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The Safety and Efficacy of Salicylic Acid Chemical Peels in

Darker Racial-ethnic Groups


Pearl E. Grimes, MD
Vitiglio & Pigmentation Institute of Southern California, Los Angeles, California, and Division of Dermatology,
University of California, Los Angeles, California

background. There is a dearth of published data regarding hydroquinone 4% prior to undergoing a series of five salicylic
chemical peels in darker racial-ethnic groups. acid chemical peels. The concentrations of salicylic acid were
objective. The purpose of the present investigation was to as- 20% and 30%. The peels were performed at 2 week intervals.
sess the clinical efficacy and safety of a new superficial salicylic results. Moderate to significant improvement was observed in
acid peel in individuals of skin types V and VI. 88% of the patients. Minimal to mild side effects occurred in 16%.
methods. Twenty-five patients were included in this pilot inves- conclusion. The results of this study suggest that superficial sal-
tigation. Nine had acne vulgaris, 5 had post-inflammatory hyper- icylic acid peels are both safe and efficacious for treatment of acne
pigmentation, 6 had melasma, and 5 had rough, oily skin with vulgaris, oily skin, textural changes, melasma, and post-inflamma-
enlarged pores. The patients were pre-treated for 2 weeks with tory hyperpigmentation in patients with skin types V and VI.

SUPERFICIAL CHEMICAL peels are an invaluable ac- mulated in a hydroethanolic vehicle at concentrations
coutrement for dermatologists when treating fine wrin- of 20% and 30% for use as a superficial peeling agent.8
kles, photoaging, keratoses, acne, and dyspigmentation. It is a lipophilic agent which produces desquamation of
The historical paradigm for such peels has been indi- the upper, lipophilic layers of the stratum corneum. Sal-
viduals with skin types I, II and III. 1 Superficial peels icylic acid is a hydroxyl derivative of benzoic acid and
are usually well tolerated by the lighter complexioned represents a carboxylic acid attached to an aromatic al-
individual. In contrast, dermatologists have been reluc- cohol, phenol. Although the efficacy of this product has
tant to perform chemical peels in darker racial-ethnic been described in Caucasians with acne and photoag-
groups because of the tendency of darker-skinned pa- ing,8,9 no studies have assessed its use in darker skin
tients to develop dyschromias in response to cutaneous types. The purpose of the present pilot investigation
injury.2 However, dyschromias are major issues of cos- was to evaluate the safety and efficacy of salicylic acid
metic concern, particularly in individuals with skin type peels in skin types V and VI.
VI (Fitzpatrick’s Classification).3 In a survey of 2,000
black patients seeking dermatologic care in a private
practice in Washington, D.C., the third most commonly- Patients and Methods
cited skin disorders were pigmentary problems other Patients
than vitiligo.4 Of these patients, the majority had a di-
agnosis of post-inflammatory hyperpigmentation fol- Twenty-five patients were included in this study. Their
lowed in frequency by melasma. Such patients are usu- mean age was 34. There were 22 females and 3 males.
ally treated conservatively with topical bleaching agents Twenty were African-American and 5 were Hispanic.
or they are offered no treatment. In light of the afore- Nine patients had acne vulgaris, 5 had post-inflamma-
mentioned findings, clinicians are in dire need of addi- tory hyperpigmentation, 6 had melasma, and 5 had
tional innovative, efficacious therapeutic options. oily skin, enlarged pores, and rough textural changes.
There is a dearth of published data regarding the effi- Pregnant or nursing women and individuals with known
cacy and safety of chemical peels in darker racial-ethnic hypersensitivity to salicylic acid and/or hydroquinone
groups.5–7 The majority of published studies have as- were excluded from the study. Informed consent was
sessed the efficacy of glycolic acid peels in individuals obtained from each patient prior to participation in
with skin type IV. Salicylic acid has recently been for- this study.

Methods
Address correspondence and reprint requests to: Pearl E. Grimes, MD, Chemical Peel Protocol. Patients were pre-treated for 2 weeks
321 North Larchmont Blvd., Suite 617, Los Angeles, CA 90004. with 4% hydroquinone. Salicylic acid peels (Beta LiftX, Medi-

© 1999 by the American Society for Dermatologic Surgery, Inc. • Published by Blackwell Science, Inc.
ISSN: 1076-0521/99/ • Dermatol Surg 1999;25:18–22
Dermatol Surg 25:1:January 1999 grimes: salicylic acid peels in darker skin 19

Table 1. Therapeutic Responses in Patients Treated with Beta-lift (Salicylic Acid) Chemical Peels (Fitzpatrick’s Skin Types V–VI)

Clinical Improvement %

No. of No (1–25%) (26–50%) (51–75%) (.75%)


Disorder Patients Response Minimal Mild Moderate Significant

Acne Vulgaris 9 0 0 1 (11%) 2 (22%) 6 (67%)


