Comparative study between fractional carbon dioxide laser versus retinoic

Accepted Article acid chemical peel in the treatment of acanthosis nigricans

Ayat A Abu Oun¹, Naglaa A. Ahmed1, 2 and Hala S.A. Hafiz3

1,2Dermatology and Venereology, Faculty of Medicine for Girls, Al-Azhar University,
Cairo, Egypt.
3Dermatology and Venereology, Faculty of Medicine for Girls, Al-Azhar University,
Cairo, Egypt.

Authors:

Ayat A Abu Oun (MSc): Dermatology and Venereology, Faculty of medicine for Girls, Al-Azhar
University, Cairo, Egypt. E-mail: dr.ayatabuoun@gmail.com.

Telephone: +201141999608. ORCID ID: 0000-0002-1550-6464

Prof. Dr. Naglaa Abdallah Ahmed (MD): Professor of Dermatology and Venereology,

Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt. E-mail:

Nagladerma@Yahoo.com. Telephone: +201141787057

Dr. Hala Shawky Abd El-Hafiz (MD): Lecturer of Dermatology and Venereology Faculty of
medicine for Girls, Al-Azhar University, Cairo, Egypt. E-mail: dr.halashawqy@hotmail.com.

Telephone: +201002237948

*Corresponding author: Ayat A Abu Oun, E-mail: dr.ayatabuoun@gmail.com

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/JOCD.14224
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 Place of work: Dermatology and venereology department at Al – Zahraa university hospital, Cairo,
Accepted Article
Egypt

Approval: The study was approved by the research ethics committee (REC) of the Faculty of
medicine for Girls, Al-Azhar University, Cairo, Egypt with approval code: (201910175).
Funding
None to declare.

Conflict of interest

None to declare.

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Accepted Article
DR. AYAT A ABU OUN (Orcid ID : 0000-0002-1550-6464)

DR. NAGLAA AHMED (Orcid ID : 0000-0001-6225-0839)

Article type : Original Contribution

Comparative study between fractional carbon dioxide laser versus

retinoic acid chemical peel in the treatment of acanthosis nigricans

Abstract:

Background: Acanthosis nigricans (AN) is a common dermatological issue with several

therapeutic modalities to treat. Despite retinoid is the first drug of choice in the treatment, the
fractional-ablative carbon dioxide (CO2) laser has revealed as a promising procedure for the
management of neck-AN, outstanding to its ability for superficial ablation of the skin surface,
with trans-epidermal melanin elimination.

Objectives: To decide whether fractional-ablative CO2 laser or retinoic acid (5%) peel is the
more effective and safe choice for AN treatment.

Methods: In this study, twenty Egyptian cases with neck-AN were enrolled, where each case
was exposed to four sessions with 2 weeks apart of both fractional CO2 laser on the right half of
the neck and retinoic acid peel on the left half. Cases were assessed by a scoring system:
Acanthosis Nigricans Area and Severity Index (ANASI) score, two blinded dermatologists, and
dermoscopically pre and one-month post-treatment.

Results: We found a highly statistically significant improvement among both treated groups
regarding (ANASI) score, and dermatologist’s assessments. Bedside, the degree of sulci cutis,

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Accepted Article
cristae cutis, brown-to-dark brown dots, and milia-like cysts dermoscopic signs improvement
was evident in both treated groups. However, fractional CO2 laser shows the superior result to
retinoic acid peel in the treatment.

Conclusion: Fractional CO2 laser and retinoic acid peel are considered effective modalities for
neck-AN treatment. However fractional CO2 laser was more effective.

