|Original Policy Date
|Last Review Status/Date
Reviewed with literature search/7:2013
|Return to Medical Policy Index|
Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.
A chemical peel refers to a controlled removal of varying layers of the skin with use of a chemical agent. The most common use for chemical peeling is as a treatment of photoaged skin. However, chemical peeling has also been used as a treatment for other conditions, including actinic keratoses, active acne, and acne scarring.
Chemical peels involve a controlled partial-thickness removal of the epidermis and the outer dermis. When skin is regenerated, a 2-3-mm band of dense, compact collagen is formed between the epidermis and the damaged layers of the dermis, resulting in ablation of fine wrinkles and a reduction in pigmentation. These changes can be long-term, lasting 15-20 years and may be permanent in some patients. Potential local complications include scarring, infection, hypopigmentation, hyperpigmentation, activation of herpes simplex, and toxic shock syndrome. (1)
Chemical peels are often categorized according to the depth of the peel: categories include superficial, medium-depth, and deep chemical peels. The precise depth of the peel depends on the concentration of the agent used, duration of the application, and the number of applications. Possible indications for each type of peel and common chemicals used, as described in 2005 by Cummings and colleagues (2) and others, is as follows:
Superficial peels (epidermal peels) affect the epidermis and the interface of the dermis-epidermis. This depth is considered appropriate for treating mild photoaging, melasma, comedonal acne, and postinflammatory erythema. Common chemical agents used for superficial peels include low concentrations of glycolic acid, 10–20% trichloroacetic acid (TCA), Jessner’s solution (a mixture of resorcinol, salicylic acid, lactic acid, and ethanol), tretinoin, and salicylic acid. As part of the treatment process, superficial peels generally cause mild erythema and desquamation, and healing time ranges from 1 to 4 days, depending on the strength of the chemical agent. With superficial peels, patients often undergo multiple sessions, generally a total of 6 to 8 peels performed weekly or biweekly.
Medium-depth peels (dermal peels) extend into the epidermis to the papillary dermis. These are used for moderate photoaging, actinic keratoses, pigmentary dyschromias, and mild acne scarring. In the past, 50% TCA was a common chemical agent for medium-depth peels, but its use has decreased due to a high rate of complications such as pigmentary changes and scarring. Currently, the most frequently used agent is a combination of 35% TCA with Jessner’s solution or 70% glycolic acid. Phenol 88% alone is also used for medium-depth peels. The healing process involves mild to moderate edema, followed by the appearance of a new, erythematous epithelium. Patients are advised to wait at least 3 months before resuming skin care services such as superficial chemical peels, and repeat medium-depth chemical peels should not be performed for at least 1 year.
Deep chemical peels (another type of dermal peel) penetrate the midreticular dermis and are used for patients with severe photodamage, premalignant skin neoplasms, acne scars, and dyschromias. The most common chemical agent used is Baker’s solution (which consists of 3 mL of 88% phenol, 8 drops of septisol, 3 drops of croton oil, and 2 mL of distilled water). The same depth can be achieved using 50% or greater TCA peel; however, the latter has a higher risk of scarring and pigmentation problems. Phenol is cardiotoxic, and patients must be screened for cardiac arrhythmias or medications that could potentially precipitate an arrhythmia. Phenol can also have renal and hepatic toxicities.
The likelihood and potential severity of adverse effects increases as the strength of the chemicals and depth of peels increases. With deep chemical peels, there is the potential for long-term pigmentary disturbances (i.e., areas of hypopigmentation), and selection of patients willing to always wear makeup is advised. Moreover, chemical peels reduce melanin protection, so patients must use protective sunscreen for 9 to 12 months after a medium- to deep-facial peel.
U.S. Food and Drug Administration (FDA) clearance or approval may not be relevant for the chemical agents used in peeling because they are prepared in-office, may have predated FDA approval, and/or may be considered cosmetic ingredients.
