Table 1.
Randomized and controlled trials, prospective and comparative studies about chemical peelings in melasma
| Author, year | Study design | Population | Interventions, efficacy parameters duration, follow-up | Results |
|---|---|---|---|---|
| Kalla, 2001 | NR, comparative | N = 100 Indian patients M:F = 1:1.6 2 groups (A, B) |
A = 6855–75% GA B = 32 10–15% TCA Parameters not specified Till significant improvement Follow-up = 3 months |
TCA: faster response, but more relapse and hyperpigmentation |
| Hurley, 2002 | R, IB, split-face | N = 21 Hispanic patients (18 completed) phototypes IV and V; 2 groups (A, B) |
A: 4% HQ cream twice daily—8 weeks B: 4% HQ cream twice daily + 20%—30% GA, every 2 weeks (20% for 4 weeks, 30% for 4 weeks) MASI, Mexameter, subjective 8 weeks No follow-up |
Significant reduction in both groups, with no difference |
| Sarkar, 2002 | Open, pilot, comparative, prospective |
N = 40 Indian patients Photo types III-V M:F = 18:22 2 groups (1, 2) |
1 = 20: MKF daily + serial GA (30–40%), 3 weeks interval 2 = 20: MKF daily 21 weeks No follow-up |
Significant improvement in both groups, more rapid and greater in group 1 |
| Khunger, 2004 | Open, pilot, split-face |
N = 10 female Indian patients |
1% RA daily X 70% GA, weekly, 12 weeks mMASI, photograph No follow-up | Significant decrease in both sides, with no difference |
| Dogra, 2006 | R | N = 50 female Pakistan patients 2 groups (A, B) |
A = 50% GA B = 20% TCA + 5% HQ and 0.025% RA 3 peels, every 3 weeks MASI, photographs No follow-up |
Same efficacy, tolerability to GA better than to TCA |
| Macedo, 2006 | Open, comparative, split-face prospective | N = 8 female Brazilian patients |
10% GA/4% HQ cream on both sides of the face + 4 bi-weekly 70% GA to one side X peeling vehicle on the other side, Clinical pictures assessed by 3 independent dermatologists No follow-up |
Similar improvement on both sides; 70% GA did not produce additional reduction in pigmentation |
| Sharquie, 2006 | NR, split-face, comparative |
N = 30 Iraqi women (26) and men (4) 24 completed (20 women, 4 men) phototype IV 2 groups (1, 2) |
1 = 15—92% LA 2 = 15 JS every 3 weeks Till desired response 2 to 5 sessions MASI Follow-up = 6 months |
Significant improvement on both sides, with no difference; no side effects |
| Erbil, 2007 | RCT |
N = 25; 15 = cases 10 = controls |
Cases: serial GA 20 → 35 → 50 → 70% every other week + daily 20% AA cream (b.i.d.) + adapalene 0.1% gel Controls: daily 20% AA cream (b.i.d.) + 0.1% adapalene gel MASI 20 weeks 20 weeks |
Good response for all, significantly better for group peels, with transient erythema and PIH in 3 patients |
| Soliman, 2007 | R, comparative |
N = 30 female patients, phototypes III and IV 2 groups (A, B) |
A = 15 20% TCA B = 15 20% TCA + topical 5% ascorbic acid + 0.05% RA gel and 4% HQ cream once daily MASI and patients’ global response 6 weeks 12 and 16 weeks |
Improvement and maintenance during follow-up A = 10 patients (67%) B = 13 patients (87%) No significant |
| Garg, 2008 | R, SB |
N = 60 Indian patients phototype IV (50 completed) 3 groups (A, B, C) M:F = 1:6.5 |
A = 15 GA 20% → 50% B = 17 0.025% RA + GA 20% → 50% C = 18 2% HQ + GA 20% → 50%) 2-weeks interval, MASI No follow-up |
All improved, most significant in C A > B > C |
| Safoury, 2009 | NR, SB, prospective split-face |
N = 20 women phototypes III and IV |
15% TCA on both sides X mJS on one Side 10 days interval MASI 10 weeks 8 weeks |
Significantly higher improvement with combination, but significant discomfort |
