Chemical Peels in Active Acne and Acne Scars

Georgios Kontochristopoulos MD, PhD, Eftychia Platsidaki MD

PII: S0738-081X(16)30272-3
DOI: doi: 10.1016/j.clindermatol.2016.10.011
Reference: CID 7109

To appear in: Clinics in Dermatology

Please cite this article as: Kontochristopoulos Georgios, Platsidaki Eftychia, Chem-
ical Peels in Active Acne and Acne Scars, Clinics in Dermatology (2016), doi:
10.1016/j.clindermatol.2016.10.011

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CHEMICAL PEELS IN ACTIVE ACNE AND ACNE SCARS

Georgios Kontochristopoulos MD, PhD1, Eftychia Platsidaki MD1

1. Department of Dermatology and Venereology, Andreas Sygros Skin

Hospital, Athens, Greece

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Corresponding author:

Eftychia Platsidaki

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5 Ionos dragoumi Street, Athens, Greece, 16121

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platsidakieft@yahoo.com MA
Abstract

Chemical peeling is a widely used procedure in the management of acne and

acne scars. It causes controlled destruction of a part or the entire epidermis,
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with or without the dermis, leading to exfoliation and removal of superficial

lesions, followed by regeneration of new epidermal and dermal tissues. The
most frequently used peeling agents are salicylic acid (SA), glycolic acid (GA),
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pyruvic acid (PA), lactic acid (LA), mandelic acid (MA), Jessner's solution
(JS), trichloroacetic acid (TCA), and phenol. Choosing the appropriate peel is
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based on patient’s skin type, the acne activity and the type of acne scars.
Combination peels minimize side effects. In acne scars, chemical peels may
be combined with other procedures in order to achieve better clinical results.
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A series of chemical peels can give significant improvement over a short

period of time, leading to patient satisfaction and maintenance of clinical
results.

Introduction

Acne has a prevalence of over 90% in the adolescent community and persists
into adulthood in approximately 12%–14% of patients1. Follicular
hyperkeratinization, increased sebum production, proliferation of
Propionibacterium acnes within the follicle and release of inflammatory
mediators into the skin contribute to the development of acne2.

Possible outcomes of the inflammatory acne lesions are acne scars which can
have a considerable emotional and psychologic distress. Minor acne scarring
may occur in up to 95% of patients and to a significant degree in only 22%. 3
They represent areas of fibrous tissue that replace normal skin following
injury.
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Skin injury initiates wound healing process through 3 stages:

1. inflammatory
2. proliferative
3. matrix remodeling.

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During the proliferative phase mainly type III collagen is produced, with much

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smaller percentage of type I collagen. In mature scars the balance of collagen
types shifts to approximately 80% of type I collagen. 4 Matrix

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metalloproteinases (MMPs) and tissue inhibitors of matrix metalloproteinases

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(TIMPs) are then produced. Decreased ratio of MMPs to TIMPs results in the
development of atrophic scars4. Atrophic scars have been subclassified into
ice pick, boxcar, and rolling scars. Sometimes, all these types of scars can be

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observed in the same patient.

Early, appropriate, and adequate treatment of acne is important in order to

minimize inflammation and prevent acne scar formation, making chemical
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peeling a widely used procedure in the management of both active acne and
acne scars.

Which peeling agent? Which concentration?

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Chemical peels are used to create a controlled chemical-induced injury to the

skin, destroy the epidermis (superficial peeling) and part of the dermis
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(medium or deep peeling), promoting skin regeneration and remodeling of

tissues. The most commonly used peeling agents are:
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1. salicylic acid (SA)

2. glycolic acid (GA)
3. pyruvic acid (PA)
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4. lactic acid (LA)

5. mandelic acid (MA)
6. Jessner's solution (JS)
7. trichloroacetic acid (TCA)
8. phenol.5

When combination peels are used, better clinical results can be achieved with
reduced risk of complications. In active acne and acne scars the above
mentioned peeling agents reduce sebum production, exert a comedolytic
effect, cause keratolysis and possess anti-inflammatory and antibacterial
properties. (Table1). In active acne they can be either performed
supplementary to classic treatment, because they promote the effect of topical
agents or provide maintenance therapy. In addition, in acne scars, they can
be used in combination with other resurfacing procedures.
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Salicylic acid (SA) is a beta-hydroxy acid. It is the peeling agent of choice for
active acne due to its strong comedolytic and sebostatic effect.6-8 SA has the
ability to dissolve intercellular cement thereby reducing corneocyte adhesion.
Used in multiple sessions it reduces the number of inflammatory and non-

