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Dermatology
Practical & Conceptual
Research | Dermatol Pract Concept. 2021;11(3):e2021063 1
Efficacy and Safety of 25% Trichloroacetic Acid Peel
Versus 30% Salicylic Acid Peel in Mild-to-Moderate
Acne Vulgaris: A Comparative Study
Surabhi Dayal1, Satbir Singh, Priyadarshini Sahu1
1 Department of Dermatology, Venereology and Leprology, Pt B D Sharma University of Health Sciences, Rohtak, Haryana, India
Key words: acne vulgaris, trichloroacetic acid, salicylic acid, Michaelsson acne score
Citation: Dayal S, Singh S, Sahu P. Efficacy and safety of 25% trichloroacetic acid versus 30% salicylic acid peel in mild-to-moderate acne
vulgaris: a comparative study. Dayal Dermatol Pract Concept. 2021;11(3):e2021063. DOI: https://doi.org/10.5826/dpc.1103a63
Accepted: January 11, 2021; Published: May 20, 2021
Copyright: ©2021 Dayal et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License BY-
NC-4.0, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and
source are credited.
Funding: None.
Competing interests: The authors have no conflicts of interest to disclose.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Surabhi Dayal, MD, Department of Dermatology, Venereology and Leprology, Pt B D Sharma University of Health
Sciences, 18, Vikas Nagar, Rohtak, Haryana, 124001, India. Email: surabhidayal7@gmail.com
Background: Both salicylic acid (SA) and trichloroacetic acid (TCA) have proven efficacy with good
safety profiles in the treatment of acne vulgaris.
Objectives: This study compared the clinical efficacy and safety of 25% TCA and 30% SA peels in the
treatment of mild and moderate acne vulgaris.
Methods: Patients with mild or moderate acne vulgaris were randomized into 2 groups of 25 persons
each, and treated with either the TCA peel or the SA peel at 2-week intervals for 12 weeks. Evaluation
of active acne was done by individual lesion counts (comedones, papules and pustules) and calculation
of the Michaelsson acne score (MAS).
Results: Both peels led to significant decrease in individual lesion counts and MAS compared to base-
line values, without significant differences between the treatment groups. Thus, the peels had equiv-
alent efficacy against acne vulgaris. The TCA peel was better in treating non-inflammatory lesions,
while the SA peel was better for inflammatory lesions, but the differences were not significant. No
serious adverse effects were recorded, but more patients in the TCA peel group experienced burning
and stinging sensations.
Conclusion: The efficacy of 25% TCA is comparable to that of 30% SA in mild-to-moderate acne
vulgaris, but safety and tolerability were better with the SA peel than TCA peel.
ABSTRACT
2 Research | Dermatol Pract Concept. 2021;11(3):e2021063
Introduction
Acne vulgaris is an inflammatory disorder of the piloseba-
ceous unit, characterized by noninflammatory lesions (ie,
comedones) and inflammatory lesions such as papules, pus-
tules, nodules, cysts and abscesses [1]. A variety of therapeu-
tic modalities are available, including systemic, topical and
physical therapies. Topical retinoids, benzoyl peroxide and
antibiotics have been the cornerstone of topical treatment of
acne [2]. Combination formulations of these topical agents
are also commonly prescribed for acne. Recently, topical dap-
sone, azelaic acid 5%, topical delta-aminolevulinic acidand
α-hydroxy acids have been used to treat acne vulgaris [3,4].
Acne vulgaris may be associated with residual pigmen-
tation and scar formation, leading to anxiety, stress and
depression. There are various treatment modalities available
for acne scars, including chemical peeling, chemical recon-
struction using TCA CROSS, dermabrasion, laser treatments,
punch techniques, subcision and dermal fillers [5]. Different
types of ablative and non-ablative lasers can be used for scar
treatment. Ablative lasers include the carbon dioxide laser
and erbium-YAG laser [6]. Non-ablative lasers stimulate
dermal fibroblasts to produce new collagen. Nd-YAG, diode
and recently a new 675-nm Red Touch laser are various types
of non-ablative lasers used to treat acne scars [7].
Chemical peel is a well-documented treatment in the
management of acne vulgaris and its sequelae, such as post-in-
flammatory hyperpigmentation (PIH) and scarring [1,8]. In
acne vulgaris, both salicylic acid (SA) and trichloroacetic acid
(TCA) have proven efficacy as peeling agents with good safety
profiles [9-12]. However, there is paucity of studies comparing
the therapeutic effect of TCA peel with the more commonly
used SA peel, especially in dark-skinned patients [9,10].
