|Year : 2020 | Volume
| Issue : 2 | Page : 80-86
Experience of cosmetology in rural Central India: a clinico-epidemiological profile and comparative study of 35% glycolic acid peel and 15% trichloroacetic acid peel in melasma
Pratiksha M Sonkusale1, Sumit Kar1, Abhay V Deshmukh2
1 Department of Dermatology, Venereology & Leprosy, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, India
2 Department of Pathology, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, India
|Date of Submission||05-Mar-2020|
|Date of Decision||23-May-2020|
|Date of Acceptance||27-Jul-2020|
|Date of Web Publication||03-Dec-2020|
Dr. Sumit Kar
Department of Dermatology, Venereology & Leprosy, Mahatma Gandhi Institute of Medical Sciences, Sevagram - 442102, Wardha, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Melasma, an acquired hypermelanosis, is challenging to treat rural population more exposed to ultraviolet (UV) rays in Central India. Chemical peeling is a new, safe and cost-effective treatment with very few studies comparing Glycolic acid (GA) peel and Trichloroacetic acid (TCA) peel in pigmented patients (Fitzpatrick skin type IV and V) in melasma using both subjective and objective methods; melasma area severity index (MASI) of evaluation. Aim: To study the clinico-epidemiological profile and to compare the therapeutic efficacy of chemical peeling with 35% GA and 15% TCA in melasma patients. Methods: 50 epidermal melasma patients were enrolled divided into two groups, 25 patients in each. These groups were treated with 35% of GA (Group A) and 15% TCA peel (Group B), respectively. They were primed and test peeled. Three sessions of peeling two weeks apart with follow up after 3 months were evaluated using subjective response and MASI score. Results: The mean age of onset was 35.20±7.11 with male to female ratio was 1: 5. The mean duration of melasma was 3.57±2.58. Positive family history (32%) was present with centrofacial (56%) was the most common pattern. Subjective evaluation in the GA group and TCA group showed good and very good response in 92% and 84% respectively. The MASI score at baseline and at 3 month for Group A was 11.8 and 3.66, while it was 10.5 and 3.7 for group B. Conclusion: Both GA and TCA peels proved to be an equally effective treatment in epidermal melasma in our study.
Keywords: Chemical peeling, glycolic acid, melasma, trichloroacetic acid
|How to cite this article:|
Sonkusale PM, Kar S, Deshmukh AV. Experience of cosmetology in rural Central India: a clinico-epidemiological profile and comparative study of 35% glycolic acid peel and 15% trichloroacetic acid peel in melasma. Pigment Int 2020;7:80-6
|How to cite this URL:|
Sonkusale PM, Kar S, Deshmukh AV. Experience of cosmetology in rural Central India: a clinico-epidemiological profile and comparative study of 35% glycolic acid peel and 15% trichloroacetic acid peel in melasma. Pigment Int [serial online] 2020 [cited 2021 Feb 27];7:80-6. Available from: https://www.pigmentinternational.com/text.asp?2020/7/2/80/302068
| Introduction|| |
The term “Melasma” which means black is derived from the Greek word “melas”. It is a commonly acquired hypermelanosis that occurs in sun-exposed areas, mostly on the face, occasionally on the neck and rarely on the forearms. It affects all races but particularly Hispanics and Asians and it is one of the most common pigment disorder among Indians. It is predominant in women but even men represents approximately 10% of all the cases. People with darker skin type (Fitzpatrick type IV, V and VI) are more prone for melasma.
The etiopathogenesis of melasma includes mainly sunlight, role of female hormonal activity, genetic predisposition along with pregnancy, oral contraceptives, estrogen progesterone therapies, thyroid dysfunction, certain cosmetics and phototoxic and anti-seizure drugs. Treatment modalities for melasma include broad spectrum sunscreen, cosmetic camouflage, chemical peeling, hydroquinone and non-hydroquinone based therapies, oral agents and lasers.
