The Safety and Efficacy of Salicylic Acid Chemical Peels in
Darker Racial-ethnic Groups
Pearl E. Grimes, MD
Vitiglio & Pigmentation Institute of Southern California, Los Angeles, California, and Division of Dermatology,
University of California, Los Angeles, California
background. There is a dearth of published data regarding
chemical peels in darker racial-ethnic groups.
objective. The purpose of the present investigation was to as-
sess the clinical efficacy and safety of a new superficial salicylic
acid peel in individuals of skin types V and VI.
methods. Twenty-five patients were included in this pilot inves-
tigation. Nine had acne vulgaris, 5 had post-inflammatory hyper-
pigmentation, 6 had melasma, and 5 had rough, oily skin with
enlarged pores. The patients were pre-treated for 2 weeks with
SUPERFICIAL CHEMICAL peels are an invaluable ac-
coutrement for dermatologists when treating fine wrin-
kles, photoaging, keratoses, acne, and dyspigmentation.
The historical paradigm for such peels has been indi-
viduals with skin types I, II and III. 1 Superficial peels
are usually well tolerated by the lighter complexioned
individual. In contrast, dermatologists have been reluc-
tant to perform chemical peels in darker racial-ethnic
groups because of the tendency of darker-skinned pa-
tients to develop dyschromias in response to cutaneous
injury.2 However, dyschromias are major issues of cos-
metic concern, particularly in individuals with skin type
VI (Fitzpatrick’s Classification).3 In a survey of 2,000
black patients seeking dermatologic care in a private
practice in Washington, D.C., the third most commonly-
cited skin disorders were pigmentary problems other
than vitiligo.4 Of these patients, the majority had a di-
agnosis of post-inflammatory hyperpigmentation fol-
lowed in frequency by melasma. Such patients are usu-
ally treated conservatively with topical bleaching agents
or they are offered no treatment. In light of the afore-
mentioned findings, clinicians are in dire need of addi-
tional innovative, efficacious therapeutic options.
There is a dearth of published data regarding the effi-
cacy and safety of chemical peels in darker racial-ethnic
groups.5–7 The majority of published studies have as-
sessed the efficacy of glycolic acid peels in individuals
with skin type IV. Salicylic acid has recently been for-
Address correspondence and reprint requests to: Pearl E. Grimes, MD,
321 North Larchmont Blvd., Suite 617, Los Angeles, CA 90004.
© 1999 by the American Society for Dermatologic Surgery, Inc. • Published by Blackwell Science, Inc.
ISSN: 1076-0521/99/ • Dermatol Surg 1999;25:18–22
hydroquinone 4% prior to undergoing a series of five salicylic
acid chemical peels. The concentrations of salicylic acid were
20% and 30%. The peels were performed at 2 week intervals.
results. Moderate to significant improvement was observed in
88% of the patients. Minimal to mild side effects occurred in 16%.
conclusion. The results of this study suggest that superficial sal-
icylic acid peels are both safe and efficacious for treatment of acne
vulgaris, oily skin, textural changes, melasma, and post-inflamma-
tory hyperpigmentation in patients with skin types V and VI.
mulated in a hydroethanolic vehicle at concentrations
of 20% and 30% for use as a superficial peeling agent.8
It is a lipophilic agent which produces desquamation of
the upper, lipophilic layers of the stratum corneum. Sal-
icylic acid is a hydroxyl derivative of benzoic acid and
represents a carboxylic acid attached to an aromatic al-
cohol, phenol. Although the efficacy of this product has
been described in Caucasians with acne and photoag-
ing,8,9 no studies have assessed its use in darker skin
types. The purpose of the present pilot investigation
was to evaluate the safety and efficacy of salicylic acid
peels in skin types V and VI.
Patients and Methods
Patients
Twenty-five patients were included in this study. Their
mean age was 34. There were 22 females and 3 males.
Twenty were African-American and 5 were Hispanic.
Nine patients had acne vulgaris, 5 had post-inflamma-
tory hyperpigmentation, 6 had melasma, and 5 had
oily skin, enlarged pores, and rough textural changes.
Pregnant or nursing women and individuals with known
hypersensitivity to salicylic acid and/or hydroquinone
were excluded from the study. Informed consent was
obtained from each patient prior to participation in
this study.
Methods
Chemical Peel Protocol. Patients were pre-treated for 2 weeks
with 4% hydroquinone. Salicylic acid peels (Beta LiftX, Medi-
Dermatol Surg 25:1:January 1999 grimes: salicylic acid peels in darker skin 19

Table 1. Therapeutic Responses in Patients Treated with Beta-lift (Salicylic Acid) Chemical Peels (Fitzpatrick’s Skin Types V–VI)

Clinical Improvement %

No. of No (1–25%) (26–50%) (51–75%) (.75%)

Disorder Patients Response Minimal Mild Moderate Significant

Acne Vulgaris 9 0 0 1 (11%) 2 (22%) 6 (67%)

