Acne is unique to humans, who tend to view it as a rite of passage. It is stated that 90% of individuals, male and female, aged between puberty and 30 years’ experience some degree of acne. It is opined that in a lifetime, a person is more likely to have acne than any other disease. ^[1]

According to the GBD study, acne vulgaris affects ~85% of young adults aged 12–25 years. Acne consistently represents the top three most prevalent skin conditions in the general population, as found in large studies. ^[2] In India, prevalence of acne from a north Indian study was reported to be 72.3%, commonly affecting the age group of 14-16 years and acne prevalence did not increase with increasing age. ^[3]

Acne vulgaris and its association with self-consciousness, social anxiety and overall impaired quality of life is well reported. ^[4] Worsening of QoL was observed with advancement in age, longer Duration of disease, and increase in severity of acne and acne scars, and the presence of post acne hyper pigmentation. This stresses the importance of early treatment of acne vulgaris in reducing disease-related psychosocial sequelae and enhancing the efficacy of treatment. ^[5]

Acne vulgaris being a chronic disorder needs long term therapy. There is always a problem of patient poor compliance due to slower response of treatment and side-effects. Still these topical and systemic therapies do not decrease the after-effects of acne i.e., post-acne pigmentation and scarring. So, there was a need for better options in the armamentarium of acne treatment to answer the above problem. ^[6]

In 1952, peeling agents for treating acne scarring were developed. Microneedling with dermaroller emerged as a novel treatment modality for the treatment of acne scars. Orentreich first described subcision or dermal needling in 1995 for scars and most recently, Fernandes, in 2006, developed percutaneous collagen induction therapy with the dermaroller. ^[7] In 1990, laser therapy made its evolvement in treating acne and is now widely used remedy as it clears the recent as well as old scars left by acne besides active lesions. In 2000, the blue/red therapy was developed along with laser therapy for easy treatment of acne. ^[8]

The current management of acne aims to alleviate symptoms, clear existing lesions, limit disease activity and hence preventing new lesions and scars from developing, and therefore avoid negative impact on quality of life. ^[9] Newer adjuvant therapeutic modalities when added to the conventional treatment modalities, decrease the downtime of lesions and side-effects, thereby revolutionizing the management strategies. ^[10] Among all the newer adjuvants, chemical peels are advantageous as they are less costly than lasers, offering a better alternative for both patient and the doctor. ^[11]

This present study is being undertaken to compare the response when chemical peeling is added to the existing armamentarium of conventional therapies.

The study was single blind randomized open prospective comparative clinical trial. It was carried out in the Department of Dermatology, Tertiary Care Teaching Hospital, during the period of January 2016 to June 2017. A total of 180 patients of either sex was enrolled according to the inclusion criteria given below and were randomly assigned to the study groups.

INCLUSION CRITERIA:

1. Patients of either sex and age ranging from 15–35 years
2. Grade 1 acne lesions – comedones with few papules
3. Grade 2 acne lesions – papules, comedones with few pustules
4. Grade 3 acne lesions –predominant pustules, papules, comedones with few

EXCLUSION CRITERIA:

1. Patients whose age is out of
2. Grade 3 nodular variant, Grade 4 acne vulgaris; truncal
3. Secondary acne (e.g., chloracne, drug‐induced acne).
4. Unwilling or unable to comply with the study proceedings to give informed written consent
5. With a history of hypersensitivity to benzyl peroxide or clindamycin or adapalene
6. Pregnant or lactating
7. Active bacterial or viral infection
8. H/o drug usage with photosensitizing potential
9. Patient with unrealistic

A total of 30 Patients were allocated randomly into each sub-groups listed below.

GROUP 1: this group includes 60 patients with grade-1 acne vulgaris i.e., comedones with few papules. Expert guidelines suggest usage of topical retinoids or topical benzyl peroxide as first line of treatment for mild/comedonal acne. Among these two, there are studies which reported that topical adapalene has slight better efficacy than topical benzylperoxide. The level of evidence for topical retinoids in the treatment of acne vulgaris is given as I (large randomized control trials exist) and the strength of recommendation is ranked as A, which indicates that there is consistent and good- quality patient-oriented evidence.