Oily skin/Rough Textural Changes 5 0 0 0 0 5 (100%)
Post-Inflammatory Hyperpigmentation 5 0 0 0 1 (20%) 4 (80%)
Melasma 6 0 0 2 (33%) 2 (33%) 2 (33%)

cis Pharmaceuticals, Phoenix, AZ) were performed at 2 moisturizers. Each subject resumed use of 4% hydroquinone
week intervals and each patient completed a series of 5 such 2 days after each peel. Photographs were taken of each pa-
peels. After thorough cleaning with a pre-cleanser contain- tient at baseline and biweekly using a Yashica Dental Eye
ing water, SD alcohol, and witch hazel, salicylic acid was Camera and Ektachrome 100 film. Clinical response was
applied to the entire face with a wedge sponge for three to graded by an independent investigator who evaluated serial
five minutes. The face was rinsed with tap water followed photographs. The rating score was as follows:
by an application of triethanolamine neutralizer and repeat
rinsing. Two 20% then three 30% salicylic acid peels were 0: no improvement
performed sequentially with a 2 week interval between each 1 to 25% clearing: minimal improvement
peel. Immediate post-peel care included bland soaps and 26 to 50% clearing: mild improvement

Figure 1. A. Pre-peel: Twenty-eight year old female with acne vulgaris. B. Improvement in acne and skin texture after 2 20% salicylic acid
peels.
20 grimes: salicylic acid peels in darker skin Dermatol Surg 25:1:January 1999

51 to 75% clearing: moderate improvement in 5/5 (100%) of patients with oily skin, enlarged pores,
Greater than 75% clearing: significant improvement and rough textural changes. There was significant dimi-
nution in excess oiliness accompanied by improvement
in skin texture. Clinically, enlarged poral orifices ap-
Results peared to shrink in size (Figure 4).
The series of salicylic acid peels in combination with
Clinical Responses 4% hydroquinone expedited and facilitated the reso-
Improvement occurred in all patients included in this lution of post-inflammatory hyperpigmentation and
pilot investigation (Table 1). Moderate to significant melasma. Moderate to significant improvement occurred
improvement was observed in 22/25 (88%). Mild clear- in 5/5 (100%) of patients with post-inflammatory hyper-
ing occurred in 3/25 (12%). Varying levels of clinical pigmentation and 4/6 (66%) of patients with melasma.
improvement were observed in all patients after the sec- Salicylic acid peels and twice daily application of 4%
ond 20% peel. hydroquinone produced substantial decreases in the in-
Moderate to significant clearing of acne vulgaris oc- tensity of hyperpigmentation and lesional area for both
curred in 8/9 (89%). The series of salicylic acid peels fa- post-inflammatory hyperpigmentation and melasma
cilitated the clearing of pustules, papules, and come- (Figure 3). There was also a decrease in overall facial
dones. This was evidenced clinically by an overall rapid pigmentation which was cosmetically acceptable for
reduction in lesions including microcomedones in acne the patient. In addition, the patients with post-inflam-
patients and those with rough oily skin and enlarged matory hyperpigmentation and melasma had improve-
pores. Acne lesions appeared to clear faster than experi- ment in skin texture (Figures 3A, 3B, 4A, 4B).
ence indicates would ordinarily occur with traditional In general, the superficial salicylic acid peels were
therapy (Figures 1, 2). Significant improvement occurred well tolerated in this series of patients with skin types

Figure 2. A. Pre-peel: Eighteen-year-old female with acne vulgaris. B. Significant clearing of numerous comedonal lesions.
Dermatol Surg 25:1:January 1999 grimes: salicylic acid peels in darker skin 21

Figure 3. A. Pre-peel: Twenty-four year old female with oily skin and post-inflammatory hyperpigmentation. B. Significant clearing of hy-
perpigmentation and improvement in the appearance of oily skin.

V and VI. Side effects were absent in 21/25 (84%). Four had transient dryness and hyperpigmentation which
patients (16%) experienced mild side effects. One pa- resolved within 7 to 14 days. Residual hypopigmenta-
tient had temporary crusting and hypopigmentation tion or hyperpigmentation did not occur. Side effects
which completely cleared in seven days. Three patients did not correlate with the duration of peel.