Oily skin/Rough Textural Changes 5 0 0 0 0 5 (100%)
Post-Inflammatory Hyperpigmentation 5 0 0 0 1 (20%) 4 (80%)
Melasma 6 0 0 2 (33%) 2 (33%) 2 (33%)

cis Pharmaceuticals, Phoenix, AZ) were performed at 2
week intervals and each patient completed a series of 5 such
peels. After thorough cleaning with a pre-cleanser contain-
ing water, SD alcohol, and witch hazel, salicylic acid was
applied to the entire face with a wedge sponge for three to
five minutes. The face was rinsed with tap water followed
by an application of triethanolamine neutralizer and repeat
rinsing. Two 20% then three 30% salicylic acid peels were
performed sequentially with a 2 week interval between each
peel. Immediate post-peel care included bland soaps and
moisturizers. Each subject resumed use of 4% hydroquinone
2 days after each peel. Photographs were taken of each pa-
tient at baseline and biweekly using a Yashica Dental Eye
Camera and Ektachrome 100 film. Clinical response was
graded by an independent investigator who evaluated serial
photographs. The rating score was as follows:
0: no improvement
1 to 25% clearing: minimal improvement
26 to 50% clearing: mild improvement

Figure 1. A. Pre-peel: Twenty-eight year old female with acne vulgaris. B. Improvement in acne and skin texture after 2 20% salicylic acid
peels.
20 grimes: salicylic acid peels in darker skin
51 to 75% clearing: moderate improvement
Greater than 75% clearing: significant improvement
Results
Clinical Responses
Improvement occurred in all patients included in this
pilot investigation (Table 1). Moderate to significant
improvement was observed in 22/25 (88%). Mild clear-
ing occurred in 3/25 (12%). Varying levels of clinical
improvement were observed in all patients after the sec-
ond 20% peel.
Moderate to significant clearing of acne vulgaris oc-
curred in 8/9 (89%). The series of salicylic acid peels fa-
cilitated the clearing of pustules, papules, and come-
dones. This was evidenced clinically by an overall rapid
reduction in lesions including microcomedones in acne
patients and those with rough oily skin and enlarged
pores. Acne lesions appeared to clear faster than experi-
ence indicates would ordinarily occur with traditional
therapy (Figures 1, 2). Significant improvement occurred
Figure 2. A. Pre-peel: Eighteen-year-old female with acne vulgaris. B. Significant clearing of numerous comedonal lesions.
Dermatol Surg 25:1:January 1999
in 5/5 (100%) of patients with oily skin, enlarged pores,
and rough textural changes. There was significant dimi-
nution in excess oiliness accompanied by improvement
in skin texture. Clinically, enlarged poral orifices ap-
peared to shrink in size (Figure 4).
The series of salicylic acid peels in combination with
4% hydroquinone expedited and facilitated the reso-
lution of post-inflammatory hyperpigmentation and
melasma. Moderate to significant improvement occurred
in 5/5 (100%) of patients with post-inflammatory hyper-
pigmentation and 4/6 (66%) of patients with melasma.
Salicylic acid peels and twice daily application of 4%
hydroquinone produced substantial decreases in the in-
tensity of hyperpigmentation and lesional area for both
post-inflammatory hyperpigmentation and melasma
(Figure 3). There was also a decrease in overall facial
pigmentation which was cosmetically acceptable for
the patient. In addition, the patients with post-inflam-
matory hyperpigmentation and melasma had improve-
ment in skin texture (Figures 3A, 3B, 4A, 4B).
In general, the superficial salicylic acid peels were
well tolerated in this series of patients with skin types
Dermatol Surg 25:1:January 1999 grimes: salicylic acid peels in darker skin 21

Figure 3. A. Pre-peel: Twenty-four year old female with oily skin and post-inflammatory hyperpigmentation. B. Significant clearing of hy-
perpigmentation and improvement in the appearance of oily skin.

V and VI. Side effects were absent in 21/25 (84%). Four had transient dryness and hyperpigmentation which
patients (16%) experienced mild side effects. One pa- resolved within 7 to 14 days. Residual hypopigmenta-
tient had temporary crusting and hypopigmentation tion or hyperpigmentation did not occur. Side effects
which completely cleared in seven days. Three patients did not correlate with the duration of peel.

