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196 Original article

Salicylic–mandelic acid versus glycolic acid peels in Egyptian


patients with acne vulgaris
Asmaa M. El Refaei, Hany A. Abdel Salam and Neveen E. Sorour

Department of Dermatology and Andrology, Faculty of Background


Medicine, Benha University, Benha, Egypt
Many studies have evaluated the glycolic acid peel (GAP) in acne vulgaris; however,
Correspondence to Neveen E. Sorour, MD, there is little in the literature about the use of a salicylic–mandelic acid peel (SMP).
Department of Dermatology and Andrology, Faculty of
Medicine, Benha University, Benha, Egypt Objective
Tel: + 201229002044; To evaluate the efficacy and the tolerability of a combination of 20% salicylic–10%
e-mails: neveensorour@yahoo.com,
neveen.sorour@fmed.bu.edu.eg mandelic acid peel (SMP) against a 35% GAP in the treatment of active acne vulgaris,
postacne scarring, and associated hyperpigmentation in Egyptian acne patients.
Patients and methods
Received 29 October 2014 This clinical trial was conducted on 40 patients with facial acne vulgaris divided
Accepted 28 March 2015
randomly into group A (n = 20), which was treated with SMP, and group B (n = 20),
Journal of the Egyptian Women’s Dermatologic which was treated with GAP for seven sessions every 2 weeks and followed up for 2
Society 2015, 12:196–202
months (week 20). An objective assessment of the treatment outcomes was
performed by the treating physicians, whereas a subjective assessment was performed
by two independent dermatologists. Patient satisfaction scores and side effects were
also assessed.
Results
Percentages of improvement in groups A and B from weeks 0 to 20 were 90.2 and
35.87% in comedones, 81.72 and 77.78% in papules, 85.38 and 75.65% in pustules,
85.29 and 68.50% in the total acne score, 66.13 and 46.88% in postacne
hyperpigmentation, 17.85 and 11.9% in icepick scars, and 29.3 and 25.8% in boxcar
scars, respectively. Both peeling agents were associated with a burning sensation,
dryness, desquamation, and acne flare.
Conclusion
Both peeling agents were effective in the treatment of inflammatory acne,
noninflammatory acne, and postacne hyperpigmentation. However, SMP proved to
have a higher efficacy than the more commonly used GAP.

Keywords:
glycolic acid peel, postacne hyperpigmentation, postacne scars, salicylic–mandelic
acid peel

J Egypt Women Dermatol Soc 12:196–202


& 2015 Egyptian Women’s Dermatologic Society
1687-1537

thereby reducing corneocyte adhesion. Because of its


Introduction lipophilicity, it has better penetration into the pilosebac-
Resolution of acne lesions may result in postinflammatory eous unit. This property of SA accounts for its strong
erythema, hyperpigmentation, or scarring. These sequelae comedolytic effect, and its utility in the treatment of
are often the main reasons for consulting a dermatologist acne. The anti-inflammatory activity of SA makes it useful
and take precedence over the acne itself [1]. In acne, in rapidly decreasing facial erythema [3].
superficial peels are beneficial due to their exfoliative and
anti-inflammatory effects. They also induce improvement Salicylic–mandelic acid peel (SMP) is a newer combina-
of skin texture, pore size, and reduction of sebum. a- tion peel that combines the properties of BHA and AHA.
Hydroxy acids (AHAs) and b-Hydroxy acids (BHAs) are The advantage of this combination is that SA is lipophilic,
the most commonly used superficial chemical peeling and thus penetrates active acne lesions quickly and has
agents. Glycolic acid (GA) is one of the AHAs that has anti-inflammatory properties, whereas mandelic acid has
been used widely in the treatment of acne. It leads to the antibacterial properties [4]. Mandelic acid is one of the
reduction of corneocyte adhesion, improves abnormal largest AHAs, and thus penetrates the epidermis more
keratinization in the infundibulum, decreases keratino- slowly and uniformly, making it an ideal peel for acne and
cyte plugging, and ultimately decreases follicular occlu- pigmentation [5]. The aim of this study was to evaluate
sion [2]. Salicylic acid (SA) is a BHA that has a phenolic the efficacy and the tolerability of the combination of
ring in its chemical structure. It is an excellent keratolytic 20% salicylic–10% mandelic acid peel against 35% glycolic
agent due to its ability to dissolve intercellular cement, acid peel (GAP) in the treatment of active facial acne
1687-1537 & 2015 Egyptian Women’s Dermatologic Society DOI: 10.1097/01.EWX.0000464740.18592.42

