How to discover the secret of youth with Croton oil
Women have used medicinals and herbals to rid themselves of the dry, wrinkled skin associated with the effects of aging since before recorded time. Cleopatra bathed in milk; tribes of the Bantu forest applied mud packs to the face and body; and today we have a multitude of “peels” to choose from, ranging from the realm of the cosmetologist to that of the plastic surgeon.
Although many feel that the laser has replaced the peel, most agree that the phenol-Croton oil peel (aka “the CC peel”) is superior to any resurfacing instrument or method because of its low cost and ability to eliminate perioral rhytides.
Many authorities continue to assert that the phenolic chemical peel is effective but tends to produce hypopigmentation, whereas a laser does not. Many physicians who have used phenolic chemical peels for years know that the hypopigmentation effect is directly related to the depth of the peel and not the specific peeling agent. The depth of the peel is directly related to the small—but highly significant—amount of Croton oil used in the formula.
The phenol-Croton oil peel, when properly applied to the correctly chosen patient, has been time-proven to be superior to any other resurfacing agent, both for its capacity to eliminate wrinkles in a uniform manner and because it is the most cost-efficient method for the elimination of facial elastosis.
History of the Phenol Peel
Primarily used by “lay peelers” of the early 20th century, the phenol peel was popularized as the fountain-of-youth formula in the early 1920s among the stars of Hollywood, according to Hetter,1 and in Miami, where individuals came upon the secret of the facial peel formula.
These “skinners” were also described as “beautifiers”; and Hetter gives credit to Douglas Montgomery, MD, as being the first physician to write about “occlusive” peels using variations of the phenol formula.
|Traditional Phenol-Croton Oil Formulas|
|Liquid phenol 88% USP||3 ml (44.02%)||3 ml||3 ml||3 ml|
|Distilled Water||2 ml||2 ml||?||2 ml|
|Croton oil||2 drops||3 drops||4 drops||5–8 drops|
|Liquid soap||8 drops||6 drops||N/A||12–18 drops|
Interestingly enough, some of the peel formulas are currently being used as over-the-counter medicinals. For example, a phenolic variant using camphor to reduce the caustic action of carbolic acid is used for oral sores. Resorcinol (1,3 dihydroxy benzene), a common product used by cosmetologists, is merely a variant of phenol using two hydroxyl groups instead of one on a benzene ring. Hydroquinone is a 1,4 dihydroxylated benzene ring.
What provoked these “skinners” to come to the conclusion that phenol (carbolic acid), together with Croton oil—when occluded—would produce a controlled desiccation of the skin is left to the uncertainty of the past. What we do know is that carbolic acid became a mainstream disinfectant in the operating room as well as in the wards when Lister introduced it, and later Halsted adopted it here in America at Johns Hopkins. It is said that the reddened, dry hands that Halsted’s chief operating nurse suffered as a result of repeated rinsing with carbolic acid prompted him to seek out the first rubber gloves used in any operating room.
Later, Halsted modified the glove to provide better dexterity by thinning the rubber—and then noted a decrease in infection rates in his patients.
The Oil of the Croton Seed
The Croton plant is a native of India and is indigenous to Ceylon, the Philippines, and Java. Joannes Scott, in his dissertation of the medicinal plants of Ceylon (Edinburgh, 1819), states that the seeds of the Croton tiglium, under the name “Gayapala,” are a most powerful purgative; and that the leaves are very acrid (acidic), causing intolerable burning in the mouth and throat.
The ancient Hindu physicians were not acquainted with the drug, which originated in China; and according to Hetter’s article, the Croton plant was most commonly used as a poison for goldfish, presumably to cull the overpopulation of koi ponds.
The use of the Croton seed as a purgative was widespread in the ancient world, partly because only one drop was necessary to produce a profound purgative effect.
Peter Borellus of France (1620-1689) purported that the use of a single drop of the oil, even when applied to the skin, gave an excellent catharsis. Geoffrey, in his Materia Medica (1756), reported that the natives of India used this oil to produce the “royal purging apple” (poma carthartica)—the “mere odor of which was said to purge persons of delicate constitution.”2
The name Croton comes from the seeds, which resemble the “dog tick” or kroton in Greek. Tiglium, in turn, is thought3 to be derived from the Greek word tilos, meaning diarrhea.
Despite its toxicity, the use of a single drop or two to produce an effect was useful for ancient physicians. They also noted that the oil “was a violent skin irritant causing erythematous redness, intense burning pain, and a vesicular-pustular eruption.”4 Felter’s only mention of using the oil externally is to condemn it.
As a purgative, however, it was useful because of the small dose needed to produce an effect, particularly when other cathartics failed. It was used as a purgative for the insane and the unconscious, as well as a revulsive to lower intracranial pressure through dilatation of the viscera.
Croton oil’s use on the skin was limited to its effect as a pustulant—much like silver nitrate—to desiccate localized areas or burn off warts. It is not a small jump to postulate that the “skinners” knew that the effects of carbolic acid would not alone produce the desiccation necessary to beautify skin that had been ravaged by age. The mystery that remains is how Croton oil and phenol became acquainted.
Medium-light Peel Formula
Very Light Peel Formula
Medium-Heavy Peel Formula
Heavy Peel Formula
Baker-Gordon Heaviest Peel Formula
The above formulas are available along with detailed text from Hetter’s article on this subject (see references).
Lay peelers all used phenol crystals and Croton oil in various combinations; they continued in their trade until they were driven out by physicians, who charged them with unauthorized medical practice. Some of the early physician peelers were HO Bames, MD,5 and others mentioned in Hetter’s chronicle of the Croton oil peel: Joseph Urkov of Chicago, George Mackee of New York, and Adolph Brown, a plastic surgeon who first published the phenol formula in the 1960 British Journal of Medicine.