In this Era of Cosmetology, chemical peels are now-a-days becoming the mainstay of a treatment for Melasma in rural population. Chemical peels aim to create injury at a specific skin depth and thus stimulate new skin growth and improve surface texture and appearance. Although both glycolic acid (GA) and trichloroacetic acid (TCA) are used for treating melasma, there have been very few studies comparing these two agents in pigmented patients (Fitzpatrick skin type IV and V) in melasma using both subjective and objective methods of evaluation (MASI). The patients in Central India are exposed to more UV rays for most of the time of the year so chemical peel is safe, affordable and effective treatment modality in rural population. This prompted us to compare these two easily available agents, GA and TCA. Both these are superficial to medium depth peels and thus are not effective for dermal melasma. Hence, by wood’s lamp examination cases of dermal melasma were not included in this study.
The present study was aimed at studying the epidemiology, clinical presentation and precipitating and/or provocation factors associated with melasma and also compared 35% GA peel and 15% TCA peel for the treatment of melasma in a rural tertiary care hospital in Central India.
| Material and Method|| |
This non-randomized interventional study was conducted in a rural tertiary care hospital located in Central India as an outpatient procedure in the Department of Dermatology, Venereology and Leprosy from January 2016 to August 2017 (1 year and 8 months). Total 50 patients with the clinical diagnosis of epidermal melasma with the written informed consent and an approval from the Institutional Ethics Committee were enrolled in the study.
Clinically diagnosed cases of epidermal melasma with Fitzpatrick skin type IV and V from age group of 20-50 years who signed the written informed consent were included.
Participant with history of hypertrophic scars, keloids, recurrent herpes labialis infection, active dermatitis, prescribed retinoids in last three months, chemical peel procedure done in last three month, taking hormones or any other drug, pregnant and lactating female and with unrealistic expectations were excluded from the study.
| Methods|| |
A structured pre-designed, pre-tested questionnaire was used to collect data related to clinico-epidemiological profile, thorough medical history and clinical examination. Wood’s light examination was performed to assess the type of melasma. Patients with epidermal melasma were selected for the further treatment and overall severity was assessed by the Melasma Area and Severity Index (MASI) score.
At the baseline, patients receiving treatment were explained regarding the procedure and were signed written informed consent. Color photographs were taken of all the patients under the standard condition in natural light as baseline, before each peel and after 3 months of follow up. They were primed two weeks before starting the chemical peeling. Patients were divided as per age and sex into two groups as Group A and Group B. Each Group consisted of 25 patients. Group A patients were treated with 35% of GA peel and Group B patients were treated with 15% TCA peel. They were test peeled and the chemical peeling was done only on those patients with no side effects of test peel.
Priming was done two weeks prior to the chemical peel with triple topical combination of hydroquinone 2%, tretinoin 0.025% and Mometasone 0.1% daily at night along with daily application of sunscreen (SPF 20.47) frequently at day time. It was stopped 1 day prior and was restarted 4 days after peeling. Patients were advised to report any side effects of the priming agents immediately. The priming agent was stopped between third peel session and 3 months of follow up period
Preparation of the peeling agent
Preparation of the peeling agent of 35% of GA solution was done by adding 50 ml GA in 50 ml of distilled water to make total volume of 100 ml. 15% of TCA was prepared by adding 15 grams of TCA crystals with 10 ml of glycerin and 90 ml of distilled water to make total volume of 100 ml.
A small 1 × 1 inches2 post auricular area was tested with 35% GA and 15% TCA prior to the full face peeling and results were evaluated after 1 week.
The patient was asked to wash the face with water and was cleansed with surgical spirit and degreased with 99.5% acetone. The eyes were covered and the sensitive areas of mucocutaneous junctions (inner and outer canthus of the eyes, vermillion border and the nasolabial folds) were protected with Vaseline. The single coat of peeling agent (35% GA and 15% TCA) was applied with cotton tip applicator (sterile ear buds) over face in cosmetic units (forehead, left cheek, right cheek and chin) and feathering stroke at edges to prevent demarcation lines for 1-3 minute till the end point for GA peel (mild transient erythema) and TCA peel (very minute speckles of frost or no frost) was seen. Neutralization of the peel was done with ice cold water for 2 minutes. Patient was then asked to wash the face with plain water for 3 minutes and applied ice cubes if erythema and burning persisted. The patient was advised to apply sunscreen before leaving the procedure room. They were advised to apply priming agent after 4 days of the peel and to stop 1 day prior before next peel for only 3 peel sessions and strictly instructed to apply sunscreen with emollient in unlimited quantity between the sessions of peels and thereafter till 3 months of follow up.
