Melasma: an Up-to-Date Comprehensive Review

The whitening efficacy of a compound formula examined using an ultraviolet-induced skin melanization model

BACKGROUND

In Eastern culture, a fair complexion is the standard of beauty, leading to appearance-related distress among women with darker skin or facial pigmentation. Women seek whitening cosmetics to enhance their skin tone or correct their pigmentation, but their safety and effectiveness are paramount factors to consider. In this study, we evaluated the safety and whitening effects of a compound formula denoted as TEST comprising astaxanthin, nicotinamide, arbutin, and tranexamic acid.

METHODS

Primary skin irritation and skin-whitening efficacy were examined. Three qualified melanization areas were treated with TEST, 7% ascorbic acid, or a blank. Skin color, the individual type angle (ITA°), and the melanin index (MI) were compared among treatment areas.

RESULTS

TEST did not induce a skin response and exhibited a significantly higher ITA° than the blank, while no significant difference was observed with that of 7% ascorbic acid. Furthermore, the MI of TEST was significantly reduced posttreatment.

CONCLUSIONS

TEST could be integrated into spot-fading and skin-whitening cosmeceuticals or functional cosmetics.

Efficacy, safety, tolerability and treatment durability of microneedling plus topical tranexamic acid in combination with topical modified Kligman lightening formula for melasma: A four-arm assessor and analyst blinded randomized controlled clinical trial

BACKGROUND

The challenging management of melasma highlights the inadequacies of conventional therapies and their high risk of recurrence. Integrating microneedling for device-assisted drug delivery with tranexamic acid (TA), recognized for its melanin synthesis inhibition, presents a novel approach that warrants further investigation to fully assess its potential in enhancing melasma treatment efficacy.

METHODS

Fifty moderate to severe melasma patients participated in this randomized outcome-assessor-blinded controlled trial. Patients were randomly allocated into two main groups. Group A received a modified Kligman formula on one hemi-face on alternate nights for 2 months (A1) and three sessions of microneedling with 10% topical TA on the other hemi-face at 1-month intervals (A2). Group B used the same modified Kligman formula on both sides of the face, with one side additionally receiving three sessions of microneedling with 4% TA (B1) and the opposite side with 10% TA (B2). Primary outcomes were % Modified Melasma Area and Severity Index (mMASI) and % visual analogue scale (VAS) change during 6 month follow-up. Adverse events including post-inflammatory hyperpigmentation (PIH) and treatment tolerability were recorded.

RESULTS

Compared to baseline, the mean mMASI reduction immediately after the final session was higher in A1, B1, and B2 (56.84%, 50.88%, and 55.87%, respectively) than in A2, which saw only a 13.16% reduction. Efficacy notably declined after the cessation of treatment across all groups. While the efficacy within groups A1, B1, and B2 was comparable, microneedling with 4% or 10% TA combined with the topical modified Kligman formula proved more potent in patients at a lower risk of PIH. Overall, 22% of patients reported PIH, particularly in the A2 group (28% of hemi-faces), with its occurrence significantly associated with treatment during warmer seasons and in darker skin phototypes. Other adverse events were not observed in any patient. Patient satisfaction was highest in groups B1 and B2, where approximately 72% reported 'excellent' satisfaction. The lowest durability rate (16%) was observed in group A2, while the highest (72%) was seen in group B2, comparable with groups A1 and B1. Treatment tolerability was reported 100% in all groups.

CONCLUSION

It was found that the modified Kligman formula outperformed microneedling-TA alone. However, with optimal patient selection, particularly targeting those at lower risk for PIH with lighter skin phototypes and scheduling treatments during less-sunny seasons, combining microneedling with 4% or 10% TA and the modified Kligman formula significantly enhanced efficacy and satisfaction rates compared to conventional topical treatment.

Research situation, hot spots, and global trends of melasma therapy: Bibliometric insights and visual analysis from 2000 to 2023

BACKGROUND

Melasma is a prevalent pigmented disease, yet its pathogenesis remains unclear, posing challenges for effective treatment. Bibliometric analysis, a novel approach to literature research, offers the opportunity to evaluate research trends through qualitative and quantitative methods. This study utilizes bibliometric methods to analyze the existing literature on melasma treatment, examining influential publications, institutions, countries, and authors through statistical analysis.

METHODS

In order to retrieve manuscripts related to the topic of melasma treatment, we conducted a search using the search formula: (TS = (melasma or Chloasma or "mask of pregnancy")) AND TS = (treatment or therapy). We searched through the Web of Science Core Collection database, covering publications from 2000 to 2023. VOSviewer, CiteSpace and the Bibliometric online site (https://bibliometric.com/app) were used to conduct this bibliometric analysis. Our analysis focused on various factors including publications, authors co-authorship, institutions, countries, citation analysis, keywords co-occurrence, references co-citation and journal co-citation.

