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An examination of the phenol-croton oil peel: Part III. The plastic surgeons' role.

In Part II, the author focused on the lay peelers' history and success using croton oil-containing phenol peeling recipes. In Part III, the author reviews what was known or should have been known about croton oil and phenol as physicians became keenly interested in face peeling in the mid-1950s. The lay peelers recognized that croton oil was a critical ingredient of the so-called phenol peel while physicians focused on phenol without recognizing the intense cytotoxic effect of croton resin. Physicians have persisted in this systematic error for 40 years. Both dermatology and plastic surgery have shown a remarkable credulity about phenol's action and lack of curiosity about croton oil's action. A hitherto unreferenced and unknown croton oil-containing formula of Adolph Brown, patented in 1959, has been unearthed, preceding Litton's and Baker's formulas in time. The recollections of Litton, Baker, Truppman, and Georgiade shed some light on the interaction between them and the lay peelers and how the formulas were transferred. Other plastic surgeons probably acquired the same knowledge, used it in their practices, but chose not to draw attention to it. None of the physicians credited the lay peelers. Brown, Litton, and Baker each could have published a complete formula, but only Baker did. However, his formula was vastly stronger than the lay formulas but, nevertheless, came to dominate medical peeling for the next 35 years because of its simplicity of preparation. A review of the peel literature reveals many oft-repeated but unsupported dogmas regarding the mode of action of phenol, which have obscured our understanding of the phenol-croton oil peel. Animal studies exist that refute these dogmas, e.g., (1) lesser concentrations of phenol wound more deeply; and (2) phenol has an all-or-nothing action. As well, studies from the early 1980s showed that the presence of croton oil caused much deeper burns than phenol alone. Suggested areas of research that could solve the conundrum of the phenol-croton oil peel are presented.