Figure 4. A. Pre-peel: Forty-two year old female with melasma and surface roughness. B. After completion of the series of salicylic acid
peels, there is significant improvement in severe hyperpigmentation and surface roughness.
22 grimes: salicylic acid peels in darker skin Dermatol Surg 25:1:January 1999

Discussion in the present investigation similar results can be ob-


tained using cleaners such as Cetaphil liquid cleanser.
In this pilot investigation, 25 patients with Fitzpatrick’s The results of this investigation using salicylic acid
Skin Types V and VI were treated with a series of 5 su- peels corroborate the safety and efficacy profile of sev-
perficial salicylic acid peels performed at 2-week inter- eral previously published studies using glycolic acid peels
vals. Conditions treated included acne vulgaris, post- in darker racial-ethnic groups.5-7 Lim and Tham5 and
inflammatory hyperpigmentation, melasma, and rough/ Wang6 treated Asian patients with melasma and acne re-
oily skin with enlarged pores. Moderate to significant spectively and reported improvement with few side ef-
improvement was observed in 88% percent of the pa- fects. In addition, Burns, et al.7 treated nineteen black pa-
tients. Mild improvement occurred in 12%. tients with post-inflammatory hyperpigmentation using
The observation of clinical improvement in the ap- a range of glycolic acid peels for comparison with a stan-
pearance of enlarged pores was maintained for 8 to 12 dard regimen of hydroquinone and tretinoin. Patients re-
weeks. Possible mechanisms for the appearance of re- ceiving the peels showed a trend toward greater and
duction in pore size include salicylic acid’s effect on more rapid improvement. Twenty of our series of patients
lipid solubility and micro comedone formation. were African-American. The peels were extremely well
Despite the notoriously labile response of melano- tolerated with few side effects in this group of patients.
cytes in darker racial-ethnic groups to cutaneous injury, The superficial 20% and 30% salicylic acid peels
the new salicylic acid peel used in this study demon- used in this study were safe and efficacious for skin
strated significant efficacy and induced minimal to no types V and VI. Salicylic acid peels offer significant ad-
side effects. Furthermore, the combined use of hydro- junctive benefit when treating acne vulgaris, oily skin,
quinone 4% in combination with the salicylic acid peel enlarged pores, textural changes, post-inflammatory hy-
expedited the clearing of hyperpigmented lesions and perpigmentation, and melasma. However, in light of
significantly decreased the occurrence of hyperpigmen- the recognized tendency of darker skin to develop dys-
tation, a common post-peel sequelae in skin types V chomias, superficial peeling should be approached with
and VI. Preliminary unpublished data from the Vitiligo care and caution.
and Pigmentation Institute of Southern California dem-
onstrated an increased frequency of post-peel hyperpig-
mentation when salicylic acid peels were used without References
the combined use of 4% hydroquinone. In addition, 1. Brody, HJ. Chemical Peeling. New York: Mosby Year Book, Inc.,
when the 30% salicylic acid peel was used as the initial 1992;33–50.
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peel concentration, there was an increased frequency of black population. Clin Plast Surg, 1993;20:27–34.
post-peel hyperpigmentation. Hence, titrating the con- 3. Grimes PE. Melasma: Etiologic and therapeutic considerations.
centration of the salicylic acid peel and the combined Arch Dermatol, 1995;131:1453–7.
4. Halder RM, Grimes PE, McLauren CI, Kress MA, Kenney JA, Jr.
use of 4% hydroquinone significantly decreased the fre- Incidence of common dermatoses in a predominantly black derma-
quency of post-peel hyperpigmentation. This combina- tologic practice. Cutis, 1983;32:388–90.
tion therapeutic approach expedited the improvement 5. Lim JT, Tham SN. Glycolic acid peels in the treatment of melasma
among Asian women. Dermatol Surg, 1997;20:27–34.
and/or resolution of post-inflammatory hyperpigmenta- 6. Wang CM, Huang CL, Hu CT, Chan HL. The effects of glycolic
tion and melasma. In addition, the combination of sali- acid on the treatment of melasma among Asian skin. Dermatol
cylic acid peels and 4% hydroquinone showed more Surg, 1997;23:23–9.
7. Burns RL, Prevost-Blank PL, Lawry MA, et al. Glycolic acid peels
rapid improvement when compared to a data base us- for post inflammatory hyperpigmentation in black patients: A com-
ing only 4% hydroquinone (Nordlund JJ, Granger C, parative study. Dermatol Surg, 1997;23:171–4.
Grimes PE, et al. Efficacy of 2% and 4% hydroquinone 8. Kligman D, Kligman AM. Salicylic acid as a peeling agent for the
treatment of acne. Cosmetic Dermatol, 1997;10:44–7.
for treatment of hyperpigmentation. Submitted manu- 9. Kligman D, Kligman AM: Salicylic acid peels for the treatment of
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Commentary
This paper expands our knowledge of using chemical peels in fects is benefited by post-peel hydroquinone treatment. This study
dark-complexioned individuals. Many practitioners are wary of by a practitioner with significant experience in treating pigmentary
performing peels on this group because of the risk of hyperpigmen- problems in darkly complexioned patents should encourage others
tation. This clinical study demonstrates that serial salicylic acid to begin offering chemical peels to this group of patients.
peels are beneficial for acne, post-inflammatory hyperpigmenta-
tion, melasma, oily skin, enlarged pores, and surface roughness. Douglas Kligman, MD, PhD
The small percentage of patients with transient pigmentary side ef- Conshohocken, Pennsylvania