Keywords: Acanthosis nigricans; Fractional CO2 laser; Retinoic acid peel; Dermoscopic

A running head: CO2 LASER VS RETINOIC ACID PEEL IN AN. TREATMENT

INTRODUCTION

Acanthosis nigricans (AN) is a skin disorder with a wide prevalence, depending on the
concomitant disorder and other elements like age, race, and Fitzpatrick skin type. This
prevalence is 25% in general researches while more than 60% in overweight specific researches.1
The AN diagnosis depends on the presence of symmetrical dark-brown hyperpigmentation,
thickening in the affected area varies between 1mm and 1cm, and a velvety texture, which can
occur especially in the flexural skin folds area.2 The AN dermatological issue indicates the
presence of systemic problems: metabolic disorder (mostly), endocrine syndrome, malignancy,
medication side effects, and genetic factor, it resembles the apex of an iceberg, that leads the
physicians to search for what of these disorders lies beneath.3 The treatment aims to treat the
underlying causes; however, the cosmetic resolution of the cutaneous lesion has an impact on the
quality of life.4 Treatment options applied for esthetic reason comprise a rich palette of
approaches and a variety of results, and these modalities have not been widely studied; anywise,
smaller powered clinical trials and case reports present in the literature and can aid providers in
creating treatment plans for cases with AN.5
The fractional-ablative laser improves textural irregularities and pigmented lesions by inducing
a very narrow tissue column of thermal damage and ablation aiming for dermal wound and
neocollagenesis which is the principal cause of improvement seen post-fractional laser
resurfacing. The surrounding skin act as reservoirs for healing, allowing rapid skin repair.6,7
Retinoic acid peel mechanism is characterized by thinning and compression of the stratum
corneum, cellular renovation accelerating the cellular turnover of keratinocytes, reversal of

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Accepted Article
epidermal cells atypia, dispersion epidermal melanin pigment, neocollagenesis by stimulation
collagen deposition in the dermis, increased glycosaminoglycans deposition, and new vascular
formation.8
Dermoscopy is, non-invasive, a widely available, easy-to-use, and useful tool for evaluating
disorders involving the structure of the skin with a color change; it provides direct visualization
of the morphological characteristics of the lesions.9 Moreover, dermoscopy can be used for
evaluating the response of AN to treatment.
Thus, we conducted this comparative split-neck intervention study, to compare fractional CO2
laser versus retinoic acid peel in the treatment of AN, based on clinical and dermoscopic
assessment.

PATIENTS AND METHODS

The present study was conducted on 20 Egyptian cases who were recruited from the outpatient
clinic of the dermatology and venereology department, during the period between December
2019 and March 2020. The study steps, expected results, side effects, and written consent, all of
these procedures were done before the enrollment of the candidates into the study.

| Inclusion criteria:-

Both sexes were included if they were more than 18 years old and had neck-AN. The diagnosis
was based upon clinical characteristics of AN (symmetrical areas of thickened, brownish‐ black
plaques, with velvety texture).

| Exclusion criteria:-
Patients with skin phototype V, VI, patients who are in the hazards of post-laser/peel
hyperpigmentation or keloid formation, pregnant and breastfeeding females, patients with a skin
infection at the neck at the time of the session, patients with malignant AN, patients who
previously applied topical treatment as retinoid, hydroquinone, and other depigmented drugs
within 1-month pre to study initiation, and patients who received systemic retinoid within six
months of study initiation, and/or immunosuppressive drugs.

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Accepted Article
| All cases were exposed to the following:-

Full history taking, general and dermatological examinations for detecting any possible disease
associated with AN, photographing for both halves of the neck by iPhone 8 plus phone’s camera
(12-megapixel), a clinical assessment by the Acanthosis Nigricans Area and Severity Index
(ANASI) score system,7 subjective evaluation via two blinded dermatologists and dermoscopic
evaluation via Dermlite HUD dermoscopy (polarized light, magnifying lens 10x, connected to
iPhone 8 plus mobile phone camera).

| Methods:-
The right half of the neck of the eligible cases was treated by a fractional CO2 Laser (DEKA,
Smartxide DOT, Serial no: U⁹ X5B 3604S, Italy) device. Using parameters for superficial
peeling and ablation (Power 10 w, Dwell time 300 μs, Spacing 350 µm, and two Stacking, with
one pass on the affected region). The left half of the neck was subjected to retinoic acid 5%
chemical peel. The formula of the peel solution contains 2.5 gm. /50ml of tretinoin solubilized by
the action of 25ml of ethanol and 25ml of mono propylene glycol, thus obtaining a solution of
tretinoin 5%.10

