The treatment of melasma: A review of clinical trials

Branch-shaped Cutaneous Hypopigmentation and Atrophy after Intralesional Triamcinolone Injection

Cutaneous changes after local corticosteroid administration may include dermal atrophy, hyperpigmentation, alopecia, and hypopigmentation. Linear hypopigmentation and atrophy after intralesional injection of triamcinolone acetonide has been reported in the literature as a very rare side effect. A 30-year-old woman visited our dermatology department for a linear hypopigmented patch with atrophy from her left foot to the lower margin of the knee. The lesion developed after injection of an intralesional corticosteroid. The patient was diagnosed with linear hypopigmentation and atrophy secondary to the triamcinolone injection.

Treatment options for rosacea with concomitant conditions

Patients with rosacea frequently present with coexisting skin conditions, such as seborrheic dermatitis, acne, perioral dermatitis, and melasma, which may complicate diagnosis and treatment. This article discusses the presentation, pathophysiology, and management of rosacea with common concomitant skin disorders.

Aspergillus flavus

Aspergillus flavus is saprophytic soil fungus that infects and contaminates preharvest and postharvest seed crops with the carcinogenic secondary metabolite aflatoxin. The fungus is also an opportunistic animal and human pathogen causing aspergillosis diseases with incidence increasing in the immunocompromised population. Whole genome sequences of A. flavus have been released and reveal 55 secondary metabolite clusters that are regulated by different environmental regimes and the global secondary metabolite regulators LaeA and VeA. Characteristics of A. flavus associated with pathogenicity and niche specialization include secondary metabolite production, enzyme elaboration, and a sophisticated oxylipin host crosstalk associated with a quorum-like development program. One of the more promising strategies in field control involves the use of atoxic strains of A. flavus in competitive exclusion studies. In this review, we discuss A. flavus as an agricultural and medical threat and summarize recent research advances in genomics, elucidation of parameters of pathogenicity, and control measures.

MITF-siRNA formulation is a safe and effective therapy for human melasma

It is unclear whether siRNA-based agents can be a safe and effective therapy for diseases. In this study, we demonstrate that microphthalmia-associated transcription factor-siRNA (MITF-siR)-silenced MITF gene expression effectively induced a significant reduction in tyrosinase (TYR), tyrosinase-related protein 1, and melanocortin 1 receptor (MC1R) levels. The siRNAs caused obvious inhibition of melanin synthesis and melanoma cell apoptosis. Using a novel type of transdermal peptide, we developed the formulation of an MITF-siR cream. Results demonstrated that hyperpigmented facial lesions of siRNA-treated subjects were significantly lighter after 12 weeks of therapy than before treatment (P < 0.001); overall improvement was first noted after 4 weeks of siRNA treatment. At the end of treatment, clinical and colorimetric evaluations demonstrated a 90.4% lightening of the siRNA-treated lesions toward normal skin color. The relative melanin contents in the lesions and adjacent normal skin were decreased by 26% and 7.4%, respectively, after treatment with the MITF-siR formulation. Topical application of siRNA formulation significantly lightens brown facial hypermelanosis and lightens normal skin in Asian individuals. This treatment represents a safe and effective therapy for melasma, suggesting that siRNA-based agents could be developed for treating other diseases such as melanoma.

A low fluence Q-switched Nd:YAG laser modifies the 3D structure of melanocyte and ultrastructure of melanosome by subcellular-selective photothermolysis

Laser treatment using low fluence for melasma was previously introduced to overcome postinflammatory hypermelanosis after Q-switched laser therapy. However, research on the mechanism of this treatment is very limited. In this study, a collimated low fluence 1064 nm Q-switched Nd:YAG laser with a pulse width of <7 ns was applied using top-hat beam mode. The aim of this study was to investigate the mode of action of this laser treatment through electron microscopy. The effectiveness of this treatment was confirmed by clinical photos, melasma area and severity index and spectrophotometer. To understand the mode of action, the three-dimensional structure of melanocytes in the epidermis was analyzed using serial images acquired by a 3VIEW surface block face scanning electron microscope. In the epidermis, after laser treatment, fewer dendrites in the melanocytes were observed compared with pretreatment. In addition, ultrastructural changes in the melanosome were studied using transmission electron microscopy, which showed that laser treatment caused selective photothermolysis on Stage IV melanosome. Therefore, this treatment should be regarded as an effective method for treating melasma through subcellular-selective photothermolysis.

