Original Contribution

Journal of Cosmetic Dermatology, 15, 367--373

Clinical efficacy and safety of 20% glycolic peel, 15% lactic peel,
and topical 20% vitamin C in constitutional type of periorbital
melanosis: a comparative study
Surabhi Dayal, MD, Priyadarshini Sahu, MD, Vijay Kumar Jain, MD, & Sneh Khetri, MD
Department of Dermatology, Venereology and Leprology, Pt B D Sharma University of Health Sciences, Rohtak, Haryana, India

Summary Introduction Periorbital Melanosis (POM) is a very common esthetic condition, yet
there is no definite treatment modality. Topical therapy is the mainstay of treatment
which includes chemical peels, vitamin C, and other depigmenting agents.
Objective To compare clinical efficacy, safety, and tolerability of 20% glycolic acid
peels, 15% lactic acid peels, and topical 20% vitamin C in treatment of constitutional
type of POM in Indian patients.
Method Ninety patients of constitutional POM were enrolled for 12 weeks. The
patients were distributed into three groups. One-third of patients underwent 3-weekly
GA peel, another one-third underwent 3-weekly lactic peel, and rest applied vitamin
C daily. Clinical improvement was assessed objectively using POM grading. Patient’s
and physicians global assessment along with patient’s global tolerance was also
evaluated.
Results More than 50% improvement in POM was observed in 73.34% of patients on
GA peel, 56.67% on lactic peel, and 26.67% on vitamin C. On comparing
improvement with respect to duration of therapy, GA peel was significantly more
effective than lactic peel from 12 weeks onward, while it was more effective than
vitamin C from 6 weeks onward. Lactic peel was more effective than vitamin C from
6 weeks onward. Physician and patient global assessment was excellent with glycolic
peel followed by lactic peel and vitamin C. The incidence of adverse effect was
maximum with GA peel followed by lactic peel and vitamin C.
Conclusion Glycolic peel was best among the three modalities, although it was
associated with increased rate of side effects.
Keywords: periorbital hyperpigmentation, chemical peeling, glycolic peel, lactic peel,
topical vitamin C

hyperpigmentation” or “dark circle under the eyes.”

Introduction
Various etiological factors have been proposed, which
Periorbital melanosis (POM) is defined as bilateral, include genetic/constitutional, dermal melanin deposi-
homogenous, hyperchromic macules and patches tion, secondary to atopic or allergic contact dermatitis,
around the eyes.1 It is also known as “periorbital anemia, stress, faulty habits, superficial location of vas-
culature, and shadowing due to skin laxity.2 Ranu
Correspondence: Surabhi Dayal, Professor, 18, Vikas Nagar, Rohtak, et al.3 had classified POM into five types, that is, consti-
Pin-124001, Haryana, India. E-mail: [email protected] tutional, postinflammatory hyperpigmentation (PIH),
Accepted for publication June 16, 2016 shadow effect, vascular (capillaries and veins), and

© 2016 Wiley Periodicals, Inc. 367

GA peel, lactic peel, and vitamin C in POM . S Dayal et al.