Copyright r 2015 Egyptian Women’s Dermatologic Society. Unauthorized reproduction of this article is prohibited.
Salicylic-mandelic acid versus glycolic acid in acne vulgaris El Refaei et al. 197

vulgaris, postacne scarring, and associated hyperpigmen- risk of complications [10]. Seven peeling sessions were
tation in Egyptian acne patients. conducted for each group every 2 weeks [weeks 0 (base
line), 2, 4, 6, 8, 10, and 12], and the patients were followed
up for 2 months after the last session (week 20). At every
session, cleansing was performed by cotton pads soaked
Patients and methods with alcohol, followed by degreasing by one or two pads
This randomized clinical trial was carried out in the soaked with acetone. Sensitive areas of the face such as the
Dermatology and Andrology Department of Benha University lips and the nasolabial folds were protected with a thin
Hospital in the period from March 2012 to March 2013. The layer of vaseline. The peeling agent was then applied over
study included 40 Egyptian patients with facial acne vulgaris, the face using cotton pads in a rubbing manner starting
postacne scarring, and associated hyperpigmentation, with with the forehead, the cheeks, and the chin, taking 30–35 s
Fitzpatrick skin types I to IV not responding to conventional using B0.8–1.0 ml per session. The peeled areas were
treatment for 3 or more months. Their ages ranged from 14 observed for the development of erythema for GAP, which
to 29 years. Exclusion criteria included the following: patients was considered as the end point of peeling. The patients
with nodulocystic lesions and severe acne types, for example, were also asked to report when they felt a stinging or
acne conglobata and acne fulminans; patients with a history burning sensation with GAP, which was considered as the
of hypertrophic or keloid scarring, or patients with hyper- alternative end point in which erythema could not be
sensitivity to SA; patients having conditions associated with discerned. With SMP, the patients experienced a stinging
poor wound healing such as oral isotretinoin therapy within sensation that lasted for 3–5 min. After the cessation of this
the previous 6 months, chemotherapy, or systemic steroid; stinging sensation, most patients developed a uniform
patients who had recent face-lifts or uncooperative patients white crystalline precipitate (pseudo-frost) in the peeled
were also excluded. Patients signed an informed consent areas (indicating the deposition of SA after its hydro-
(parent or guardian if the patient was younger than 18 years ethanolic vehicle had volatilized). This was considered as
old) after approval of the study by the research ethics the end point of peeling. In patients who did not develop
committee of the Faculty of Medicine in Benha University. the pseudo-frost, the cessation of the stinging sensation
Oral and topical medications being taken for acne were was considered as the end point. Care was taken to not
discontinued 4 weeks before peeling. allow blanching to appear, which was indicative of a deeper
A thorough dermatological examination was performed to peel causing epidermolysis. The duration of each peeling
determine the skin type according to Fitzpatrick’s session with GA was serially increased by 1 min at each visit
classification (from I to IV), the acne severity according until a maximum of 5 min. The total duration of the
to Hayashi et al. [6] (mild, moderate, severe, or very peeling sessions varied from 3 to 5 min with SMP. As soon
severe), the number of each active acne vulgaris lesion as the end point was reached, the peel was neutralized with
according to Michaëlsson et al. [7] (comedones, papules, 15% sodium bicarbonate solution (in case of GAP) or cold
and pustules), the extent of postacne hyperpigmentation water (in case of SMP), and then the patients were asked
by calculating the approximate surface area involved (the to wash their faces with copious amounts of cool tap water.
right and the left cheeks and the forehead were taken to They were asked to pat, and not rub, the face. The patients
constitute 30% each, and the chin accounted for 10%) were asked to apply a sunscreen with a sun protection
according to Garg et al. [5], and the classification of factor of greater than 15 on their faces before leaving the
postacne scars according to Jacob et al. [8] (icepick, hospital and copious moisturizing cream at home (panthe-
boxcar, or rolling); calculation of the total number of each nol cream).
type was performed.
Objective assessment
Evaluation of active acne lesions
Methods Evaluation was performed using a method devised by
This randomized clinical trial was carried out on 40 patients Michaëlsson et al. [7] by multiplying the number of each
who were divided randomly, by the sealed envelope type by its severity index (0.05 for comedones, 1 for
method, into two groups: group A (GA) comprised 20 papules, and 2 for pustules), and by adding each sum, a
patients (treated with 20% salicylic–10% mandelic acid total acne score was obtained. The assessment of acne
peels) and group B (GB) comprised 20 patients (treated lesions was performed at baseline (week 0), at each visit,
with 35% GAPs). The SMP was prepared by mixing SA and at the follow-up visit.
(20 g), mandelic acid (10 g), and 70% ethyl alcohol (up to
100 ml). The GAP 35% was available as GA 70%, which was Evaluation of postacne hyperpigmentation
prepared by mixing GA 70% (50 ml) with distilled water The extent of postacne hyperpigmentation was assessed
(up to 100 ml). The chemicals were obtained from El- by calculating the approximate surface area involved. The
Goumhouria Co. for trading medicines, chemicals, and right and the left cheeks and the forehead were taken to
medical appliances (Cairo, Egypt). As a prepeel care, constitute 30% each, and the chin accounted for 10% [5].
patients of both groups were instructed to use topical The assessment of the severity of postacne hyperpig-
tretinoin cream 0.05% at bed time for 2 weeks before mentation was performed using the grade severity of
peeling [9] to assist in producing uniform penetration of hyperpigmentation according to Gold et al. [11]. It was
the peeling agent, reducing the re-epithelialization time also performed at baseline (week 0) and at weeks 4, 8, 12,
after peel, accelerating wound healing, and reducing the and 20.

