الفهرس 
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Abstract
Melasma is an acquired increased pigmentation of the skin characterized by symmetrical and confluent grey-brown patches mostly on the areas of the face exposed to the sun, such as the cheek bones, forehead, and chin. It may occasionally affect other areas such as the neck and forearms (Newcomer, 1961).
Chemical peels are a well-known modality of treatment for melasma. The basic mechanism of the action of chemical peels in melasma is the removal of unwanted melanin by causing a controlled chemical burn to the skin. Peels have proved to be useful agents for melasma both as a sole treatment as well as an adjunct to other topical therapies (Sheth & Pandya, 2011).
The aim of this study is to compare the efficacy of 20% trichloroacetic acid and 70% glycolic acid in treatment of epidermal melasma.
This study was carried out at the Dermatology, Venereology, and Andrology outpatient clinic in Sohag University Hospital, Egypt. The study was approved by the Ethical Commette of the faculty. A total of fifty patients diagnosed clinically as melasma were chosen randomly and recruited in this study. They were treated with TCA 20% peels (right side of the face) versus glycolic acid 70% peel (left side of the face) in a split face manner.
The mean age ranged from 20-52 years, with a mean of 34.94±8.874 years, all patients were females, the majority of them of rural residence. The duration of the disease ranged from 1-18 years, with a mean of 5.66±3.66 years.
Regarding skin type, most of patients had skin type IV (72.0%), then type III (16.0%) and lastly type V (12.0%). Melasma in the present study showed predominantly a centrofacial pattern (58%).
The main precipitating factor in recruited patients was sunlight (80%) followed by pregnancy (78%), family history was detected in (40%) of patients, and use of cosmetics (22%). Past history of oral contraceptive pills use was detected in (34%) of patients.
Regarding clinical response: in the right side, a good response was detected in 38 patients (76%), moderate in 6 patients (12%) and mild in 6 patients (12%); and in the left side, good response was detected in 26 patients (52%), moderate in 18patients (36%) and mild in 6 patients (12%).
As regards the comparison between the degree of improvement in right side of the face (TCA 20%) and in left side (glycolic 70%); the subjective response, as graded by the patient, showed significantly difference in the mean of clinical response in TCA 20% peel of right side of the face (2.00 ± 0.56) versus the mean of clinical response in glycolic 70% peel of left side of the face (1.76 ± 0.66).
Comparing the MASI score before treatment in the right and left sides, it showed that there was no statistically significant difference. Comparison between MASI score before and after treatment in the right side showed that the mean of the MASI score post- treatment (4.1± 2.1) in the right side of the face was significantly decreased than the mean of the MASI pre-treatment (6.7± 2.9). Comparison between MASI score before and after treatment in the left side showed that the mean of the MASI score post- treatment (3.6± 2.06) in the left side of the face (TCA peel) was significantly decreased than the mean of the MASI score pre-treatment (5.9± 2.9). When we compared the MASI score after treatment in the right and left sides, we found that there is no statistically significant difference.
The complications during follow up period in the right side were post-peel erythema which was obvious in 7 patients (14%), 3 patients (6%) reported post peel crackening lasted for 3-4 days and relieved by using topical antibacterial ointment and emollients, 5 patients suffered from transient post inflammatory hyper-pigmentation (10%) . No relapse was occurred. The complication in the left side were post peel erythema which was seen in 6% of patients, and 6% of patients reported post-inflammatory hyper pigmentation and prolonged exfoliation during follow up period. Relapse was seen in only four cases after a follow up of 6 months in left side of the face (glycolic acid 70%) at the same site (patients did not avoid UV radiation and neglected sun screen usage). Other patients maintained the results achieved with the regular use of sunscreens.
The improvement in treatment response both side of the face showed direct proportion with skin photo-type especially in patients with skin photo type IV. As regard the Correlation between disease duration and treatment response it was found that the response of melasma to 20%TCA peel and 70% glycolic acid peel was not affected by its duration.
It was found that no significant correlation between clinical response and MASI score before and after treatment in both sides of the face. A statistically significant association was observed between skin type and MASI score before treatment (positive correlation). After treatment it showed negative correlation.
CONCLUSION
from the previous mentioned results we observed that chemical peeling with 20% TCA and 70% glycolic acid significantly reduces MASI scores and both are equally effective in the treatment of melasma.
There is also need to evaluate the role of combination therapy and design protocols to provide optimum results and prevent relapses.
It is essential to use sun block after chemical peeling to avoid hyperpigmentation.
However permanent melasma cure in our community is very difficult due to our climate, frequent sun exposure with long summer time, darker skin photo-type and high priced sunscreen as regard income.