others. Of these, constitutional type is the most com- was taken, including age, gender, personal and family
mon type followed by PIH type.3 Constitutional type is history, history of atopy or drug intake, lifestyle, use of
characterized by the presence of curved bands of cosmetics, precipitating factors such as photosensitiv-
brownish to black pigmentation on the skin of lower ity, allergies, seasonal variations, presence of associated
eyelids approximating the shape of orbital rim with fre- pigmentation in other areas of the face, and the body
quent involvement of upper eyelids.3 and presence of any concomitant illness such as ane-
There is no definite treatment for POM, thus making mia, gastrointestinal diseases, hepato-biliary diseases,
its treatment a difficult challenge for the dermatolo- renal diseases, and thyroid diseases.
gists. A variety of therapeutic agents have been tried, Exclusion criteria included patients <18 years, preg-
but none has been found to be entirely satisfactory. nancy, lactating mothers, allergy, hypersensitivity to
Therefore, topical treatments are the mainstay of man- the formulations to be used in the study, photosensitiv-
agement for constitutional type of POM. Available ity, and unrealistic expectation those with any other
treatment modalities include topical retinoid acid, cutaneous or systemic disease. Patient who had taken
chemical peels, vitamin C, LASER therapy, autologous any other treatment (laser, dermabrasion, surgery,
fat-transplantation-injectable fillers, and surgery radiation, etc.) on the affected region performed less
(blepharoplasty).4 than 6 months prior to the beginning of the study
Vitamin C and its derivatives, such as magnesium were also excluded.
ascorbyl phosphate and ascorbic acid glucoside, have a Following baseline investigations were carried out in
long history as topical skin-lightening agents.5 Vitamin each patient: complete blood count, serum TSH, serum
C has two major functions: (1) it inhibits melanogene- transaminases level, serum cholesterol, and random
sis in human melanocytes, thus reducing melanin syn- blood sugar. While history, physical examination, and
thesis, and (2) it regulates the collagen synthesis, thus baseline investigation are usually sufficient to deter-
increasing the dermal collagen.5 mine the primary cause of periorbital hyperpigmenta-
Chemical peeling is a medical procedure which tion, confirmation by histologic examination may
causes controlled destruction of skin, leading to exfolia- rarely be necessary.7 Histopathology examinations
tion, followed by regeneration of new epidermal and were not performed due to esthetic concerns.
dermal tissues. Today, a plethora of peeling agents is
available. Those most commonly used for POM are
Treatment protocol
alpha hydroxyacids (AHAs) and tricholoroacetic acid
(TCA). Both glycolic and lactic acid are AHAs. Glycolic The patients were distributed into three groups using
acid is a superficial to medium-depth peel while lactic computer-generated randomization chart with thirty
acid is superficial peel.6 patients in each group. The first group of patients (GA
Although, both glycolic and lactic peels as well as peel group) underwent 3-weekly 20% GA peel, second
vitamin C are being used in various centers, but to the group of patients (Lactic peel group) underwent 3-
best of our knowledge, there are no studies comparing weekly 15% lactic peel, and third group of patients
these three agents in constitutional type of POM. Our (topical vitamin C) applied 20% topical vitamin C daily
aim of the study was to compare the clinical efficacy at nighttime. The total duration of therapy was
and safety of 20% glycolic acid peels, 15% lactic peels, 12 weeks.
and topical 20% vitamin C in the treatment of consti- Peeling was performed using the basic guidelines for
tutional type of POM in Indian patients. chemical peeling.8 The patients were also instructed to
keep their eyes closed during the application. All
patients were instructed to avoid direct sunlight, to
Material and methods
apply a sunscreen (SPF 50 + ) before any sun expo-
The study was a 12-week, open-label, nonblinded, sure, and to wear sunglasses.
prospective, interindividual clinical trial performed in The degree of improvement in periorbital pigmenta-
the department of dermatology, Pt. Bhagwat Dayal tion was assessed at baseline, 3, 6, 9 and 12 weeks,
Sharma, University of Health Sciences, Rohtak, over objectively using grading system for periorbital hyper-
one and half years duration from November 2013 to pigmentation (POH) as suggested by Sheth et al.9
April 2015. Ninety patients of 18 years and above Color photographs were taken of all patients at base-
with constitutional POM were included in this study. line and at every 3-weekly interval. Secondary out-
Prior written consent was taken from all the patients come measures such as the side effects, if any, were
after explanation of the procedure. A detailed history recorded.

368 © 2016 Wiley Periodicals, Inc.

 GA peel, lactic peel, and vitamin C in POM . S Dayal et al.

Clinical assessments two groups was analyzed using Wilcoxon Signed-Rank

test and Mann–Whitney test, respectively. Likewise,
• Photographs of every patient at baseline and after
physician and patient global assessment between two
treatment were taken with high-resolution digital
groups was analyzed using Mann–Whitney test.
camera (i.e., Nikon coolpix S6300 16 MP Digital
Camera with 10 zoom, nikkor glass lens, and full
HD). The percentage of pigmentary clearance was Significance of results
evaluated by means of photographs and by two All tests were performed at a 5% level of significance;
experienced dermatologists who were not involved thus, an association was significant (S) if the P-value
in the treatment. was less than 0.05 and nonsignificant (NS) if P > 0.05.
• Grading of POH was performed in comparison with
surrounding skin as follows (given by Sheth et al9):
Results
0 – Skin color comparable to other facial skin
areas, Baseline characteristics of patients
1 – Faint pigmentation of infraorbital fold,
2 – Pigmentation more pronounced, Of total 90 patients included in the study, 60 were
3 – Deep dark color, all four lids involved, females and 30 were males, with a male:female ratio
4 – Grade 3 + pigmentation spreading beyond of 2:1. When age incidence was compared in the three
infraorbital fold. groups, there was no statistical difference between
them (mean age in GA peel group was 25.63 
• Physician global assessment: medical observation 4.575 years, in lactic peel group was 26.00  3.806
was performed using the following grading scale10: years, and in topical vitamin C group was 25.20 
o Poor improvement – 0–25% 5.129 years) with P-value = 0.792. Similarly, there
o Fair – 25–50% was no statistical difference in duration of POM
o Good – 50–75% between the three groups (mean duration of POM in
o Excellent – >75% GA peel group was 3.18  1.91 years, lactic peel
group was 3.29  1.73 years, and topical vitamin C
• Patient’s global assessment10: patient’s assessment group was 2.71  1.86 years) with P-value = 0.510.
was graded as poor, fair, good, and excellent. Median of baseline POM grading in all the three groups
10
• Patient’s global tolerance : patient’s tolerance was was 3 (Table 1).
calculated using patient’s global tolerance and
graded as poor, fair, good, and excellent.
Efficacy evaluation