Copyright r 2015 Egyptian Women’s Dermatologic Society. Unauthorized reproduction of this article is prohibited.
198 Journal of the Egyptian Women’s Dermatologic Society

Assessment of postacne scars An objective evaluation of the treatment outcomes


It was performed using the scar severity score in which performed by the treating physicians revealed the
the number of each type of acne scar was counted following:
(rolling, least severe; boxcar, more severe; and icepick,
most severe), and then multiplied by its weighting factor
(1 for rolling, 2 for boxcar, and 3 for icepick), yielding the Comedones
overall score according to Lipper and Perez [12]. It was Both agents produced improvement in comedones during
performed at baseline and at weeks 4, 8, 12, and 20. the study. The difference between the two peeling agents
was statistically significant from week 2 (GA 13.05 ± 8.532,
GB 21.1 ± 11.2, P = 0.025), week 4 (GA 9.10 ± 7.376, GB
19.1 ± 10.396, P = 0.008), and week 6 (GA 5.95 ± 4.936,
Subjective assessment
GB 17.6 ± 10.338, P = 0.001) and highly significant from
Two uninvolved dermatologists made a subjective assess-
week 8 (GA 4.40 ± 4.122, GB 16.30 ± 9.979) to week 20
ment of the improvement in the overall appearance by
(GA 1.80 ± 1.852, GB 14.3 ± 10.032). Percentages of
comparing the photographs at the baseline and those at the
improvement in comedones from week 0 to week 20 were
subsequent peeling sessions using a five-point visual
90.2 and 35.87% in GA and GB, respectively, with a
analogue scale (VAS): (1) worse, (2) no change, (3) poor
statistically significant difference (Po0.05).
(o30% improvement), (4) fair (31–60% improvement),
and (5) good (460% improvement) [5]. These assessments
were made at weeks 4, 8, 12, and 20. Clinical photographs Papules
using a Sony Cyber-shot digital camera 8 mega pixels (Sony Both agents led to an improvement in papules during the
Corp., Tokyo, Japan) with standardized positioning were study. The difference between the two agents was
taken at baseline (week 0) and at weeks 4, 8, 12, and 20. significant from week 12 (GA 2.0 ± 1.45, GB 3.25 ± 1.41,
Patient satisfaction was assessed as poor, fair, and good, with P = 0.006) and week 20 (GA 2.45 ± 1.28, GB 3.4 ± 1.57,
< 30, 30–60, and >60% improvement, respectively. Side P = 0.020). Percentages of improvement in papules were
effects seen in each group were recorded at every session. 81.72 and 77.78% in GA and GB, respectively, with a
statistically significant difference (P = 0.006).