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inflammatory acne lesions, while erythema, dryness, and burning sensation

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have been the most common side effects.5 The efficacious concentration for
acne scars is 30%, repeated every 3-4 weeks for a total of 3-5 sessions.4 In

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patients with ethnic skin, SA remains an excellent superficial peeling agent ,as

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the others have been associated with post-inflammatory pigment alteration. It
has the ability for self-neutralization with a very good safety profile. In a recent
study, oral isotretinoin combined with 20% SA peels at a 2 weekly interval in

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patients with active acne showed better results compared with isotretinoin
monotherapy.6 Another benefit of SA is its lightening effect on post-
inflammatory pigmentation due to acne.9
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Glycolic acid (GA) is an alpha-hydroxy acid ,which decreases corneocyte
cohesion and promotes desquamation and epidermolysis. Due to its
exfoliative properties, it is widely used as a superficial peeling agent.10 In
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addition, a study has shown that GA peel has an anti-inflammatory effect on

acne through its bactericidal effect on P. acnes.11 GA peel has been proven
effective at improving mild, moderate, and severe nodular acne.12 Through a
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series of peels significant improvement is achieved. Acne patients are

satisfied and clinical results are maintained for a long period of time.13 In a
comparative study using 70% GA and Jessner’s Solution in acne patients.
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Though acne improved in both to the same extent, there was more exfoliation
seen in the Jessner’s Solution group.14
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In acne scars, glycolic acid increases dermal hyaluronic acid and collagen
gene expression by increasing secretion of IL-6.15 Glycolic acid, in the
concentration of 10-30% for 3-5 minutes at fortnightly intervals, revealed that
the treatment is quite effective and safe in the management of superficial
scarring.16 In another study, glycolic acid peels were compared versus
salicylic-mandelic acid combination peels (SMPs) in active acne vulgaris and
post-acne scarring. Both agents were effective and safe with SMPs
demonstrating higher efficacy.17 Combination of microneedling and glycolic
acid peels had a significant improvement in acne scars.18 General
contraindications include contact dermatitis, pregnancy, and glycolate
hypersensitivity. Side effects, such as temporary hyperpigmentation or
irritation, are not significant, and it is generally considered as a well-tolerated
procedure.19

Pyruvic acid (PA) is an alpha-ketoacid with keratolytic, antimicrobial, and

sebostatic properties. It stimulates new collagen production and can be used
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in treatment of acne scars. During treatment desquamation, transient intense

stinging and a burning sensation may be present. Several studies have
proposed the use of 40%–70% pyruvic acid for the treatment of moderate
acne scars.20-21

Lactic acid (LA) is a weak a-hydroxy acid, which reduces the thickness of the

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stratum corneum by decreasing corneocyte cohesion.22 It has skin lightening

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and moisturizing effect. A pilot study, using full strength 92% pure lactic acid

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peel to improve superficial acne scarring, showed a definite improvement in
the texture, pigmentation, and appearance of the treated skin, with lightening
of scars.23

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Mandelic acid (MA) is another a-hydroxy acid. As its molecule is large, skin
penetration is slow and is considered as a safe superficial peeling agent. It

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has been used at 20-50% concentrations for skin rejuvenation and lightening.
A combination of 20% salicylic acid peel and 10% mandelic (SMP) has been
proven effective in acne vulgaris and post-acne scarring.17
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Jessner's Solution (JS) consists of 14% salicylic acid, 14% resorcinol or
citric acid, and 14% lactic acid in 95% ethanol and is used as a superficial
peeling agent. In a recent study,there wasmarked diminution of acne scars
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was seen in patients treated with 20% TCA and Jessner's solution versus
20% TCA alone.24It is contraindicated in active inflammation, dermatitis, or
infection of the area to be treated.
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Trichloroacetic acid (TCA) is the gold standard in chemical peels, which can
be used either as a superficial, medium depth, or deep peel, depending on the
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concentration used. Application causes protein denaturation, resulting in a

readily observed white frost and destruction of epidermis, papillary, and upper
reticular dermis.25 The clinical effect of TCA in acne scars is due to the
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resultant increase in dermal volume of collagen, glycosaminoglycans, and

elastin.24 When performed properly, TCA peel can be one of the most
satisfying procedures in acne scar treatment, but it is not indicated for dark
skin due to the high risk of hyperpigmentation; however, one group has shown
medium-depth TCA peeling to be a safe and effective method of treating acne
scars even in patients with dark complexion.26