GROUP 2: includes patients with grade-2 acne vulgaris lesions i.e., papules, comedones with few pustules. This can also be described as mild papulopustular acne. The proliferation of P. acnes, an anaerobic Gram positive bacterium, was thought to play a pivotal role in acne-associated inflammation. Because of presence of inflammatory lesion, patients in this group require a topical antibiotic along with topical retinoid/BPO as per expert opinion..The combination of topical retinoid with topical antibiotic has the level of evidence of I, II and the strength of recommendation is ranked as A. Among all the available topical antibiotics clindamycin 1% is currently preferred.

GROUP 3:  Patients with grade-3 acne vulgaris lesions i.e., predominant inflammatory lesions like pustules, papules, few nodules, comedones were included in Group-3 of this study. This grade can also be described as moderate-severe papulopustular acne. 30 of them who were randomly allocated in 3A group were started on combination of topical and systemic therapy

A total of 60875 patients attended the DVL department of Hospital. Out of these patients, an average of 5500 patients came with complaint of acne vulgaris (all grades included). Out of these 180 patients who fulfilled the inclusion and exclusion criteria were included in the study. They were randomly allocated in the groups. Results obtained are presented here in the following tables and figures.

TABLE-01: SEX DISTRIBUTION:

Acne vulgaris was more common in females than in males with a sex ratio of 1.32:1.

TABLE-02: AGE DISTRIBUTION: Distribution of the patients according to age groups.

Distribution in each subgroup is shown in individual boxes mentioned under each value.

This shows that the most affected is 15-20 year age group and there is a female preponderance in all age groups.

FIGURE-1: ASSOCIATED OTHER SKIN CONDITIONS IN ACNE VULGARIS

PATIENTS:

Among 180 patients, 42 patients had dandruff (seborrhea capitis) – 20 men and 22 women; 4 male patients and 1 female patient had tinea corporis, 2 male patients had scabies, 1 female patient had amyloidosis, 1 male patient had folliculitis of scalp, 1 female patient had telogen effluvium, 1 male patient had pityriasis versicolor, 1 female patient had associated melasma, 1 male patient had pityriasis rosea.

Most commonly associated disorder seen in this study was dandruff (seborrhea capitis)

– 26.7%.

ASSOCIATED ACNE VULGARIS COMPLICATIONS – ACNE SCARS & PIH:

ACNE SCARRING: Out of 180 patients enrolled in the study, 137 had acne scarring, which accounts to 76.1%.

The type of scarring present in grade 1, grade 2 and grade 3 acne patients are mentioned below:

FIGURE -2: Acne scars in Group 1 patients (GRADE-1):

Most of the patients in this group had no scars of any type. Out of 60 patients only 17 of them had scars. 15 patients had ice-pick scars while only 2 had a combination of ice- pick and rolling scars.

THERAPEUTIC RESPONSE OBSERVED IN PATIENTS OF GROUP 1A: (Topical

adapalene 0.1% gel):

Out of 30 patients in this group, only 11 patients completed the course of topical therapy of 16 weeks. Rest of the patients was lost to follow-up. So, the mean MASI scores of 11 patients are recorded below:

TABLE – 03: The mean MASI score results of group 1A are shown below:

TABLE – 4: The mean MASI scores of Group-1B are shown below:

TABLE-4: Percentage improvement seen in group 1A and 1B after 4 follow-ups:

From the above FIGURES 17 &18 and TABLE-10, it can be seen that the percentage reduction/ improvement of lesions is relatively more in patients of group 1B with an overall percentage reduction of 90.5% of lesions when compared with 77.4% overall reduction of lesion in group 1A patients.

TABLE – 5: The mean MASI scores of Group-2A are shown below:

TABLE-6: The mean MASI scores of Group-2B are shown below:

From the above FIGURES 21 & 22 and TABLE-18, it can be seen that the percentage reduction/ improvement of lesions is relatively more in patients of group 2B with an overall percentage reduction of 71.4% of lesions when compared with 45.4% overall reduction of lesion in group 2A patients.