RESULTS

A total of 943 articles and 200 reviews were published between 2000 and 2023, accumulating a total of 8628 citations. The average number of citations per item was 18.85, and the average number of citations per year was 292.69. The most prolific author, Sungeun Chang, contributed a total of 9 articles. Cario University emerged as the top research institution. The United States led in terms of article publications with a count of 276. In the past 5 years, the research trends in this field have primarily focused on tranexamic acid and epidermal melasma, as indicated by the burst analysis of publications and keywords.

CONCLUSIONS

The United States continues to lead in terms of institutions and research output. The current emphasis is on the meticulous implementation of tranexamic acid and laser therapy. It is crucial to foster enhanced collaboration among countries, institutions, and authors to facilitate improved research.

Laser-mediated Solutions: Breaking Barriers in Transdermal Drug Delivery

Skin diseases pose challenges in treatment due to the skin's complex structure and protective functions. Topical drug delivery has emerged as a preferred method for treating these conditions, offering localized therapy with minimal systemic side effects. However, the skin's barrier properties frequently limit topical treatments' efficacy by preventing drug penetration into deeper skin layers. In recent years, laser-assisted drug delivery (LADD) has gained attention as a promising strategy to overcome these limitations. LADD involves using lasers to create microchannels in the skin, facilitating the deposition of drugs and enhancing their penetration into the target tissue. Several lasers, such as fractional CO2, have been tested to see how well they work at delivering drugs. Despite the promising outcomes demonstrated in preclinical and clinical studies, several challenges persist in implementing LADD, including limited penetration depth, potential tissue damage, and the cost of LADD systems. Furthermore, selecting appropriate laser parameters and drug formulations is crucial to ensuring optimal therapeutic outcomes. Nevertheless, LADD holds significant potential for improving treatment efficacy for various skin conditions, including skin cancers, scars, and dermatological disorders. Future research efforts should focus on optimizing LADD techniques, addressing safety concerns, and exploring novel drug formulations to maximize the therapeutic benefits of this innovative approach. With continued advancements in laser technology and pharmaceutical science, LADD has the potential to revolutionize the field of dermatology and enhance patient care.

Energy-Based Devices for the Treatment of Facial Skin Conditions in Skin of Color

Background

The development of microfocused ultrasound and fractional radiofrequency-based devices has expanded the range of cosmetic treatment options for patients with skin of color. Fractional non-ablative laser treatments can also be safely performed in skin types III-VI with appropriate settings and adjunctive topical treatments.

Objective

We sought to review the available literature on the use of energy-based devices for treatment of facial skin conditions in skin types III-VI.

Methods

A PubMed search was performed on studies from 2010-2021 assessing safety and efficacy of fractional ablative and non-ablative lasers, radiofrequency, and microfocused ultrasound-based treatments for conditions such as acne scars, melasma, benign pigmented lesions, rhytids, and skin laxity in skin types III-VI.

Results

Seven randomized trials, fourteen prospective cohort studies, and six retrospective reviews were included. Combination treatment with fractional radiofrequency and non-ablative laser has demonstrated efficacy in the treatment of acne scars in skin of color with minimal adverse effects. Laser-assisted drug delivery with low-density 1927-nm thulium or diode lasers has been shown to reduce the number of treatments required for significant clearance of melasma as compared with other modalities. Microfocused ultrasound has been shown to safely treat skin laxity in skin of color.

Limitations

There is a paucity of studies which include patients with skin type VI, limiting our overall understanding of the safety of these treatments in skin of color.

Conclusion

There are numerous available studies demonstrating safety and efficacy of energy-based devices for the treatment of facial skin conditions in skin types III-VI, but the significant variation among their designs, methods of assessment, and study populations highlights the need for larger meta-analyses to further interpret their results.

Update on Melasma Treatments

Melasma is a prevalent hyperpigmentation condition known for its challenging treatment due to its resemblance to photoaged skin disorders. Numerous studies have shed light on the intricate nature of melasma, which often bears similarity to photoaging disorders. Various therapeutic approaches, encompassing topical and systemic treatments, chemical peeling, and laser therapy, have exhibited efficacy in managing melasma in previous research. However, melasma often reoccurs despite successful treatment, primarily due to its inherent photoaged properties. Given that melasma shares features with photoaging disorders, including disruptions in the basement membrane, solar elastosis, angiogenesis, and mast cell infiltration in the dermal layer, a comprehensive treatment strategy is imperative. Such an approach might involve addressing epidermal hyperpigmentation while concurrently restoring dermal components. In this article, we provide a comprehensive review of conventional treatment methods frequently employed in clinical practice, as well as innovative treatments currently under development for melasma management. Additionally, we offer an extensive overview of the pathogenesis of melasma.

