Medical Policy: 08.01.07
Original Effective Date: January 1994
Reviewed: March 2019
Revised: March 2019
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.
Chemical peels and dermabrasion are skin resurfacing procedures that remove the epidermis and superficial layers of skin to allow re-epitheliazation. Chemical peels and/or dermabrasion are types of treatment that are generally utilized for treating large areas where lesions are multiple and diffuse. Both procedures are established dermatological treatments for specific skin conditions and may be recommended for the treatment of precancerous skin lesions (i.e. actinic keratoses); however in many cases these methods of treatment do not improve function and are utilized for improving personal appearance. Treatments intended to improve personal appearance or that do not improve functional deficits are considered cosmetic in nature.
Chemical peels involve controlled removal of varying layers of the skin with the use of a chemical agent such as phenol, trichloroacetic acid, Jessner’s solution, and alpha-hydroxy acids. Chemical peels can be used as a treatment for multiple actinic keratosis when treatment of numerous individual lesions is not practical, and for various stages of acne that is unresponsive to more conservative treatments. Chemical peeling also has a number of cosmetic uses including the treatment of photo-aged skin, uneven pigmentation, solar elastosis, and diminishing age-related wrinkles.
Chemical peels are often categorized according to the depth of the peel, the precise depth of the peel depends on the concentration of the agent used, duration of the application, and the number of applications:
Actinic keratosis (pre-malignant lesions) are common skin lesions associated with extended exposure to the sun, with estimated prevalence in the United States of 11% to 26%. These lesions are generally considered to be a precursor of squamous cell carcinoma (SCC). The risk of progression to invasive SCC is unclear, but estimates vary from 0.1% to 20%. For patients with multiple actinic keratosis, the risk of developing invasive SCC is estimated as being between 0.15% and 80%. Treatment options include watchful waiting, medication treatment, cryosurgery, chemical peel, and surgical resection.
Evaluating the effect of using chemical peels on patients with actinic keratoses, compared to alternatives such as watchful waiting, topical or oral medications, destructive treatments, or photodynamic therapy, would ideally include well controlled comparative studies, such as randomized controlled trials (RCTs) with follow up to compare outcomes such as occurrence of malignancy and treatment related morbidity. Alternatively, comparison of robust observational studies may help to demonstrate the comparative effectiveness of treatment options by showing the benefit in destroying actinic keratosis, the durability of this effect, and harms of associated treatment related morbidities.
Older review articles have suggested that chemical peels might be appropriate when there are numerous lesions (i.e. > 10), making treatment of the individual lesions impractical.
Kaminaka et. al. (2009) investigated the efficacy and prognostic relevance of phenol peels in Japanese patients with actinic keratosis and Bowen disease using clinical and histologic criteria. A total of 46 patients were treated with phenol peels, and followed up for at least 1 year after treatment. Biopsy specimens were taken before and after treatment. Cases of complete response were classified by the number of treatment sessions. They evaluated parameters for epidermal thickness, proliferation, dysplasia, and apoptosis, and clinical characteristics to correlate phenol peels with assessments of efficacy, patient-selection criteria, and risk for transformation to cutaneous squamous cell carcinoma. There were 39 (84.8%) patients with a complete response after one to 8 treatment sessions. Statistically, differences in clinical improvement with peels and the number of treatment sessions correlated with histology, personal history of skin cancer, tumor thickness, and cyclin A expression. The authors concluded, phenol peels are very effective for treating precancerous lesions of actinic keratosis and Bowen disease. In addition, the study clearly demonstrates that tumor thickness and cyclin A could be specific and useful markers as adjunctive diagnostic tools to predict the efficacy of phenol treatment of these lesions.
