tients, very superficial or superficial chemical peels are more commonly used due to lower risk of post inflammatory hyperpigmentation31 as the skin is usually dark colored. Among these peels, Glycolic acid is the most commonly used agent.32 It is considered a very versatile peeling agent as it has good penetration of the skin because of lower molecular weight, increased bio- availability, gets easily neutralized and its effect is usually superficial. Hence, is safe with very few post peel complications.33 It is available in concentrations ranging from 20% to 70%. Glycolic acid peeling has been shown to be efficacious and well tolerated in melasma34, 35 in various studies.
Some studies have been done combining glycolic acid peeling with various topical agents like azelaic acid 20% plus adapalene gel 0.1%;36 hydroquinone 4%;37 glycolic acid cream 10% plus hydroquinone
4%38 to enhance the efficacy of treatment and have shown better results. Sarkar et al, studied the glycolic acid peeling
in combination with topical application of 5% hydroquinone plus 0.05% tretinoin plus 1% hydrocortisone in a cream base ie, modified Kligman’s formula and concluded that this combination therapy gives additional benefit with rapid and greater improvement
in melisma.39 This is of considerable importance because this combination therapy, with its higher efficacy and minimal untoward effects, may prove to be an important line of therapy in melasma which is a therapeutic challenge for the clinician and is an emotional stress to the patient due to cosmetic disfigurement.
Paucity of controlled trials demonstrating the effectiveness of glycolic acid peels either alone or in conjunction with tretinoin, hydroquinone and topical steroids in darker racial/ethnic groups, where melasma is extremely common prompted us to undertake a clinical trial to study the efficacy and safety of serial glycolic acid peeling combined with topical regimen of 2% hydroquinone, 1% hydrocortisone and 0.05% tretinoin in the treatment of melasma.
Forty Indian patients with Fitzpatricks skin type III-V with moderate
to severe melasma of epidermal variety were included in this study. Study was conducted between June 2007 to Jan 2009. Patients were followed for atleast 24 weeks.
- Every patient with facial melasma seeking medical treatment
voluntarily in Department of Dermatology, Pt. BD, Sharma PGIMS, Rohtak, India.
- Epidermal variety of melasma on Wood’s lamp examination.
- Interest to participate in research.
- Pregnant and lactating women
- Hypersensivity to formulation used in the study
- Patients on oral contraceptives, hormonal replacement therapy,
oral retinoids or any other concurrent medications.
- Active or recurrent herpes simplex infection
- Facial warts or molluscum contagiosum
- Keloidal tendencies
- Unrealistic expectations
- Active dermatosis of atopic, seborrheic or other eczematous type.
All patients were explained about the risk of the procedure and written informed consent was obtained prior to the procedure. Detailed history of all the patients was taken to rule out all exclusion criteria and history of all precipitating factors or initiating factors was recorded. Patients were then subjected to complete dermatological examination including Wood’s light examination and Melasma area severity index (MASI)40 scoring was done. Patients with only epidermal variety of melasma were chosen for the study. Forty patients were taken for the study and were randomly divided into two groups of 20 each. Written informed consent was obtained from each patient. All patients were advised
to apply topical sunscreen of SPF 15 or more.
In Group 1 (Peel group) serial glycolic acid peeling with topical regimen (2% hydroquinone, 1% hydrocortisone and 0.05% tretinoin)
was used. A post auricular test peel was performed and left for 15-20 minutes for detection of any hypersensitivity to the ingredients of the peeling agent. All patients in peel group were given serial glycolic acid peel sessions. Total 8 sessions were performed at 3 weekly interval. In first session 30% glycolic acid was used for 1 to 2 minutes, in 2nd session 30% glycolic acid was used for 3 minutes, in 3rd session 30% glycolic acid was used for 4 minutes, in 4th session 40% glycolic acid was used for 1 to 2 minutes, in 5th session 40% glycolic acid was used for 3 minutes, in 6th session 40% glycolic acid was used for 4minutes,