Changes in flavonoid content and tyrosinase inhibitory activity in kenaf leaf extract after far-infrared treatment

The tyrosinase inhibitory activity of ethanolic extract of kenaf (Hibiscus cannabinus L.) leaf was evaluated before and after subjecting it to far-infrared (FIR) irradiation. The main component of the extract was analyzed as kaempferitrin (kaempferol-3,7-O-α-dirhamnoside). Prior to FIR irradiation, no inhibitory activity of the extract was detected in a tyrosinase assay. However, after FIR irradiation for 1h at 60°C, significant tyrosinase inhibitory activity (IC(50)=3500 ppm) was observed in it. In HPLC analysis, derhamnosylation products (kaempferol, afzelin, and α-rhamnoisorobin) were detected. The inhibitory activity may be due to the existence of derhamnosylation products. This study demonstrated that FIR irradiation can be used as a convenient tool for deglycosylation of flavonoid glycoside.

Treatment of refractory melasma with the MedLite C6 Q-switched Nd:YAG laser and alpha arbutin: a prospective study

OBJECTIVE

To evaluate the effectiveness of a Q-switched Nd:YAG laser (MedLite C6; HOYA ConBio, Fremont, CA, USA) and 7% alpha arbutin solution (Skin Advance Laboratory, Japan) in the treatment of melasma.

METHODS

This was a prospective study of 35 refractory melasma cases treated with 10 weekly laser sessions, two monthly follow-up treatments and topical 7% alpha arbutin solution. Clinical photographs and severity grading on a 5-point scale were carried out by an independent observer at each visit.

RESULTS

At 6 months, 30% of study subjects received results in the excellent clearance category (> 81% reduction of melasma) and 36.7% received good (51-80% reduction) clearance. Mild and transient side effects included discomfort during treatment, erythema, whitening of fine hair and urticaria. Three cases of mottling hypo-pigmentation (8.57%) and two cases of recurrence of melasma (5.71%) were recorded.

CONCLUSION

Combination therapy with the MedLite C6 and 7% alpha arbutin solution is an effective and well-tolerated treatment for refractory melasma.

Melasma treated with intense pulsed light

BACKGROUND

Hypermelanosis includes a diverse group of genetic and acquired skin anomalies that appear as darker, hyperpigmented areas. Melasma, in particular, is a hypermelanotic condition that affects sun-exposed skin in females. Whether this condition is acquired or genetic is still controversial. However, it clearly correlates with exposure to UV light, a genetic predisposition, and hormonal variations (from pregnancy or oral contraceptives).

METHODS

Between October 2006 and March 2008, 38 patients with melasma were treated with intense pulsed light (IPL) at the LASER Center of the Department of Health Science, Plastic and Reconstructive Surgery Session, University of L'Aquila. Diagnosis was based on medical history, physical examination, and video microscopy.

RESULTS

Results were graded as excellent, good, moderate, or poor. Grades were given according to outcome scale and reported complications. All 38 patients had follow-up checks at 30 days, 3 months, and 6 months and someone at more than 1 year. Results were excellent in 18 patients (47.37%), good in 11 (28.95%), moderate in 5 (13.16%), and poor in 4 cases (10.52%).

CONCLUSION

From a careful review of the scientific literature and according to our personal clinical experience, IPL stands out as an effective tool in the treatment and healing of a high percentage of hypermelanosis and melasma, with a very low risk of complications and an excellent satisfaction rate among patients.

Interventions for melasma

BACKGROUND

Melasma is an acquired symmetrical pigmentary disorder where confluent grey-brown patches typically appear on the face. Available treatments for melasma are unsatisfactory.

OBJECTIVES

To assess interventions used in the management of all types of melasma: epidermal, dermal, and mixed.

SEARCH STRATEGY

In May 2010 we searched the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (Clinical Trials) in The Cochrane Library, MEDLINE, EMBASE, PsycINFO, and LILACS. Reference lists of articles and ongoing trials registries were also searched.

SELECTION CRITERIA

Randomised controlled trials that evaluated topical and systemic interventions for melasma.

DATA COLLECTION AND ANALYSIS

Study selection, assessment of methodological quality, data extraction, and analysis was carried out by two authors independently.

