|Year : 2013 | Volume
| Issue : 1 | Page : 6-11
Easy phytic peel as a therapeutic agent in acne vulgaris and melasma
Sahar Al-Mokadem, Ola Al-Aasser, Amani Nassar, Eman A Al-Sharkawy
Department of Dermatology and Venereology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
|Date of Submission||01-Jan-2013|
|Date of Acceptance||05-May-2013|
|Date of Web Publication||23-Jun-2014|
MD, Department of Dermatology and Venereology, Faculty of Medicine, Zagazig University, Zagazig, Sharkia Governorate
Source of Support: None, Conflict of Interest: None
Phytic acid (myoinositol hexaphosphate) is found in almost all grains, fibers, and plants. It is a natural plant antioxidant. Easy phytic peel is a commercial product; it has a slow release, which promotes continuous penetration of the skin, and requires no external neutralization.
The aim of this study was to evaluate the effect of chemical peeling using a solution composed of phytic acid, glycolic acid, lactic acid, and mandelic acid in the treatment of acne vulgaris and melasma.
This study was carried out on 40 patients: 20 with active lesions of acne vulgaris and 20 with melasma. Both groups were treated with the aforementioned solution every week for 6 weeks.
A highly significant decrease in the Global Acne Grading System scores and the Melasma Area Severity Index scores was reported after treatment (P<0.001) in case of patients with acne and melasma, respectively. However, the results of peeling were much more promising in patients with active acne compared with in those with melasma. No side effects were observed during or after treatment.
Peeling with this combination can be considered an effective, safe, and well-tolerated procedure in the treatment of patients affected with active acne and melasma.
Keywords: acne vulgaris, chemical peeling, easy phytic peel, melasma
|How to cite this article:|
Al-Mokadem S, Al-Aasser O, Nassar A, Al-Sharkawy EA. Easy phytic peel as a therapeutic agent in acne vulgaris and melasma. Egypt J Dermatol Venerol 2013;33:6-11
|How to cite this URL:|
Al-Mokadem S, Al-Aasser O, Nassar A, Al-Sharkawy EA. Easy phytic peel as a therapeutic agent in acne vulgaris and melasma. Egypt J Dermatol Venerol [serial online] 2013 [cited 2017 Oct 16];33:6-11. Available from: http://www.ejdv.eg.net/text.asp?2013/33/1/6/135106
| Introduction|| |
Various chemical peeling agents have been used in the topical treatment of mild-to-moderate papulopustular acne, either alone or in association with other therapies. A series of superficial chemical peels can give marked improvement in active acne over a short period of time 1.
Different therapeutic modalities have been used in the treatment of melasma. However, an optimal cheap and safe agent has not yet been discovered. Bleaching agents and chemical peels were the most frequently used methods in treatment of melasma. Chemical peels have become established as the treatment of choice in melasma, especially among lighter-complexioned individuals. Chemical peeling can be a modality to remove excess epidermal pigment in epidermal and mixed types of melasma 2.
α-Hydroxy acids are a group of organic acids found in natural foods and are often commercially referred to as fruit acids. Although they are found in nature – in sugarcane (glycolic acid), sour milk (lactic acid), and fruits (malic, citric and tartaric acids) – the α-hydroxy acids used in dermatological and cosmetic products are usually produced synthetically 3.
Phytic acid (myoinositol hexaphosphate) is found in almost all grains, fibers, and plants. It is a natural plant antioxidant. Easy phytic peel (EPP) is a commercial product that is composed of phytic acid, in addition to a mixture of glycolic acid, lactic acid, and phenyl glycolic (mandelic) acid. It has a slow release, which promotes continuous penetration of the skin, and requires no external neutralization 4.
This study aimed to evaluate the efficacy and safety of EPP as a therapeutic chemical peeling agent in the treatment of papulopustular acne vulgaris and melasma.
| Patients and methods|| |
Forty patients selected from the Dermatological Outpatient Clinic of Zagazig University Hospital between May 2011 and January2012 were included in the study. They were divided into two groups:
Group A: this group included 20 patients (four male and 16 female) with papulopustular acne whose ages ranged from 15 to 21 years. Their skin types were III, IV, or V.
Group B: this group included 20 patients with melasma (three male and 17 female) whose ages ranged from 27 to 41 years. Their skin types were III, IV, or V.
Written informed consent was obtained from each patient. All patients were subjected to full history taking and full clinical and dermatological examination. Any topical or systemic treatment was discontinued at least 1 month before the beginning of the study. Patients taking systemic retinoids, pregnant and lactating women, and those who had undergone previous laser therapy were excluded.
The degree of acne severity was scored before and after each session using a Global Acne Grading System (GAGS). This system divides the face, chest, and back into six areas (forehead, each cheek, nose, chin, and chest and back) and assigns a factor of 1, 2, or 3 to each area on the basis of size. Each type of lesion is given a value depending on the severity: 0, no lesions; 1, one or more comedone; 2, one or more papule; 3, one or more pustule; 4, one or more nodule. The score for each area is the product of the most severe lesion multiplied by the area factor. These individual scores are then added to obtain the total score. A score of 1–18 is considered mild; 19–30 is moderate; 31–38 is severe; and more than 39 is very severe 5.