Therefore, the present study was undertaken to compare the
efficacy and safety of 25% TCA peel versus 30% SA peel for
mild-to-moderate facial acne vulgaris in Indian patients.
Material and Methods
This was a 12-week, prospective, randomized interindividual
study. The study was approved by the ethics committee of Pt.
B. D. Sharma, University of Health Sciences, Rohtak
(approval letter no. IEC/Th/18/SVD/01). Patients with
acne vulgaris presenting to the outpatient clinic of the
Department of Dermatology were consecutively included in
the study. Written informed consent was obtained from all
patients aged ≥ 18 years and guardians of the patients age
less than 18 years in the study.
Patient Selection
Patients with mild or moderate facial acne vulgaris (grade
I, comedones, occasional papules; and grade II, comedones,
many papules, few pustules), as defined by Vaishampayan et
al. [3], were eligible for inclusion in the study. Patients were
excluded if they had grade III or IV acne vulgaris (ie, with
infiltrates, abscesses and nodulocystic lesions); if they were
taking any acne medications or had taken oral or topical
medications in the past 4 weeks; if they were pregnant or
nursing a baby; if they had known hypersensitivity to the
formulations used in the study or a history of photosensitiv-
ity, hypertrophic scars, keloidal tendency, active or recurrent
herpes simplex infection, or any kind of active dermatosis;
and if they had unrealistic expectations. A detailed history
was taken to rule out all exclusion criteria. A history of all
precipitating or initiating factors was taken.
Treatment
Included patients were randomized into 2 equal groups
using a chit-based lottery method. Patients of group 1 were
treated with 25% TCA peel and patients of group 2 were
given 30% SA peels, at 2-week intervals for a total of 12
weeks. Clinical evaluation was done every 2 weeks through-
out the study period. To detect hypersensitivity to the peeling
agents, a test peel was done by applying the treatment to the
postauricular area.
Peeling was done according to the standard guidelines for
chemical peeling [13]. In the TCA peel group, development
of uniform erythema as diffuse redness with light cloudy
white frosting was considered the desired endpoint. In the
SA peel group, immediate whitening, (ie, pseudofrost) within
30 seconds was the end point. After achieving the endpoint,
the peel was removed by rinsing with cold water followed by
gentle drying with gauze. Any acute minor side effects related
to the therapy were treated with appropriate medication by
an investigator.
Clinical Assessment of Efficacy
Clinical photographs of each patient were taken at 2-week
intervals, with front, right and left views of the face. Michael-
son acne scores (MAS) [14] were calculated at baseline and
at each visit. Acne improvement was graded according to the
reduction in mean MAS between baseline and 12 weeks, and
evaluated as good when greater than 50%, fair when 21%-
50%, and poor when less than 20%.
Statistical Analysis
The Statistical Package for Social Sciences (SPSS) for
Microsoft Windows 20th version was used for statistical
analysis. For the comparison of nominal or continuous data
such as age distribution, duration of disease, individual lesion
count and MAS within the group and between the groups,
paired and unpaired Student’s t tests were used, respectively.
Categorical data, ie, sex of the patients and improvement in
acne in each group, were compared using the chi-squared test.
Research | Dermatol Pract Concept. 2021;11(3):e2021063 3
The tests were performed at a 5% level of significance and an
association was found to be significant if the P value was <.05.
Results
A total of 50 patients with mild or moderate acne vulgaris
were included in the study and randomized to treatment with
either a 25% TCA peel or 30% SA peel. The groups were
comparable with respect to age distribution, sex, duration of
disease and mean MAS at baseline (Table 1). There were no
statistically significant differences between the groups with
respect to mean comedo, papule and pustule counts before
starting the therapy. Before-after clinical photographs for one
patient in each group are shown in Figures 1 and 2.
Evaluation of Clinical Efficacy
The mean comedo counts at the end of therapy were
significantly lower than the baseline values in both groups
(Figure 3). The decrease started after 2 weeks of therapy and
remained statistically significant throughout the therapy. How-
ever, there was no difference between the two groups in terms
of the change in comedo counts at the end of therapy (P = .89).
The mean percentage decrease in comedo counts from baseline
in group 1 was 53.91% (SD = 9.43%) and in group 2 53.71%
(SD = 13.66%), without a significant difference (P = .95).