MAIN RESULTS

We included 20 studies with a total of 2125 participants covering 23 different treatments. Statistical pooling of the data was not possible due to the heterogeneity of treatments. Each study involved a different set of interventions. They can be grouped into those including a bleaching agent such as hydroquinone, triple-combination creams (hydroquinone, tretinoin, and fluocinolone acetonide), and combination therapies (hydroquinone cream and glycolic acid peels), as well as less conventional therapies including rucinol, vitamin C iontophoresis, and skin-lightening complexes like Thiospot and Gigawhite.Triple-combination cream was significantly more effective at lightening melasma than hydroquinone alone (RR 1.58, 95% CI 1.26 to 1.97) or when compared to the dual combinations of tretinoin and hydroquinone (RR 2.75, 95% CI 1.59 to 4.74), tretinoin and fluocinolone acetonide (RR 14.00, 95% CI 4.43 to 44.25), or hydroquinone and fluocinolone acetonide (RR 10.50, 95% CI 3.85 to 28.60).Azelaic acid (20%) was significantly more effective than 2% hydroquinone (RR 1.25, 95% CI 1.06 to 1.48) at lightening melasma but not when compared to 4% hydroquinone (RR 1.11, 95% CI 0.94 to 1.32).In two studies where tretinoin was compared to placebo, participants rated their melasma as significantly improved in one (RR 13, 95% CI 1.88 to 89.74) but not the other. In both studies by other objective measures tretinoin treatment significantly reduced the severity of melasma.Thiospot was more effective than placebo (SMD -2.61, 95% CI -3.76 to -1.47).The adverse events most commonly reported were mild and transient such as skin irritation, itching, burning, and stinging.

AUTHORS' CONCLUSIONS

The quality of studies evaluating melasma treatments was generally poor and available treatments inadequate. High-quality randomised controlled trials on well-defined participants with long-term outcomes to determine the duration of response are needed.

Topical treatment of melasma

Melasma is a common hypermelanotic disorder affecting the face that is associated with considerable psychological impacts. The management of melasma is challenging and requires a long-term treatment plan. In addition to avoidance of aggravating factors like oral pills and ultraviolet exposure, topical therapy has remained the mainstay of treatment. Multiple options for topical treatment are available, of which hydroquinone (HQ) is the most commonly prescribed agent. Besides HQ, other topical agents for which varying degrees of evidence for clinical efficacy exist include azelaic acid, kojic acid, retinoids, topical steroids, glycolic acid, mequinol, and arbutin. Topical medications modify various stages of melanogenesis, the most common mode of action being inhibition of the enzyme, tyrosinase. Combination therapy is the preferred mode of treatment for the synergism and reduction of untoward effects. The most popular combination consists of HQ, a topical steroid, and retinoic acid. Prolonged HQ usage may lead to untoward effects like depigmentation and exogenous ochronosis. The search for safer alternatives has given rise to the development of many newer agents, several of them from natural sources. Well-designed controlled clinical trials are needed to clarify their role in the routine management of melasma.

Pycnogenol: a blend of procyanidins with multifaceted therapeutic applications?

Great interest is currently centred on the biologic activities of pycnogenol a standardized plant extract obtained from the bark of the French maritime pine Pinus pinaster (formerly known as Pinus maritima), Aiton, subspecies Atlantica des Villar (Pycnogenol, Horphag Research Ltd., UK, Geneve, Switzerland), which grows in the coastal southwest France. The quality of this extract is specified in the United States Pharmacopeia (USP 28). Between 65% and 75% of Pycnogenol are procyanidins comprising of catechin and epicatechin subunits with varying chain lengths. Other constituents are polyphenolic monomers, phenolic or cinnamic acids and their glycosides. As many studies indicate, pycnogenol components are highly bioavailable. Uniquely, pycnogenol displays greater biologic effects as a mixture than its purified components do individually indicating that the components interact synergistically. Pycnogenol is now utilized throughout the world as a nutritional supplement and as a phytochemical remedy for various diseases ranging from chronic inflammation to circulatory dysfunction, including several impaired psycho-physiological functions. Owing to the basic chemical structure of its components, the most obvious feature of pycnogenol is its strong antioxidant activity. In fact, phenolic acids, polyphenols, and in particular flavonoids, are composed of one (or more) aromatic rings bearing one or more hydroxyl groups and are therefore potentially able to quench free radicals by forming resonance-stabilized phenoxyl radicals. In this review, emphasizing the molecular, cellular, and functional bases of therapy, data appearing in the peer-reviewed literature and focussing the main therapeutic applications of pycnogenol will be summarized and critically evaluated.