Skin lightening was observed in most of the patients in

Statistical analysis
all the three groups. However, improvement in POM of
The data obtained were entered in MS Excel spread- more than 50% was observed in 73.34% of patients on
sheet, coded appropriately, and later cleaned for any GA peel, in 56.67% of patients on lactic peel, and in
possible errors. Analysis was carried out using SPSS 26.67% of patients on topical vitamin C application
(Statistical Package for Social Studies, Hisar, Haryana, (Figs 1, 2, and 3). On comparing the improvement in
India) Microsoft windows 20th version. Categorical grading of POM with respect to the duration of ther-
data were presented as percentages (%). Quantitative apy, GA peel was significantly more effective than lac-
and qualitative data between groups were analyzed tic peel from 12 weeks onward (P-value = 0.035),
using one-way ANOVA test and Kruskal–Wallis H test, while it was more effective than vitamin C from
respectively. POM grading within a group and between 6 weeks onwards (P-value = 0.007). Lactic peel was

Table 1 Mean of baseline characteristic of patient and median of grading of POM before treatment in different study groups

Parameters 20% Glycolic peel 15% Lactic peel Topical vitamin C P- value

Mean age (in years) 25.63  4.575 26.00  3.806 25.20  5.129 0.792 (insignificant)
Mean duration of POM (in years) 3.18  1.91 3.29  1.73 2.71  1.86 0.510 (insignificant)
Median of baseline grading of POM 3 3 3 –

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GA peel, lactic peel, and vitamin C in POM . S Dayal et al.

(a) (a)

(b) (b)

Figure 1 (a) Periorbital melanosis before 20% GA peels. (b) Peri- Figure 2 (a) Periorbital melanosis before 15% lactic peels. (b)
orbital melanosis after 20% GA peels. Periorbital melanosis after 15% lactic peels.

Safety evaluation

more effective than vitamin C from 6 weeks onwards Safety was assessed by evaluating patient’s global toler-
(P-value = 0.034) (Fig. 4). ance and adverse effects. Most patients (76.67%)
Both physician and patient’s global assessment for described a good to excellent tolerability (patient’s glo-
all the three groups after the treatment are given in bal tolerance; Table 4) with best tolerability in vitamin
Tables 2 and 3. In each group, there was no statisti- C group (i.e., 50% had excellent tolerance) followed by
cal difference between physicians and patients global lactic peel group (i.e., 30% had excellent tolerance)
assessment (P -value = 0.676). However, on compar- and glycolic peel group (26.67%). The most common
ing physician global assessment between the three adverse effect was erythema followed by burning, irri-
groups, glycolic peel was found to be better than lac- tation, itching, and dryness (Fig. 5). However, these
tic peel with statistically significant difference between were only temporary and did not necessitate cessation
them (P-value = 0.010). Similarly, there was a statis- of treatment. No hyper-or hypopigmentation or scar-
tically significant difference between the physician glo- ring was observed post-treatment. The incidence of
bal assessment of glycolic peel and topical vitamin C adverse effects in GA peel group was more (33.33%)
(P-value = 0.00) and lactic peel and topical vitamin C than lactic peel (20%) and topical vitamin C (10%).
(P-value = 0.048) (Table 2). Consequently, the patient
global assessment was reported as excellent in
Discussion
36.67% of patients on GA peel, 16.67% of patients on
lactic acid peel while 0% on topical vitamin C POM is one of the extremely common, yet unexplored
(Table 3). causes of esthetic disfigurement among Indian patients.

370 © 2016 Wiley Periodicals, Inc.

 GA peel, lactic peel, and vitamin C in POM . S Dayal et al.