There was significant decrease in mean papule count from
the baseline values in both groups at the end of 12 weeks
of therapy (Figure 4). The decrease started at 2 weeks and
remained significant throughout the therapy. However, the
difference between the groups was not significant at the end
of therapy (P = .34). The percentage decrease in mean papule
count in group 1 was 56.68% (SD = 13.12%) and in group
2 59.93% (SD = 13.94%), without a significant difference (P
= .4) after 12 weeks of therapy.
There was significant decrease in mean pustule count
from the baseline values in both groups at the end of 12
weeks of treatment (Figure 5). A significant decrease in mean
pustule count from baseline was observed in group 1 at the
end of 4 weeks, while the decrease in mean pustule count
started earlier, ie, at the end of 2 weeks in group 2. However,
the difference between the groups in terms of pustule count
was not significant at the end of therapy (P = .28). The per-
centage decreases in mean pustule count in groups 1 and 2
were 51.98% (SD = 19.32%) and 55.15% (SD = 18.01%),
respectively, but the difference was not significant (P = .55).
There was significant decrease in mean MAS in both
groups from baseline to the end of therapy (Figure 6). The
significant decrease in mean MAS was observed at the end
of 2 weeks in both groups. However, the difference in mean
MAS between the groups was not significant at the end of
therapy (P = .74). On comparing the groups in terms of per-
centage decrease in mean MAS at the end of 12 weeks with
respect to baseline, group 2 showed slightly better results with
a percentage decrease of 55.97% (SD = 11.32%) as compared
to 54.64% (SD = 9.32%) in group 1. However, the difference
between the groups was not significant (P = .65).
On analyzing the change in MAS between the start
and end of therapy, we found that all patients had good or
fair improvement and none had poor improvement. Good
improvement (>50% decrease in MAS) was seen in 15 of
the 25 patients in group 1 (TCA peel) and in 17 patients of
group 2 (SA peel), without a significant difference (P = .54).
Fair improvement (20%-50% decrease in MAS) was present
in 10 patients in group 1 and 8 patients in group 2 (P = .52).
Adverse Effects
As far as side effects are concerned, burning and stinging
sensations were more common in group 1 (20 of 25 patients)
than in group 2 (10 of 25 patients); this difference was sta-
tistically significant (P = .004). Post-peel erythema was also
more common in group 1 (10 of 25 patients) than in group 2
(4 of 25 patients), but this difference was not significant (P =
Table 1. Baseline Characteristics of the 50 Patients with Acne Vulgaris
TCA peel group
(n = 25)
SA peel group
(n = 25) P
Age (years), mean (SD) 17.9 (2.4) 17.8 (1.9) .95
Sex, n .56
Male 9 11
Female 16 14
Disease duration (months), mean (SD) 18.24 (17.92) 24.24 (21.56) .075
Comedone count, mean (SD) 157.08 (83.49) 164.04 (70.96) .75
Papule count, mean (SD) 38.8 (18.06) 37.72 (20.46) .84
Pustule count, mean (SD) 14.44 (5.8) 13.96 (7.88) .8
MAS, mean (SD) 146.2 (59.62) 146.78 (51.27) .97
MAS = Michaelsson acne score; SA = salicylic acid; SD = standard deviation; TCA = trichloroacetic acid.
4 Research | Dermatol Pract Concept. 2021;11(3):e2021063
.05). PIH was observed in 5 patients in group 1 and 2 patients
in group 2 (not significant). It resolved on its own in group
2, while in group 1 it resolved after treatment with topical
application of mild desonide cream and strict sun protection
for 1 week. No patient in the study had blistering, crusting,
scaling, hypertrophic scarring or keloid formation.
Discussion
Chemical peeling is a well-known treatment for acne. Peeling
agents that have been used in the treatment of acne vulgaris
include alpha hydroxy acids (eg, glycolic acid, lactic acid,
mandelic acid), beta hydroxy acids (eg, salicylic acid, lipohy-
droxy acid), tretinoin peels, TCA peels and Jessner’s solution
[1,9-12,15-17]. TCA peel is effective for histologically and
clinically improving the skin in a variety of dermatological
conditions [18,19]. It has been used to treat acne, either alone
or in combination with other drugs. SA peel (20%-30%) is
a well-established superficial peeling agent for the treatment
of acne vulgaris [3], and its efficacy has been documented by
several studies [3, 8-12]. SA is effective against both acne and
PIH, which are common in people with skin of dark color. Its
whitening effect is an important factor in its choice as a super-
ficial peeling agent for Asian patients with acne vulgaris [20].