Acne in skin of color: practical approaches to treatment

Acne vulgaris, one of the most commonly encountered conditions in dermatology, affects individuals in all racial and ethnic groups, yet clinical presentation varies among different skin types. Acne, particularly when it is severe, may significantly impact an individual's quality of life and psychological well-being. Potential sequelae, such as postinflammatory hyperpigmentation and keloid scarring, occur more frequently in individuals with skin of color and may be long lasting or permanent. Acknowledging the potentially long-term physical and emotional scars caused by acne vulgaris, attention has focused on management strategies that limit the disease to an early stage. Early and efficacious treatment of acne in skin of color patients may minimize pigmentary abnormalities and keloid scarring. By recognizing racial and ethnic differences in clinical presentation and potential sequelae, treatment regimens may be tailored to ensure favorable outcomes for patients of all skin types.

Low-fluence Q-switched neodymium-doped yttrium aluminum garnet laser for melasma with pre- or post-treatment triple combination cream

BACKGROUND

Topical triple combination (TC) treatment is considered the primary approach to melasma. Recently, collimated low-fluence 1,064-nm Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) laser treatment has attracted attention as an alternative approach.

OBJECTIVES

To compare the clinical efficacy and adverse effects of low-fluence Q-switched Nd:YAG laser when performed before and after treatment with topical TC using a split-face crossover design.

METHODS

Thirteen patients with melasma received topical treatment with TC cream or 1,064-nm Q-switched Nd:YAG laser treatment on opposite sides of the face for 8 weeks, and then treatments were reversed for 8 weeks. Responses were evaluated using the Melasma Area and Severity Index scoring system, spectrophotometry measurements, and a subjective self-assessment method.

RESULTS

After 16 weeks, better results were seen in subjective assessments when laser treatment was used after 8 weeks of topical TC treatment than before usage of TC. There were no significant adverse effects with the laser treatments.

CONCLUSIONS

Laser treatment after topical TC cream was found to be safer and more effective than the post-treatment use of topical agents.

Melasma in Latin America: options for therapy and treatment algorithm

OBJECTIVE/AIM

To examine approaches to therapy for melasma in Latin Americans and to propose treatment algorithms for patients with mild, moderate and severe melasma.

BACKGROUND

Melasma is prevalent in up to 10% of the Latin American population. It is found in all racial groups and is more common in subjects with darker skin phototypes. A number of topical treatments and procedures have been used for melasma. Topical treatments containing hydroquinone are the most popular. Care must be taken when treating melasma to avoid inducing post-inflammatory hyperpigmentation and ochronosis. Determination of the severity of melasma (using the Melasma Area Severity Index and/or Physician's Global Assessment) and choice of the most effective and suitable treatment and/or procedure for individual patients is therefore essential. Sun protection is mandatory for all melasma patients.

METHODS

Thirty-one clinical studies of topical treatments, chemical peels and laser and other therapies used for treating melasma were assessed for the level and quality of clinical evidence, by the Latin American Pigmentary Disorders Academy. The results of this analysis were combined with differential diagnosis guidelines and methods for assessing treatment success to establish algorithms for treating mild and moderate-to-severe melasma.

RESULTS

The most appropriate first-line treatment for mild melasma is hydroquinone 4%, triple combination cream containing hydroquinone 4%, tretinoin 0.05% and fluocinolone acetate 0.01%, double combination (e.g. 4% hydroquinone and 0.1% tretinoin) or non-phenolic therapy where there is an allergy to compounds. In moderate-to-severe melasma, triple combination cream is the recommended first-line treatment. Second-line treatment is double combination or hydroquinone 4% where triple therapy is not available or if allergic to compounds. Sun avoidance measures and broad spectrum sunscreens with high SPF are fundamental for the successful management of the disease.

Hirseins inhibit melanogenesis by regulating the gene expressions of Mitf and melanogenesis enzymes

Previously, we reported that Thymelaea hirsuta extract has antimelanogenesis effect on B16 murine melanoma cells. The extract was subjected to fractionation, and hirsein A (HA) and hirsein B (HB) were discovered and tested for their ability to regulate melanogenesis in B16 cells. Western blot (WB) analysis was carried out to determine the expression of tyrosinase. Moreover, to elucidate the possible mechanism behind melanogenesis regulation, real-time PCR using primers for Mitf, Tyr, Trp1 and Dct genes, and protein kinase C (PKC) activity assay were carried out. Results clearly show that 0.1 mum HA and HB significantly reduced the melanin content. This reduction in melanin content was accompanied by reduced tyrosinase expression as detected by WB analysis. There was also a significant decrease in the expression level of Mitf gene in HA- and HB-treated cells. HA down-regulated the expressions of Tyr, Trp1 and Dct, whereas HB down-regulated only those of Trp1 and Dct. Interestingly, HB-treated cells had lower kinase activity than HA-treated cells indicating a possible difference in the activities of the compounds but with the same mechanism of melanogenesis regulation. We report for the first time that HA and HB can down-regulate melanogenesis by down-regulating Mitf gene expression, leading to reduced expressions of Tyr, Trp1 and Dct. The hirseins were also able to reduce the kinase activity, suggesting the possible involvement of PKC in the overall ability of the hirseins to down-regulate melanogenesis.