Statistical analysis
Collected data were tabulated and analyzed using SPSS 16 Pustules
software (Statistical Package for Social Science; SPSS Inc., The difference between both groups appeared to be
Chicago, Illinois, USA). Categorical data were presented as significant from week 10 (GA 2.65 ± 1.725, GB
the number and percentages, whereas quantitative data 4.2 ± 2.353, P = 0.045), week 12 (GA 1.75 ± 0.910, GB
were expressed as the mean and SD. The percent of 2.95 ± 1.468, P = 0.012), and week 20 (GA 2.2 ± 1.473,
improvement was calculated by Fisher’s exact test, the GB 3.75 ± 1.997, P = 0.026). Percentages of improve-
paired t-test, and the w2-test. Patient satisfaction was ment in pustules were 85.38 and 75.65% in GA and GB,
calculated by Mc Nemar’s test and the k test. P values less respectively, with a statistically significant difference
than 0.05 were considered significant and values less than (P = 0.000).
0.001 were considered highly significant.
The total acne score
Although both agents led to an improvement in the total
Results acne score, SMP was seen to be more effective, with a
Forty patients were included in the study. All of them (32 significant difference from week 6 onward (Table 1). The
females and eight males) completed the study. The percentage reduction in the total acne score from week 0
means ± SD for age in GA and GB were 19.8 ± 4.02 and to week 20 was 85.29 and 68.50% in GA and GB,
19.55 ± 4.19 years, respectively. Seventeen patients were respectively, with a statistically significant difference
females and three patients were males in GA compared (Po0.001).
with 15 females and five males patients in GB,
respectively. The mean ± SD for the age of onset of acne Table 1. A comparison between both groups regarding the total
acne score from week 0 to week 20
in GA and GB was 14.40 ± 2.30 and 14.20 ± 1.673 years,
respectively, whereas the mean ± SD for the disease
Group A (N = 20) Group B (N = 20)
duration was 5.40 ± 2.521 and 5.70 ± 3.5703 years for GA Weeks (mean ± SD/weeks) (mean ± SD/weeks) t-test P
and GB, respectively. Eighteen patients had skin type III
and two patients had skin type IV in GA compared with 0 52.7 ± 12.57 57.25 ± 11.62 1.097 0.286
2 40.33 ± 11.04 48.65 ± 10.40 2.291 0.034*
17 and three patients in GB, respectively. The 20 patients 4 29.75 ± 10.64 35.8 ± 8.22 1.785 0.090
in GA had moderate acne compared with 19 patients with 6 20.63 ± 9.27 29.25 ± 8.46 2.921 0.009*
moderate acne and one with severe acne in GB. 8 14.75 ± 6.49 22.6 ± 7.98 3.298 0.004*
10 10.35 ± 3.95 19.88 ± 6.95 4.965 o0.001**
Comparison between both groups regarding age, sex, 12 6.575 ± 2.03 16.65 ± 6.19 6.464 o0.001**
the age of onset, the duration of acne, the skin type, and 20 7.75 ± 3.06 18.05 ± 6.51 5.578 o0.001**
the acne severity was nonsignificant (P = 0.848, 0.695, *Po0.05 was considered significant, whereas **Po0.001 was
0.755, 0.761, 0.52, and 1.0, respectively). considered highly significant.