In common with the “skinners,” physicians used very minute quantities of Croton oil, used phenol as a solvent to dissolve the Croton oil, diluted the mixture with distilled water, and added a saponification agent to stabilize the emulsion.
The Mechanism of the Peel
Phenol is a protoplasmic poison that is readily absorbed through intact skin. Litton,6 Spira,7 and others are credited with studying the absorption of phenol during chemical peeling, while many others have since evaluated the use of phenol alone and in combination with Croton oil.
Application of carbolic acid to the skin disrupts the sulfur bonds that give keratin and cellular protein their structure. With the denaturation of keratin, phenol combines with it to form a larger modality with altered lipid solubility, which was thought to limit the penetration of phenol during the keratocaogulation process.
The effect on the dermis is to leave the reticular dermis intact, produce fibrosis or new collagen derived from the reticular dermis, and permanently alter the pattern of collagen and elastin. Biopsies show that fibrous elements of the dermis are flattened into laminated strands that assume a new, parallel position with respect to the skin surface, giving bulk as much as 20 times that of the epidermis.8
The new structural support and realignment with neocollagen deposition produces a compaction of the collagen so that it has less of a tendency to contract or wrinkle. This new collagen has been proven to be long lasting and different from the old—giving rise to overall “dermal expansion.”9
Studies1,10 have shown that phenol alone peels more deeply with increasing concentrations from 50% to a maximum of 88% and gives only a light peel with nonocclusion at maximum strength. Also, occlusion of the phenol increases the depth of penetration, and the addition of Croton oil in minute amounts greatly increases the depth of peel and the recovery time to full healing.
According to Hetter, the depth of chemical peel can easily be determined by the length of time of recovery:
5 days = light peel
7 days = medium peel
10–14 days = medium–heavy peel.
Mixing the Brew
Hetter suggests standardizing the phenol-Croton oil mixture by first preparing a stock solution of 24 ml of phenol 88% USP, and 1 ml (25 drops) of Croton oil, which contains 0.04 ml, or one drop, of Croton oil/ml of solution. Using the stock solution allows the separation of the amount of Croton oil and the percentage of phenol to a precise degree of certainty.
Hetter postulates that the Croton oil may very well be the “agent,” that the phenol may just be a carrier or solvent, and that mixing the carrier oil and water emulsion may produce a different picture when interacting with keratin protein, as stated above.
It has been stated9 that the combination of phenol with keratin and other cellular proteins and their denatured by-products alters lipid solubility, which may or may not alter the penetration of phenol but may alter the desiccation effect of Croton oil resins. Hetter suggests changing the solvent to ethyl alcohol and then starting over again to investigate the relationship between phenol and Croton oil.
The cases presented here were performed by this author using the Baker8,11 formula, with 2 cc of phenol, 3 cc of distilled water, 8 drops of soap, and 3 drops of Croton oil. Occlusion was accomplished with the application of waterproof tape, which was removed in 48 hours. A standard burn dressing of either iodoform-impregnated gauze or indigo-impregnated gauze was used, followed by cold cream applications on the fourth–seventh day. Healing was complete within the fifth–seventh day.
While laser resurfacing may be more accurate in determining the depth of obliteration for resurfacing, chemical peels produce a different injury. Chemical burns obviously are completely unique in their interaction with the underlying dermal structures. The exact mechanism and interaction between the all-elusive Croton oil and the skin remains an enigma; but with the excellent directives given by Hetter, one need not conclude that phenol peels are passé. Rather, plastic surgery training programs must continue to address and train students in traditional as well as new technologies to maintain our knowledge and preeminence, lest the oncoming “aesthetic medical” practitioners become our new “skinners.”
John Bradford Fisher, MD, is the former chief of the Department of Plastic Surgery at the United States Naval National Medical Center. In 1981, he co-authored the first American publication on suction lipectomy, now known as liposuction. He can be reached at (714) 773-9010 or via email at [email protected].
1. Hetter GP. An examination of the phenol-croton oil peel: parts I-IV. Plast Reconstr Surg. 2000;105(1,2,3):227–1083.
2. Potter SOL. A compend of materia medica: therapeutics and prescription writing. Available at: [removed]www.ibiblio.org/herbmed/eclectic/potter[/removed]-comp/main.html
3. Lloyd JU. History of the vegetable drugs of the U.S.P.: Croton tiglium. Available at: [removed]www.ibiblio.org/herbmed/eclectic/lloyd[/removed]-hist/crotontigl.html
4. Felter HW. The eclectic materia medica: pharmacology and therapeutics. Available at: [removed]www.ibiblio.org/herbmed/eclectic/felter/croton[/removed]-tigl_oleu.html
5. Bames HO. Truth and fallacies of face peeling and face lifting: Med J Record. 1927;126:86.
6. Litton C, Fournier P, Capinpin A. A survey of chemical peeling of the face. Plast Reconstr Surg. 1973;51(6):645–647.
7. Spira M, Gerow FJ, Hardy SB. Complications of chemical face peeling. Plast Reconstr Surg. 1974;54(4):397–403.
8. Converse, et al. The healing of wounds. Ann Surg. 1944;120:873.
9. Fisher GT, Fisher JB. Chemosurgery. In: Stark RB, ed. Aesthetic Plastic Surgery. Boston:Little and Brown; 198:310-350.
10. Dupont C, Ciaburro H, Prevost Y, Cloutier G. Phenol skin tightening for better dermabrasion. Plast Reconstr Surg. 1972;50(6): 588–590.
11. Baker TJ, Gordon HL, Mosienko P, Seckinger DL. Long-term histological study of skin after chemical face peeling. Plast Reconstr Surg. 1974;53(5): 522–525.