Received: 25 April 2018 | Revised: 30 May 2018 | Accepted: 21 June 2018

DOI: 10.1111/jocd.12763

ORIGINAL CONTRIBUTION

Combination chemical peels are more effective than single

chemical peel in treatment of mild‐to‐moderate acne vulgaris:
A split face comparative clinical trial

Eman Nofal1 MD | Ahmad Nofal1 MD | Khalid Gharib1 MD |

Mohammad Nasr1 MD | Ahmed Abdelshafy1 MD | Eman Elsaid1 MSc

Department of Dermatology and

Venereology, Faculty of Medicine, Zagazig
University, Zagazig, Egypt
Correspondence
Eman Nofal, Department of Dermatology
and Venereology, Faculty of Medicine,
Zagazig University, Zagazig, Egypt.
Email: emannofal@gmail.com
Summary
Background: Successful management of acne involves choosing proper medication.
Chemical peeling is a well‐known option in treatment of acne vulgaris.
Objective: To evaluate and compare the clinical efficacy and safety of combination
chemical peels vs single peel in treatment of mild‐to‐moderate acne.
Methods: The study included 45 patients with mild‐to‐moderate acne divided into
three equal groups. Group A underwent combination sequential peels with modified
Jessner's solution (MJ) followed by trichloro acetic acid (TCA20%) on the right (Rt)
side of the face vs TCA 30% on the left (Lt) side. Group B was treated by combina-
tion peels of salicylic (20%) mandelic (10%) (SM) mixture on the Rt half vs salicylic
acid 30% on the Lt half. Group C underwent combination sequential peeling of MJ
and TCA on the Rt side vs SM combination peels on the Lt side. All patients
received six sessions with 2‐week intervals and followed up for 3 months after the
last session. Side effects were reported.
Results: Both sides of the face showed significant improvement of acne lesions but
improvement was significantly higher and earlier in sides treated by combination
peels. Side effects were minimal.
Conclusion: In conclusion, combination peels achieved a higher and earlier thera-
peutic response with a reasonable cost that is maintained for a relatively long peri-
ods than single peel. Combination sequential peels gave the best results.

1 | INTRODUCTION
Acne vulgaris is a chronic inflammatory disease of pilosebaceous
unit. It is not a life‐threatening condition but it lasts for years and
causes physical and emotional stress.1 Successful management of
acne involves choosing right medication according to the type of
acne: mild, moderate, or severe.2
Chemical peeling is a documented option in the treatment of
active acne. The mechanism of action lies in causing desquamation by
targeting the corneosomes and keratinocytes, enhancing breakdown
3
and decreasing cohesiveness. It also increases epidermal activity of
enzymes, leading to epidermolysis and exfoliation and induces
improvement of skin texture and pore size and reduces sebum pro-
duction.4 Action of peel depends on depth of penetration. Superficial
peel involves stratum spinosum up to entire epidermis (salicylic acid
20%‐30%, glycolic acid 20%‐70%, trichloroacetic acid (TCA) 10%‐30%
and Jessner’s solution), medium depth which involves upper reticular
dermis, Monheit’s combination (Jessner’s + 35% TCA), and Coleman's
combination (glycolic 70% + TCA 35%), and deep peel which involves
mid‐reticular dermis and Barker‐Gordon formula (phenol 88% + tap
water + liquid soap + croton oil)5.
Modified Jessner's (MJ) is a combination of lactic acid 17%, sali-
cylic acid 17%, and citric acid 8% in ethanol 95%. It is available in

J Cosmet Dermatol. 2018;1–9. wileyonlinelibrary.com/journal/jocd © 2018 Wiley Periodicals, Inc. | 1