Three sessions of chemical peeling were done every 2 weeks apart 0, 2 and 4 week. Final evaluation of patients was done 3 months after the last peeling. Coloured photographs were taken and MASI score was calculated at baseline, before each peel and after 3 months of follow up. Patients were strictly instructed to apply sunscreen lotion (SPF 20.47) during and after therapy along with emollients in unlimited quantities. Subjective improvement before and at the completion of study in the patient was graded as no response if no change in MASI score at 3 months; mild response if less than 25% changes; moderate response with 25% to <50% decrease in MASI score; good response with 50% to < 75% decrease in MASI score and very good response with more than 75% decrease in MASI score. Objective analysis of each patient was calculated by Melasma Area and Severity Index (MASI) score at the beginning and after each peel and the results were evaluated statistically. The face was divided into the four regions (forehead 30%, right malar region 30%, left malar region 30% and chin 10%) and each area was given numerical value (A, 0-6). The sum of severity of darkness (D, 0-4) and homogeneity (H, 0-4) was multiplied by the numerical value and percentage of the total area involved. These values were added to obtain MASI score.
MASI = Forehead 0.3 (D+H) A + right malar 0.3 (D+H) A + left malar 0.3 (D+H) A + chin 0.1 (D+H) A
The study protocol was approved by the Institute Ethics committee before proceeding. Informed consent was taken from patients before procedure and before taking photographs. Patient confidentiality was maintained.
Statistical analysis was done by using descriptive and inferential statistics using chi-square test, student’s paired t-test and unpaired t-test. SPSS 22.0 version software and Graph Pad Prism 6.0 version was used and P < 0.05 is considered as level of significance.
| Results|| |
The mean age was 35.20±7.11. The male is to female ratio were 1: 5.2. Maximum number of patients were from lower middle class (52%) followed by lower class (38%) socio-economic status [Table 1].
The mean duration of melasma 3.57±2.58 and the mean age of onset of melasma was 31.62±6.75. Sun exposure was maximum (>3 hrs/day) and moderate (1–3 hrs/day) in 42% and 40% patients, respectively. Family history was positive in only 32% patients. Melasma developed after application of cosmetic in 26% and after pregnancy in 24% patients [Table 1].
In all patients, cheeks (100%) followed by nose 82%, forehead 50% were the affected site. Centrofacial (56%) was the most common pattern followed by malar (42%) and the mandibular (2%). According to Fitzpatrick skin type, maximum number of patients belonged to skin type V (82%) followed by IV (18%) [Table 1].
Subjective analysis showed good and very good response in each GA (84%) and TCA (92%) group from baseline to 3 months. It was statistically significant (p=0.0001) in both the groups [Table 2].
The improvement in MASI score in GA group at 0 week and 3 months of the follow-up visit was 10.54±6.75 and 3.72±1.45 and it was 11.87±4.39 and 3.66± 0.99 in TCA group respectively [Table 3] and [Figure 1]. All the values in each week at 2 weeks, 4 weeks and 3 months were statistically significant (P = 0.0001) [Table 4] and [Table 5]. There was no significant difference in decrease in MASI score at the end of 3 months of follow up between both the groups (P = 0.78 and 0.80) [Table 4] and [Table 5]. However, TCA peel showed initial rapid decrease [Figure 2] and in GA peel there was gradual decrease [Figure 3] in MASI score after the first two peels but the response was comparable in each group at the end of peeling sessions and both group showed equally efficacious response.
|Figure 2 TCA group: (a) pretreatment at baseline, (b) post treatment at 3 months.|
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|Figure 3 GA group: (a) pretreatment at baseline, (b) post treatment at 3 months.|
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When compared within two groups, the most common side effect was erythema (GA: 60%, TCA: 88%), irritation (GA: 32%, TCA: 76%), burning (GA: 68%, TCA: 16%). Hyperpigmentation was seen in (GA: 2%, TCA: 6%) and post peel cracking in 4% of TCA group [Table 6] and [Figure 4].
| Discussion|| |
In Indian skin types, superficial peels are preferably used over medium depth to deep peels for being safe and to prevent post inflammatory hyperpigmentation. The superficial peels are useful with variable results after multiple sessions. Rotational treatment may be required and maintenance with topical therapy is mandatory. Recurrence is very common in melasma and pigment improvement may be partial. Thus, it has limited applications in dark skin types. Chemical peels are combined with triple combination to increase the efficacy.
