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BACKGROUND Many clinicians have used glycolic acid (GA) peels for facial acne, scarring, and hyper-
pigmentation, mainly in lighter skin types. Salicylic–mandelic acid combination peels (SMPs) are a
newer modality, and there have been no well-controlled studies comparing them with other conven-
tional agents.
OBJECTIVE To compare the therapeutic efficacy and tolerability of 35% GA peels and 20% salicylic–10%
mandelic acid peels in active acne and post-acne scarring and hyperpigmentation.
METHODS AND MATERIALS Forty-four patients with facial acne and post-acne scarring and hyperpig-
mentation were divided into two groups, with one receiving GA peels and the other SMPs at fortnightly
intervals for six sessions. The treating physician performed objective evaluation of treatment outcomes.
The patients, the treating physician, and an independent observer made subjective assessments. Side
effects of both agents were also noted.
RESULTS Both the agents were effective, but SMPs had a higher efficacy for most active acne lesions
(po.001) and hyperpigmentation (po.001). Side effects were also lesser with SMPs.
CONCLUSION Both the agents were effective and safe in Indian patients, with SMPs being better for
active acne and post-acne hyperpigmentation.
Timpac Engineers, New Delhi, India, provided the NeoStrata salicylic-mandelic peel.
All authors are affiliated with Department of Dermatology, Venereology and Leprology, Maulana Azad Medical College
and Associated Lok Nayak Hospital, New Delhi, India
& 2008 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.
ISSN: 1076-0512 Dermatol Surg 2009;35:59–65 DOI: 10.1111/j.1524-4725.2008.34383.x
59
CHEMICAL PEELS FOR ACNE
of acne and its sequelae, but there are no published Evaluation of Post-Acne Scars and
studies using these SMPs for acne. Therefore, the Hyperpigmentation
present study, which aimed at determining the effi-
The post-acne scars were classified as icepick, box-
cacy and side effects of GA peels and SMPs for the
car, and rolling according to the classification
treatment of acne and post-acne scarring and
described by Jacob and colleagues, and the total
hyperpigmentation, was undertaken.
number of each type was calculated.14
60 D E R M AT O L O G I C S U R G E RY
GARG ET AL
face like the lips and nasolabial folds were protected The patients were followed up 2 weeks after the last
with a thin layer of petrolatum. GA peel or SMP was peel (Week 12) and again 3 months later (24 weeks).
then applied over the face using a fan-shaped sable
brush in a predetermined clockwise manner starting
over the forehead, right cheek, chin, left cheek, nose, Assessment
upper lip, and lastly the infraorbital areas, taking 30 The treating physician made an objective assessment
to 35 seconds to accomplish and using approxi- of the changes in active acne lesions, post-acne
mately 0.8 to 1.0 mL per session. The peeled areas scarring, and hyperpigmentation at each visit.
were observed for the development of erythema for
GA peels, which was considered the end point of The patient, the treating physician, and an indepen-
peeling. The patients were also asked to report when dent observer also made a subjective assessment of
they felt a stinging or burning sensation with GA the response on a 5-point visual analog scale: good
peels, which was considered the alternative end point (460%), fair (31–60%), poor (o30%), no change,
in patients in whom erythema could not be discerned or worse. These assessments were made at Weeks 4,
(because of dark skin color). With SMP, the patients 8, 12, and 24. Clinical photographs using standard-
experienced a stinging sensation that lasted for 3 to 5 ized positioning were taken at baseline and at 4, 8,
minutes. After the cessation of this stinging sensa- 12, and 24 weeks. The side effects seen with both
tion, most patients developed a uniform white crys- agents in the two groups during the peeling period
talline precipitate, ‘‘pseudofrost,’’ in the peeled areas and during follow-up were noted in the proforma.
(indicating the deposition of salicylic acid after its
hydroethanolic vehicle had volatilized). This was
considered the end point of peeling. In patients who Statistical Analysis
did not develop the pseudofrost, the cessation of the The data were analyzed using the paired t-test for
stinging sensation was considered the end point. parametric data and the Wilcoxon signed rank test
Care was taken not to allow blanching to appear, and Mann-Whitney U test for nonparametric data.
which was indicative of a deeper peel causing po.05 was taken as significant.