Tranexamic Acid Ameliorates Skin Hyperpigmentation by Downregulating Endothelin-1 Expression in Dermal Microvascular Endothelial Cells

BACKGROUND

Although reports suggest that tranexamic acid (TXA) has clinical benefits for melasma patients by oral, intralesional and topical treatment, the optimal route of TXA therapy and the underlying mechanism involved remain poorly defined.

OBJECTIVE

To compare the skin lightening effect between oral TXA and topical TXA and to dissect the molecular mechanisms using ultraviolet B (UVB)-induced hyperpigmentation mouse model, ex vivo cultured human skin explant, and cultured melanocytes (MCs) and endothelial cells.

METHODS

Melanin content and cluster of differentiation 31 (CD31)-positive cell numbers were measured in tail skins from UVB-irradiated mice treated by intragastral or topical TXA using immunofluorescent and Fontana-Masson staining. The conditioned medium (CM) was harvested from human umbilical vein endothelial cells treated with or without 3 mM TXA and was used to treat MCs for 48 hours. mRNA and protein levels of tyrosinase and microphthalmia-associated transcription factor were measured using quantitative real-time reverse transcription polymerase chain reaction and western blotting assays. HMB45- and CD31-positive cell numbers as well as melanin content were also examined in ex vivo cultured human skin explants.

RESULTS

The hyperpigmented phenotype were significantly mitigated in UVB-irradiated tail skin plus intragastral TXA-treated mice compared with mice treated with UVB only or with UVB plus topical TXA. CD31-positive cell numbers correlated with the anti-melanogenic activity of TXA therapy. The data from cultured cells and skin tissues showed that suppression of endothelin-1 (ET-1) in vascular endothelial cells by TXA reduced melanogenesis and MC proliferation.

CONCLUSION

Oral TXA outperforms topical TXA treatment in skin lightening, which contributes to suppression of ET-1 in dermal microvascular endothelial cells by TXA.

A randomized, controlled, split-face, double-blind comparison of a multimodality pigment-correcting serum containing lotus sprout extract versus hydroquinone for moderate to severe facial hyperpigmentation, including melasma, in a diverse population

Background

Hyperpigmentation results in uneven skin tone, with darker skin types disproportionately affected.

Objective

Assess efficacy and safety of a novel, hydroquinone (HQ)-free, multimodal pigment-correcting serum (Advanced Brightening Treatment [ABT]) versus 4% HQ in moderate to severe hyperpigmentation, including melasma.

Methods

In this split-face study, ABT and 4% HQ were applied topically on randomly assigned facial sides twice daily for 12 weeks. Hyperpigmentation, skin tone evenness, modified Melasma Area and Severity Index (mMASI), Melasma Quality of Life Questionnaire (MelasQoL), self-assessment questionnaires, and tolerability were assessed.

Results

Subjects (n = 113; melasma subgroup, n = 44) were Asian (22%), Black/African American (27%), Hispanic (22%), and White/Caucasian (28%). ABT achieved comparable results to 4% HQ. ABT was well tolerated and resulted in improvement versus baseline at all visits in mean overall hyperpigmentation (-11.7% at week 12; P ≤ .001), skin tone evenness (-8.8%, P ≤ .005), and, in the melasma subgroup, mMASI (-50.6%; P ≤ .011) and MelasQoL scores (33.0 vs 46.6 for week 12 vs baseline, respectively; P ≤ .011), with similar results across racial subgroups. ABT was preferred over 4% HQ, with high satisfaction rate (≥89%).

Limitations

Quality of life improvements per treatment were not evaluated separately.

Conclusion

Efficacy and safety of ABT is comparable to 4% HQ in individuals with facial hyperpigmentation, including melasma, across multiple racial/ethnic backgrounds.

Melasma: A Step-by-Step Approach Towards a Multimodal Combination Therapy

Melasma is a common challenge in the field of pigmentary skin disorders, exerting a significant emotional and psychosocial burden on patients. The persistent and recurring nature of melasma complicates its management in routine clinical practice. This comprehensive review outlines a stepwise, practical approach encompassing diagnostic, preventive and therapeutic strategies for the management of melasma. A thorough exploration of aggravating and exacerbating factors, including sun exposure, hormonal imbalances, photosensitizing medication and cosmetics, is essential for a holistic assessment of the disease. With an emphasis on consistent and effective photoprotection, initial topical treatment modalities target the melanin production and/or the transfer of melanosomes to keratinocytes. Topical tyrosine inhibitors emerge as the first choice for reducing and preventing hyperpigmentation, with compounds such as thiamidol or tranexamic acid (TXA) being preferred for their safety profile over hydroquinone (HQ), kojic acid and arbutin. Combination with chemical peels can further enhance the therapeutic efficacy, even in cases with resistant melasma. In more severe cases, laser- and light-based interventions may be considered, but with the caveat of the likelihood of recurrence within 3-6 months. Assisted TXA delivery, via either fractional non-ablative laser or microneedling techniques, can further improve clinical outcomes. In conclusion, an optimal melasma management strategy is a multimodal approach, which includes effective photoprotection and a mix of different topical treatments targeting melanin synthesis, the anti-inflammatory environment, senescence and vascularity. Complementary procedures, such as chemical peels, and laser, light-based or microneedling procedures, with or without TXA, can further expedite melanin clearance in more severely affected instances. Individual discussions with patients regarding treatment expectations, recurrence likelihood and potential side effects are paramount to a comprehensive and successful therapeutic journey.

