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Lactic acid peeling in superficial acne scarring in Indian skin

Silonie Sachdeva, MD

Carolena Skin, Laser & Research Centre, Jalandhar Punjab, India

Summary Introduction Chemical peeling with both alpha and beta hydroxy acids has been used toimprove acne scarring with pigmentation. Lactic acid, a mild alpha hydroxy acid, has

been used in the treatment of various dermatological indications but no study is

reported in acne scarring with pigmentation.

Aims To evaluate the efficacy and safety of full strength pure lactic acid 92% (pH 2.0)

chemical peel in superficial acne scarring in Indian skin.

Material and Methods Seven patients, Fitzpatrick skin type IV-V, in age group 2030years with superficial acne scarring were enrolled in the study. Chemical peeling was

done with lactic acid at an interval of 2 weeks to a maximum of four peels. Pre- and

post-peel clinical photographs were taken at every session. Patients were followed every

month for 3 months after the last peel to evaluate the effects.

Results At the end of 3 months, there was definite improvement in the texture, pig-

mentation, and appearance of the treated skin, with lightening of scars. Significant

improvement (greater than 75% clearance of lesions) occurred in one patient (14.28%),

good improvement (5175% clearance) in three patients (42.84%), moderate

improvement (2650% clearance) in two patients (28.57%), and mild improvement

(125% clearance) in one patient (14.28%).

Keywords: acne scarring, acne vulgaris, chemical peel

Lactic acid (2-hydroxypropanoic acid) is a mild alpha-

hydroxy acid derived from sour milk or bilberries. Its role

in chemical peeling is defined to reduce fine wrinkling, to

reduce uneven pigmentation, and to improve the texture

of sun-damaged skin. Pure full-strength lactic acid

(F.S-LA) peels have been shown to improve melasma.1

However, no study with LA peeling in acne scarring in

dark skin has been reported. We conducted a pilot study

to evaluate the efficacy and safety of F.S-LA (92%, pH

2.0) chemical peel in superficial acne scarring in Indian

skin. A total of seven patients (six female and one male),

with Fitzpatrick skin type IVV in age group 20

30 years, were enrolled in the study after taking

Figure 1 A 23-year-old female, Fitzpatrick skin type IV, with

comedonal acne and superficial acne scarring, right side of the

face.

Correspondence: Dr. Silonie Sachdeva, Consultant Dermatologist, Carolena

Skin, Laser & Research Centre, Jalandhar Punjab 144022, India.

E-mail: siloniederm@yahoo.com

Accepted for publication April 24, 2010

Research Letter

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complete relevant history pertaining to chemical peels.

Four peels were performed on every patient at interval of

2 weeks. Pre- and postpeel clinical photographs were

taken at every session. The first peel was performed withhalf-strength (H.S) lactic acid (LA)-46%, with broad end

Q-tip buds, and a maximum of two coats were applied.

The peel was kept on patients skin for a minimum of 2

3 min depending upon patients tolerance. The end

point was mild pink erythema in first peel. The peel was

neutralized with the ice-cold sponges. All patients were

given postpeel instructions, which included use of a

sunscreen with sun protection factor 30, use of a mild

Figure 3 Same patient, left side of the face (prepeel).

Figure 5 A 27-year-old female Indian patient, Fitzpatrick skin

type V with pitted scarring, left side of the face.

Figure 2 Same patient after four chemical peels with lactic acid

showing good improvement, 3 months after treatment (right side

of the face).

Figure 4 Same patient, postpeel.

Figure 6 Same patient after four chemical peels with lactic acid

showing good improvement, 3 months after treatment.

2010 Wiley Periodicals, Inc. Journal of Cosmetic Dermatology, 9, 246248 247

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cleanser, and use of lactocalamine at home for first 2

3 days followed by a good moisturizer till next visit.

Patients were strictly instructed to avoid any pricking or

scratching. The second peel was performed with F.S-LA-

92% and neutralized after 3 min. The third and fourth

peels were performed with F.S-LA and kept on the skin

for 4 and 5 min, respectively. Most patients were able to

tolerate F.S-LA peel for 5 min at last session. If any

grayish white spots suggestive of epidermolysis were

noted or patient complained of an intolerable burning

sensation, peel was neutralized earlier than 5 min.

Patients were followed every month for 3 months after

the last peel to evaluate the effects. The subjective

assessment was carried out by the treating physician,

along with the opinion of the patients, and the assess-

ment was confirmed with pre- and posttreatment clinical

photographs.

The mean age of patients in our study was

25.33 years. While two patients were Fitzpatrick skintype IV, five patients were Fitzpatrick skin type V.

Patients primarily had two forms of acne scars, the

superficial atrophic form and the pitted (ice-pick) form.

LA peel was well tolerated by most of the patients with

mild erythema and stinging. Frosting was not noticeable

at first peel with H.S-LA, but with F.S-LA peel, frosting

was seen in all the patients. Patients reported tolerable

burning sensation with F.S-LA peel which subsided in 5

10 min. At the end of 3 months of follow-up period,

clearance of acne scars was noted in all patients.

Significant improvement (>75% clearance of lesions)

occurred in one patient, good improvement (5175%

clearance) in three patients (Figs 16), moderate

improvement (2650% clearance) in two patients, and

mild improvement (125% clearance) in one patient.

Transient postinflammatory hyperpigmentation was

observed in one patient and was treated with a topical

combination of moderate potency steroid, retinoid, and

hydroquinone. There was no allergic reaction, irritant

reaction, or outbreak of any bacterial or viral infection

after the peels.

The aim of our pilot study was to determine the

efficacy of F.S-LA peels in superficial atrophic and ice-

pick acne scars. The patient compliance was good in our

study as all patients completed a set of four peels. Along

with clearance of scars, there was definite improvement

in the texture, pigmentation, and appearance of pores.

However, chemical peeling with LA is useful only for

superficial acne scars as it is not an aggressive peel. For

deep atrophic acne scars, a combination of chemical

peeling and dermabrasion is a recognized useful modal-

ity.2,3 For deep ice-pick scars, the only effective treat-

ment is complete removal of the scar which can be

performed by punch excision and grafting.4

We conclude that LA peeling is well tolerated by the

patients of dark skin and can be a useful modality to

treat superficial acne scarring. We hope to do a largenumbered clinical trial to further validate the efficacy of

LA peeling in dark skin.

References

1 Sharquie KE, Al-Tikreety MM, Al-Mashhadani SA. Lactic

acid chemical peels as a new therapeutic modality in mel-

asma in comparison to Jessners solution chemical peels.

Dermatol Surg 2006; 32: 142936.

2 Kempiak SJ, Uebelhoer N. Superficial chemical peels and

microdermabrasion for acne vulgaris. Semin Cutan Med

Surg 2008; 27: 21220.

3 Ayhan S, Baran CN, Yavuzer R et al. Combined chemicalpeeling and dermabrasion for deep acne and posttraumatic

scars as well as aging face. Plast Reconstr Surg 1998; 102:

123846.

4 Koo SH, Yoon ES, Ahn DS et al. Laser punch-out for acne

scars. Aesthetic Plast Surg 2001; 25: 4651.

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