| Kumari, 2010 | NR, comparative |
N = 40 Indian women 2 groups (1, 2) |
1 = 20 12% GA or 0.1% RA cream, at night, previously, for 2 weeks + 20–35% GA 2 = 20 10–20% TCA every 15 days MASI Photographs 12 weeks No follow-up |
Similar efficacy MASI reduction: 79% for GA 73% for TCA No difference Fewer side effects for GA compared to TCA |
| lknur, 2010 | Single-blind, randomized, right-left of the face | N = 31 Turkish patients (24 completed) | 12 serial peel GA X AFA. 2 weeks interval. mMASI 6 months. No follow-up |
Significant decrease of mMASI No difference AFA—less irritating |
| Kodali, 2010 | RCT, split-face, prospective | N = 20 Latin American women (18 completed) |
20%—30% SA every 2 weeks 4 peels on one side of the face X 4% HQ cream to both sides, twice daily Narrowband reflectance spectrophotometry No follow-up |
Significant reduction in pigment intensity, no difference between sides 20% to 30% SA peels are were not effective for melasma |
| Faghihi, 2011 | RCT, DB, split-face | N = 63 patients (male and female) |
70% GA X 1% RA peel, 4 sessions 2 weeks interval, MASI 8 weeks No follow-up |
No difference RA 1% more tolerable |
| Puri, 2012 | NR, comparative |
N = 30 Indian patients M:F = 1:6.5 2 groups (A, B) |
A: 15% TCA B: 35% GA peel every 3 weeks MASI 15 weeks No follow-up |
Same efficacy, TCA: more side effects |
| Sobhi, 2012 | SB, right-left comparison |
N = 14 Egyptian women, phototypes IV-V |
Right side: 70% GA 6 sessions X Left side: nanosome vitamin C applied by iontophoresis MASI Photographs evaluated by two single-blinded physicians No follow-up |
Both sides improved Nanosome vitamin C was better Few and transient side effects |
| Mahajan, 2015 | RCT, DB |
N = 40 Indian patients (38 completed) 2 groups (1, 2) |
1 = 20 just TC 2 = 20 serial GA peel 2-weeks interval + 20% AA cream MASI, digital photography, VAS 12 weeks 12 weeks |
Significant reduction in MASI with no difference between groups |
| Sarkar, 2016 | R, comparative |
N = 90 Indian patients 3 groups (A, B, C) |
Before peels: 4% HQ + 0.05% RA cream, 4 weeks A = 35% GA B = SM 20% AS / 10% mandelic acid C = phytic acid peels. every 14 days MASI Photography 12 weeks Follow-up = 20 weeks |
MASI reduction: A = 62.36% B = 60.98% C = 44.71% 35% GA and SM were equally efficacious and safe and more effective than phytic acid peels SM was better tolerated |
| Choudhary, 2017 | R, parallel control, comparative, SB |
N = 36 female patients 12, melasma 12, photomelanosis 12, post acne pigmentation, 3 groups (1, 2, 3) (4 patients each) |
1. 20% SA every 2 weeks 2. 50% GA every 3 weeks 3. 15% TCA every 3 weeks 6 sessions Investigator’s Global Improvement Assessment, Patient’s satisfaction grading scale based in photographs No follow-up |
Improvement (all together) marked = 27.77% (10/36) moderate = 36.11% (13/36) mild = 36.11% (13/36) No difference All well tolerated |
| Abdel-Meguid, 2017 | RCT, IB, split face, right-left, assessor-blinded | N = 24 female Egyptian patients, phototypes IV-V |
20%-25% TC + JS X 20%-25% TCA alone 6 sessions 2 weeks interval MASI photographs No follow-up |
Significant decrease in MASI for both regimens; JS + TCA: more effective |
RCT randomized controlled trial, R randomized, NR non-randomized, SB single-blind, DB double-blind, IB investigator-blind, TC triple combination (2%, HQ, 0.05%, RA, 0.01%); Fluocinolone), AA azelaic acid, mMASI modified Melasma Area and Severity Index, VAS Visual Analog Scale, PIH post-inflammatory hyperpigmentation, MKF modified Kligman formula, M:F Male:Female