(a) is no universally effective treatment for POM. Little is

published in the literature regarding this displeasing
entity. However, there are several therapeutic
approaches that may be effective in reducing pigmen-
tation in POM which includes superficial chemical
peels of which AHAs are most favored. Earlier others
have used lactic acid and TCA peels in POM.10 GA peel
has not yet been used much for POM. Besides peels,
topical vitamin C has also been used by earlier workers
with good results in POM.5 However, there is paucity
of studies in the literature comparing various therapeu-
tic modalities for POM with regard to efficacy and
safety till date. Therefore, we underwent this trial com-
paring the clinical efficacy, safety, and tolerability of
20% GA peel, 15% lactic peel, and topical vitamin C in
(b)
90 Indian patients suffering from constitutional POM.
In the present study, of 90 patients, females outnum-
bered males with male-to-female ratio of about 2.91:1.
This female preponderance has also been reported pre-
viously by Sheth et al.9 The higher prevalence among
females may be due to a presumed increase in report-
ing by female patients because of their cosmetic con-
cern. Most of our patients in all the three groups were
in the age group of 21–40 years, representing the
group which is most esthetically concerned. All the
three treatment groups matched statistically with
respect to age, duration of therapy, and baseline POM
grading. Our study showed that the clinical improve-
ment in POM was maximum in GA peel group fol-
Figure 3 (a) Periorbital melanosis before topical vitamin C appli- lowed by lactic peel group, while topical vitamin C
cation. (b) Periorbital melanosis after topical vitamin C application. group showed the least improvement. When the
improvement in the grading of POM with respect to
duration of therapy was analyzed, it was found that
GA peel gave the fastest result followed by lactic peel
and the slowest effect was seen with vitamin C group.
In contrary to this, side effects were found to be more
with GA peel followed by lactic peel and minimum
with vitamin C group.
Both GA and lactic acid are AHA and act through
same mechanism of action. AHAs decrease corneocyte
cohesion leading to sloughing of dead cells and stimu-
lation of new cell growth in the basal cell layer. In
higher concentrations, they cause epidermolysis.11
However, products with a small molecular size per vol-
ume are more active and penetrate the skin more dee-
ply.6 This increased efficacy of GA peel as compared to
lactic acid peel can be explained on the basis of molec-
Figure 4 Improvement in grading of periorbital melanosis.
ular size of glycolic acid. As GA has smaller molecular
size per volume as compared to lactic acid, so it can
POM generally affects 30% of Indian population,9 penetrate the skin deeper and faster as compared to
interfering with the facial appearance and giving the lactic acid and produce much better and faster effect as
patients a tired, sad, or hungover look. Currently, there compared to lactic acid.

© 2016 Wiley Periodicals, Inc. 371

GA peel, lactic peel, and vitamin C in POM . S Dayal et al.

Table 2 Physician’s global assessment in various treatment groups

20% Glycolic peel 15% Lactic peel 20% Vitamin C

Number of patients Percentage (n = 30) Number of patients Percentage (n = 30) Number of patients Percentage (n = 30)

Excellent 13 43.33% 11 36.67% 1 3.33%

Good 9 30% 10 33.33% 9 30%
Fair 7 23.33% 6 20% 13 43.33%
Poor 1 3.33% 3 10% 7 23.33%

Table 3 Patient’s global assessment in various treatment groups

20% Glycolic peel 15% Lactic peel 20% Vitamin C

Number of patients Percentage (n = 30) Number of patients Percentage (n = 30) Number of patients Percentage (n = 30)

Excellent 11 36.67% 5 16.67% 0 0%

Good 10 33.33% 11 36.67% 8 26.67%
Fair 7 23.33% 11 36.67% 10 33.33%
Poor 3 10% 3 10% 12 40%

Table 4 Patient’s global tolerance

20% Glycolic peel 15% Lactic peel 20% Vitamin C

Number of patients Percentage (n = 30) Number of patients Percentage (n = 30) Number of patients Percentage (n = 30)

Excellent 8 26.67% 9 30% 15 50%

Good 12 40% 13 43.33% 12 40%
Fair 10 33.33% 8 26.67% 3 10%
Poor 0 0% 0 0% 0 0%

Figure 5 Adverse effects during and after the treatment.

In the recent years, vitamin C emerged as another hyperpigmentation. Firstly, it affects the monopherase
modality in the treatment of POM.5 There are various activity of tyrosinase via which it inhibits the enzyme
mechanism by which vitamin C reduces the periorbital tyrosinase, thus reducing melanin synthesis.12

372 © 2016 Wiley Periodicals, Inc.

 GA peel, lactic peel, and vitamin C in POM . S Dayal et al.

Secondly, it also has an antioxidant effect, thus pre- References

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