2 |
one strength, but the depth to which it penetrates the skin can be
increased by applying several layers during the peel.6 Trichloroacetic
acid (TCA) is a crystalline inorganic compound which causes coagula-
tive necrosis of cells through extensive protein denaturation produc-
ing structural cell death.7
Salicylic acid is 2‐hydroxybenzoic acid or orthohydroxybenzoic
acid. It is derived from willow bark, sweet birch, and wintergreen
leaves and can also be synthesized artificially.8 It is a lipophilic agent,
which induces desquamation of upper lipophilic layers of stratum
corneum. It is the safest in ethnic population.9 Mandelic acid is one
of the largest alpha‐hydroxy acids which penetrate the epidermis
more slowly and uniformly, making it an ideal peeling agent for sen-
sitive skin of patients with acne. Salicylic mandelic mixture (SM) is
relatively a new combination peel.10
Previous studies which used combination chemical peels in treat-
11
ment of acne vulgaris are very scarce. The aim of this study was
to evaluate and compare the clinical efficacy and safety of combina-
tion chemical peels vs single chemical peel in treatment of mild‐to‐
moderate acne vulgaris.
2 | PATIENTS AND METHODS
This clinical trial was carried out at the outpatient clinics of Derma-
tology and Venereology Department, Faculty of Medicine; Zagazig
University Hospitals in the period from February till September 2017
after approval of the Institutional Review Board (IRB), an informed
consent was taken from every patient.
2.1 | Patients
The study included 45 patients with mild‐to‐moderate acne vulgaris
who did not take any treatment either topical or systemic at least
two months before the study. Exclusion criteria included patients
with severe acne vulgaris, patients on systemic retinoids in the previ-
ous 6 months, and patients with herpes simplex infection, impetigo
lesions, or fungal infection in the face.
2.2 | Methods
All patients were subjected to full history and dermatological examina-
tion to assess skin type, postacne hyperpigmentation, and scars.
12
Severity of acne was assessed by Khunger and Kumar. A prepeel test
was performed by application of the peeling agent on a 1 cm × 1 cm
area in the right retro‐auricular area. The patients were examined after
1 week and if they tolerated the peel well, they received facial peeling.
2.3 | Patients were then divided into three equal
groups (each including 15 patients)
Group A was treated with combination sequential peels of MJ
solution followed by TCA 20% in the right (Rt) side of the face
and TCA 30% alone in the left (Lt) side (a split face technique).
NOFAL ET AL.
Group B underwent peeling by a combination peel of salicylic
acid 20%—mandelic acid 10% (SM) mixture in the Rt side of the
face and salicylic acid 30% in the Lt side.
Group C underwent peeling by combination sequential peels of
MJ solution and TCA 20% in the Rt side of the face and a combi-
nation peel of SM in the Lt side.
A prepeel preparation was applied in all patients by topical
tretinoin 0.05% to increase evenness of peeling and hydro-
quinone 4% to decrease postpeel inflammatory hyperpigmentation
for 2 weeks and stopped two days before the session. A post-
peel moisturizer and a sunscreen were prescribed to all patients.
Every patient received six sessions with 2‐week intervals
between the sessions and followed up for 3 months after the last
session.
2.4 | Procedure
2.4.1 | Group A: MJ solution plus TCA 20% vs TCA
30%
Degreasing was done by cotton soaked with alcohol then ace-
tone, sensitive areas of the face like the lips and nasolabial folds
were protected with a thin layer of petrolatum, and patients
were asked to close their eyes. MJ solution was applied on the
Rt side of the face by using cotton tipped wooden applicator in
a rolling manner starting over the right half of forehead, right
cheek, right half of chin, and lastly right half of nose until ery-
thema occurred which was the end point. Some patients experi-
enced skin burning and cessation of burning was considered the
end point. Patients were asked to wash their faces by water for
neutralization and pat to dry, then TCA 20% was applied until
frosting occurred which was considered the end point (self‐neu-
tralization). On the Lt side of the face, TCA 30% was applied
until frosting occurred.
2.4.2 | Group B: SM mixture vs Salicylic acid 30%
After degreasing, SM was applied on the Rt side of the face, the
patients experienced a stinging sensation that lasted for 1‐2 minutes
followed by a uniform white precipitate “pseudofrost.” The appear-
ance of the pseudofrost or the cessation of stinging was considered
the end point of peeling. On the Lt side, salicylic acid 30% was
applied until pseudofrost occurred or stinging sensation stopped.
The peels were neutralized by asking the patients to wash their
faces.
2.4.3 | Group C: MJ solution plus TCA 20% vs SM
mixture
After degreasing, MJ followed by TCA20% solution was applied on
the Rt side of the face as in group A. SM was applied as in group B
on the Lt side.
NOFAL ET AL.
2.5 | Clinical assessment
13