Copyright r 2015 Egyptian Women’s Dermatologic Society. Unauthorized reproduction of this article is prohibited.
Salicylic-mandelic acid versus glycolic acid in acne vulgaris El Refaei et al. 199

Postacne hyperpigmentation The patient satisfaction score


The two agents caused improvement in postacne At week 12, two patients graded their total improvement as
hyperpigmentation throughout the study, with a statisti- poor, five patients as fair, and 13 patients as good in GA
cally significant difference between both groups from compared with one, 13, and 6 patients in GB, respectively
week 12 (P = 0.034) to week 20 (P = 0.045) (Table 2). (w2 = 6.47, P = 0.039). These results were matched with
Percentages of improvement in postacne hyperpigmenta- those obtained by the VAS in GA (Mc Nemar’s test = 3.0,
tion were 66.13 and 46.88% in GA and GB, respectively, P = 0.22), and the degree of agreement with the VAS was
with a statistically significant difference (P = 0.011). 85% (k test = 0.67, Po0.001). In GB, patient satisfaction
score results were matched with those obtained by the VAS
(Mc Nemar’s test = 1.0, P = 0.61), and the degree of
Icepick scars agreement with the VAS was 75% (k test = 0.52, P = 0.005).
Both agents produced an improvement in icepick scars
(Table 3) with no statistically significant difference
between both groups at week 20 (P = 0.570). Percentages
of change in icepick scars from week 0 to week 20 were Discussion
17.85 and 11.9% in GA and GB, respectively, with a The present study reported that SMP were safe and
statistically nonsignificant difference (P = 0.259). effective in the treatment of both noninflammatory and
inflammatory lesions of facial acne vulgaris. After undergoing
peels, the percentage of improvement from week 0 to week
Boxcar scars 20 was 90.2% in comedones, 81.72% in papules, 85.38% in
Both agents produced an improvement in boxcar scars pustules, 85.29 % in total acne scores, 66.13% in postacne
(Table 4) with no statistically significant difference hyperpigmentation, 17.85% in icepick scars, and 29.3% in
between the two agents at week 20 (P = 0.84). Percen- boxcar scars. These results were comparable with those of
tages of change in boxcar scars from week 0 to week 20 Garg et al. [5], who evaluated the efficacy of the combination
were 29.3 and 25.8 % in GA and GB, respectively, with a of 20% salicylic–10% mandelic acid peels in the treatment of
statistically nonsignificant difference (P = 0.130). facial acne, postacne scars, and hyperpigmentation in Indian
patients. They found that the percentage of improvement
According to the VAS score assessed by the two
from week 0 to week 24 was 45.7% in comedones, 47.7% in
uninvolved dermatologists (Table 5), it was found that
papules, 58.4% in pustules, 52.3% in total acne scores, 59.8%
SMP had a higher overall improvement than GAP (Figs 1
in postacne hyperpigmentation, 13.2% in icepick scars, and
and 2).
23.3% in boxcar scars. The deviation between these results
and the results obtained in the present study could be
explained by differences in the skin type and the
Side effects
environmental conditions.
Four (20%) patients in GA developed a burning or
stinging sensation against two (10%) patients in GB. To the best of our knowledge, there are no published data
Sixteen (80%) patients in GA had visible desquamation on SMP being used for the treatment of acne, except the
against eight (40%) patients in GB (P = 0.025). Dryness study of Garg et al. [5]. However, many studies had
was seen in three (15%) patients in GA and in two (10%) evaluated the efficacy of the SA peels in the treatment of
patients in GB. Acne flare was seen in two (10%) patients acne [13–16]. Hashimoto et al. [13] evaluated the efficacy
in each group. of 30% SA peels in the treatment of acne. They found

Table 2. A comparison between both groups regarding postacne hyperpigmentation from week 0 to week 20

Weeks Group A (N = 20) (mean ± SD/weeks) Group B (N = 20) (mean ± SD/weeks) t-test P

0 6.2 ± 1.32 6.4 ± 1.71 0.318 0.758


4 5 ± 1.15 6 ± 1.76 1.399 0.195
8 3.7 ± 1.89 4.7 ± 1.49 1.205 0.259
12 2.5 ± 1.35 4 ± 1.63 2.496 0.034*
20 2.1 ± 1.37 3.4 ± 1.26 2.327 0.045*
*Po0.05 was considered significant.