epidermolysis. The duration of each peeling session
with GA was serially increased by 1 minute at each
visit until a maximum of 5 minutes and varied from
Results
1 to 5 minutes. The total duration of the peeling
sessions varied from 3 to 5 minutes with SMP. All 44 patients (33 women and 11 men) completed
the study. The mean age of the patients was 22 7 3.0
As soon as the end point was reached, the peel was (range 16.0–27.0). Half of the patients were aged 20
neutralized by asking the patients to wash their faces to 24 years. Onset of acne occurred between the ages
with copious amounts of cool tap water. They were of 14 and 16 in 59.1% of the patients. The interval
then asked to pat, and not rub, the face dry. The between onset of acne and scarring was 2 to 4 years
patients were asked to apply a sunscreen with a sun in 52.3% of patients. All of the study subjects had
protection factor (SPF) of greater than 15 on their used topical retinoids and antibiotics before entering
faces before leaving the clinic. They were sent home the study. Oral antibiotics had been prescribed to
with instructions to apply a moisturizing cream if the 72.7% of the patients at some point during the
facial skin felt too dry, to avoid or minimize sun course of their disease, although none had ever taken
exposure, and to apply sunscreen whenever exposed oral isotretinoin.
to the sun. They were cautioned not to apply any
cream or face wash containing AHAs, salicylic acid, Objective evaluation of treatment outcomes done by
or retinoids. the treating physician revealed the following.
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CHEMICAL PEELS FOR ACNE
Comedones: Both agents produced a significant re- Pustules: Both the agents led to highly significant
duction in comedones, although SMPs brought improvement throughout the study, although the
about a significant change earlier (at 4 weeks). The pustules were seen to increase after peeling with
difference between the two agents was statistically SMPs was discontinued at 12 weeks, and the differ-
significant from 8 weeks onwards (p = .01). The ence between the effects of the two agents decreased
change in comedones (Week 0 to Week 24) with GA from 12 weeks (p = .002) to 24 weeks (p = .04). The
peel was 20.9% and with SPM was 45.7%, which change in pustules (Week 0 to Week 24) was 34.7%
was statistically significantly different (po.001). with GA peels and 58.4% with SPMs (p = .02).
Papules: Although both of the agents led to signifi- Nodules and cysts: No significant improvement in
cant improvement at the end of the study, the effect nodules and cysts was noticed with either agent.
of SMPs was apparent much earlier. However, the
papules were seen to increase after peeling with Total Acne Score: Although both of the agents led to
SMPs was discontinued, and the difference between highly significant (po.001) improvement in the total
the effects of the two agents decreased from 12 acne score, SPMs were seen to be more effective
weeks (po.001) to 24 weeks (p = .02) (Figure 1). (Figure 2), with a significant difference from 12
The change in papules (Week 0 to Week 24) was weeks onward. The change in total acne score (Week
27.3% with the GA peel and 47.7% with the SMP 0 to Week 24) was 27.3% with GA peel and 52.3%
(p = .02). with SPM (Po.001).
Figure 1. (A–C) Results with salicylic–mandelic acid peeling. (A) Baseline photographs showing multiple active acne lesions
with post-acne hyperpigmentation. (B) Photographs at 12 weeks depicting noticeable reduction in active acne lesions and
hyperpigmentation. (C) Photographs at 24 weeks showing significant decrease in acne lesions and post-acne hyperpig-
mentation, with overall improvement in skin texture.
62 D E R M AT O L O G I C S U R G E RY
GARG ET AL
100
Mean Total acne score
70 63.63
80 60
% of patients
50 45.45 45.45
60
40 40
27.27
30
20 18.18
20
0 9.09
0 wks 4 wks 8 wks 12 wks 24 wks 10 00 0 0
Weeks 0
1 2 3 4 5
Glycolic acid peel Salicylic mandelic peel Visual analog score (VAS)
60 54.54
% of patients
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CHEMICAL PEELS FOR ACNE
64 D E R M AT O L O G I C S U R G E RY
GARG ET AL
The findings in our study indicate that GA peels and 8. Grover C, Reddy BSN. The therapeutic value of glycolic acid peels
in dermatology. Ind J Dermatol Venereol Leprol 2003;69:148–50.
SMPs are efficacious in acne with post-acne scarring
and hyperpigmentation, with SPMs being better 9. Wang CM, Huang CL, Hu CTS, et al. The effect of glycolic acid
on the treatment of acne in Asian skin. Dermatol Surg
for most inflammatory acne lesions and post-acne 1997;23:23–9.
hyperpigmentation. Therefore the combination of an 10. Davies M, Marks R. Studies on the effect of salicylic acid on
AHA and a BHA like the SPM may prove to have normal skin. Br J Dermatol 1976;95:187–92.
higher efficacy and better tolerability than the more 11. Vedamurthy M. Salicylic acid peels. Ind J Dermatol Venereol
Leprol 2004;70:136–8.
commonly used AHAs alone in patients with acne
and its sequelae. 12. Taylor MB. Summary of mandelic acid for the improvement of
skin conditions. Cosmet Dermatol 1999;12:26–8.
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