1. Michaelson acne score (MAS): which depends on lesion count-
ing and severity index for each lesion: Comedones are valued at
0.5; papules at 1.0; and pustules at 2.0. By multiplying the num-
ber of each lesion by its severity index, we obtain a total score
that represents the severity of acne. MAS was calculated before
treatment, at every session, at the end of treatment, and at the
end of the follow‐up (3 months after the last session).
2. Quartile grading scale (QGS): Digital color facial photographs
were taken using a Sony Cyber‐shot digital camera (DSC‐W690,
Tokyo, Japan). Left and right profile views were obtained at base-
line, before the 1st session, after the 6th session, and at the end
of the follow‐up period. For independent clinical assessment,
three dermatologists evaluated the photographs. Improvement
was graded as follows: excellent improvement if >75%; very
good improvement (50%‐74%); good improvement (25%‐49%);
and poor improvement (<25%).
3. Patients' satisfaction was assessed for each patient, (Grade 0)
unsatisfied, (Grade 1) moderately satisfied, and (Grade 2) well sat-
isfied.
2.5.1 | Side effects
Immediate and delayed side effects were recorded at each session
and in the follow‐up period.
2.6 | Statistical analysis
The collected data were computerized and statistically analyzed
using SPSS program version 22.0. Qualitative data were represented
as frequencies and percentages, quantitative data were expressed as
mean ± SD (Standard deviation), chi‐square test was used to calcu-
late differences between qualitative variables, and paired t test was
used to compare between means of two groups before and after
treatment. Differences between parametric multiple were calculated
by ANOVA and nonparametric data by Kruskal‐Wallis. P value was
set at <0.05 for significant results and <0.001 for highly significant
results.
3 | RESULTS
All patients completed the study.
a Clinical data are illustrated in Table 1. The three groups were
matched as regards age, gender, skin type, type of acne, duration
of acne, and Michaelson score before treatment.
b Therapeutic response
3.1 | According to MAS
See Tables 2 and 3.
| 3
Group A: Rt side: The mean MAS was 21.1 before treatment.
After treatment, it decreased to 7.1 with a highly significant dif-
ference (P = 0.001). In the Lt side, the score was 20.9 before
treatment and decreased to 9.9 after treatment with a highly sig-
nificant difference (P = 0.001). In the follow‐up period, the scores
were 8.2 in the Rt side and 10.40 in the Lt side. When compar-
ing between both sides at the end of the study and the follow‐
up period, a highly significant differences (P = 0.001) were
detected in favor of the Rt side. Earlier improvement of the
lesions was reported in the Rt side, Figure 1.
Group B: Rt side: The mean MAS was 20.0 before treatment.
After treatment, it decreased to 6.4 with a highly significant dif-
ference (P = 0.001). In the Lt side, the score was 19.7 before
treatment and decreased to 8.7 after treatment with a highly sig-
nificant difference (P = 0.001). When comparing between both
sides at the end of the study, a significant difference (P = 0.006)
was detected in favor of the Rt side. In the follow‐up period, the
scores were 9.20 and 10.60 in the Rt and Lt sides, respectively,
with no significant differences (P = 0.245). Earlier improvement
was noticed in the Rt side, Figure 2.
Group C: Rt side: The mean MAS was 19.9 before treatment and
6.6 after treatment with a highly significant difference
(P = 0.001). In the Lt side, the score was 18.7 before treatment
and decreased to 8.0 after treatment with a highly significant dif-
ference (P = 0.001). In the follow‐up period, the scores were
7.40 and 9.00 in the Rt and Lt sides, respectively. When compar-
ing between both sides at the end of the study and follow‐up
period, no significant differences (P = 0.112) were detected. Both
sides showed early improvement, Figure 3.
3.2 | According to QGS
See Table 4.
Group A: Rt side: An excellent response was achieved in five
patients (33.3%), a very good response in 6 patients (40.0%), a
good response in three patients (20.0%), and one patient (6.7%)
had a poor response. In the Lt side, an excellent response was
achieved in one patient (6.7%), a very good response in five
patients (33.3%), a good response in eight patients (53.3%), and
one patient (6.7%) had a poor response. A highly significant dif-
ference was detected between the Rt and the Lt sides in favor
of the Rt side (P = 0.001).
Group B: Rt side: An excellent response was achieved in five
patients (33.3%), a very good response in five patients (33.3%),
and a good response in five patients (33.3%). In the Lt side, no
patients (0%) achieved an excellent response, a very good
response in six patients (40.0%), a good response in seven
patients (46.7%), and two patients (13.3%) had a poor response.
A highly significant difference was detected between both sides
in favor of the Rt side (P = 0.001).
Group C: In the Rt side, an excellent response was achieved in five
patients (33.3%), a very good response in five patients (33.3%), a
4 | NOFAL ET AL.