Dermal chemical peels used to treat patients with numerous (greater than 10) actinic keratoses or other premalignant skin lesions, such that treatment of the individual lesions becomes impractical, may be considered medically necessary.
Epidermal chemical peels used to treat patients with active acne that has failed a trial of topical and/or oral antibiotic acne therapy are considered medically necessary. In this setting, superficial chemical peels with 50–70% alpha hydroxy acids are used as a comedolytic therapy. (Alpha hydroxy acids can also be used in lower concentrations [8%] without the supervision of a physician.)
Epidermal chemical peels used to treat photoaged skin, wrinkles, or acne scarring or dermal peels used to treat end-state acne scarring are considered cosmetic and not medically necessary.
Requests for all chemical peels should be carefully evaluated to determine whether their rationale is primarily cosmetic. Epidermal peels would only be considered medically necessary in patients with active acne who have failed other therapy. Dermal peels would be considered medically necessary only in patients with multiple actinic keratoses.
There are a variety of CPT codes that describe chemical peels. CPT codes 15788 and 15789 describe epidermal peels, for the facial and nonfacial areas, respectively. CPT codes 15792 and 15793 describe the corresponding dermal peels. A distinct CPT code, 17360, specifically describes chemical exfoliation for acne. Chemical exfoliation may be considered part of the general dermatology evaluation and management services and, therefore, Plans may consider whether to accept separate billing for chemical exfoliation as a treatment of acne.
BlueCard/National Account Issues
The approach to use of chemical peels for treatment of active acne and post-acne scarring will depend on benefit language related to definitions of medically necessary, reconstructive, and cosmetic services. Some Plans may consider active acne a disease and thus its treatment eligible for coverage, while the treatment of post-acne scarring may be considered cosmetic, since active disease is no longer present. Other Plans may consider treatment of post-acne scarring to be reconstructive. Procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect. Not all benefit contracts include benefits for reconstructive services. Benefit language supersedes this document.
Making the distinction between active and inactive acne can be difficult. However, simultaneous treatment ith either antibiotics or tretinoin is one indication that the patient has active ongoing disease.
The policy was developed with an initial literature search of the MEDLINE database through January 1998. The policy has been updated with searches of the MEDLINE database; the most recent search is for the period May 2012 through June 18, 2013. The key literature is described below.
A major 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 have 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. (3, 4) Photodynamic therapy is another option for the treatment of patients with multiple actinic keratoses.
Review articles have also suggested that chemical peels may be appropriate for treatment of active acne when other treatments have failed. (5) 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 are considered cosmetic.
Several randomized trials that used a split-face design have been published. In 2011, Levesque and colleagues in France published findings from a single-blind trial that included 20 patients with active comedonal acne. (6) To be eligible, patients needed to have at least 5 noninflammatory acne lesions on each side of the face and to have fewer than 30 inflammatory acne lesions on the entire face. Participants were required to stop using other acne medications prior to starting the chemical peel treatment. The treatments being compared were a salicylic acid peel and a lipophilic hydroxic acid (LHA) derivative of salicylic acid; patients received one treatment to one side of their face (selected randomly) and the other treatment to the second side. Treatments occurred every other week for a total of 6 peels. At the end of the treatment period, the reduction in the proportion of noninflammatory lesions was 55.6% on the LHA side and 48.5% on the salicylic acid side; the difference between groups was not statistically significant, p=0.88. The number of lesions decreased significantly between baseline and the end of treatment in both groups, p<0.001. Both treatments were well-tolerated (as assessed by a global tolerance scale); there was no significant difference between treatments in erythema, p=0.10.