In 2017, Holzer et. al. conducted a randomized, observer-blinded, intrapatient comparative study to investigate the efficacy and safety of 35% trichloroacetic acid (TCA) versus aminolaevulinic acid 20% (ALA) PDT in patients with extensive field cancerization and multiple actinic keratosis (Aks) on the face or the scalp. Twenty-eight patients with at least five AKs in two comparable anatomical areas on the head were treated with 35% TCA and ALA PDT randomly assigned to each area. Their therapeutic efficacy, adverse events and cosmetic outcome were assessed by a blinded investigator at 1, 3, 6 and 12 months after treatment. After 12-months' follow-up TCA and ALA PDT reduced the total lesion count, the primary outcome, by 31% and 58%, respectively (P = 0.006). Complete clearance of pre-existing AKs were 49% for TCA and 74% for ALA PDT (P = 0.011). Treatment failure (number of AKs greater than 50% of the baseline count) was observed in seven patients (25%) after TCA and in two patients (7%) after PDT treatment. Treatment-related pain was significantly higher for ALA PDT (visual analogue scale 7.5 ± 2.3 vs. TCA: 5.1 ± 2.6; P = 0.04), whereas scarring (n = 6, 21%) was seen only in TCA treated patients.
Clinical input obtained in 2010 by BlueCross BlueShield Association (BCBSA) supported the use of chemical peels for the treatment of actinic keratosis when there are numerous lesions, making treatment of the individual lesions impractical and they have failed to respond to treatment with topical 5-FU or imiquimod, unless contraindicated.
For individuals who have actinic keratosis who receive chemical peels, the evidence includes older systematic reviews and case series that have suggested that chemical peels might be appropriate when there are numerous lesions (i.e. > 10), making treatment of the individual lesions impractical. The evidence also includes nonrandomized and randomized clinical trials that suggest chemical peels are effective in treating precancerous lesions of actinic keratosis. Additional controlled studies, preferably randomized, are needed. However, clinical input in 2010 by BlueCross BlueShield Association (BCBSA) supported the use of chemical peels for treating multiple actinic keratosis.
Acne vulgaris is the most common skin condition among adolescents, affecting an estimated 80% of 13 to 18 year olds. Acne, particularly moderate-to-severe manifestations, can cause psychological distress including low self-esteem, depression and anxiety. There are a variety of oral and topical treatments for acne. An additional treatment option includes chemical peels.
Evaluating the effect of chemical peels on active acne compared to alternatives (e.g. topical or oral medication) would ideally include well controlled comparative studies, such as RTC’s with follow up for outcomes such as resolution of severe acne and occurrence of disease related psychologic symptoms (e.g. depression, anxiety). For individuals who have moderate-to-severe active acne who receive chemical peels, the evidence includes randomized controlled trials (RCTs). One small randomized trial was placebo-controlled, it found greater efficacy with active treatment than placebo. Several RCTs comparing chemical peel agents in patients with acne have generally reported comparable improvement with types of chemical peel agents studied. However, no studies were identified comparing chemical peel agents with conventional acne treatment. Additional comparative randomized controlled trials are needed. However, clinical input from physician specialty societies and academic medical centers obtained in 2010 supported the use of chemical peels as a second line treatment of active moderate to severe acne.
In 2010, Ilknur et. al. conducted a single-blind, randomized, right-left comparison study to compare the therapeutic effects of glycolic acid (GA) peels and amino fruit acid (AFA) peels in patients with acne vulgaris. Twenty-four patients received 12 serial peels (GA and AFA, at concentrations from the lowest to the highest) on the two halves of the face at 2-week intervals for 6 months. In addition, cutaneous tolerability assessments during the applications and the patient preference test between both peeling methods at the end of the study were performed. There was a statistically significant decrease in the number of non-inflamed lesions with GA following the first month and with AFA following the second month (p < 0.05). The decrease in the number of inflamed lesions was statistically significant with GA at the end of the fifth and sixth months and with AFA only at the end of the fifth month (p < 0.05). When the two applications were compared with each other, there was not a statistically significant difference in terms of non-inflamed and inflamed lesions (p > 0.05). During the application, it was observed that AFA peels caused fewer problems than GA peels did. AFA concentrations were increased more rapidly and more sessions were performed at the highest concentration of AFA. The authors concluded, based on the results of this study, we can state that both GA and AFA peels are efficacious for comedonal acne. And, compared to a GA peel, an AFA peel is less irritating and better tolerated.