Table 3. A comparison between both groups regarding icepick scars from week 0 to week 20

Weeks Group A (N = 20) (mean ± SD/weeks) Group B (N = 20) (mean ± SD/weeks) t-test P

0 48.0 ± 12.12 46.7 ± 12.35 0.30 0.77


4 45.86 ± 11.05 46.7 ± 12.4 0.208 0.842
8 43.7 ± 11.33 44.6 ± 12.66 0.21 0.84
12 40.3 ± 10.23 41.57 ± 10.74 0.386 0.713
20 39.43 ± 9.24 41.14 ± 10.50 0.603 0.570

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200 Journal of the Egyptian Women’s Dermatologic Society

Table 4. A comparison between both groups regarding boxcar Figure 1.


scars from week 0 to week 20

Group A (N = 20) Group B (N = 20)


Weeks (mean ± SD/weeks) (mean ± SD/weeks) t-test P

0 9.7 ± 2.7 8.86 ± 1.95 0.891 0.407


4 9.7 ± 2.7 8.86 ± 1.95 0.891 0.407
8 8.3 ± 2.93 8.57 ± 1.9 0.24 0.818
12 7.14 ± 3.02 6.86 ± 1.95 0.225 0.83
20 6.86 ± 3.242 6.57 ± 2.23 0.213 0.84

Table 5. A comparison between both groups regarding the


visual analogue score
SMPs GAPs
Weeks Visual analogue score [N (%)] [N (%)] w2 P

4 Worse 0 (0) 0 (0) 6.508 0.039*


No change 5 (25) 13 (65)
Poor 10 (50) 5 (25)
Fair 5 (25) 2 (10)
Good 0 (0) 0 (0)
8 Worse 0 (0) 0 (0) 10.125 0.0175*
No change 1 (5) 3 (15)
Poor 5 (25) 13 (65)
Fair 10 (50) 3 (15)
Good 4 (20) 1 (5)
12 Worse 0 (0) 0 (0) 8.19 0.0167*
No change 0 (0) 0 (0)
Poor 1 (5) 2 (10)
Fair 4 (20) 12 (60)
Good 15 (75) 6 (30)
20 Worse 0 (0) 0 (0) 6.667 0.036*
No change 0 (0) 0 (0)
Poor 1 (5) 4 (20)
Fair 5 (25) 10 (50)
Good 14 (70) 6 (30)
GAP, glycolic acid peel; SMP, salicylic–mandelic acid peel.
A patient treated with salicylic–mandelic acid peel. (a) A photograph at
*Po0.05 was considered significant.
week 0 showing inflammatory lesions, noninflammatory acne lesions,
and postacne hyperpigmentation. (b) A photograph at week 20
showing good improvement in the overall appearance according to
that there was a 75% reduction in comedones and an visual analogue scale.
improvement of the acne grade in all patients (grades II
and III of acne were decreased to grade I). Dainichi
et al. [14] reported a greater than 75% reduction in both
inflammatory and noninflammatory acne with 30% SA Throughout the present study, SMP was more effective
peel. Joshi et al. [15] and Ahn and Kim [16] found that SA than GAP in the treatment of both noninflammatory and
peels had a whitening effect on the skin and improved inflammatory acne lesions. This is because of the unique
postacne hyperpigmentation. lipophilic and anti-inflammatory properties of SA, which
seems to be the dominant agent in the combination
Throughout the present study, GAP showed an improve- (SMP) [3]. Moreover, mandelic acid is one of the largest
ment in both inflammatory and noninflammatory acne AHAs and penetrates the epidermis more slowly and
lesions. The percentage of improvement from week 0 to uniformly, making it an ideal peel for acne and pigmenta-
week 20 was 35.87% in comedones, 77.78% in papules, tion [5]. GA, in contrast, is hydrophilic, which makes it a
75.65% in pustules, 68.50% in total acne scores, 46.88% in weaker comedolytic agent. Furthermore, it does not have
postacne hyperpigmenation, 11.9% in icepick scars, and the anti-inflammatory properties of SA. El Akhras et al. [18]
25.8% in boxcar scars. These results were comparable to compared the effect of 70% GAP and 30% SA peels in the
those of Garg et al. [5], who found that the percentages of treatment of postacne hyperpigmentation, and they
improvement from week 0 to week 24 were 20.9% in reported that both agents were effective in the treatment
comedones, 27.3% in papules, 34.7% pustules, 27.3% in of postacne hyperpigmentation. These results support the
total acne scores, 46.3% in postacne hyperpigmentation, synergetic effect of adding mandelic acid to SA (SMP) in
10.4% in icepick scars, and 20.1% in boxcar scars. The the treatment of postacne hyperpigmentation.
results of the present study concur with those reported
by Perić et al. [17]. They evaluated the efficacy of 35% In the present study, both agents led to a subtle decrease
GAP in mild to moderate inflammatory acne. They found in the number of icepick and boxcar scars with no
76.7% reduction in papules and 80.0% reduction in statistically significant difference. This might be ex-
pustules. plained by the fact that both the peeling agents are