TABLE- 7: Statistical analysis: Paired sample test for Group 3A:

TABLE- 8: Percentage improvement of acne lesions in group 3A and 3B:

From the above FIGURES 25 & 26 and TABLE-26, it can be seen that the percentage reduction/ improvement of lesions is relatively more in patients of group 3B with an overall percentage reduction of 88.2% of lesions when compared with 65.6% overall reduction of lesion in group 3A patients

Acne vulgaris did not show any relationship with regard to occupation in our study. A majority of patients were school or college students. This can be explained in regard of age group and stress as majority of them experience stress during exam period, changes in diet and sleep patterns. This relationship was also reported in few studies like Durai and Nair et al. ^[12]

Acne is not an inherited condition, though has an inherited predisposition. In this study, 24% of the patients gave a positive family history. This is consistent with report from south Indian study, Durai and Nair which reported 21.4% patients with positive family history. A study from north India, Gupta et al ^[13] reported a little higher incidence of 39%. Studies from other countries reported a higher incidence like Eleni et. Al reported 26.7% patients with positive family history, Cunliffe WJ reported 40%.

Dietary relationship with acne vulgaris is most debated. ^[14] Level of evidence of this relationship is II, which indicates a limited and lesser quality randomized studies. In this study, 16.7% of patients associated acne flare-ups with ingestion of high fat diet. Studies from other countries reported a higher association. This is because of higher intake and quantity of high glycemic food ingestion in western countries compared to ours. ^[15]

There are no published studies which used the combination therapy of conventional and adjuvant modes. Few studies used chemical peeling as monotherapy with 30% salicylic acid in moderate grade of acne and reported variable results. Sadaf fasih et al^[16] reported an improvement of 62%, Sayed & Abdel-motaleb study^[17] reported 70% improvement, Jartarkar SR et al^[18] reported 66% improvement of total lesion count. This less improvement reported might be because of using chemical peels as monotherapy.

Among 90 patients who had salicylic acid peeling as their treatment protocol, less than half of patients (46.7%) complained of mild burning sensation post peel and 21% of them complained of mild erythema. All of these subsided within a few hours following application of moisturizer and sunscreen. The percentage of these side-effects seen was less than those reported in other studies. Jaffary F et al^[18] reported 85% burning sensation post peeling. Sayed & Abdel-Motaleb^[19] reported burning sensation in 87.5% patients and transient erythema in 7.5% patients.

When the percentage improvement of all the patients in 6 subgroups are compared, we can see that, in patients of Group-1, marked improvement was seen more in subgroup 1B than in subgroups 1A. In group-2 patients, moderate improvement was seen in 11 patients of subgroup- 2A while subgroup-2B had 14 patients. 13 Patients of subgroup 2B showed marked improvement, while the maximum improvement seen with subgroup 2A was 73.2%. In group-3 patients, 3A subgroup had moderate improvement in 25 patients and while 3B subgroup had 3 patients. In 3B subgroup, most of the patients i.e., 28 had marked improvement, while 2 patients of subgroup 3A had marked improvement.

This shows that addition of adjuvant therapies to conventional regimens results in a marked improvement of total number of lesions at higher rates compared to usage of conventional regimens only.

Chemical peels can be regarded as an important adjuvant therapy in treating patients of acne vulgaris for achieving better and faster results, patient satisfaction and their compliance to treatment. Various modes of emerging treatment modalities should be employed in treating along with conventional modes of therapy for the betterment of both patient and clinician without forgetting the basic conventional therapy guidelines

Acne vulgaris is a chronic, relapsing disease and is one of the most prevalent skin conditions affecting humans globally and the single most common reason for dermatologic consult. There is a need for more comparative studies in the armamentarium of conventional treatment using both topical and systemic treatments. There is also a need for comparative trails using conventional and physical modalities. Conventional treatments cannot be ignored and they are important in addressing the main pathophysiological mechanisms. Physical modalities of treatment like chemical peeling can be considered as an important adjuvant, which resulted in a faster clinical response and patient satisfaction. It is affordable and with minimal downtime, and can be performed in any dermatologist’s office.