We found only 2 studies that compared the efficacy and
safety of SA and TCA peels [9,10]. In a recent study by Abdel
Hay et al [10], a combination solution of 20% azelaic acid
and 20% SA was compared with 25% TCA peel in 34 patients
with mild or moderate acne vulgaris. At the end of 8 weeks,
significant improvements were seen in both treatment groups.
However, the difference between the 2 treatments was not sig-
nificant. According to the authors, the combination of azelaic
acid and SA is recommended in the early stage of the disease,
ie, when patients have inflammatory lesions, while TCA is
preferred for patients with non-inflammatory lesions. In a
comparative, split-face study by Abdel Meguid et al [9], 25%
TCA peels and 30% SA peels were compared in 20 patients of
Fitzpatrick skin types III to V with facial acne. At the end of the
Figure 1. Improvement in lesions of acne vulgaris before and after TCA peel.
BEFORE TREATMENT AFTER TREATMENT
Research | Dermatol Pract Concept. 2021;11(3):e2021063 5
Figure 2. Improvement in lesions of acne vulgaris before and after SA peel.
study, total improvement was more frequent with the SA than
TCA peel, but the difference was not statistically significant.
Total improvement in comedones was more frequent with
TCA peeling, while improvement of inflammatory lesions was
more frequent on the side treated with the SA peel. However,
the results did not reach the level of statistical significance.
Our study enrolled 50 patients with mild or moderate
acne vulgaris. Objective evaluation of active acne was done
by individual lesion counts (comedones, papules and pus-
tules) and calculation of MAS. In terms of improvement
in non-inflammatory lesions (ie, comedones), both peels
brought a significant decrease in mean comedo counts from
their respective baseline values. The percentage decrease
in non-inflammatory lesions was slightly more with 25%
TCA peel than 30% SA peel; however, the difference was
not significant at the end of therapy. This finding is in
agreement with the study by Abdel Meguid et al [10], and
may be due to fact that both TCA peel and SA peel have
comedolytic action.
The mechanism of action of TCA peel in the treatment
of acne vulgaris is due to its ability to diminish corneocyte
cohesion and keratinocyte plugging, thus helping in comedo-
lytic action. In addition, application of TCA to the skin
causes precipitation of proteins and coagulative necrosis of
epidermal cells, leading to removal of damaged skin and its
replacement by normal tissue [19]. The effect of SA is mainly
due to the lipophilic activity and comedolytic effect. The
initial event in comedo formation is excessive keratinization
in the mid-portion of the follicular canal; due to its lipophilic
nature, SA preferentially acts on the sebaceous unit which is
required and important for comedolysis [9]. Since both TCA
and SA facilitate comedolysis, the effectiveness of both peels
with respect to comedolytic action may be comparable.
In our study, a significant decrease in mean papule count
was observed after 2 weeks of therapy, but there was no sig-
nificant difference between the groups at the end of therapy.
The overall percentage decrease in mean papule count was
better in group 2 (SA peel group) than in group 1 (TCA peel
BEFORE TREATMENT AFTER TREATMENT
6 Research | Dermatol Pract Concept. 2021;11(3):e2021063
group), but the difference was not significant. Similarly, a
significant decrease in mean pustule count started earlier
(ie, at 2 weeks) in the SA peel group than TCA peel group
in which it was seen at 4 weeks of therapy. Furthermore,
the overall percentage decrease in mean pustule count was
better in the SA peel group than the TCA peel group, but the
difference was not significant. Thus, there was statistically
significant decrease in mean pustule count after completion
of therapy in the 2 groups, but the difference was not signif-
icant at the end of therapy. The study by Abdel Meguid et al
[9] found that 30% SA peels are superior to 25% TCA peels
for treating inflammatory lesions in dark-skinned patients.
Thus, the results of our study regarding the improvement
in inflammatory acne lesions are in agreement with that
study. The better effects in terms of improvement of papules
and pustules (inflammatory lesions) with the SA peel than
TCA peel may be due to the anti-inflammatory action of SA
through inhibition of the arachidonic acid cascade [21,22].
On analyzing the improvement in MAS, there was a
statistically significant difference from baseline values to the
Figure 3. Mean comedo counts in Group 1 (TCA peel) and Group 2 (SA peel) throughout the treatment period.
