Abstract:<br/>Introduction: Chemical Peel is a cosmetic procedure that is becoming a popular modality in treating acne vulgaris (AV). Mandelic acid (MA) is an upcoming peeling agent for AV due to its anti‐inflammatory and antibacterial traits. Hence, it is worthwhile to appraise this newer agent's effectiveness and safety profile and compare it with a more traditional and established peeling agent, salicylic acid (SA), in the treatment of AV.<br/><br/>Aims: Comparison of efficacy of 30% SA peels with 40% MA in Grade 1 and 2 facial acne vulgaris in south Indian patients.<br/><br/>Methods and Material: One hundred patients suffering from mild‐to‐moderate facial AV were distributed randomly into two groups of 50 each, with group A receiving 40% MA peel and group B receiving 30% SA peel at an interval of two weeks for six sessions. The duration of the study was twelve weeks. Clinical pictures and Michaelson acne scores (MAS) were used to evaluate the effectiveness of treatment objectively. Adverse effects of both the peeling agents were also noted. <br/><br/>Results: Overall, there was no significant difference in the efficacy between the two peels. However, adverse effects were slightly higher with SA peel.<br/><br/>Conclusions: The 30% SA peel was equally effective as 40% MA peel in Grade 1 and 2 facial acne vulgaris. However, safety profile and tolerability were better in the MA peel group than the SA peel group.

Objective To explore the clinical efficacy and safety of supramolecular salicylic acid <br/>(SSA) 30% chemical peels combined with micro-injection of the recombinant humanized type III collagen (rhCol III) in the treatment of melasma in Chinese population.<br/>Methods A total of 74 patients diagnosed with melasma from 2021 to 2023 were selected and received 3 treatments of micro-injection using the recombinant humanized type III collagen (rhCol III) once a month. The frequency of the SSA treatment was twice a month,and the concomitant treatment was allowed for every 4 weeks . The modified Melasma Area and Severity Index (mMASI) and the Physician Global Assessment (PGA) and Patient Satisfaction were used to evaluate the treatment efficacy before treatment, 1 month, 3 months and 6 months after treatment respectively, and the adverse reactions were observed and recorded. SPSS 22.0 software was used for statistics. <br/>Results Compared with the baseline, the mMASI score was significantly decreased after treatment (P < 0.05), and was continuously declined at 6 months after treatment compared with 1 month after treatment (P < 0.05). The number of patients whose PGA score showed moderate improvement after treatment was more than 85% , and the Patient Satisfaction score showed that 56.25% of patients were satisfied and 28.23% of patients were very satisfied. Adverse effects were not observed in any patient during the combined treatment, Only mild desquamation and dryness of skin were observed in 6 patients, and temporary darkening of the lesions after improper light protection was observed in 3 patients. All patients noted slight pain which did not persist and did not discourage them from choosing the next treatment.<br/>Conclusion:The combination treatment of 30% SSA chemical peels combined with micro-injection of the rhCol III was an effective therapy for melasma. The limitation of the present study was that it was a retrospective analysis; more high-quality, prospective, blinded, controlled clinical trials are required to evaluate the efficacy based on the current study.<br/>Key words: SSA chemical peels ; recombinant humanized type III collagen,melasma; efficacy; safety

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Sequential peels in the treatment of dermatologic and aesthetic indications<br/>Peeling agents showing improvements in different dermatologic and aesthetic concerns have made chemical peels a very versatile procedure. Different molecules have unique mechanisms of actions and combining them in different ways can offer a synergistic effect on the primary condition. Sequential peel is a technique in which peels are applied in sequence. The first peel is applied, and its action is terminated after a specific amount of time. This is followed by the application of another peeling agent which can be left on as a leave on peel or may be neutralized after a certain amount of time depending on the peel and the indication being treated. The first peel enhances the penetration of the second peeling agent by causing a controlled exfoliation resulting in a greater peel depth. Different peeling agents have different acidity (pKa) and combining them in a single formulation may not be pharmacologically compatible and may disturb their individual efficacy. Hence two peels are applied one after another in order to achieve the optimal result of both the peeling agents. Sequential peeling is effective in acne, acne with post inflammatory hyperpigmentation, scars, photoaging, tanning, melasma, lichen planus pigmentosus, keratosis pilaris, acanthosis nigricans, cutaneous amyloidosis and skin rejuvenation. A study conducted on sequential peeling (Mahmoud et al) for acne concluded that sequential peeling with glycolic acid (GA) and salicylic acid (SA) was equally effective in reducing lesion count, disease grading and IL levels in comparison with doxycycline alone or in combination with the same peeling regimen. SA 30 % peel followed by GA 35-70% peel is an effective treatment modality for acne with post inflammatory hyperpigmentation (PIH) as well as pustular acne. SA30 % peel may be followed by lactic acid (LA) 80% peel for the improvement of acne excorie. LA acts as a moisturising and lightening agent in the scratched and dry lesions of acne excorie with PIH. Comedonal acne responds well to SA 30% peel followed by retinol peel. Retinol peels may be left on the skin for 4-8 hours depending on skin sensitivity. Previous studies have shown that GA, SA, Trichloroacetic acid (TCA) and LA chemical peels are efficacious in melasma. For melasma, sequential peeling with TCA 15% followed by modified Jessner’s solution has been tried by previous authors. Modified Jessner's solution improved results along with TCA in melasma and proved to be a useful adjuvant. Several combination peels containing TCA and phenol can be used following application of GA 20-35% in facial melasma. Combination peels containing glycolic kojic acid (33 % GA and 7% kojic acid) followed in sequence with the application of a combination peel containing TCA and tranexamic acid (TXA) may also be tried to improve pigmentation. For dermal pigmentary conditions like cutaneous amyloidosis, acanthosis nigricans and lichen planus pigmentosus a superficial peel containing GA may be followed by a medium depth peel containing TCA 15% and Phenol 15%. Patients should be counselled that the greater peel depth may result in fine desquamation for a week following the treatment. Chemical peels can be performed in sequence for dull skin, tanning and an overall rejuvenation of the skin. LA or GA in combination with ascorbic acid peels help to provide a faster improvement in dull and photodamaged skin. Periorbital Melanosis also responds well to sequential peeling. In a previous study LA 15% in combination with TCA 3.75 % has been used in periorbital hyperpigmentation. Arginic acid peels can be followed in sequence by combination peels containing mandelic acid and thioglycolic acid with the aim of improving the hemosiderotic pigmentation in dark circles. Keratosis pilaris (KP) is also an indication for using sequential peels. A SA 30% or GA 70% chemical peel may be followed sequentially by a leave on tretinoin peel in order to improve the pigmentation and follicular prominence associated with KP. Sequential peels carry lower risk when two superficial peels are combined as opposed to combining two medium depth peels. Deep peels in sequence in darker skin type should be avoided considering the risk of post treatment complications.

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