A stability indicating RP-HPLC-UV assay method for the simultaneous determination of hydroquinone, tretinoin, hydrocortisone, butylated hydroxytoluene and parabens in pharmaceutical creams

Multicomponent drugs are medications that combine two or more active pharmaceutical ingredients in a single dosage form. These dosage forms improve the patient compliance, reduce the risk of drug interactions, and simplify dosing regimens. However, quality control of these multicomponent dosage forms can be challenging, especially if the final product contains four or more ingredients that are active (comprise stabilizers, preservatives, excipients, and other components). This problem can be more pronounced if the excipients can interfere with the analysis. In this work, a stability indicating assay method was developed and validated (according to the ICH International Guidelines) for the simultaneous determination of hydroquinone (HQ), tretinoin (TRT), hydrocortisone (HCA), butylated hydroxytoluene (BHT), methyl paraben (MP) and propyl paraben (PP) in commercially available pharmaceutical creams. The proposed method is based on gradient elution using X-Bridge C18 (150 × 4.6 mm, 5 µm) column with a flow rate of 1 mL/min. The linear ranges (μg/mL) were 240-560 for HQ, 24-56 for MP, 132-308 for HCA, 6-14 for PP, 12-28 for BHT, 6.6-15 for TRT. During the validation process, the intra- and interday precision and trueness (evaluated as recovery) were found to be below 2.0% and between 100-102%, respectively. System suitability tests (SST) allow validating the herein proposed procedure specifically for pharmaceutical and industrial applications. SST test shows that the reported procedure fulfill with the Guidelines, allowing excellent separation of the analytes with very sensitive, accurate (precise and true) and reproducible quantitation of each analytes. The method was successfully applied in forced degradation studies of the six analytes. Specifically, acid degradation slightly affected HCA and BHT (91% recovery), while alkaline degradation drastically reduced HCA recovery (5.5%) and moderately affected BHT (85%). Photodegradation primarily influenced TRT quantity, and oxidative degradation intensified the BHT peak (130%).

Dermatology in black skin

The vast majority of publications in dermatology refer to lightly pigmented skin, with few addressing the peculiarities of black skin. In addition there is no consensus on what it means to be black in different regions of the world. The lack of knowledge on the subject makes it difficult to recognize and manage dermatoses in this type of skin. This article aims to review the literature on intrinsic characteristics, as well as epidemiological and clinical aspects of the cutaneous manifestations of different dermatoses in black skin. It was found that there are sometimes striking differences, in the structural, biological, and functional aspects when comparing lightly pigmented and black skin. There are also physiological changes that need to be recognized to avoid unnecessary interventions. Some dermatoses have a higher incidence in black skin, such as acne, eczema, dyschromia and dermatophytosis. On the other hand, several dermatoses are more specific to black skin, such as pseudofolliculitis barbae, keloid, dermatosis papulosa nigra, ulcers caused by sickle-cell anemia, dactylolysis spontanea, confluent and reticulated papillomatosis of Gougerot and Carteaud, and some diseases of the hair and scalp (including fragile and brittle hair, traction alopecia, folliculitis keloidalis nuchae, folliculitis dissecans and central centrifugal cicatricial alopecia). A spectrum of peculiar aspects of specific dermatoses, including sarcoidosis, lichen planus (with emphasis on the pigmentosus variant), psoriasis, lupus erythematosus, vitiligo, syphilis, pityriasis versicolor, and neoplasms are highlighted. In the latter, characteristics of basal cell carcinoma, squamous cell carcinoma, and melanoma are compared, in addition to highlighting unusual aspects of primary cutaneous T-cell lymphoma, endemic Kaposi sarcoma, and dermatofibrosarcoma protuberans.

Combination of 5% cysteamine and 4% nicotinamide in melasma: Efficacy, tolerability, and safety

BACKGROUND

Melasma is a chronic dermatosis that impacts the patient's quality of life and can present considerable challenges in terms of effective treatment.

OBJECTIVE

To evaluate the effectiveness, tolerability, and safety of 5% cysteamine combined with 4% nicotinamide in female subjects with melasma.