Levesque et. al. (2011) performed a split-face randomized trial comparing a chemical peel containing a lipophilic hydroxy acid derivative of salicylic acid with a salicylic acid peel in 20 patients with comedonal acne. A total of six peels at 2-week intervals were performed. Efficacy was evaluated by counting non-inflammatory and inflammatory lesions and by performing a global change in acne assessment. Safety was assessed by evaluating adverse events, global tolerance, and the presence of erythema, scaling, and dryness. There was a statistically significant decrease of 55.6% and 48.5% from baseline to Day 98 in the mean number of noninflammatory lesions for the sides treated with lipohydroxyacid and salicylic acid peels, respectively (P < 0.001). There was no significant difference in the degree of reduction in noninflammatory lesions between the two peels. There was no significant reduction in the number of inflammatory lesions. Both peels were generally very well tolerated. The authors concluded, this study suggests that lipohydroxyacid peels can be beneficial to subjects with comedonal acne.
In 2014, Kaminaka et. al. conducted a randomized, double-blind, placebo-controlled, split-face comparative study to determine the safety and efficacy of glycolic acid (GA) peels in the treatment of moderate acne vulgaris in Asian skin. Twenty-six patients with moderate acne were treated with 40% GA (pH 2.0) on half of the face and placebo on the other half. The procedure was performed five times at 2-week intervals. The GA sides had statistically significant reductions in acne lesions at each time point from baseline values. There were statistically significant differences between the GA and placebo sides. The GA sides had better responses for non-inflammatory lesions than for inflammatory lesions. In bioengineering measurements, sebum levels were statistically significantly reduced after the initiation of therapy on both sides at weeks 8 and 10, but there were no statistically significant differences between the two sides. The authors concluded, 40% of the GA peels significantly improved moderate acne in this study.
Dayal et. al. (2017) compared the efficacy of 30% salicylic acid (SA) versus Jessner’s solution (JS) peels in treatment of mild to moderate facial acne in Indian patients. A total of 40 patients with mild to moderate AV were enrolled for 12 weeks and were randomly divided into two groups: group 1, 30% SA peels and group 2, JS peels were performed 2 weeks apart with total of six peels in 12-week duration. Clinical improvement was assessed objectively using Michaelsson acne scores (MAS) and clinical photographs. Side effects were observed at each visit. At the end of therapy, improvement in MAS and percentage decrease in MAS were significantly higher in group 1 as compared to group 2. Likewise, decrease in mean comedone counts in group 1 was significantly higher as compared to group 2. However, there was no statistically significant difference in the decrease in mean papule and pustule counts between the two groups. Both the groups tolerated the peels well. The authors concluded, 30% SA peels were more effective than JS peels in treatment of noninflammatory lesions, that is, comedones and in overall improvement of mild-to-moderate facial acne vulgaris.
Clinical input obtained in 2010 by BlueCross BlueShield Association (BCBSA) supported the use of chemical peels as a second-line treatment of active moderate to severe acne.
For individuals who have moderate to severe active acne who receive chemical peels, the evidence includes randomized controlled trials which suggest that chemical peels in the treatment of active acne are effective. However, no studies were identified comparing chemical peel agents with conventional acne treatment. Clinical input in 2010 by BlueCross BlueShield Association (BCBSA) supported the use of chemical peels as a second-line treatment of active moderate to severe acne.
Dermabrasion is a dermatologic procedure that exerts its therapeutic effect by removing the epidermis and superficial dermis, allowing re-epithelialization from the underlying skin to occur. With dermabrasion, a specialized hand held instrument is used to “sand” the skin, removing the epidermal surface in order to improve contour. Therefore, this technique is best used for superficial lesions of the face.
Standard dermabrasion uses a wire brush or diamond fraise (a stainless steel wheel which diamond chips have been bonded) abraders to plan the skin whereas laser dermabrasion involves the use of the argon laser, ultrapulse carbon dioxide (CO2) laser, or flashlamp-pumped pulsed dye laser to resurface the entire face, and has been used as an alternative to standard dermabrasion in treating patients with active acne with scarring.