In the present study, the mean age of melasma was 35.20±7.11 similar to 32±6.9 years by Krupashankar et al. The female patients outnumbered the male patients with F:M ratio as 5.2:1 as compared to 6.5:1 reported by Puri in Punjab. While several other studies, conducted across the country found female to male ratio as 4:1.,,, In our study, 52% patients belonged to lower middle socioeconomic class similar to the studies reported as 56% by Krupashankar et al. and 59% by Jagannathan et al. respectively.
The mean duration of melasma was 3.57±2.58 years and mean of onset of melasma was 31.62±6.75 years which was similar to the studies conducted by Achar and Rathi, Kumari and Thappa, Puri, Kavya, Jagannathan et al. and Pawar et al. The history of sun exposure (>3 hours/day) was 42% and 32% patients had positive family history. These findings are very well correlated to 55.1% and 33% by Achar and Rathi, 35.9% and 31.1% Krupashankar et al., 28% and 36.11% by Kavya, 22% and 33% by Jagannathan et al. It shows that ultraviolet light is one of an important etiological factors in the pathogenesis of melasma. There appears to be an increase in the number and activity of melanocytes in the epidermis of patients with melasma. The melanocytes appear to be functionally altered. Pregnancy (24%) and cosmetics (26%) were aggravating factor for melasma which coincide with 22.4% and 23.3% by Achar and Rathi and 36% and 22% by Kavya, 15% and 21% by Jagannathan et al. The findings strengthen the evidence of hormonal involvement in melasma. High levels of progesterone, estrogen and melanocortin triggers melasma during pregnancy. Centrofacial (56%) was most common pattern followed by malar (42%) similar with the study of Achar and Rathi, Krupashankar et al. and Kavya respectively. Whereas, malar followed by centrofacial was common pattern as per Kumari and Thappa and Puri. This difference in various patterns of melasma may be attributed to the environmental or regional variations. Fitzpatrick skin type V (82%) followed by IV (18%) which was similar to the study by Pawar et al.,Jagannathan et al. observed skin type III or IV and Kumari and Thappa found IV- VI.
Subjective evaluation showed good and very good response in GA (84%) and TCA (92%) of the patients correlating to the findings of GA (75%) and TCA (65%) by Kumari and Thappa, a GA (70%) and TCA (64%) by Puri while in a comparative study of Sachedeva GA (30%) and TCA group (23.4%) showed good response patients.
In the present study, the average decrease in MASI scores in both groups from baseline was statistically significant [Figure 1] while comparison of decrease in MASI scores between both the groups at the end was not statistically significant which was similar to Puri and Kumari and Thappa. However, TCA peel [Figure 2] showed an initial rapid response and GA peel [Figure 3] showed gradual response after first two peels but the response was comparable in the two groups at the end of the peeling with both the group showing equally efficacious response [Figure 1]. These findings were consistent with study conducted by Kumari and Thappa.
In the present study, the most common side effects in GA and TCA groups were erythema (60% and 88%), irritation (32% and 76%), burning (68% and 16%), post inflammatory hyperpigmentation (12% and 6%) and post peel cracking (TCA: 2%) which was similar to the study by Puri.
In our study, triple combination topical agent was used as a priming agent which could have affected the final response. Also, we have selected only cases of epidermal melasma in our study which is known to have better clinical response to chemical peeling. These could be the probable limitation of our study.
| Conclusion|| |
In this era of cosmetology, chemical peels are becoming the mainstay of a treatment for melasma. Superficial chemical peeling (15% TCA and 35% GA) are equally effective in the treatment of epidermal melasma with better clinical response. In Central rural India, chemical peeling can prove to be safe, affordable and effective treatment modality with few side effects. They also have an added advantage of facial rejuvenation. Thus, we recommend further studies with different concentrations of TCA (15% and higher) and glycolic acid (35-70%) using larger samples of people and in other pigmentary disorders in Central India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]