T A B L E 1 Clinical data of the studied groups

Group A Group B Group C
N (15) (15) (15) F P
Age
Mean 19.6000 17.8000 18.7333 1.581 0.218
Standard deviation 3.48056 1.78085 2.78944
Gender
Female N (%) 14 (93.3) 13 (86.7) 14 (93.3) 0.54 0.76
Male N (%) 1 (6.7) 2 (13.3) 1 (6.7)
Duration of acne (y)
Mean 4.6667 2.7333 4.1333 2.09 0.13
Standard deviation 3.86683 1.27988 2.19957
Skin type
Type III N (%) 15 (100.0) 14 (93.3) 14 (93.3) 1.04 0.59
Type IV N (%) 0 (0.0) 1 (6.7) 1 (6.7)
Type of acne
Mild N (%) 8 (53.3) 8 (53.3) 7 (46.7) 0.17 0.91
Moderate N (%) 7 (46.7) 7 (46.7) 8 (53.3)
Postacne Hyperpigmentation N (%) 7 (46.7) 7 (46.7) 8 (86.7) 0.17 0.91
Postacne scar N (%) 3 (20.0) 3 (20.0) 2 (13.3) 0.31 0.85
MAS before treatment
Rt side 21.13 ± 7.41 20.2 ± 7.73 19.9 ± 7.16
Lt side 20.87 ± 8.7 19.7 ± 6.5 18.7 ± 6.9
P 0.74 0.56 0.49

N: number of patients.

good response in four patients (26.7%), and one patient (6.7%) had
a poor response. In the Lt side, an excellent response was
achieved in four patients (26.7%), a very good response in two
patients (13.3%), a good response in six patients (40.0%), and three
patients (20.0%) had a poor response. There was no significant dif-
ference between the Rt and the Lt sides (P = 0.68).
Group C: Five patients (33.3%) were well satisfied and 10
patients (66.7%) were moderately satisfied with their response in
the Rt side. In the Lt side, three patients were well satisfied
(20.0%), eight patients (53.3%) were moderately satisfied, and 4
patients (56.7%) were unsatisfied. No statistically significant dif-
ferences were found between the Rt and the Lt sides
(P = 0.116).