MEAN COMRDONE COUNT
164.04
157.08
147.76
145.8
133.48
129.04
121.2
116.32
P–VALUE
DURATION OF THERAPY
108.56
104.56
94.28
92.76 79.64
GROUP 1
GROUP 2
77.6
160
180
140
120
100
80
60
40
20
0.75
0
0.890.92 0.920.82 0.820.8
BASELINE 2ND WEEK 4TH WEEK 6TH WEEK 8TH WEEK 10TH WEEK 12TH WEEK
Figure 4. Mean papule counts in Group 1 (TCA peel) and Group 2 (SA peel) throughout the treatment period.
MEAN PAPULE COUNT
38.8
37.72
34.44
33.36 29
26.8
25.16
23.68
P–VALUE
DURATION OF THERAPY
21.56
20.16
18.52
17.12
16.2
GROUP 1GROUP
2
14.08
45
40
35
30
25
20
15
10
0.84
0
5
0.340.83 0.580.61 0.640.68
BASELINE 2ND WEEK 4TH WEEK 6TH WEEK 8TH WEEK 10TH WEEK 12TH WEEK
Research | Dermatol Pract Concept. 2021;11(3):e2021063 7
end of therapy in both groups, but the difference between
groups was not significant. Thus, our result is in agreement
with those of Abdel Meguid et al [9], who also found that the
efficacy of 25% TCA peels and 30% SA peels are comparable
in the treatment of mild-to-moderate acne vulgaris.
As far as side effects are concerned, patients of both
groups tolerated the peels very well. However, the SA peel
was found to be safer in terms of side effects like erythema
and PIH, and was superior as far as burning and stinging
sensations were concerned. No patient experienced any
serious adverse effect requiring cessation of therapy. How-
ever, as skin of color is more prone to developing PIH, the
SA peel seems to be the better choice for dark skin owing
to the additional advantage of its whitening effects [15,20].
The anti-inflammatory action of SA further adds to its bene-
ficial effects as compared to TCA peel [21,22]. Furthermore,
our patients also demonstrated better tolerability to the
SA peel than the TCA peel in the form of less burning and
stinging, which enhances the compliance of patients with
skin of color.
Figure 5. Mean pustule counts in Group 1 (TCA peel) and Group 2 (SA peel) throughout the treatment period.
MEAN PUSTULE COUNT
14.44
13.96
13.76
12.04
12
10.8
10.6
9.4
P–VALUE
DURATION OF THERAPY
9.16
8.36
7.68
7.56
7.16
GROUP 1
GROUP 2
5.92
16
14
12
10
8
6
4
20.8
0
0.280.43 0.920.54 0.570.43
BASELINE 2ND WEEK 4TH WEEK 6TH WEEK 8TH WEEK 10TH WEEK 12TH WEEK
Figure 6. Mean Michaelsson acne scores (MAS) in Group 1 (TCA peel) and Group 2 (SA peel group) throughout
the treatment period.
MEAN MAS COUNT
146.78
146.2
135.48
131.62
119.86
113.06
106.76
100.62
P–VALUE
DURATION OF THERAPY
96.88
89.26
81.18
78.98
69.12
GROUP 1GROUP 2
65.96
160
140
120
100
80
60
40
20
0.97
0
0.740.8 0.840.65 0.540.65
BASELINE 2ND WEEK 4TH WEEK 6TH WEEK 8TH WEEK 10TH WEEK 12TH WEEK
8 Research | Dermatol Pract Concept. 2021;11(3):e2021063
Our study has strengths related to the relatively larger
study group and the use of an objective method to analyze the
improvement of acne, ie, calculation of MAS. However, there
are also a few limitations to our study. Firstly, follow-up was
not done to determine the recurrence rate among the patients.
Secondly, we did not evaluate the patients’ satisfaction with
the treatments.
Conclusions
Our study demonstrated that the efficacy of 25% TCA peel
is comparable to that of the 30% SA peel in the treatment of
mild or moderate facial acne vulgaris in Indian patients. Fur-
thermore, the 30% SA peel is marginally better than the 25%
TCA peel for inflammatory lesions, while for non-inflamma-
tory lesions 25% TCA seems better. In terms of safety and tol-
erability, the 30% SA peel was better than the 25% TCA peel,
as a greater number of patients in the 25% TCA peel group
developed adverse effects such as burning, stinging, PIH and
post-peel erythema than in the 30% SA peel group. Hence,
this study infers that although the therapeutic efficacies of the
25% TCA and 30% SA peels are comparable in Indian acne
vulgaris patients, the 30% SA peel seems to be the treatment
of choice for Indian patients due to its lightening effects and
the lesser chance of causing PIH.
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