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DOI: 10.5272/jimab.2004101.42
Journal of IMAB - Annual Proceedings (Scientific Papers) - 2004, vol. 10, book 1

Sonia ValkovaDepartment of Dermatology and Venereology,University Hospital – Pleven ABSTRACT
Melasma is one of the most common, therapy-resist- The aim of the present study was to assess and com- ant forms of acquired hyperpigmentation. The aim of the pare the efficacy and side effects of chemical peels with 35% present study was to assess the efficacy and side effects of glycolic and 15% trichloroacetic acids (TCA) in conjunc- chemical peels with 35% glycolic and 15% trichloroacetic tion with 20% azelaic acid cream in the treatment of acid (TCA) in conjunction with 20% azelaic acid cream in the treatment of melasma. Twenty-six women aged 22-54years with different forms of melasma have been treated. Six PATIENTS AND METHODS
of them were with phototype II, 11 with phototype III and PATIENTS
9 with phototype IV. Disease severity was assessed at the Twenty-six women aged 22-54 years (mean 25) were beginning and at the end of therapy according to the enrolled in the study. The pattern of melasma was as fol- Melasma Area and Severity Index (MASI). Patients were lows - six patients with centrofacial, four with mandibular, randomly divided in two groups – Group I (n=12) treated four with malar and twelve with mixed melanosis. The mean with 35% glycolic acid and Group II (n=14) treated with duration of the disease was 10,6 years. Six women had 15% TCA. A significant reduction in MASI values after Fitzpatrick skin type II, 11 were with skin type III and 9 with therapy was observed in all patients without significant skin type IV. Thirteen had had previous pregnancy, 11 had difference between Group I and Group II (t=0,12; ð>0,05).
received oral contraceptives and 2 had been on estrogen No statistical difference was established among final MASI replacement therapy. Fifty percent of the patients used no values of women with phototypes II, III and IV (t=0,25; photoprotection outdoors. Ten women had undergone ð>0,05). Side effects were light and negligible. Therapy was previous treatment with other agents with different, but as positively assessed by the patients. In conclusion, chemical a whole poor response. Nursing and pregnant patients as peels with 15% TCA and 35% glycolic acid in conjunction well as those who had conducted depigmenting therapy with 20% azelaic acid reduce significantly MASI values during the previous three months were excluded from the after therapy and are equally effective in the treatment of study. According to their birth date patients were randomly allocated in two groups - Group I (n=12) treated with 35%glycolic acid peel and Group II (n=10) treated with 15% Key words: melasma, peel, glycolic acid, TCA
Melasma is an acquired hyperpigmentation of the Patients were pretreated with tretinoin (Acnederm gel face affecting predominantly women. Multiple etiologic 0,05%) for two weeks. A series of four peels spaced 15 days factors have been implicated: high estrogen states (pregnan- cy, oral contraceptives), genetic factors, cosmetics and The face was first treated with a mild cleanser and autoimmune thyroid disease. Sunlight exposure appears to water and prepared with a pre-peel toner. TCA was applied with two cotton-tipped applicators. Hydrating mask was Conventional therapy for melasma consists of kerato- spread on the whole face after the appearance of even lytic (tretinoin, resorcin, glycolic and trichloroacetic acids etc) pinkish-white frosting. Glycolic acid was applied with a soft and depigmenting agents (hydroquinone, kojic and azelaic fan-like brush. The peeling solution was neutralized and acids). It has been established that chemical peels potentiate removed with water after the development of slight erythema the effect of the depigmenting agents and reduce significantly the Melasma Area and Severity Index (MASI) (3, 4, 5, 6).
After the peel the patients were directed to use emol- 42 / JofIMAB 2004, vol. 10, book 1 / lients in unlimited quantities and broad-spectrum sunscreens.
their daily activities. The glycolic acid procedure was asso- As soon as they healed they would start application of 20% ciated with stinging and nipping, which were most pro- azelaic acid cream (Skinoren, Schering) in conjunction with sunscreens and would continue applying them after the end Sixteen of the patients (8 from Group I and 8 from Group II) assessed therapeutic efficacy as greater than 90%improvement, 8 (6 from Group I and 2 from Group II) – as Assessment of therapeutic efficacy
greater than 50% improvement and 2 (Group I) - as greater The same investigator evaluated all patients. This was performed before and after treatment and six months afterthe end of the therapeutic course. Melasma severity was Adverse reactions
scored using the MASI (2). In this system the face is divided They were observed in eight patients from Group I into four areas: forehead, right malar, left malar and chin and included persisting postpeel erythema (on the cheeks, that correspond respectively to 30%, 30%, 30% and 10% chin and around the nose). It was treated with moderately of total face area. The melasma in each of these areas was potent topical corticosteroids. In two patients crusting graded on three variables: percentage of total area involved developed as a result of a deeper penetration of the solu- on a scale from 0 (no involvement) to 6 (90-100% tion. In six women from Group II postlesional hyper-pig- involvement); darkness on a scale from 0 (absent) to 4 (severe); homogeneity on a scale from 0 (minimal) to 4(maximum). The MASI was then calculated by the follow- Long-term follow-up
Seventeen (65%) of the patients were followed-up six months after the treatment. Only the ten of them, who +0,3(DML+HML)AML+0,1(DC+HC)AC, where D is continued topical therapy with sunscreens and azelaic acid darkness, H is homogeneity, A is area, F is forehead, MR is maintained improvement. The others experienced relapse, right malar, ML is left malar, C is chin and the values 0,3 although they were still improved over the pretreatment and 0,1 are respective percentages of total facial area.