3.3 | According to patients’ satisfaction

See Table 5.
Group A: Rt side: seven patients (46.6%) were well satisfied, six
patients (40.0%) were moderately satisfied, and two patients
(13.3%) were unsatisfied with their response. In the Lt side,
seven patients (46.6%) were moderately satisfied and eight
patients (53.3%) were unsatisfied. Statistically, there was a signifi-
cant difference in favor of the Rt side (P = 0.004).
Group B: Rt side: eight patients (53.3%) were well satisfied, five
patients (33.3%) were moderately satisfied, and two patients
(13.3%) were unsatisfied with their response. In the Lt side, six
patients (40.0%) were moderately satisfied and nine patients
(60.0%) were unsatisfied. Patients' satisfaction was a significant
in favor of the Rt side (P = 0.009).
3.4 | Whitening effect
Whitening effect was noticed in the whole face in 6 patients (40.0%)
in group A, four patients (26.7%) in group B, and 8 patients (53.3%)
in group C, with a significant difference (P = 0.01) in favor of
group C.
3.5 | Postacne hyperpigmentation and scars
Improvement of postacne hyperpigmentation in the whole face
was noticed in four patients (57.1%) in group A, four patients
(57.1%) in group B, and eight patients (61.5%) in group C.
Improvement of postacne scars was also noticed in two patients
(66.7%) in group A, one patient (33.3%) in group B, and two
patients (100%) in group C.
NOFAL ET AL. | 5

T A B L E 2 Therapeutic response according to MAS in each side at T A B L E 3 Comparison between Rt and Lt sides in the same group
the same group regarding MAS at the end of the study and the follow‐up period
Standard Paired t/ Standard Paired t/
Group Mean Deviation sign P Group Mean Deviation sign P
Group A Group A
Rt side (before 21.1333 9.41971 7.021 0.001** Rt (after 7.1333 7.92029 −4.126 0.001**
treatment) treatment)
Rt side (after 7.1333 7.92029 Lt (after 9.9000 7.93770
treatment) treatment)
Lt side (before 20.872 8.7412 6.713 0.001** Rt follow‐up 8.2 3.803 −3.897 0.001**
treatment) Lt follow‐up 10.40 4.306
Lt side (after 9.9000 7.93770 Group B
treatment)
Rt (after 6.3667 4.59995 −3.267 0.006*
Group B treatment )
Rt side (before 20.2000 8.73580 9.591 0.001** Lt (after 8.7333 5.65012
treatment) treatment )
Rt side (after 6.3667 4.59995 Rt follow‐up 9.20 5.167 −1.360 0.245
treatment)
Lt follow‐up 10.60 6.841
Lt side (before 19.7333 7.73214 8.423 0.001**
treatment) Group C

Lt side (after 8.7333 5.65012 Rt (after 6.6333 4.52953 −1.496 0.157

treatment) treatment)

Group C Lt (after 8.0000 3.56571

treatment )
Rt side (before 19.9000 8.16832 12.149 0.001**
treatment) Rt follow‐up 7.40 3.050 −1.687 0.112

