of active acne when other treatments have failed (Van Scott, 1989).  While low concentrations of chemical agents can be administered by the patient at home, higher concentrations are administered in the dermatologist’s office. Superficial glycolic acid peels are usually done as an adjunct to other comedolytic therapy done in the office. Since chemical peeling does not represent a curative therapy, treatments may be continued over the course of years. Superficial peels for these patients represent a more intense form of therapy, inasmuch as referral to a dermatologist is required. Therefore patients with acne requesting coverage for chemical peels should have failed a trial of topical and oral antibiotic therapy for acne.

 

Other applications of chemical peels, including treatment of photoaged skin, wrinkles and acne scarring were considered cosmetic.

 

Two small controlled studies evaluating chemical peels were identified. Both used randomized split-faced designs and compared the effects of two chemical peeling agents. The stronger study methodologically was published in 2008 by Kessler and colleagues (Kressler, 2008).  This single-center study evaluated chemical peels as adjuvant therapy in 20 patients who were at least 13 years old and had mild to moderately severe facial acne with a minimum of 10 papules and/or pustules. It compared treatment with an alpha-hydroxy acid (30% glycolic acid) and a beta-hydroxy acid peel (30% salicylic acid). Patients were treated every 2 weeks for a total of six weeks, and were followed for 2 months after the last treatment. Ten percent of the patients had completed a course of isoretinoin over a year before enrollment (used of isoretinoin within a year was an exclusion criterion). At the time of study enrollment, 75% of patients were using topical medication and 25% were on oral antibiotics; no changes in acne medication were allowed during the study period. The authors did not report the length of time that patients had been using other acne treatments. The primary outcome was clinical response according to a blinded evaluator, categorized as good (more than 50% improvement), fair (21%-50% improvement), poor (10-20% improvement), no change or worse. A total of 17 of the 20 patients were included in the analysis; 1 patient dropped out and 2 were lost to follow-up. At 1 month after the last treatment visit, acne lesions declined by 43% on the glycolic acid peel side and 47% on the salicylic acid peel side, a non-significant between-group difference. There was also no between-group difference in response at 2 months; the evaluator rated as having good or fair improvement 75% of the glycolic acid peel sides and 80% of the salicylic acid peel sides. Both chemical agents resulted in improvement compared to baseline. There were similar number of adverse events with each chemical agents; common adverse events were redness and scaling. A limitation of the study was that it did not include a control group of patients who did not receive chemical peeling so it is uncertain whether either type of peel was more effective than standard treatment.

 

The other study, published in 1999, was conducted in Korea by Kim and colleagues and reported on 26 patients with mild to moderate acne (Kim, 1999). The two treatments were 70% glycolic acid and Jessner’s solution (resorcinol, salicylic acid, and lactic acid in ethanol). Treatments were repeated 3 times every 2 weeks, for a total treatment period of 6 weeks. A blinded physician evaluated each face before each treatment and 2 weeks after the last treatment. The authors reported that 26 patients completed the study but did not state the number of patients who were initially included. Moreover, they reported the number of face sides judged to have improvement in acne (8 sides, 31%, improved with each chemical agent) but did not specify when this outcome was measured e.g. after the last treatment or at final follow-up. Also missing were any previous or concurrent acne treatments patients received. Finally, like the Kessler study, the study by Kim and colleagues lacked a control group that did not receive chemical peels.

 

No controlled studies evaluating chemical peels for treatment of actinic keratoses were identified. The search yielded one case series, a prospective study from Japan that included 46 patients, 32 with actinic keratoses and 14 with Bowen’s Disease (Kaminaka, 2009).  There was no minimum number of actinic keratoses required for inclusion; that is, the study did not specifically address treatment of multiple actinic keratoses. Patients received phenol peels with 100% pure phenol applied locally to the lesions once a month for a maximum of 8 months (less if a complete response was achieved) Biopsies were performed on all lesions before and at the end of therapy. Twenty-nine of the 32 (91%) patients with actinic keratoses achieved a complete response (defined as an undetectable lesion at least 1 month after the last phenol application). The average number of treatments for patients with actinic keratoses was 2.9. Ten of the 12 (83%) patients with Bowen’s Disease had a complete response and the average number of treatments in this group was 5.5. All patients were followed for at least a year after treatment; median follow-up was 2.8 years. By the 1-year follow-up, 2 of 46 patients (4.3%), 1 with actinic keratoses and 1 with Bowen’s Disease, had experienced recurrences. No systemic side effects were reported. The study was limited by lack of a control group, and a small sample size, especially in the sub-set of patients with Bowen’s Disease.

 

British Association of Dermatologists: In 2007, they published a guideline on the management of actinic keratoses (de Berker, 2007). Chemical peels were given a ‘C, III” rating, meaning that there is “poor evidence to support the use of the procedure” and the evidence consists of “opinions of respected authorities based on clinical experience, descriptive studies or reports of expert committees”.

 

American Academy of Dermatology: In 2007, they published a guideline on management of acne vulgaris which included the statement, “There is limited evidence regarding the benefit of physical modalities including glycolic acid peels and salicylic acid peels.” (Strauss, 2007)

 

There is a paucity of studies evaluating chemical peels. Review articles and clinical opinion supports the use of chemical peels for treating multiple actinic keratoses and as second-line treatment of active acne.. There are no studies that demonstrate the medical necessity for use of chemical peels in the treatment of photoaged skin or acne-related scarring.

 

 

 

 

 

 

 

 

 

 

A literature search conducted using the MEDLINE database through July 2015 did not reveal any new information that would prompt a change in the coverage statement.   

 

 

 

 

 

 

 

 

 

 

 

Steeb et al conducted a systematic review and meta-analysis assessing the efficacy and safety of chemical peels for the treatment of actinic keratosis (Steeb, 2020). 8 trials were included in the systematic review. This includes 4 RCTs, 2 non-randomized controlled trials, and 2 single-arm studies. Data analysis and interpretation of results were challenged by the presence of multiple study designs and the investigation of multiple distinct comparisons. The studies included in the review were at a high risk for selection bias as only 1 study clearly described the generation of a random sequence and performed allocation concealment. None of the patients in the studies were blinded; blinding of the outcome assessor was described in 1 study. Additionally, the chosen efficacy outcomes refer to short-term clearance rates but may not reflect long-term results. Overall, the authors concluded that additional high-quality studies and a standardization of peeling protocols were warranted in order to appropriately determine the value of chemical peeling as a treatment for actinic keratoses.