1. Zaenglein AL, Pathy AL, Schlosser BJ, et Guidelines of care for the management of acne vulgaris. J Am AcadDermatol 2016; 74:945.
2. Lynn DD, Umari T, Dunnick CA, Dellavalle RP. The epidemiology of acne vulgaris in late adolescence. Adolescent Health, Medicine and Therapeutics. 2016;7:13-25. doi:10.2147/AHMT.S55832.
3. Kubba R, Bajaj A K, Thappa D M, Sharma R, Vedamurthy M, Dhar S, Criton S, Fernandez R, Kanwar A J, Khopkar U, Kohli M, Kuriyipe V P, Lahiri K, Madnani N, Parikh D, Pujara S, Rajababu K K, Sacchidanand S, Sharma V K, Thomas J. Epidemiology of Indian J DermatolVenereolLeprol 2019;75, Suppl S1:3
4. Sharma RK, Dogra S, Singh A, Kanwar AJ. Epidemiological patterns of acne vulgaris among adolescents in North India: A cross-sectional study and brief review of Indian J PaediatrDermatol2017;18:196-201
5. Durai PT, Nair Acne vulgaris and quality of life among young adults in South India. Indian J Dermatol2015;60:33-40
6. Gupta A, Sharma YK, Dash KN, Chaudhari ND, Jethani Quality of life in acne vulgaris: Relationship to clinical severity and demographic data. Indian J DermatolVenereolLeprol2016;82:292-7.
7. Arshdeep, De What's new in the management of acne?. Indian J DermatolVenereolLeprol2017;79:279-87
8. Handog EB, Datuin ML, Singzon IA. Chemical peels for acne and acne scars in asians: Evidence based J CutanAesthetSurg2012;5:239-46
9. Kubba R, Bajaj A K, Thappa D M, Sharma R, Vedamurthy M, Dhar S, Criton S, Fernandez R, Kanwar A J, Khopkar U, Kohli M, Kuriyipe V P, Lahiri K, Madnani N, Parikh D, Pujara S, Rajababu K K, Sacchidanand S, Sharma V K, Thomas Pathogenesis of acne. Indian J DermatolVenereolLeprol 2019;75, Suppl S1:5-9
10. Al-Shobaili HA, Salem TA, Alzolibani AA, Robaee AA, Settin AA. Tumor necrosis factor-a -308 G/A and interleukin 10 -1082 A/G gene polymorphisms in patients with acne vulgaris. J DermatolSci 2012;68:52-5.
11. Makrantonaki E, Ganceviciene R, Zouboulis An update on the role of the sebaceous gland in the pathogenesis of acne. Dermato-endocrinology. 2011;3(1):41-49.
12. Burkhart CG, Burkhart CN. Expanding the microcomedonetheoryand acne therapeutics: Propionibacterium acnes biofilm producesbiological glue that holds corneocytes together to form plug. J AmAcadDermatol2017;57:722‐4.
13. Sahdo B, Särndahl E, Elgh F, Söderquist Propionibacterium acnesactivates caspase‐1 in human neutrophils. APMIS 2013;121:652‐63.
14. Melnik BC, Schmitz Role of insulin, insulin‐like growth factor‐1,hyperglycaemic food and milk consumption in the pathogenesis ofacne vulgaris. ExpDermatol2019;18:833‐41.
15. Kubba R, Bajaj A K, Thappa D M, Sharma R, Vedamurthy M, Dhar S, Criton S, Fernandez R, Kanwar A J, Khopkar U, Kohli M, Kuriyipe V P, Lahiri K, Madnani N, Parikh D, Pujara S, Rajababu K K, Sacchidanand S, Sharma V K, Thomas Factors precipitating or aggravating acne. Indian J DermatolVenereolLeprol 2019;75, Suppl S1:10-2
16. Melnik BC, Zouboulis CC. Potential role of FoxO1 and mTORC1in the pathogenesis of Western diet‐induced ExpDermatol2013; 22:311‐5.