Copyright r 2015 Egyptian Women’s Dermatologic Society. Unauthorized reproduction of this article is prohibited.
Salicylic-mandelic acid versus glycolic acid in acne vulgaris El Refaei et al. 201

Figure 2. observed. Regarding the side effects throughout the present


study, it was found that both agents were tolerable to all
patients: a burning or stinging sensation was found in 20% of
the patients with SMP against 10% of the patients with GAP.
These results concur with those obtained by Garg et al. [5].
They found that 17.3% of the patients developed a burning
or stinging sensation with SMP against 8.7% of patients with
GAP.
In the present study, dryness was seen in 15% of the
patients with SMP against 10% of the patients with GAP.
In contrast, 80% of the patients with SMP had visible
desquamation against 40% of the patients with GAP.
These results are not in agreement with that reported by
Garg et al. [5]. They reported dryness only with SMP
(14.28%). Also, they reported that 8.7% of the GAP
patients and no patients with SMP had visible desquama-
tion. This might be explained by the different methods of
formulation of the peeling agents (vehicle) in this study.

Conclusion
The SMP proved to have a higher efficacy than the more
commonly used GAP in the treatment of both inflammatory
and noninflammatory acne and postacne hyperpigmentation,
whereas both peeling agents had nonsatisfactory results in all
types of acne scars. Both peeling agents were safe, with
tolerable side effects.

Acknowledgements
Conflicts of interest
There are no conflicts of interest.