Rt side (after 6.6333 4.52953 Lt follow‐up 9.00 3.873

treatment)
Lt side (before 18.721 6.9412 11.379 0.001**
treatment)
Lt side (after 8.0000 3.56571
treatment)
*significant; **highly significant.
3.6 | Side effects
Peeling agents were well tolerated by all patients on both sides of
the face and no patients have been forced to drop out of the study.
Group A: Burning sensation occurred in 4 patients (26.4%) in the Rt
side and five patients (33.3%) in the Lt side and lasted just few min-
utes during session. Erythema occurred in three patients (20.0%) in
both side and lasted few hours after session. Exfoliation occurred in
two patients (13.3%) in the Rt side and lasted 5 days after sessions.
Group B: Stinging sensation occurred in five patients (33.3%) in the
Lt side and lasted few minutes during sessions. No patients devel-
oped erythema or exfoliation in both sides. Group C: In the Rt side,
burning sensation and erythema occurred in three patients, exfolia-
tion occurred in two patients (13.3%) and lasted 4 days after ses-
sions. No side effects were reported in the Lt side.
4 | DISCUSSION
In the present study, we compared the efficacy and safety of combi-
nation peels vs single peel in the treatment of mild‐to‐moderate acne
vulgaris. Both sides of the face showed significant improvement of
*significant; **highly significant.
acne lesions with minimal side effects but the improvement was sig-
nificantly higher and earlier in the sides treated by combination peels
as assessed by MAS, QGS, and patients' satisfaction. When compar-
ing the two forms of combination peels in group C, there was no sig-
nificant difference in the therapeutic response. Up to our
knowledge, this is the first study that compared two different combi-
nation peels (MJ plus TCA combination sequential peels and SM
combination peels) vs single peels and vs each other in the same
study using the split face technique.
Several authors have studied the effectiveness of different single
peeling agents in the treatment of acne vulgaris, and they all
reported significant improvement in the acne lesions.14–18 On the
other hand, only one study by Garg et al11 had evaluated the use of
combination peels vs single peel in the treatment of acne vulgaris.
In group A, MJ followed by TCA 20% is combination sequential
peels that achieve a more uniform penetration and are excellent
peels with a low safe concentration of TCA to decrease the risk of
postinflammatory hyperpigmentation.19 We have used MJ instead of
Jessner's solution to avoid complications with resorcinol present in
Jessner's solution such as allergic reactions and hyperpigmentation.6
MJ is a superficial peeling agent containing salicylic acid, lactic and
citric acids and all of them produce corneocyte detachment and sub-
sequent desquamation of the stratum corneum.20 TCA exerts its
beneficial action through decreasing corneocyte cohesion and ker-
atinocyte plugging and through precipitation of proteins and coagula-
tive necrosis of epidermal cells.7 Although both MJ and TCA are
6 |
strong comedolytic agents, we could not detect differences in the
therapeutic response between inflammatory and noninflammatory
lesions. All were significantly improved as assessed by MAS.
21
Puri used the same combination peels (MJ plus 20% TCA) in
the treatment of acne scars and reported good results. We could
not compare our results with his study because he treated acne
scars and not active acne vulgaris. Actually, we have used the same
combination peels according to his clinical trial in acne scars.
In Group B, SM mixture is a combination peel that combines the
properties of an alpha‐hydroxy acid (AHA) and a beta‐hydroxy acid.
Salicylic acid has a unique lipophilic property which produces
desquamation of upper lipophilic layers of stratum corneum and sol-
ubilization of intercellular cement substance thus reducing corneo-
cyte adhesion. Moreover, salicylic acid has an anti‐inflammatory
action.9 Mandelic acid has a dual nature as an AHA with both poten-
tial cosmeceutical activity and well‐established antibacterial activity
that is thought to play an important role in improvement of
NOFAL ET AL.
F I G U R E 1 Group A: Significant
difference in the therapeutic response in
favor of Rt side at the end of treatment
and follow‐up
inflammatory lesions. It also reduces corneocyte cohesion and leads
to keratolysis.10
Garg et al11 used glycolic acid peel vs SM peels in two groups of
patients with active acne lesions, postacne hyperpigmentation, and
scarring at fortnightly intervals for six sessions. They aimed at compar-
ing a conventional agent (glycolic acid) vs a newer modality (SM peels)
in a whole face technique. They reported that both agents produced
a significant reduction in comedones, papules, and pustules but SM
peels achieved a higher and earlier efficacy which goes in accordance
with our results. We may claim that our study is superior to their
study. We have used two forms of combination peels in three groups
of patients using a split face technique. Our methods of assessment
were more accurate and our results were clearly presented. Their clin-
ical assessment was so vague; we could not detect the grades of
improvement and their percentage in their report. Moreover, although
they used MAS in their assessment, they did not mention clear data
about the score before treatment and after treatment.
NOFAL ET AL.
F I G U R E 2 Group B: Significant
difference in the therapeutic response in
favor of the Rt side at the end of
treatment with no significant difference in
the follow‐up
In group C, there were no significant differences in the therapeu-
tic response between both sides that were treated by combination
peels at the end of treatment and the follow‐up period. The high
therapeutic response achieved with combination peels could be
attributed to the synergistic action of the combination peels that
enhances the depth of peel without using a higher concentration of
the peeling agent.22 These results are justified and go in accordance
with those of group A and group B, that is combination peels were
superior when compared with a single peel but when compared with
each other, neither one was superior. Although QGS and patients'
satisfaction were higher for the side treated by MJ plus TCA (combi-
nation sequential peels) than SM combination peels in group C, the
differences were not statistically significant.
Postacne hyperpigmentation and scars improved in all groups
with a mean of 48.5% and 71.4%, respectively. Also, there was a
whitening effect with a significant difference (P = 0.01) in favor of
group C. All peeling agents used in this study lead to remodeling of
| 7
collagen and elastin fibers and deposition of glycosaminoglycans
resulting in improvement of the scars.5,23 Because of the resurfacing
of the epidermis, the melanin content is decreased and redistributed
improving hyperpigmentation.11 These results agreed with some pre-
vious studies.11,21,24
Patients' satisfaction is a subjective method for assessment of
the therapeutic response. In the present study, it almost matched
the therapeutic response according to MAS and QGS. Previous stud-
ies did not give a comment about the patients' satisfaction. Patients'
satisfaction is a very important item in assessment as it reflects the
success of treatment, pushes us to improve our performance, and is
actually our final goal.
Side effects were few, mild, and well tolerated in all groups. The
least side effects occurred in the sides treated by SM combination
peels in groups B and C with no downtime and patients could con-
tinue their usual daily activity. Similar side effects were reported by
Puri21 and Garg etal11 They added the occurrence of itching,
8 | NOFAL ET AL.