Infraorbital dark circles: definition, causes, and treatment options

BACKGROUND

Infraorbital dark circles refer to the conditions that present with darkness of the infraorbital eyelids. Although it is not a medical concern, it can be a cosmetic concern for a large number of individuals. Moreover, clear definition and possible causes have not been elucidated.

OBJECTIVE

To review the possible causes and treatment options for infraorbital dark circles.

METHODS

The article is based on a review of the medical literature and the author's clinical experience in treating infraorbital dark circles.

CONCLUSION

Possible causative factors of infraorbital dark circles include excessive pigmentation, thin and translucent lower eyelid skin overlying the orbicularis oculi muscle, and shadowing due to skin laxity and tear trough, but because multiple factors cause infraorbital dark circles in the majority of patients, it is essential to identify the cause and choose the appropriate treatment according to the cause.

Combined use of intense pulsed light and Q-switched ruby laser for complex dyspigmentation among Asian patients

BACKGROUND

Dyspigmentation is a common cosmetic concern among Asians. Many individuals exhibit mixed pigmentary entities including melasma, flat/small seborrheic keratoses, ephelides, solar lentigines and acquired bilateral nevus-of-Ota-like macules (ABNOM). We term this phenomenon complex dyspigmentation (CD) and suggest that a combination strategy may be more efficacious than any singular modality.

OBJECTIVE

To determine the effectiveness of combined intense-pulsed light (IPL) for global photorejuvenation along with Q-switched ruby laser (QSRL) for targeted pigment dissolution.

STUDY DESIGN/MATERIALS AND METHODS

Twenty-five Korean women with CD (defined as >2 types of facial pigmentary disorders) were initially treated with IPL followed by repeat treatments every 3-4 weeks as needed. The QSRL treatments, set at low fluence, were added either during the same session or within 1 week of the IPL treatment. Improvement was assessed by the patient, the treating physician and a blinded evaluation of pre- and post-treatment photographs.

RESULTS

Using a 4-point scale (1 = poor, 2 = fair, 3 = good, 4 = excellent), 19/25 patients (76%) reporting good-to-excellent response (score "3" or "4"). Two independent physician assessment revealed that 15/25 patients (60%) showed 76-100% improvement while 19/25 patients (76%) showed at least 50% improvement. Side-effects were minimal: 3 patients had transient post-inflammatory hyperpigmentation (12%) and 1 patient (4%) had linear hypopigmentation.

CONCLUSIONS

Combination treatment with IPL and QSRL is an effective and safe treatment for CD among Asian patients.

Hyperpigmentation and melasma

Facial and neck pigmentations are significant cosmetic problems. They are common in middle-aged women, related to endogenous (hormones) and exogenous factors (cosmetics, perfumes, sun exposure), and often represent paramount causes of emotional distress. Although melasma is the most common cause of facial pigmentation, there are many other forms including drug-induced and postinflammatory hyperpigmentation. We review pathogenesis, clinical and histopathological data, effect on quality of life, and treatment options in facial hyperpigmentation disorders.

A new concept in the topical treatment of onychomycosis with cyanoacrylate, undecylenic acid, and hydroquinone

The authors report a pilot study of a new approach for the topical treatment of onychomycosis using physiologic principles of fungal growth and serial debridement. In total, 154 patients were studied for 1 year with mild, moderate, and severe nail disease. Negative mycologic cultures in these 3 groups were 100%, 65%, and 35%, respectively. All patients reported subjective improvement in the first 3 months.

Therapeutical Approaches in Melasma

Melasma (cloasma) is a typical hypermelanosis and a common dermatologic skin disease that involves sun-exposed areas of the skin. It mostly affects women of reproductive age. Solar and ultraviolet exposure are the most crucial etiologic factors. Pregnancy, certain endocrine disorders and hormonal treatments, cosmetics, phototoxic drugs, and antiseizure medications are well-known inducing and exacerbating factors. A classification of melasma is based on Wood's light examination, classifying it in four major clinical types and patterns: epidermal, dermal, mixed, and indeterminate. Different treatment options are currently available for melasma. The choice of proper treatment should take into account the type of melasma to be treated, the skin complexion of the patient, possible previous treatments, the expectations and compliance of the patient, and the season in which the treatment is started.