At the end of the treatment patients were asked to give their subjective assessment of their clinical response DISCUSSION
Melasma is a serious medical and esthetic problem, especially in dark-skinned people. Despite the impressive Statistical methods
number of available therapeutic agents treatment results are Statistical analysis was performed with the help of often disappointing, as the condition usually recurs. The Student,s t-test for comparing MASI values before and after principle rules in the treatment of melasma include treatment and among patients with phototypes II, III and IV.
avoidance of excessive sun exposure, retardation of melano-cyte proliferation, inhibition of melanosome formation and promotion of melanosome degradation (6). This could be Clinical results
achieved by regular use of depigmenting agents and A statistically significant decrease in average MASI sunscreens with or without keratolytics.
scores after treatment was observed in both Group I and Superficial and medium-depth chemical peels are Group II (Group I – MASI before treatment 13,8±9,4; after recommended for the treatment of melasma, mainly in fair- treatment 5,0±1,2; t=18,9; ð<0,001; Group II - MASI before skinned individuals. People with higher phototype are treatment 14,6±7,7; MASI after treatment 6,2±1,9; t=16,3; usually resistant to therapy and therapeutic results are ð<0,001). No statistically significant difference was found unsatisfactory (5). However, this was not observed in our between MASI values after the two therapeutic regimens patients probably because of the small number of women (t=0,12; ð>0,05), as well as among MASI scores of patients with phototype IV. Chemical peels act by increasing the with phototypes II, III and IV (MASI after treatment for penetration of medical therapy, not only by “peeling off” the phototype II - 6,0±2,7, for phototype III - 6,8±1,5 and for pigment (3). This was confirmed in the study conducted by phototype IV - 7,7±2,2; t=0,25; ð>0,05).
Sarkar R et al (5) in two groups of Indian patients. The firstgroup was treated with 30 and 40% glycolic acid peels and Patients, subjective assessment
a topical regimen of a modified Kligman formula (0,05% After treatment patients were asked to evaluate the tretinoin, 2% hydroquinone and 1% hydrocortisone). The discomfort from the two different peeling solutions. They other group received the topical regimen alone. After a total found the TCA peel caused more discomfort – slight pain of six peels a significant decrease in MASI values was and strong stinging during the application, excessive desq- established in both groups (p<0,001). The women who uamation during the next 4-5 days, which interfered with received the glycolic acid peel showed a statistically / JofIMAB 2004, vol. 10, book 1 / 43 significant trend toward a more rapid and greater them assessed therapeutic efficacy as excellent (greater than 90% improvement) and 8 (31%) as good (greater than 50% Azelaic acid is a naturally occurring, straight-chained, improvement). Side effects were light and negligible except saturated dicarboxylic acid that acts as a competitive for the postlesional hyperpigmentation, which disappeared inhibitor of tyrosinase and interferes directly with melanin in about 4 weeks. It developed most often around the mouth biosynthesis. Various studies report “good” to”excellent” and on the chin in TCA-treated patients probably as a result results in 63-80% of the patients with melanosis after 6 of the premature desquamation of the epidermis in these re- months of treatment with 20% azelaic acid cream in gions due to the active contraction of the muscles during conjunction with broad-spectrum sunscreens (1). Azelaic acid has practically no effect on normal melanocytes and its The long-term follow-up of the patients demonstrat- long-term use has not been associated with ochronosis. Such ed that therapeutic results persist only in those of them, who changes were not observed in our patients also.
continued the topical application of azelaic acid and broad- The results of the present study demonstrate that spectrum sunscreens. This confirms the necessity of a chemical peels with 35% glycolic and 15% TCA in conjunc- constant maintenance therapy of melasma - an obligatory tion with azelaic acid and tretinoin are equally effective in condition for the achievement of long-lasting therapeutic the treatment of melasma and are positively accepted by the patients. This was confirmed by the fact that 16 (62%) of REFERENCES:
Coleman PW ðåä. Skin Resurfacing. Will- with a topical regimen in the treatment of Treatment of melasma with Jessner,s solu- CEM, Finkel LJ et al. Topical retinoic acid tion versus glycolic acid: a comparison of (Tretinoin) for melasma in black patients.
clinical efficacy and evaluation of the pre- dictive ability of Wood,s light examination.
J Am Acad Dermatol 1994;36 (4): 589-593.
tients. Am J Clin Dermatol 2004;5(3): 161- 5. Sarkar R, Kaur C, Bhalla M, et al.
Address of the coresponding author:
Sonia Valkova
Clinic of Dermatology,
91, Gen. Vladimir Vazov str., 5800 Pleven, Bulgaria
44 / JofIMAB 2004, vol. 10, book 1 /


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