Do Peeling Agents Work for Melasma?
Wednesday, September 01, 2004
Melasma is one of the most common pigmentary disorders in
patients with skin of color, and may also be observed, although
less frequently, in Caucasians. Estimates of prevalence range from
1.5% to 10.1%, based on patients presenting to outpatient clinics
in various countries.1-6 Despite its high
prevalence, treatment of melasma is often difficult, causing
frustration for both patients and physicians. Since melasma is
exacerbated by sun exposure, sunscreens are critical for successful
Hydroquinone is the most commonly used depigmenting agent
worldwide for melasma. Maximum treatment effect is usually seen
within a few months, and one study demonstrated a 40% rate of
complete clearing after 12 weeks of therapy with 4%
hydroquinone.7 In order
to improve efficacy, many agents have been added to hydroquinone,
including glycolic acid,8 tretinoin,9 and
corticosteroids. A recently developed formulation containing
hydroquinone, tretinoin, and fluocinolone acetonide showed
significant improvement in 78% of subjects in a large, multicenter
trial.10 Despite these
successful outcomes, many patients relapse or do not clear
completely with topical therapy. Thus, other modalities, including
chemical peels, have been used in the treatment of melasma in order
to achieve greater success.
Peeling agents are an attractive alternative in the treatment of
melasma. Milder peeling agents, such as glycolic acid, remove the
stratum corneum, and thus may enhance the penetration of
depigmenting agents. Stronger peeling agents, such as
trichloracetic acid, remove deeper layers of the epidermis, and may
also remove the superficial dermis, including the pigmentation
causing melasma. Unfortunately, peeling agents that cause
irritation often lead to unacceptable postinflammatory
hyperpigmentation, particularly in patients with skin of color.
Several studies have evaluated the efficacy of peeling agents for
Lim et al. studied 10 women from Singapore with melasma
treated with glycolic acid.11 The patients applied a
cream containing 10% glycolic acid and 2% hydroquinone to both
sides of the face, and received glycolic acid peels of 20% to 70%
concentration to one side of the face only for up to 5 minutes
every 3 weeks. The study duration was 26 weeks, during which time
the patients received a total of 8 peels. All patients had at least
4 peels at a 70% concentration. The peeled side did somewhat
better, but the difference was not statistically significant, using
subjective methods of assessing pigmentation. No instrumentation
was used to assess the degree of pigmentation. Stinging and redness
lasting less than 1 hour occurred in all patients. One experienced
a burn with a 20% glycolic acid peel, causing temporary
Lawrence et al. reported a series of 16 women of
various skin types with melasma who were treated with monthly 70%
glycolic acid peels on one side of the face and Jessner's peels on
the other 12. Fourteen patients
received 1 to 3 peels. The average lightening in pigmentation was
similar on both sides, and the overall melasma area and severity
index (MASI) decreased by 63%, with no difference between the
glycolic acid side and the Jessner's side. Unfortunately, all
patients also applied tretinoin and hydroquinone to both sides of
the face, and there was no control. Evaluation of patient
improvement included objective colorimetry, which did not show a
difference between the two sides. Most patients found the glycolic
acid peel more painful than the Jessner's peel. Three patients had
serous crusting and 4 had persistent erythema on the glycolic acid
side, requiring parenteral or topical corticosteroids.
A study performed in India on 25 women with moderate-to-severe
melasma used 10% glycolic acid and 2% hydroquinone applied daily to
the lesions along with monthly 50% glycolic acid peels up to 5
minutes for 3 months.13
The average improvement in MASI score was 46.7%, but there was no
control group and the methods of evaluating pigmentation were
subjective. Again, the presence of daily hydroquinone therapy
causes difficulty in evaluating the true efficacy of the peels in
this study. Only 1 patient developed hyperpigmentation after 3
peels, while the others had no side effects.
Another study from India treated 40 patients with melasma using
a modified Kligman's formula (tretinoin, hydroquinone, and
hydrocortisone) for 21 weeks.14 One half of the patients
also received serial glycolic acid peels of 30% to 40%
concentration for 1 to 3 minutes at 3-week intervals. The peeled
group had an 80% improvement in MASI score, while the nonpeeled
group had an improvement of 63%. The difference between the groups
was statistically significant, but again, the methods of evaluation
were subjective and there was no evaluator-blinding performed.
Adverse effects were minimal, with all patients in the peel group
and 8 in the control group developing mild erythema and superficial
desquamation. Among patients in the peel group, 2 developed focal
superficial vesicles with postinflammatory hyperpigmentation, and 2
had persistent erythema, requiring topical corticosteroids.
A small study from Italy reported 20 patients with melasma who
were treated with 6 to 12 peels containing 50% glycolic acid and
10% kojic acid at 2-week intervals.15 Using subjective
evaluation methods, the investigators found that 30% of the
patients had complete regression, 60% had partial regression, and
10% did not improve. However, the patients were of lighter skin
types (2 and 3) and there was no control group. Mild desquamation
lasting 3 to 4 days was noted in most patients. A small,
uncontrolled study including 6 African-American and Hispanic
patients with melasma treated with 5 salicylic acid peels of 20% to
30% concentration at 2-week intervals showed
moderate-to-significant improvement in 4 patients (66%).16 However, all patients also
used daily 4% hydroquinone topically and the methods of evaluation
were subjective. Tolerance to the peels was generally good.
A recurrent theme in the above studies is a caution to avoid
irritation in patients with skin of color, since this can lead to
postinflammatory hyperpigmentation. Indeed, stronger peeling
agents, such as trichloracetic acid, are rarely used in
darker-skinned patients because of this risk, with all recent
studies using milder glycolic, salicylic, and kojic acid peels.
Unfortunately, most studies using peeling agents for melasma lack
controls, blinding, and objective methods of evaluation, or do not
study typically resistant darker skin types.
To address these problems, a study was performed using glycolic
acid peels on a uniform group of 21 Hispanic women with melasma who
applied 4% hydroquinone twice daily to both sides of the face.17 The patients received
glycolic acid peels of 20% to 30% concentration for 3 to 5 minutes
to one side of the face only, with the other side serving as a
control. The goal was to determine if glycolic acid peels added to
a regimen containing daily 4% hydroquinone cream was better than
the use of 4% hydroquinone alone. A total of 4 peels were applied,
at 2-week intervals. Investigators were blinded, and improvement
was objectively assessed using a mexameter (narrow-band reflectance
spectrometer). Subjective evaluation was performed using physician
and patient global assessments, linear analog scale, and MASI
scores. As expected, both sides of the face improved significantly,
but there was no added benefit to the side receiving the glycolic
acid peels. All patients had mild tingling and erythema during the
peel, and only 3 were able to tolerate a peel duration of 5
minutes. Four developed moderate or severe erythema during and
after a peel, but without epidermolysis or erosions.
With the conflicting data presented above, the efficacy of
peeling agents in the treatment of melasma is anything but clear.
Chemical peels remain one of the most commonly performed procedures
by dermatologists. These peels are often used in patients with skin
of color to improve the appearance of the skin. While texture may
improve with the use of peels, there is not good evidence that
melasma can be improved. Mild peels tend to be well tolerated, but
the therapeutic window is narrow and irritation with resulting
postinflammatory hyperpigmentation may occur. The cost of a series
of peels may be significant. Thus far, the best results in patients
with melasma have been obtained using varying formulations
containing hydroquinone, tretinoin, and corticosteroids. Further
randomized, controlled trials using peeling agents of various
concentrations and formulations are needed before this therapy can
be recommended for melasma.
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- Lawrence N, Cox SE, Brody HJ. Treatment of melasma with
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