METHODS

This single-center, single-arm, prospective, open-label study evaluated patients with melasma using a combination cream of 5% cysteamine and 4% nicotinamide in a progressive regimen (60 min in the first month, 120 min in the second month, and 180 min in the third month).

RESULTS

Overall, 35 treated subjects exhibited reduced modified Melasma Area and Severity Index (mMASI) (p < 0.001) and decreased MelasQoL scores (p < 0.001), accompanied by improved brightness, luminosity, homogeneity, and spot intensity (p < 0.001). Photographic and colorimetric analysis revealed smaller spots and improved homogeneity.

LIMITATIONS

Adherence to progressive daily treatment could not be evaluated long-term.

CONCLUSION

A combination cream comprising 5% cysteamine and 4% nicotinamide was effective, tolerable, and safe for treating melasma.

Efficacy and safety of novel topical pigment-correcting regimen with biweekly diamond tip microdermabrasion procedures on facial hyperpigmentation

BACKGROUND

Facial hyperpigmentation can negatively affect an individual's emotional and psychosocial well-being.

AIMS

Assess safety and tolerability of a combination of microdermabrasion (DG) procedures using a novel brightening pro-infusion serum (EC-DG) with a targeted at-home treatment regimen in subjects with mild to severe facial hyperpigmentation, including melasma, post-inflammatory hyperpigmentation, and dark spots.

PATIENTS/METHODS

This 12-week, open-label study enrolled 18 subjects (Fitzpatrick skin types I-IV) who underwent 6 in-office DG procedures with EC-DG (one procedure administered biweekly), along with daily topical application of a brightening treatment serum and dark spot cream. End points included change from baseline across multiple skin quality attributes and the Melasma Area and Severity Index (MASI), self-assessment questionnaires, and tolerability assessments.

RESULTS

The combination treatment was well tolerated and resulted in significant (p ≤ 0.05) improvements from baseline in radiance, tactile roughness, and moisturization/hydration immediately after the first treatment, in MASI score at day 3, and in overall hyperpigmentation at week 4. Most (94.1%) subjects were satisfied with treatment.

CONCLUSIONS

DG procedures using EC-DG combined with a targeted at-home skincare regimen are effective and tolerable for treating facial hyperpigmentation across a broad range of skin types.

Definition of refractory melasma and its treatment: a review

Although patients with refractory melasma have been treated using various methods, there is still no precise definition or summary of the therapies. To define refractory melasma and conduct a review of the treatments, we searched for relevant publications in PubMed, Web of Science, and the Cochrane Library, and a total of 35 references were obtained. Refractory melasma can be roughly defined as an ineffective treatment for melasma, including topical bleaching agents, chemical peels, laser therapy, microdermabrasion for more than six months, or chemical peels treated more than six times. Meanwhile, physicians should be careful when treating patients with darker skin and dermal or mixed types of melasma since these individuals do not respond well to treatment. Lasers combined with other methods, especially different types of lasers or topical agents, are considered more effective than monotherapy. Oral tranexamic acid (TXA) is a prospective cure for refractory melasma. Other methods include a combination of chemical peels, microneedling, or injections with additional therapies. In conclusion, we were able to provide a rough definition of refractory melasma and list the available therapies. According to the literature, the most prevalent treatment is laser combination therapy. However, laser treatment should be considered only after topical agents and chemical peeling have failed. Considering its side effects, efficacy, and safety, oral TXA may be a better option, but more research is needed to make a firm conclusion. Moreover, maintenance therapy is required after treatment.

Comparative efficacy and safety of tranexamic acid for melasma by different administration methods: A systematic review and network meta-analysis

BACKGROUND

Tranexamic acid (TA) is a new and promising drug for the treatment of melasma.

OBJECTIVES

This network meta-analysis aims to compare the efficacy and safety of various ways of administration of TA on melasma.

METHODS

We collected researches from PubMed, EMBASE, Cochrane Library and Web of Science. Melasma area severity index (MASI) is used to evaluate the severity of melasma. After treatment with different TA administration methods, a difference in MASI is named ΔMASI. We evaluate the curative effect by comparing the ΔMASI of different TA administration methods at a certain time point.

RESULTS

At the Weeks 4, 8, and 12 and the last follow-up, the ΔMASI of oral TA combined with routine topical agents (oTA + RTA) was higher than that of intradermal TA (iTA), topical TA (tTA) as well as microneedling TA (MNsTA), with statistical significance. At the 8th week, the ΔMASI of oTA was higher than that of iTA, with statistical significance. Compared with placebo, oTA showed statistically significant differences at Week 4, while tTA, iTA, and MNsTA showed statistically significant differences starting from Week 8.

