Original Paper

Acid Peel in the Treatment of Melasma

1 2 3 4 5
Begum ST , Khan MAL , Hasan MS , Khan MSI , Karim ATMR

Abstract
Introduction: Melasma is a common hyperpigmented Introduction
disorder of skin which has severe impact on the Melasma is a common acquired symmetric hyper-
quality of life. Many modalities of treatment are melanosis characterized by irregular light to grey
1
available to treat melasma. Among them chemical brown macules involving sun exposed areas . The
peeling is one of the most popular and widely used pathogenesis of melasma is not fully understood but
method of treatment for melasma. pregnancy, estrogen ingestion, ultraviolet (UV) light
exposure, and family history are well recognized
2
Objective: The present study was aimed to assess association . Topical hydroquinone is the most
the efficacy of 30% trichloroacetic acid versus 35% common treatment of melasma. Other treatment
glycolic acid peel in the treatment of melasma. modalities include retinoic acid (tretinoin), kojic acid,
azelaic acid and combination of hydroquinone,
3
Materials and Methods: The prospective randomized tretinoin and corticosteroids . Now a day’s chemical
study included 50 patients of melasma of both peel, laser treatment and intense pulsed light therapy
sexes, in 20-55 years age group. Patients were are widely used popular method of treatment for
randomly divided into two equal groups A and B. melasma. Among them, chemical peeling provides
Group A was treated with trichloroacetic acid (TCA more rapid response in treating melasma. Chemical
30%) peel and group B with glycolic acid (GA 35%) peels are used to create injury at a specific skin
peel. Five peels were done serially at intervals of 21 depth with the goal of stimulating new skin growth
4
days. Patients were followed up every 3 weekly for 6 and improving surface texture .Chemical peels are
weeks after the last peel. The disease severity was classified by the depth of action into superficial,
monitored with digital photography and melasma medium, and deep peels. Specific peeling agents
area and severity index (MASI) score which were should be selected based on the disorder to be
calculated at baseline, 6 weeks, 12 weeks and 18 treated and determined by the histological level or
5
weeks. A visual analog scale (VAS) was calculated severity of skin pathology to maximize the outcome .
6
at baseline, 12 weeks and 18 weeks. Today plethora of peeling agents is available . The
most commonly used chemical peeling agents
Results: Glycolic acid showed better response include Phenol, Trichloroaceticacid (TCA), Alpha
compared to trichloroacetic acid at the end of five Hydroxyacids(AHAs) eg. Glycolic acid (GA) and Beta
peels, but this difference was not statistically significant Hydroxyacids eg. Salicylic acid. Although both TCA
(p>0.05). Chemical peeling with trichloroacetic acid and GA are being used in various centers, there have
produced significantly more erythema, burning been very few studies comparing these two agents.
sensation (p<0.05) and higher incidence of post peel We undertook this study to compare the therapeutic
inflammatory hyperpigmentation (p< 0.05) compared response of 35% glycolic acid (GA 35%) versus 30%
to glycolic acid. trichloroacetic acid (TCA 30%) on melasma.

1. Maj Syeda Tania Begum, MBBS, DDV, FCPS, Classified Specialist in Dermatology and Venereology, CMH, Dhaka
2. Brig Gen Md Abdul Latif Khan, MBBS, DDV, FCPS (Dermatology & Venereology), Adviser and Head, Department of
Dermatology and Venereology, CMH, Dhaka 3. Col Md Sayeed Hasan, MBBS, DDV, FCPS, Senior Classified Specialist
and Associate Professor, Dermatology and Venereology, Armed Forces Medical College, Dhaka 4. Lt Col Md Shirajul
Islam Khan, MBBS, DDV, MCPS, FCPS, Classified Spl in Dermatology & Venereology, CMH, Dhaka 5. Lt Col ATM
Rezaul Karim, MBBS, DDV, MCPS, FCPS, Classified Spl in Dermatology, CMH, Comilla.