All cases were advised to put topical anesthetic cream (containing lidocaine or lignocaine 5%)
under occlusion to the laser-treated half of the neck for 60 minutes before laser sessions, and for
eye safety, wet gauze pads and goggles were used. After that, the skin was cleansed till the
cotton pads appeared clean from all dirt. The peeling-treated half was degreased by acetone,
while the laser-treated half was cleaned by a non-alcoholic cleanser (saline). Three coats of peel
solution were applied homogeneously by gauze to the peeling-treated half of the neck and the
skin acquires a yellowish coloration, thus making it easier to visualize the agent. The peel left for
11
4 hours then washed by water. After done the laser session, ice packs were applied
immediately for cooling, and the cases were recommended to put a steroid ointment and
emollient on the neck for 4 days after the session, which was performed every two weeks up to 4
times.

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Accepted Article
| Methods of evaluation:-
Patients underwent a clinical assessment by the ANASI score system as shown in (Figure 1).
The evaluation was done at baseline and was repeated one month after the end of treatment. The
total length of one half of the neck (measured from a point at the junction between the chin and
upper neck in full neck extension to appoint at the inter-clavicular space), and the total width of
one half of the neck (measured from the point at the junction between the chin and upper neck to
a point just below the nape hairline). By multiplying the resulting two numbers we will obtain
the total area of half of the neck. After that, the affected area is obtained by multiplying the
longest length by the longest width. A percentage was then obtained, and a value was chosen
depending on the diagram revealed in (Figure 1). According to the extent of severity of
pigmentation and thickness, their values were obtained depending on the diagram revealed in
(Figure 1). After that, both values are summed up and multiplied by the area value to get the
score.7 According to the assessment by ANASI score system, patients were classified into 3
subgroups corresponding to severity i.e., (ANASI score <10) = mild case, (ANASI score >10 <
20) = moderate case, and (ANASI score > 20) = sever case.

The cases underwent a subjective evaluation via two blinded dermatologists, who commented on
the improvement of the treatment by comparing the figures before and one month after treatment
on each half of the neck separately, for each case and set a specific percentage score from (0-
100%) for each half of the neck based on the extent of improvement to all cases.
Novel acanthosis nigricans dermoscopic score was designed by the authors to assess AN
dermoscopically before and after treatment. As the score is new, it was performed by a one
trained dermatologist. The investigator looked at the typical dermoscopic signs of AN: sulci
cutis, cristae cutis, brown-to-dark brown dots, and milia-like cysts. All those signs were checked
if they were present or not on the treated halves before and one month after therapy.

| Statistical analysis:-

Data were collected and entered into the SPSS version 23.0. Armonk, New York: IBM
Corporation, Released 2015). The quantitative data were presented in the form of mean, standard
deviations, ranges, median, and inter-quartile range (IQR) while qualitative variables were

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Accepted Article
presented as numbers and percentages. The comparison between groups regarding qualitative
data was done using the Chi-square test while quantitative data was done using the Mann-
Whitney test for independent groups and Wilcoxon Rank test for paired groups. The confidence
interval was set to 95% and the margin of error accepted was set to 5%. So, the p-value was
considered significant at the level of <0.05.
RESULTS

Twenty Egyptian participants were included in the current study. Their ages ranged from 18 to
44 years with a mean of 27.15 ± 8.93 SD, and sixteen of them were females. The duration of AN
ranged between 2 – 20 years among the studied group, with a median (IQR) was 5.5 (4 -9). Nine
cases were Fitzpatrick skin type Ⅲ, eight cases were type Ⅳ, and three cases were type Ⅱ. In all
participants the severity of disease before therapies was the same on both halves of the neck
according to the ANASI score, however, participants had different degrees of AN severity;
eleven cases had moderate AN, six cases had severe AN, while three cases had a mild degree of
severity according to the ANASI score. The BMI (Kg/m2) was ranged from 22.8 to 42 with a
mean of 32.44 ± 4.00 SD; fourteen participants were obese, four participants were extremely
obese, while two participants only were within normal BMI. One-fourth of the participants were
hypertensive and no one was diabetic (Table 1).