Another single-blind split-face randomized trial in acne patients was published in 2010 by Ilknur and colleagues in Turkey. (7) Treatments being compared in this study were glycolic acid peels and amino fruit peels. The study included 30 patients with non-inflamed lesions and superficial inflamed lesions, with acne grades 0.25 to 2 according to Leeds criteria. Patients received a series of 12 peels on the 2 halves of their face at 2-week intervals (total of 6 months). Twenty-four of 30 (80%) patients completed the study. The mean number of non-inflamed lesions on the glycolic acid side decreased from 49.1 (standard deviation [SD]: 40.6) at baseline to 18.3 (SD: 12.9) at 6 months. The mean number of non-inflamed lesions on the amino fruit acid side decreased from 45.6 (SD: 43.5) at baseline to 17.1 (SD: 14.2) at 6 months. The reduction in lesions was not significantly different between groups. Findings were similar for the other primary outcome, number of superficial inflamed lesions. At 6 months, the number of inflamed lesions was 6.9 (SD: 5.2) on the glycolic acid side and 7.0 (SD: 7.3) on the amino fruit acid side (p>0.05).
In 2008, Kessler and colleagues published a double-blind split-face study evaluating chemical peels as adjuvant therapy in 20 patients who were at least aged 13 years and had mild to moderately severe facial acne with a minimum of 10 papules and/or pustules. (8) The study 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 6 weeks and were followed for 2 months after the last treatment. 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 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 side and 80% of the salicylic acid peel side. Both chemical agents resulted in improvement compared to baseline. There were a similar number of adverse events with each of the chemical agents; common adverse events were redness and scaling.
In 2013, Bae and colleagues published a single-blind split-face study comparing chemical peels with salicylic acid and Jessner’s solution in 13 Korean patients with active acne who were otherwise healthy and had not undergone acne treatment for at least the previous 3 months. (9) It is unclear whether the study was randomized. Patients received a total of 3 treatment sessions; sessions occurred at 2-week intervals. On the side treated with Jessner’s solution, inflammatory lesion count decreased from a mean of 14.5 at baseline to a mean of 8.8 after the third treatment. Comparable numbers for the salicylic acid side were a mean of 12.2 at baseline to a mean of 7.8 after the third treatment. For non-inflammatory lesions, mean count on the Jessner’s solution side was 18.6 at baseline and 14.3 after the third treatment. Mean counts on the salicylic acid side were 22.7 at baseline and 14.7 after the third treatment. Between-group statistics were not reported.
All of the above studies compared 2 chemical peel agents. No studies were identified that included a control group of patients who received a different type of treatment; therefore, it is uncertain whether either type of peel was more effective than an alternative treatment.
No controlled studies that evaluated 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. (10) 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 1 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 adverse effects were reported. The study was limited by lack of a control group and a small sample size, especially in the subset of patients with Bowen’s disease.
Clinical Input Received through Physician Specialty Societies and Academic Medical Centers
In response to requests, input was received through 3 Physician Specialty Societies and 4 Academic Medical Centers while this policy was under review in 2010. While the various Physician Specialty Societies and Academic Medical Centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the Physician Specialty Societies or Academic Medical Centers, unless otherwise noted. The clinical input was consistently in agreement with the medically necessary indications for dermal and epidermal chemical peels. Several reviewers supported use of chemical peels for post-acne scarring.
At the time of policy creation, review articles and clinical opinion supported the use of chemical peels for treating multiple actinic keratoses and as second-line treatment of active acne. More recent clinical input, obtained in 2010, continues to support the policy statements. As of June 2013, there is still a paucity of controlled studies evaluating chemical peels for the above indications, particularly studies comparing chemical peels to alternative treatments. There are no studies that demonstrate the medical necessity for use of chemical peels in the treatment of photoaged skin or acne-related scarring; thus these uses are considered not medically necessary.
Practice Guidelines and Position Statements
British Association of Dermatologists: In 2007, they published a guideline on the management of actinic keratoses. (11) 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.” (12) The acne guideline is scheduled to be updated in July 2014.
Medicare National Coverage
No national coverage determination.
- Habif TP. Clinical Dermatology 5th edition : Mosby; 2009.
- Cummings CW, Haughey BH, Thomas JR et al. Otolaryngology: Head and Neck Surgery, 4th edition. : Mosby; 2005.