JAFMC Bangladesh. Vol 12, No 1 (June) 2016 68

Materials and Methods In addition, Visual Analog Scale (VAS) ranging from
This was a prospective randomized study of 18 0 to +10 was assessed by comparing follow-up
weeks duration conducted during the period from images to the baseline photograph pretreatment.
May 2015 to October 2015. Fifty patients of VAS were assessed by the dermatologist colleague
melasma attending the dermatology outpatient who was blinded for the study. On the VAS, 0
department at CMH Dhaka were selected into the represents no pigmentation and 10 represents
study and were randomly allotted to Group-A and maximum pigmentation. VAS measurements of
Group-B. All the patients of both sexes and between photographic documentation were available at time
the ages of 20-55 years were included. Pregnant or points 0 (baseline),12 weeks and 18 weeks. Five
lactating females, patients with a known hyper- peels were done serially at intervals of 21 days for
sensitivity to chemical peel, patients applying topical every patient. Patients were followed every 3 weekly
retinoids, females taking oral contraceptive pill and for 6 weeks after the last peel in both the
patients with active infection were excluded. An groups.The outcome of treatment was calculated by
informed consent was taken from all the patients. comparing the mean MASI scores in the two groups
Detailed history regarding the duration and extent of at 6 weeks, at 12 weeks and 18 weeks. In addition,
the disease, family history, past treatment and efficacies of each treatment agents were evaluated
aggravating or initiating factors were recorded. by comparing the reduction in mean MASI at 12
Group A comprised of 25 patients who received weeks from baseline and comparing the mean VAS
peeling with trichloroacetic acid (TCA-30%) and at 12 weeks. All the data collected were then
Group B comprised of 25 patients who received analyzed by standard data analysis software’s.
glycolic acid peel (GA-35%). In Group A, Peeling
agent was kept until the appearance of frosting and Results
in Group B for three minutes. Both the peeling There were 50 patients included in the study with 47
agents were then neutralized with cold water. Before females and only 3 males, in the age range 20 years
applying the chemical agent the face was washed and 55 years with a mean of 34.3±5.9 years.
with soap and water and then degreasing was done Duration of melasma ranged between 1 and 8 years
with commercially available alcohol pad. No pre peel with a mean 3.2±2.3 years. There was no significant
treatment was done. A post auricular test peel was precipitating factor observed in relation to occurrence
performed and left for 15-20 minutes to find any of melasma. Most cases (84%) were of epidermal
hypersensitivity in all patients. After peeling all type and one-fourth (16%) of the cases were of
patients were advised strict sun protection and mixed type of melasma. The most common pattern
liberal use of emollients and sunscreen with SPF 50. was malar (78%) followed by centrofacial pattern
Clinical examination including Melasma Area and (24%) and mandibular (10%). Figure-1 shows the
Severity Index (MASI) scores of all the patients were MASI scores at baseline 6,12 and 18 weeks.
noted. MASI score was calculated ranking the Response to treatment in MASI scoring after 12 weeks
severity of melasma in terms of its Darkness (D), was 78% reduction (from 26.5 to 5.9) in GA group
Homogeneity(H) of appearance and the percentage and 79% reduction (from 28.9 to 6) in TCA group.
Area of the face affected (A) and then using the
following formula:
MASI = 0.3(D F + H F )A F + 0.3(D MR + H MR ) A
MR + 0.3(D ML + H ML )A ML + 0.1(D C + H C )AC.

Darkness was ranked from 0 to 4, Homogeneity

from 0 to 4 and Area from 0 to 6. MASI score was
calculated at baseline, 6 weeks, 12 weeks and 18
weeks. The lesions were photographed with and
without flash with a standard 5 mega pixel digital
camera at 30 cm distance and approximately 2 MB
resolution. Fig-1: MASI score objective assessment in both groups.

