Professional Documents
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Keywords:
glycolic acid peel, postacne hyperpigmentation, postacne scars, salicylic–mandelic
acid peel
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
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
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
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
Copyright r 2015 Egyptian Women’s Dermatologic Society. Unauthorized reproduction of this article is prohibited.
200 Journal of the Egyptian Women’s Dermatologic Society
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
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.
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