Figure 4. A. Pre-peel: Forty-two year old female with melasma and surface roughness. B. After completion of the series of salicylic acid
peels, there is significant improvement in severe hyperpigmentation and surface roughness.
22 grimes: salicylic acid peels in darker skin
Discussion
In this pilot investigation, 25 patients with Fitzpatrick’s
Skin Types V and VI were treated with a series of 5 su-
perficial salicylic acid peels performed at 2-week inter-
vals. Conditions treated included acne vulgaris, post-
inflammatory hyperpigmentation, melasma, and rough/
oily skin with enlarged pores. Moderate to significant
improvement was observed in 88% percent of the pa-
tients. Mild improvement occurred in 12%.
The observation of clinical improvement in the ap-
pearance of enlarged pores was maintained for 8 to 12
weeks. Possible mechanisms for the appearance of re-
duction in pore size include salicylic acid’s effect on
lipid solubility and micro comedone formation.
Despite the notoriously labile response of melano-
cytes in darker racial-ethnic groups to cutaneous injury,
the new salicylic acid peel used in this study demon-
strated significant efficacy and induced minimal to no
side effects. Furthermore, the combined use of hydro-
quinone 4% in combination with the salicylic acid peel
expedited the clearing of hyperpigmented lesions and
significantly decreased the occurrence of hyperpigmen-
tation, a common post-peel sequelae in skin types V
and VI. Preliminary unpublished data from the Vitiligo
and Pigmentation Institute of Southern California dem-
onstrated an increased frequency of post-peel hyperpig-
mentation when salicylic acid peels were used without
the combined use of 4% hydroquinone. In addition,
when the 30% salicylic acid peel was used as the initial
peel concentration, there was an increased frequency of
post-peel hyperpigmentation. Hence, titrating the con-
centration of the salicylic acid peel and the combined
use of 4% hydroquinone significantly decreased the fre-
quency of post-peel hyperpigmentation. This combina-
tion therapeutic approach expedited the improvement
and/or resolution of post-inflammatory hyperpigmenta-
tion and melasma. In addition, the combination of sali-
cylic acid peels and 4% hydroquinone showed more
rapid improvement when compared to a data base us-
ing only 4% hydroquinone (Nordlund JJ, Granger C,
Grimes PE, et al. Efficacy of 2% and 4% hydroquinone
for treatment of hyperpigmentation. Submitted manu-
script). Although a tri-ethanolamine neutralizer was used
Commentary
This paper expands our knowledge of using chemical peels in
dark-complexioned individuals. Many practitioners are wary of
performing peels on this group because of the risk of hyperpigmen-
tation. This clinical study demonstrates that serial salicylic acid
peels are beneficial for acne, post-inflammatory hyperpigmenta-
tion, melasma, oily skin, enlarged pores, and surface roughness.
The small percentage of patients with transient pigmentary side ef-
Dermatol Surg 25:1:January 1999
in the present investigation similar results can be ob-
tained using cleaners such as Cetaphil liquid cleanser.
The results of this investigation using salicylic acid
peels corroborate the safety and efficacy profile of sev-
eral previously published studies using glycolic acid peels
in darker racial-ethnic groups.5-7 Lim and Tham5 and
Wang6 treated Asian patients with melasma and acne re-
spectively and reported improvement with few side ef-
fects. In addition, Burns, et al.7 treated nineteen black pa-
tients with post-inflammatory hyperpigmentation using
a range of glycolic acid peels for comparison with a stan-
dard regimen of hydroquinone and tretinoin. Patients re-
ceiving the peels showed a trend toward greater and
more rapid improvement. Twenty of our series of patients
were African-American. The peels were extremely well
tolerated with few side effects in this group of patients.
The superficial 20% and 30% salicylic acid peels
used in this study were safe and efficacious for skin
types V and VI. Salicylic acid peels offer significant ad-
junctive benefit when treating acne vulgaris, oily skin,
enlarged pores, textural changes, post-inflammatory hy-
perpigmentation, and melasma. However, in light of
the recognized tendency of darker skin to develop dys-
chomias, superficial peeling should be approached with
care and caution.
References
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2. Grimes PE, Hunt SG. Considerations for cosmetic surgery in the
black population. Clin Plast Surg, 1993;20:27–34.
3. Grimes PE. Melasma: Etiologic and therapeutic considerations.
Arch Dermatol, 1995;131:1453–7.
4. Halder RM, Grimes PE, McLauren CI, Kress MA, Kenney JA, Jr.
Incidence of common dermatoses in a predominantly black derma-
tologic practice. Cutis, 1983;32:388–90.
5. Lim JT, Tham SN. Glycolic acid peels in the treatment of melasma
among Asian women. Dermatol Surg, 1997;20:27–34.
6. Wang CM, Huang CL, Hu CT, Chan HL. The effects of glycolic
acid on the treatment of melasma among Asian skin. Dermatol
Surg, 1997;23:23–9.
7. Burns RL, Prevost-Blank PL, Lawry MA, et al. Glycolic acid peels
for post inflammatory hyperpigmentation in black patients: A com-
parative study. Dermatol Surg, 1997;23:171–4.
8. Kligman D, Kligman AM. Salicylic acid as a peeling agent for the
treatment of acne. Cosmetic Dermatol, 1997;10:44–7.
9. Kligman D, Kligman AM: Salicylic acid peels for the treatment of
photoaging. Dermatol Surg, 1998;24:325–8.
fects is benefited by post-peel hydroquinone treatment. This study
by a practitioner with significant experience in treating pigmentary
problems in darkly complexioned patents should encourage others
to begin offering chemical peels to this group of patients.
Douglas Kligman, MD, PhD
Conshohocken, Pennsylvania