A Woods’ light was used to differentiate between epidermal and dermal melasma. Melasma lesions of epidermal type exhibit enhancement of color contrast, whereas those of dermal type show no enhancement. Patients with mixed-type melasma have enhancement of lesions in some areas and no enhancement in other areas. Melasma severity was scored before and after each session using the Melasma Area and Severity Index (MASI).
The MASI score is an index used to quantify the severity of melasma and changes observed during therapy. According to the MASI score, the face is divided into four areas: the forehead, the right malar, the left malar, and the chin, which correspond to 30, 30, 30, and 10% of the total face area, respectively. The melasma in each of these areas was graded on three variables: percentage of total area involved, on a scale of 0 (no involvement) to 6 (90–100% involvement); darkness, on a scale of 0 (absent) to 4 (severe); and homogeneity, on a scale of 0 (absent) to 4 (maximum). The MASI score was then calculated using the following equation:
where D is darkness, H is homogeneity, A is area, F is forehead, MR is right malar, ML is left malar, C is chin, and the values 0.3, 0.3, 0.3, and 0.1 are the respective percentages of total facial area 6.
Chemical peeling procedure
Before the chemical peeling procedure, the skin was cleansed with an alcohol-free cleanser and dried after washing. The EPP solution (Skin Tech Company and distributed by Bio-Egypt Company, Girona, Spain) was applied evenly over the face with a cotton-tipped applicator. Two coats were applied one after the other without rubbing, and no neutralization was performed. The treated area was massaged, to ensure an even application, until the stinging sensation diminished appreciably. However, if accidental frosting took place, neutralization was performed immediately with sodium bicarbonate solution. The skin was left unwashed for 8 h. Peeling was repeated every week for a total of six sessions. Very fine sloughing of skin was observed after 2–3 days from the sessions. The post-treatment regimen consisted of cutaneous hydration and daily use of a high-spectrum sunscreen during the whole treatment period.
Evaluation of patients
The patients were evaluated every week before the next session and were thereafter followed up fortnightly for 2 months. At each visit, changes in clinical appearance were assessed. Photographs of the right and left profiles and full face were taken for each patient to assess the response to treatment.
Data were checked, entered, and analyzed using the SPSS version 15 computer software package (SPSS Inc., Chicago, Illinois, USA). Data were expressed as mean±SD for quantitative variables and as number and percentage for categorical variables. For comparison of two means values, the paired t-test was used. A P value of less than 0.05 was considered statistically significant and that of less than 0.001 was considered highly significant.
| Results|| |
Group A (acne group)
In this group, 16 patients (80%) were female and four (20%) were male; their ages ranged from 15 to 21 years, with a mean age of 18.5±2.1 years.
The difference in the average GAGS score before and after treatment was statistically highly significant (P<0.001) [Table 1].
Very good response in the form of complete disappearance of comedones, papules, and pustules was observed in four patients (20%). Good response in the form of disappearance of more than 75% of active lesions was observed in six patients (30%). Moderate response in the form of an improvement of 50–75% in active lesions was observed in five patients (25%). Mild response in the form of improvement of less than 50% in active lesions was observed in five patients (25%) [Figure 1] and [Figure 2].
|Figure 1: (a) A patient with mild acne (before treatment). (b) A patient with mild acne showing good response (after treatment).|
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|Figure 2: (a) A patient with moderate acne before treatment. (b) A patient with moderate acne showing very good response (after treatment).|
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There was a significant correlation between the degree of acne and response to treatment (P<0.05). Patients with mild acne showed a significantly better response to treatment compared with those having other types of acne. There was a higher incidence of improvement among patients with moderate acne, but no statistical correlations could be ascertained because the number of patients in each group (mild, moderate, and severe) was not equal [Table 2].
|Table 2: Relationship between the degree of acne and the response to treatment|
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Group B (melasma group)
In this group, 17 patients (85%) were female and three (15%) were male; their ages ranged from 27 to 41 years, with a mean age of 32.75±2.2 years.
Seven patients (35%) had a family history of melasma. Eight patients (40%) had a history of conception and five patients (25%) had taken oral contraceptive pills. Forty-five percent of melasma patients showed exacerbation of their melasma on sun exposure. All patients had been suffering from melasma since more than 2 years and were resistant to previous medical therapies.
On Wood’s light examination, 15 patients (75%) were found to have epidermal melasma, two patients (10%) had dermal melasma, and three patients had mixed melasma (15%).
The difference in the MASI score before and after treatment was statistically highly significant (P<0.001) [Table 3].