The advantages of TCA are low cost and the fact that penetration can be
easily evaluated by the color of frost.27 Combining TCA peel with other
procedures have been previously described in acne scars’ treatment. A study
Combining non-ablative fractional laser and 20% TCA peel had better results
than each individual modality in the treatment of atrophic acne scars.28
Another group found that deep peeling, using phenol and 20% TCA peeling,
was effective in treating post-acne atrophic scars.29
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A new technique has been proposed, using focal application of TCA, called
CROSS (chemical reconstruction of skin scars) method.30 TCA CROSS
technique is the use of high concentrations TCA (50-100%) applied with
wooden applicators to isolated atrophic acne scars. It is applied for a few

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seconds until a white frosting appears within the scar. This has shown high

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efficacy and additionally reduces the risk of hypopigmentation by sparing the
adjacent normal skin and adnexal structures.31The procedure can be repeated

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at 4-week intervals up to a total of three treatments. TCA CROSS technique
is particularly useful for icepick scarring.32-33 A pilot study evaluated the safety

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of the TCA CROSS technique using 100% TCA among Asians with darker
skin types ,and all patients had good to excellent results,34 while a larger study

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was conducted using the same method with excellent results achieved in
more than 70% of patients.35 An additional study evaluated the efficacy and
safety of intradermal injection of Platelet-rich plasma (PRP), 100% focal TCA,
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and combined skin needling plus topical PRP in the treatment of atrophic
acne scars, and all patients showed highly significant improvement in acne
scars.36
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Phenol is a deep chemical peeling agent, which causes epidermolysis and

dermal elastolysis, resulting in neocollagenesis.37 Caution is necessary due
to systemic absorption that may cause cardiotoxicity, nephrotoxicity, and
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respiratory depression. A phenol peel is very effective in treating acne

scars.38,.29
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Choosing the appropriate peel based on the type of acne

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The selection of the appropriate peel depends on patients skin type, the acne
activity, and the type of acne scars (Table 2). This ensures better results and
minimizes complications. In active acne the treatment goal is reduction of
inflammation, quick decrease in lesional count, and improvement of overall
skin texture. Superficial peels are used in comedonal and papulopustular
acne. 20-30% SA, 70% GA, 40-60% PA, 20-25% MA, JS, 10%TCA are
preferred.3,4,28 In nodulocystic acne, superficial peels are not indicated.

The best results are achieved in macular scars. Superficial peelings, including
30% SA, 20-70% GA, 92% LA, JS and 10-25% TCA, as well as medium depth
peelings including 40-60% PA, 25-50% TCA, and combined peelings, such as
25% SA + 25-30% TCA, JS + 35% TCA, SMP, are m recommended for
superficial acne scars.3,39

For deep scars, deep peelings have been proven to be effective. Those
commonly used are TCA at concentrations over 40%, TCA CROSS method,
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and phenol.40-41Although clinical improvement is observed, deep scars usually

do not disappear completely. In addition, given the high risk of side effects
caution is required.42

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Chemical peels and isotretinoin

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In the past, peels, lasers, and dermabrasion have been associated with

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hypertrophic scars and keloid when used during or soon after completion of
isotretinoin treatment. The mechanism is unknown. A possible explanation

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was through increased penetration of the chemical agent, induction of
angiogenesis, and synthesis of inhibitors of collagenase. 43 The European
evidence-based (S3) guidelines for the treatment of acne recommend acne

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scar repair procedures to be avoided within 6 months post isotretinoin
treatment;44 however, there are small studies, suggesting that isotretinoin is
not an absolute contraindication for peeling.6,45-46 Until further evidence
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emerges, we recommend avoiding chemical peels for at least 6 months after
cessation of isotretinoin.
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Conclusions

Chemical peels are very useful in the treatment of acne, targeting multiple
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pathogenic factors of the disease. Combination peels minimize side effects.

Although superficial peels are useful in active acne, they are not considered
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an effective treatment for deep acne scars, where medium depth peels and
TCA CROSS method are preferred. Caution is needed when medium and
deep peels are used in dark skinned patients due to the risk of pigmentary
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changes. A long-term maintenance program will usually preserve the clinical

results achieved with chemical peels.

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Table 1: Mechanism of action of various peeling agents in acne
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Table 2: Effectiveness of chemical peels in different types of acne