References
1 Handog EB, Datuin MS, Singzon IA. Chemical peels for acne and acne scars
in Asians: evidence based review. J Cutan Aesthet Surg 2012; 5:239–246.
2 Rendon MI, Berson DS, Cohen JL, Roberts WE, Starker I, Wang B. Evidence
and considerations in the application of chemical peels in skin disorders and
aesthetic resurfacing. J Clin Aesthet Dermatol 2010; 3:32–43.
3 Kessler E, Flanagan K, Chia C, Rogers C, Glaser DA. Comparison of alpha-
and beta-hydroxy acid chemical peels in the treatment of mild to moderately
severe facial acne vulgaris. Dermatol Surg 2008; 34:45–50.
4 Khunger N. Facial peels. Chapter 14. In: Prendergast PM, Shiffman MA,
editors. Aesthetic medicine: art and techniques, 1st ed. Berlin, Heidelberg:
Springer-Verlag; 2011. pp. 157–167.
5 Garg VK, Sinha S, Sarkar R. Glycolic acid peels versus salicylic–mandelic
acid peels in active acne vulgaris and post-acne scarring and
hyperpigmentation: a comparative study. Dermatol Surg 2009; 35:59–65.
6 Hayashi N, Akamatsu H, Kawashima M. Acne Study Group. Establishment of
A patient treated with glycolic acid peel. (a) A photograph at week 0 grading criteria for acne severity. J Dermatol 2008; 35:255–260.
showing acne lesions and postacne hyperpigmentation. (b) A photo- 7 Michaëlsson G, Juhlin L, Vahlquist A. Effects of oral zinc and vitamin A
graph at week 20 showing fair improvement in acne lesions and in acne. Arch Dermatol 1977; 113:31–36.
postacne hyperpigmentation according to visual analogue scale. 8 Jacob CI, Dover JS, Kaminer MS. Acne scarring: a classification system and
review of treatment options. J Am Acad Dermatol 2001; 45:109–117.
9 Zakopoulou N, Kontochristopoulos G. Superficial chemical peels. J Cosmet
Dermatol 2006; 5:246–253.
superficial peels and they serve only to resurface the upper 10 Khunger N. IADVL Task Force. Standard guidelines of care for
layers of the epidermis. Through an indirect mechanism, chemical peels. Indian J Dermatol Venereol Leprol 2008; 74
(Suppl):S5–S12.
both stimulate the dermal fibroblasts to deposit more 11 Gold MH, Hu JY, Biron JA, Yatskayer M, Dahl A, Oresajo C. Tolerability and
collagen, elastin, and glycosaminoglycans in the papillary efficacy of retinoic acid given after full-face peel treatment of photodamaged
dermis. A more orderly and parallel arrangement of the fibers skin. J Clin Aesthet Dermatol 2011; 4:40–48.
12 Lipper GM, Perez M. Nonablative acne scar reduction after a series of
is also seen with both agents [19]. Thus, a gradual and slight treatments with a short-pulsed 1,064-nm neodymium:YAG laser. Dermatol
decrease in the number of icepick and boxcar scars was Surg 2006; 32:998–1006.

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202 Journal of the Egyptian Women’s Dermatologic Society

13 Hashimoto Y, Suga Y, Mizuno Y, Hasegawa T, Matsuba S, Ikeda S, et al. 16 Ahn HH, Kim IH. Whitening effect of salicylic acid peels in Asian patients.
Salicylic acid peels in polyethylene glycol vehicle for the treatment of co- Dermatol Surg 2006; 32:372–375.
medogenic acne in Japanese patients. Dermatol Surg 2008; 34:276–279. 17 Perić S, Bubanj M, Bubanj S, Jančić S. Glycolic acid peeling in the treatment
14 Dainichi T, Ueda S, Imayama S, Furue M. Excellent clinical results with a new of mild to moderate inflammatory facial acne vulgaris. Sci Res Essays 2011;
preparation for chemical peeling in acne: 30% salicylic acid in polyethylene 6:6671–6680.
glycol vehicle. Dermatol Surg 2008; 34:891–899. 18 El Akhras A, Esmail NA, Ahmed AH, Ghaith EI. Comparison between glycolic
15 Joshi SS, Boone SL, Alam M, Yoo S, White L, Rademaker A, et al. acid and salicylic acid in facial peeling in superficial post acne scars, post acne
Effectiveness, safety, and effect on quality of life of topical salicylic acid peels pigmentation and epidermal melasma. Med J Cairo Univ 2011; 79:83–87.
for treatment of postinflammatory hyperpigmentation in dark skin. Dermatol 19 Kligman D. Technologies for cutaneous exfoliation using salicylic acid.
Surg 2009; 35:638–644. Dermatol Ther 2001; 14:225–227.

Copyright r 2015 Egyptian Women’s Dermatologic Society. Unauthorized reproduction of this article is prohibited.

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