- Brodland DG, Roenigk RK. Trichloroacetic acid chemexfoliation (chemical peel) for extensive premalignant actinic damage of the face and scalp. Mayo Clin Proc 1988; 63(9):887-96.
- Morganroth GS, Leffell DJ. Nonexcisional treatment of benign and premalignant cutaneous lesions. Clin Plast Surg 1993; 20(1):91-104.
- Van Scott EJ, Yu RJ. Alpha hydroxy acids: procedures for use in clinical practice. Cutis 1989; 43(3):222-8.
- Levesque A, Hamzavi I, Seite S et al. Randomized trial comparing a chemical peel containing a lipophilic hydroxy acid derivative of salicylic acid with a salicylic acid peel in subjects with comedonal acne. J Cosmet Dermatol 2011; 10(3):174-8.
- Ilknur T, Demirtasoglu M, Bicak MU et al. Glycolic acid peels versus amino fruit acid peels for acne. J Cosmet Laser Ther 2010; 12(5):242-5.
- Kessler E, Flanagan K, Chia C et al. Comparison of alpha- and beta-hydroxy acid chemical peels in the treatment of mild to moderately severe facial acne vulgaris. Dermatol Surg 2008; 34(1):45-50; discussion 51.
- Bae BG, Park CO, Shin H et al. Salicylic acid peels versus Jessner's solution for acne vulgaris: a comparative study. Dermatol Surg 2013; 39(2):248-53.
- Kaminaka C, Yamamoto Y, Yonei N et al. Phenol peels as a novel therapeutic approach for actinic keratosis and Bowen disease: prospective pilot trial with assessment of clinical, histologic, and immunohistochemical correlations. J Am Acad Dermatol 2009; 60(4):615-25.
- de Berker D, McGregor JM, Hughes BR. Guidelines for the management of actinic keratoses. Br J Dermatol 2007; 156(2):222-30.
- Strauss JS, Krowchuk DP, Leyden JJ et al. Guidelines of care for acne vulgaris management. J Am Acad Dermatol 2007; 56(4):651-63.
|CPT||15788||Chemical peel, facial, epidermal|
|15789||Chemical peel, facial, dermal|
|15792||Chemical peel, nonfacial epidermal|
|15793||Chemical peel, nonfacial, dermal|
|17360||Chemical exfoliation for acne|
|ICD-9 Procedure||86.24||Chemosurgery of skin (includes chemical peel of skin)|
|ICD-9 Diagnosis||238.2||Neoplasm of uncertain behavior; skin|
|706.1||Other acne (cystic, pustular, vulgaris, etc.)|
|ICD-10-CM (effective 10/1/14)||D48.5||Neoplasm of uncertain behavior of skin|
|ICD-10-PCS (effective 10/1/14)||ICD-10-PCS would only be used if the procedure is done inpatient|
|3E00XTZ||Introduction, skin and mucous membranes, external, destructive agent|
|Type of Service||Therapy|
|Place of Service||Physician’s office|
|4/10/98||Add to Therapy section||New policy|
|7/10/98||Replace policy||Policy revised; added CPT codes|
|7/12/02||Replace policy||Policy reviewed without literature review; new review date only|
|10/09/03||Replace policy||Policy reviewed by consensus; no changes in policy; no further review scheduled|
|07/08/10||Replace policy||Policy returned to active review; policy updated with literature review through May 2010; clinical input reviewed; no change in intent of policy statements; background and Rationale sections re-written; references 1, 3 and 6-10 added; other references renumbered/removed.|
|7/14/11||Replace policy||Policy updated with literature review through May 2011. No change in policy statements. Reference 7 added; other references renumbered/removed.|
|07/12/12||Replace policy||Policy updated with literature review through May 2012. No change in policy statements. Reference 6 added; other references renumbered/removed.|
|7/11/13||Replace policy||Policy updated with literature review through June 18, 2013. No change in policy statements. Reference 9 added; other references renumbered/removed.|