CONCLUSIONS

Among various ways of administration of TA, oTA + RTA has the best effect on melasma. In the short term, the curative effect of oTA is better than that of iTA, and the onset time of oTA is faster than that of tTA, iTA and MNsTA. In the long run, the curative effect of TA alone has nothing to do with the mode of administration.

Exposure factors in the occurrence and development of melasma (Review)

Melasma is an acquired pigmentation disease that mainly involves the development of symmetrical yellow-brown facial patches. The incidence rate of the disease is increasing yearly. Therefore, actively studying the exposure factors that induce melasma could contribute to the prevention and treatment of this disease. In the present review, the possible exposure factors were summarized.

Management of Melasma: Laser and Other Therapies-Review Study

Melasma is a commonly occurring pigmented skin condition that can significantly affect one's appearance, described as symmetric hyperpigmentation that presents as irregular brown to gray-brown macules on various facial areas, such as the cheeks, forehead, nasal bridge, and upper lip, along with the mandible and upper arms. Due to its complex pathogenesis and recurrent nature, melasma management is challenging and the outcomes following treatment are not always deemed satisfactory. Solely treating hyperpigmentation may prove ineffective unless paired with regenerative techniques and photoprotection, since one of the main reasons for recurrence is sun exposure. Hence, the treatment protocol starts with addressing risk factors, implementing stringent UV protection, and then treatment using different strategies, like applying topical treatments, employing chemical peels, laser and light therapies, microneedling, and systemic therapy. This review aims to provide a summary of the effectiveness and safety of the frequently employed laser and light therapies for treating melasma, focusing on laser therapy as a treatment for melasma.

Best practices in the treatment of melasma with a focus on patients with skin of color

BACKGROUND

Melasma is a chronic hypermelanosis of the skin that affects approximately 1% of the global population, predominantly affects women, and is more prevalent in skin of color. Melasma is a common driver for patients with skin of color to seek out a dermatologist for treatment, and ensuring the right approach for these patients is important because some treatments may be associated with adverse side effects. Because of the chronicity of the disease and established psychosocial and emotional impacts, there is a large need to ensure care follows the best available evidence on the treatment of patients with melasma.

OBJECTIVE

Here, we summarized current available topical treatments for melasma with considerations dermatologists should have for their patients with skin of color.

METHODS

Steering committee consensus on clinical best practices.

RESULTS

We describe a flexible and focused treatment algorithm that reflects both treatment and maintenance periods that is a consensus of our extensive clinical experience.

LIMITATIONS

Use of real-world evidence and potential for individual practice bias.

CONCLUSION

Melasma can be challenging to treat, particularly in patients with skin of color, and our recommendations for best practices for patients in the United States are an important step toward standardizing care.

Prevalence of depression in melasma: a systematic review and meta-analysis

Background

Due to cosmetic disfigurement, melasma can negatively affect the quality of life and emotional and mental health, further leading to depression.

Objective

Prevalence rates of depression in patients with melasma vary widely across studies. The aim of this systematic review and meta-analysis was to estimate the prevalence of depression among melasma patients.

Methods

The PubMed, Embase, Web of Science, and Scopus databases were searched to identify articles evaluating the prevalence of depression in melasma patients from their inception to 12 July 2023. Studies were reviewed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and a meta-analysis was performed using the Stata 14.0 software.

Results

Sixteen studies met the eligibility criteria out of the 859 studies, containing a total of 2,963 melasma patients for this systematic review and meta-analysis. Meta-analyses revealed that the pooled prevalence of depression among patients with melasma was 43.4% (95% CI 30.5-56.2%, Q-value = 808.859, d.f. = 15, p < 0.001, tau2 = 0.065, I2 = 98.1%). The meta-regression found that the publication year, sample size, and study quality were not significant moderators for the observed heterogeneity in prevalence. A subgroup analysis according to depression assessment methods showed that the prevalence of depressive disorders was 24.2% (95% CI 16.8-31.6%), and the prevalence of depressive symptoms was 45.1% (95% CI 31.2-59.0%). A subgroup analysis by geographic regions showed that patients in Asia had the highest prevalence of depression at 48.5% (95% CI 26.0-71.0%), compared to other regions. A subgroup analysis by study design showed that the prevalence of depression in case-control studies was almost identical to cross-sectional studies. In the case of OR, the pooled OR of depression between patients with melasma and health controls was 1.677 (95% CI 1.163-2.420, p = 0.606, I2 = 0.0%).

Conclusion

The prevalence of depression was relatively high in patients with melasma, and there was a correlation between melasma and depression, encouraging clinicians to screen for depression in their patients and providing a combination of physical and psychosocial support. If necessary, they should be referred to formal mental health services to seek professional psychological intervention.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, CRD42022381378.