Dermabrasion was initially developed to combat acne scars; this is the most common indication of its use. It has also been used to actinic keratosis. Dermabrasion has proven effective in treating multiple recalcitrant actinic keratosis (AK) lesions in cases where numerous AK lesions (e.g. more than 10) have been documented and where lesions are diffuse with severe actinic damage. In general, AK lesions are precancerous skin lesions that occur on the epidermis (outer layer of the skin) and result from long-term exposure to the sun. Dermabrasion also has a number of cosmetic applications such as diminishing age-related wrinkles and skin discolorations, minor scars and scaring from acne.
Dermabrasion is contraindicated in patients with active acne, as active stages of acne pose a greater risk of infection and may exacerbate skin inflammation.
Microdermabrasion is a non-invasive, non-surgical cosmetic procedure that can be performed either by a physician or in some cases by the individual in a home setting. The non-invasive treatment exfoliates or removes the top layer of skin (i.e. stratum corneum) and is frequently performed to diminish the signs of aging. Dermabrasive procedures that resurface the superficial layer of skin, including but not limited to those used to reduce signs of aging, are considered cosmetic.
Dermabrasion have been proven safe and effective for treatment of actinic keratosis when lesions are diffuse making treatments impractical, and when other conventional methods of treatments have either failed, are not tolerated, or are contraindicated.
In 2016, the American Academy of Dermatology published a guideline on the management of acne vulgaris makes include the following statement regarding chemical peels: "Miscellaneous Therapies and Physical Modalities: Studies exist suggesting that chemical peels may improve acne. However, large, multicenter, double blinded control trials comparing peels to placebo and comparing different peels are lacking. Glycolic acid and salicylic acid chemical peels may be helpful for non-inflammatory (comedonal) lesions. However, multiple treatments are needed and the results are not long lasting. In the opinion of the work group, chemical peels may result in mild improvement in comedonal acne."
Treatment of Precancers (Diffuse Actinic Keratoses, Field Cancerization)
Fewer high quality data are available regarding the efficacy and safety of several other treatments that are sometimes used and may be considered for treating actinic keratoses: chemical peels (trichloroacetic acid) and ablative skin surfacing (e.g. dermabrasion, laser). These studies have all confirmed that laser resurfacing or chemical peel significantly reduced the quantity of actinic keratoses, although in some studies they were less effective than PDT or 5-FU. The use of chemical peels and ablative skin resurfacing varies widely across NCCN institutions.
NCCN recommendations for low risk basal cell skin cancer (BCC) include: 1) C&E in areas without hair growth (i.e. excluding terminal hair bearing regions such as the scalp, pubic and axillary regions, and beard area in men provided that treatment be changed to excision if the adipose is reached; 2) standard excision if lesion can be excised with 4-mm clinical margins and with closure techniques such as linear closure, second intention healing or skin graft; and 3) RT for non-surgical candidates, generally limited those older than 60 years of age because of risk of long term toxicity.
If margins are positive after excision, patients should receive adjuvant therapy.
The NCCN Panel discussed the use of alternative therapies as first line treatment in patients with low risk, superficial BCC where surgery or radiation is contraindicated or impractical. These include 5-FU, imiquimod, PDT with porifimer sodium or ALA, or vigorous cryotherapy. Data suggest that the cure rate of these approaches may be lower compared with surgery. On the other hand, panelist experience indicated that they may be effective for anatomically challenging locations, and recurrence are often small and manageable. Panelists agreed that these therapies may be considered for superficial BCCs based on patient preference.
The current NCCN guideline does not include or indicate the use of chemical peels or dermabrasion in the treatment of low risk basal cell skin cancer.
Chemical peels may be considered medically necessary for the following indications:
Treatment of numerous (10 or more) actinic keratosis when:
Dermabrasion may be considered medically necessary for the treatment of actinic keratosis when the following is met:
Dermabrasion for the treatment of active acne is considered not medically necessary, as this treatment is contraindicated in patients with active acne, as active stages of acne pose a greater risk of infection and may exacerbate skin inflammation.
Chemical peels and dermabrasion would be considered cosmetic in nature and therefore not a contract benefit for the following indications, including but not limited to:
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