JAFMC Bangladesh. Vol 12, No 1 (June) 2016 69

There was no significant difference in reduction of Discussion
MASI scores at the end of five peels after 12 weeks Melasma is more common in women of child-
between both the groups (P > 0.05). However, TCA bearing age, although men also suffer from the
8,9
peel showed an initial rapid response compared to condition and account for 10% of the cases .
GA but results were statistically insignificant. In the Melasma affects all races, but is observed more
TCA group, the patients reported a quicker frequently among individuals with skin type IV-VI,
improvement but at the end of peeling sessions, especially in woman, who live in areas of intense
10
both the groups showed equally efficacious ultraviolet radiation . There are three clinical
response. Based on the extent of improvement, the patterns-centrofacial, malar, and mandibular-depending
patients were arbitrarily classified into one of the upon the area of localization. Histologically, melasma
following categories: very good if there was >75% is divided into three types: epidermal, dermal, and
11
reduction from baseline VAS; good if VAS reduced mixed . Chemical peeling aims at production of
by 50-74%; moderate if VAS reduced by 25-49% controlled chemical burn of epidermis and/or dermis,
and mild if <25% reduction in VAS was achieved. resulting in resurfacing of epidermis and remodeling
Table-1 reveals good and very good response was of collagen and elastic fibre with deposition of
76% in GA group and was 68% in TCA group glycosaminoglycans in dermis. Both the agents used
(statistically insignificant). in this study, TCA 30% and GA 35%, are superficial
11
peels . In this study, the average age of patients
Improvements shown according to VAS in and duration of the disease is comparable to studies
12
both groups at the end of peeing sessions from India . The types of melasma in our patients
ntage Improvement TCA GA are also similar to the study from India probably due
14
good (>75%) 4 7 to same skin type . In this study and most other
studies the commonest pattern was malar followed
(50-75%) 13 12 12,13
by centrofacial . In another Indian study carried
rate (25-50%) 3 3
out by Kalla et al GA and TCA showed comparable
<25%) 5 3 14
results on subjective scores given by patients .
They had not used any scientific scoring system like
During the study, the frequencies of serious side MASI for comparison. In this study both the
effects were very low. Table-II shows mild burning chemical agents used for chemical peel shows
sensation in 92% of patients in GA group and 8% comparable results depending on MASI and VAS
experience moderate burning but there were score and none has statistically significant better
moderate to severe burning in 92% of patients in the result than other (Figure-1). Kalla et al observed a
14
TCA group and mild burning in 8% of the patients. more rapid response to TCA than GA in their study .
Post peel crackening and hyperpigmentation were As with our study the local irritant effects and post
reported in 48% of cases in TCA group but none of peel crackening were more with TCA than with GA.
the patients in the GA group (Table-II). Relapse and hyperpigmentation were much less in
this study. The rate of post peel inflammatory
Complication during peeling and follow up period hyperpigmentation was higher in the TCA group
ca on TCA GA P value (48%) than GA group and statistically significant
rning 2(8%) 23(92%) <0.5 (Table-2). TCA group of patients also complain more
ate burning 6(24%) 2(8%) <0.5 burning sensation than GA group. In a recent study
burning 17(68%) 0 >0.5 from Pakistan, The mean score of response
el inflammatory calculated for both the groups revealed better
12(48%) 0 >0.5 overall clinical response in TCA group than in GA
gmenta on
group but this difference was statistically
15
There was significant improvement in the texture insignificant (P>0.05) comparable to our study .
and glow of skin appreciated by 76% of the patients Limitation of our study included the observer bias in
in GA group, which was not appreciated in TCA the subjective scoring. To eliminate this, MASI
group. No relapse was seen within follow up period. scoring was done by a single-blinded independent

JAFMC Bangladesh. Vol 12, No 1 (June) 2016 70

person. Post inflammatory hyperpigmentation has 5. Wiest L. Chemical peels in aesthetic dermatology.
been reported to be the most common side effect Hautarzt 2004; 55:611–20.
12
with GA facial peels but in this study the frequency
of all side effects was much lower as compared to 6. Konda S, Geria AN, Halder RM. New Horizons in
11,14
that of other studies . This may have been due to Treating Disorders of Hyperpigmentation in Skin of
the specific time of application, method of application Color. Seminars in Cutaneous Medicine and Surgery
and strict adherence to sun protection. No patient 2012; 31(2):133.
developed herpes, vesiculation or post peel keloid
as was reported in other studies. Regular use of 7. Gilchrest BA, Fitzpatrick TB, Anderson RR, et al.
sunscreen helped in maintaining the result of the Localization of melanin pigmentation in the skin with
peels on follow up. Post peel crackening effect that Wood's lamp. Br J Dermatol 1977; 96:245-8.
occurred only with TCA and not with GA makes it
beneficial for patients to continue outdoor activities 8. Karen JK, Pomeranz MK. Skin changes and diseases
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BA, Paller AS, Leffell DJ, editors. Dermatology in General
Medicine, 7th ed. New York: McGraw-Hill 2008:955-62.
Conclusion
35% GA and 30% TCA concentrations of facial peel 9. Vazquez M, Maldonado H, Benaman C, et al.
are effective treatment for melasma with significant Melasma in men: A clinical and histologic study. Int J
improvement and without any major side effects. Dermatol 1988; 27:25-7.
The beneficial results achieved can be maintained
with topical application of sunscreen SPF-50. 10. Grimes PE. Melasma: Etiologic and therapeutic
Regular use of sunscreens prevents the chances of consideration. Arch Dermatol 1995; 131:1453-7.
recurrence of melasma. GA peel is associated with
fewer side effects than TCA and has the added 11. Nguyen TH, Rooney JA. Trichloroacetic acid peels.
advantage of facial rejuvenation and does not Dermatol Ther 2000; 13:173-82.
hamper patient’s daily routine.
12. Kumari R, Thappa DM. Comparative study of
trichloroacetic acid versus glycolic acid chemical
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