Preparation of paeoniflorin-glycyrrhizic acid complex transethosome gel and its preventive and therapeutic effects on melasma

Paeoniflorin (PF) and glycyrrhizic acid (GL) have skin beautifying effects of anti-inflammation, anti-oxidation, inhibition of melanin formation, and reduction of skin pigmentation. To improve the transdermal permeability of PF and GL in transdermal drug delivery system (TDDS) and enhance their anti-melasma efficacy, PF-GL transethosome (PF-GL-TE) was prepared by ethanol injection method, and finally gelled with carbomer-940 to form PF-GL-TE gel. Consequently, the obtained PF-GL-TE is small and uniform, with an average particle size and a PDI value of about 167.9 nm and 0.102. PF-GL-TE gel showed sustained release behavior and high transdermal permeability in vitro release and transdermal tests. Meanwhile, PF-GL-TE gel played significant preventive effects on melasma induced by progesterone injection and ultraviolet radiation B (UVB) irradiation. According to the results of H&E staining and Masson staining of rat skin, PF-GL-TE gel can alleviate the skin inflammation of and reduce the loss of collagen fibers of back skin in the melasma model rats. Compared with the PF-GL mixture gel, PF-GL-TE gel significantly attenuated the oxidative damage of liver and skin by increasing the activity of SOD and reducing the content of MDA. The results of Western blot showed that PF-GL-TE gel might down-regulate melanin-related proteins expressions of MITF/TYR/TRP1 and TRP2 to prevent and treat melasma. These findings indicate that PF-GL-TE gel is an effective TDDS for delivering PF and GL into the skin, providing a promising preparation for effective prevention and treatment of melasma.

Chemical Peels in Treatment of Melasma

Superficial chemical peels are one of the most popular skin resurfacing procedures in a dermatologists' clinic today due to quick application process, fast recovery, good patient acceptance, and excellent cosmetic results. The role of various peeling agents like glycolic acid, salicylic acid, trichloroacetic acid, Jessner's solution, retinoic acid, and lactic acid in the management of melasma has been established as that of an additional or maintenance therapy. This article details the current evidence and recommendations for the use of chemical peels in the treatment of melasma, a chronic and recurrent hyperpigmentary disorder.

Platelet-Rich Plasma in Dermatology: New Insights on the Cellular Mechanism of Skin Repair and Regeneration

The skin's recognised functions may undergo physiological alterations due to ageing, manifesting as varying degrees of facial wrinkles, diminished tautness, density, and volume. Additionally, these functions can be disrupted (patho)physiologically through various physical and chemical injuries, including surgical trauma, accidents, or chronic conditions like ulcers associated with diabetes mellitus, venous insufficiency, or obesity. Advancements in therapeutic interventions that boost the skin's innate regenerative abilities could significantly enhance patient care protocols. The application of Platelet-Rich Plasma (PRP) is widely recognized for its aesthetic and functional benefits to the skin. Yet, the endorsement of PRP's advantages often borders on the dogmatic, with its efficacy commonly ascribed solely to the activation of fibroblasts by the factors contained within platelet granules. PRP therapy is a cornerstone of regenerative medicine which involves the autologous delivery of conditioned plasma enriched by platelets. This is achieved by centrifugation, removing erythrocytes while retaining platelets and their granules. Despite its widespread use, the precise sequences of cellular activation, the specific cellular players, and the molecular machinery that drive PRP-facilitated healing are still enigmatic. There is still a paucity of definitive and robust studies elucidating these mechanisms. In recent years, telocytes (TCs)-a unique dermal cell population-have shown promising potential for tissue regeneration in various organs, including the dermis. TCs' participation in neo-angiogenesis, akin to that attributed to PRP, and their role in tissue remodelling and repair processes within the interstitia of several organs (including the dermis), offer intriguing insights. Their potential to contribute to, or possibly orchestrate, the skin regeneration process following PRP treatment has elicited considerable interest. Therefore, pursuing a comprehensive understanding of the cellular and molecular mechanisms at work, particularly those involving TCs, their temporal involvement in structural recovery following injury, and the interconnected biological events in skin wound healing and regeneration represents a compelling field of study.

Efficacy and safety of metformin for melasma treatment: a systematic review and meta-analysis