Good response in the form of a decrease of more than 75% in MASI scores was observed in five patients (25%). Moderate response in the form of a decrease of 50–75% in MASI scores was observed in nine patients (45%). Five patients (25%) reported mild response in the form of a decrease of less than 50% in MASI scores. No response with an absence of any change in MASI scores was observed in one patient (5%) [Figure 3].
|Figure 3: (a) A patient with epidermal melasma (before treatment). (b) A patient with epidermal melasma showing very good response (after treatment).|
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There was a significant correlation between the degree of improvement and type of melasma. Patients with epidermal-type melasma showed a significantly better response to treatment compared with patients with other types of melasmas [Table 4].
|Table 4: Relationship between the type of melasma and the response to treatment|
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Frosting was observed in two patients in group A, and it resulted in superficial crust formation, which sloughed rapidly with no residual postinflammatory hyperpigmentation.
| Discussion|| |
Chemical peeling of the skin involves the topical application of a chemical agent to produce a controlled injury to a desired depth, thus allowing subsequent regeneration of the skin, which can result in improved texture, more homogeneous pigmentation, and less wrinkling. It is a relatively low cost, simple procedure, and healing thereafter is usually quite rapid 7.
Many agents are available for chemical peeling today. New agents are being researched, and older agents are being used in different combinations and formulations to create new ways of peeling 8.
This study was carried out to evaluate the role of a multicomponent commercial peeling agent (EPP) in the treatment of acne vulgaris and melasma.
The study included 40 patients divided into two groups, each comprising 20 patients. Group A included patients with acne vulgaris and group B included patients with melasma.
There was a statistically significant improvement in the clinical profile after intervention in both groups.
In the acne group, the decrease in the mean GAGS score was 16.7, whereas in the melasma group the decrease in the mean MASI score was 9.7. Therefore, the EPP solution as a mixture of peeling agents was effective in peeling, but the results were much promising in patients with acne than in those with melasma.
In both groups, a clinical response could be detected soon after the first session, and further improvement could be detected during the next sessions; however, it was noticed that some patients, especially those of the melasma group, showed recurrence after the third session, which was attributed to the lack of compliance to sunscreens and continuous exposure to sunlight without protection.
In this study, no prepeel or postpeel treatments were used: only a sunscreen was applied, and the skin was kept hydrated.
The EPP solution was well accepted by patients because of the very limited discomfort in the postpeel period. No marked erythema was noticed after the peeling procedure, and desquamation, if it occurred, was very slight. We did not observe any case of either persistent erythema or postinflammatory hyperpigmentation.
During the sessions, frosting was detected in two patients (10%) of group A, which resulted in a brown crust formation that sloughed rapidly with no postinflammatory hyperpigmentation.
The solution was well accepted, and the patients did not feel the typical burning sensation but only experienced a tingling sensation that lasted for an average of 30 min.
To our knowledge, phytic acid was not used frequently in peeling procedures, either as a single agent or combined with other agents. Phytic acid (2–4%) has proven to be efficient in the treatment of epidermal melasma, especially when associated with glycolic acid or retinoic acid 9.
In another study that used individually other peeling agents such as glycolic acid, the decrease in the mean MASI score was 8.6, which is less than that observed in our study. In the previous study, pretreatment was used in the form of topical application of tretinoin (0.05%), and a sunscreen with a sun protection factor of 15 or more was applied daily for 1–2 weeks. Similarly, the postpeel treatment involved application of tretinoin (0.05%) and hydroquinone (4%) during the first 24 h after peeling 10.
Another study showed that the therapeutic response of acne patients ranged from good to fair in 75% of patients treated with a glycolic acid peel 11.
Sarkar et al. 12 reported local side effects in the form of focal superficial vesiculation and herpes labialis on using glycolic acid for treating melasma. Khunger 13 reported that pigmentary changes and prolonged erythema were the most common complications after a chemical peel with glycolic acid (70%).
In the study by Sharquie et al. 6, full-strength lactic acid solution (92%) was used as a peeling agent every 3 weeks. It was found that the decrease in the mean MASI score was 7.9. However, it is noteworthy that these patients had epidermal melasma only. In addition, some patients complained of discomfort or redness of the face.
The previous results were in accordance with those of our study but again showed a smaller volume of decrease in mean MASI scores compared with our results. We also observed that best results were seen in patients with epidermal melasma. Compared with lactic acid alone, the EPP solution was found to be less irritating and better tolerated.
On using a pyruvic acid peel for acne vulgaris and melasma, it was observed that the decrease in the mean GAGS score and the mean MASI score was 13.6 and 3.5, respectively, which are less than that observed in our patients 14.
On comparing with other peeling agents such as salicylic acid (30%), the EPP was shown to be devoid of side effects such as erythema, dryness, desquamation of the treated areas, and crusting 15.
However, a series of four salicylic acid peels with concentrations of 20–30% were not effective in the treatment of melasma when added to a twice-daily hydroquinone cream (4%) 2.
In our study, in the melasma group of patients, the pigmentation recurred because of lack of patient compliance on the use of sunscreens and frequent exposure to sunlight without protection.
Hyperpigmentation was the commonly observed side effect with superficial peels, especially with trichoracetic acid, in people living in tropical countries with intense ultraviolet exposure such as India 16. It can be concluded that the EPP solution is a good treatment modality for active acne vulgaris and melasma. It was found that patients with acne were more responsive to treatment compared with those with melasma after the same number of sessions.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]