| Clinical response by ANASI score:-

On both halves of the neck, the score before therapy ranged from 2 - 35 with a median (IQR) 15
(12 - 22.5), while after therapy, on the laser-treated half the score ranged from 0 - 10 with a
median (IQR) 3 (0 - 5), and ranged from 0 - 20 with a median (IQR) 8 (5 - 12) on the peeling-
treated half. Regarding the score; there was a highly significant reduction in the score on both
halves after therapy, with no significant difference between both halves before therapy, while
there was a highly significant difference between both halves after therapy, with superior results
appeared over the laser-treated half than the peeling-treated half. By comparing the difference
value between the laser and peeling halves; a significant difference with a better outcome was
found over the laser-treated half than the peeling-treated half, as shown in (Table 2) (Figure 3,
4, 5, 6 A/B).

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Accepted Article
| Dermoscopic evaluation:-

As regards the dermoscopic assessment, the number of improved dermoscopic signs was higher
in the laser-treated half [19 (95%), 19 (95%), 15 (75%), and 8 (40%)] than on the peeling-treated
half [17 (85%), 17 (85%), 6 (30%), and 4 (20%)] regarding sulci cutis, cristae cutis, brown-to-
dark brown dots, and milia-like cysts respectively. While there was no significant difference
between laser and peeling halves regards the improvement of; sulci cutis, cristae cutis, and milia
like cysts, a highly significant difference were found regards the improvement of brown-to-dark
brown dots between both halves for the laser-treated half over the pealing-treated half (Table 3)
(Figure 3, 4, 5, 6 C/D).

| Subjective evaluation by a blinded dermatologist:-

According to the median of improvement, as described by both blinded dermatologists, there was
a highly significant difference, between the median (IQR) on the laser-treated half 80.25 (68.5 -
97.5), compared to the median (IQR) on the peeling-treated half 51.25 (50 – 71.5), where the
median of improvement accentuate that fractional CO2 laser was a more effective treatment for
neck-AN (Figure 2).

| Evaluation of side effects in the studied group:-

The side effects were minimal in the form of erythema after laser and peeling sessions in 2
patients, appeared later, after taking a detailed patient history, it was found that these patients
were not following the post-therapy care, and one patient developed post-inflammatory
hypopigmentation after the first laser session at the beginning of the study, which improved after
resetting the parameter to the that mentioned above in our study.

DISCUSSION

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Accepted Article
The skin is a mirror of the body by showing signs of internal disorder, whereas, recognizing
these signs helps in the early diagnosis and treatment of these disorders.1 One of the most
important signs is AN, which may indicate the presence of underlying disorder, which should be
searched for and treated. However, cosmetic concerns for AN are important aspects of therapy.

For esthetic reasons, dermatologists treat it with variable success by prescribing topical
keratolytic, laser procedures, or chemical peels. 3 In our study, we compare fractional CO2 laser
and retinoic acid peel for treatment AN, and the results demonstrated that both treatments
improve AN, however, fractional CO2 laser gave a higher outcome in AN treatment than retinoic
acid peel.

Since the procedures were performed by more than one investigator, randomization regarding the
side was not performed. Besides, to facilitating evaluation of the results of the treatments through
figures.

The parameters used in the laser were intended to obtain superficial ablation and peeling with
melanin pigments shuttle and trans-epidermal pigments elimination, so the 14 days period
between each session was sufficient.