F I G U R E 3 Group C: No significant
difference in the therapeutic response at
the end of treatment and follow‐up

T A B L E 4 Therapeutic response according to Quartile grading scale

Rt.side Lt. side

Excellent Very good Good Poor Excellent Very good Good Poor P
Group A 5 6 3 1 1 5 8 1 0.001**
33.3% 40.0% 20.0% 6.7% 6.7% 33.3% 53.3% 6.7%
Group B 5 5 5 0 0 6 7 2 0.001**
33.3% 33.3% 33.3% 0.0% 0.0% 40.0% 46.7% 13.3%
Group C 5 5 4 1 4 6 4 1 0.68
33.3% 33.3% 26.7% 6.7% 26.7% 40.0% 26.7% 6.7%

**highly significant.

swelling, and folliculitis in the group treated with TCA but not with
21
combination sequential peels of MJ and TCA and dryness, photo-
sensitivity and initial acne flare in one patient treated with SM com-
bination peels.11
Follow‐up of the patients after 3 months revealed that the peels
regimen works well and the achieved improvement is well main-
tained although there was no adjuvant therapy in this period.
Combination peels were still superior to single peel in groups A and
C. This may raise questions about delayed effects of chemical peel-
ing on acne vulgaris, postacne hyperpigmentation, and scars and sug-
gest a consideration of maintenance sessions at spaced intervals to
keep the achieved improvement.
There is no consensus about the numbers of sessions or intervals
between treatment sessions. We preferred to choose the two‐week
NOFAL ET AL. | 9

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How to cite this article: Nofal E, Nofal A, Gharib K, Nasr M,
Abdelshafy A, Elsaid E. Combination chemical peels are more
effective than single chemical peel in treatment of mild‐to‐
moderate acne vulgaris: A split face comparative clinical trial.
J Cosmet Dermatol. 2018;00:1–9. https://doi.org/10.1111/
jocd.12763