Fractional CO2 laser gave impressive results to our participants, bedside the above it also
improves the skin texture, tightening, and collagen remodeling, which for sure enhances the
friction later on. There are previous trials that confirmed the effectiveness of the CO2 laser in the
treatment of AN, part of it is cited, such as the study of Bredlish et al who conducted a case of
severe pseudo-AN accompanied with pruritus and maceration, which was unresponsive to topical
therapy but responded very well to CO2 which done with continuous-wave, at (15 W) for three
sequential sessions with a month apart between it. The results prove that the CO2 laser is fast and
easy to perform for complete ablation of the lesion without any complication. Six months later,
no scarring or recurrence has been shown.12 While Wijnberg studied the effect of laser in the
48-years-old male who had AN in the face from several years ago. The patient was treated with
two passes (5 Watt, E12) of CO2 laser. After two weeks, a significant improvement was noted,
also there was no recurrence for one year of follow-up. 13
Topical retinoid is considered one of the most important modalities for AN treatment, especially
14
in cases of AN where no underlying disorder is often detectable, as in unilateral nevoid AN.
Retinoid decrease the stratum corneum, enhance epidermal turnover, correct hyperkeratosis, and

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 cause epidermal thickness to return to its normal state.15 Besides, it is a comedolytic and a
Accepted Article
depigmenting agent, as it inhibits tyrosinase and tyrosinase-related protein 1 activity, reduced
transfer of melanosomes from melanocytes to keratinocytes, and increased turnover of melanin-
laden keratinocytes.16 The retinoic acid peel is a superficial peeling often used in Brazilian
clinics to treat various disorders like acne, melasma, skin photoaging, and non-melanoma skin
malignancy.17 There are no studies to date that have evaluated the efficacy of retinoic acid
chemical peel in the treatment of AN. Moreover, Lahiri et al reported the trial about the efficacy
of tretinoin 0.05% cream in thirty cases; the study has noted improvement of hyperkeratosis in
all cases, and total clearance of hyperpigmentation in a quarter of the cases, however, frequent
15,18
administration of topical tretinoin was needed for maintenance. Also, Treesirichod et al
used topical 0.1% adapalene gel and 0.025% tretinoin cream in the treatment of childhood-AN.
The therapies improved AN with mild cutaneous irritation in all cases which gradually improved
during the study. 19

In our study, we used retinoic acid peel 5% on the left half of the neck, and the cases showed
significant improvement (clinically and dermoscopically) in the lesion compared to baseline.
However, we have done only 4 peeling sessions compared to daily use of the cream for several
weeks, also we found that no patients in our study experienced cutaneous irritation as it
happened in the Treesirichod et al study, which may be due to the prescribed emollient and
topical steroid for few days after the session to our patients, bedsides the advantage of this peel
to the absence of burning sensation after applying it. In our study, most of the cases had obesity-
related AN, so we encouraged weight loss in conjunction with the treatment of AN.

The advantages of our study include; the use of both therapies on the same patient and thus we
have eliminated all other factors that could affect the results, such as the differences in sex, age,
weight, Fitzpatrick skin type, and associated underlying cause. Besides, the use of both clinical
and dermoscopic scores for evaluation is another advantage. However, we admit that the present
study has some limitations; the study included only candidates suffering from AN in the neck,
and therefore, results may be different if they are conducted for patients with different lesion
sites. Besides, the study sample size was small therefore the results cannot be generalized to the
general population, and the use of a subjective method for dermoscopic evaluation is another
limitation.

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Accepted Article
Inspired by our result, we recommend using both therapies together in AN treatment, where 4
sessions of peel are done firstly with 14 days interval, for secure moderate peeling acceptable to
the patient, followed by fractional CO2 laser sessions to obtain an optimum cosmetic outcome
without recurrence. In this situation, laser parameters and sessions can be modified consequently.
Besides, enrolling a larger number of cases with different sites of the lesion is required, this
would be a suggestion for further trials.

CONCLUSION

This study was the first study that compared fractional CO2 laser versus retinoic acid peel for AN
treatment. Although there are many methods of treatment, and acanthosis nigricans persists a
difficult dermatosis to treat, the present study demonstrated that both therapies are safe and very
effective lines for the treatment neck-AN. however, fractional CO2 laser was found to be more
efficacious than retinoic acid peeling both clinically and dermoscopically.

ETHICS STATEMENT

The study was approved by the research ethics committee (REC) of the Faculty of Medicine for
Girls, Al-Azhar University, Cairo, Egypt with approval code: (201910175).

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