Objective: Metformin has recently been demonstrated to have an anti-melanogenic activity. Nevertheless, clinical evidence of the effectiveness of metformin in melasma is lacking. The objective of this study was to assess the efficacy and safety of metformin in the treatment of melasma. Methods: MEDLINE, Embase, PubMed, Cochrane Library (CENTRAL), Scopus, CINAHL, and grey literature databases were searched to 4 October 2022 and updated on 26 February 2023. Randomized controlled trials (RCTs), quasi-RCTs, observational studies, case series, and case reports investigating the efficacy and safety of metformin for melasma were included. The Melasma Area Severity Index (MASI) scores that changed from baseline were pooled using fixed-effects model and expressed as standardized mean differences (SMDs) and 95% confidence intervals (CIs). Results: Three RCTs including 140 patients with melasma were included. The results demonstrated that after 8 weeks, 15% topical metformin significantly reduced the Melasma Area Severity Index (MASI) score compared to placebo (1 trial; n = 60; MD, -0.56; 95% CI, -1.07 to -0.04; p = 0.034). Furthermore, when compared to triple combination cream (TCC), 30% topical metformin demonstrated similar efficacy in reducing the MASI score after 8 weeks (2 trials; n = 80; MD, 0.19, 95% CI, -0.25 to 0.63; p = 0.390). Patients using 30% topical metformin had fewer adverse events compared to TCC users, although no statistical difference was found. Conclusion: Topical metformin was as effective as triple combination cream (TCC) in decreasing changes in the MASI score in patients with melasma, with minimum adverse events. Further studies with larger sample sizes, longer follow-up times, and well-designed trials are required. Systematic Review Registration: Identifier PROSPERO (CRD42022351966).

Use of Picosecond Laser for Melasma Treatment: A Narrative Review

Background: Melasma results from the imbalance of the mechanisms that regulate skin pigmentation, causing the appearance of hyperpigmented patches. Treatment includes topical and oral agents, chemical peelings, microneedling, and laser therapy. The picosecond laser was developed to minimize pain and skin discoloration, which can sometimes be associated with laser treatments. It emits short pulses of energy that last from 300 to 500 picoseconds, leading to a more significant fragmentation of melanin, with miniminal risk of scarring and thermal lesions in the surrounding skin. Objective: The authors aimed to review the use of picosecond laser in the treatment of melasma and further provide an overview of the other current available options. Conclusions: While the use of picosecond laser for the treatment of melasma has yielded good results, further studies with longer follow-up periods and a higher number of patients are needed.

A comprehensive review of platelet-rich plasma for the treatment of dermatologic disorders

Platelet-rich plasma (PRP) offers anti-inflammatory and regenerative properties through angiogenesis, cell differentiation, and proliferation. Although studied in many dermatologic conditions, its efficacy is not well-understood. Our objective is to review the use and effectiveness of PRP for dermatologic conditions. A literature search was performed through PubMed and yielded 54 articles published between January 2000 and November 2021; articles written in English were reviewed. Intradermal injections were associated with increased hair density in androgenic alopecia. Successful treatment of inflammatory nail diseases with PRP has been reported. Improvement in psoriasis was described, but only two studies were available. PRP was associated with higher patient self-assessment scores of photoaging and fine lines. Treatment with PRP in melasma has been associated with improved subjective satisfaction, but not with objective measures of disease improvement. PRP can serve as a safe and potentially effective adjunct for hair loss, vitiligo, nonhealing wounds, photoaging, and acne scars. An important barrier to interpreting PRP research is lack of standardization of PRP preparation protocols, inconsistent clinical endpoints, and frequent combination treatments. However, PRP is relatively noninvasive, has a well-established safety profile, and patient satisfaction is often high as patients perceive great benefit from treatment with PRP.

The Effect of Melasma on the Quality of Life in People with Darker Skin Types Living in Durban, South Africa

Melasma is a common skin disorder of acquired hyperpigmentation that appears commonly on the face. Although asymptomatic, melasma causes psychosocial and emotional distress. This study aimed to assess melasma's severity on people with darker skin types, evaluate the effects of melasma on the quality of life (QoL), and establish QoL predictors in affected individuals. This was a cross-sectional analytic study that enrolled 150 patients from three private dermatology clinics in Durban, South Africa who were diagnosed with melasma. The severity of melasma alongside QoL were measured using a melasma area and severity index (MASI) score and melasma quality of life scale (MELASQoL), respectively. The associations among factors and QoL were explored using multivariable methods and stepwise regression analysis. p-values less than 0.05 were considered significant. Enrolled patients were predominantly females (95%), of which 76% were of black African ethnicity, 9% were of Indian ethnicity, and 15% had mixed ancestry, with an average age of 47.30 years. Family history revealed that 61% had no prior melasma cases, while 39% had affected relatives, most commonly mothers (41%). The cheeks were the most common site for melasma. MASI score of Masi (β = 0.209, t = 2.628, p < 0.001), the involvement of cheeks (β = -0.268, t = -3.405, p < 0.001), level of education (β = -0.159, t = -2.029, p = 0.044), and being menopausal (β = -0.161, t = -2.027, p = 0.045) were found to be predictors of QoL. A regression model was created to forecast MELASQoL using these four predictors. This equation's significance lies in its ability to enable the remote assessment of MELASQoL based on these four variables. It offers a valuable tool for researchers and medical professionals to quantitatively and objectively evaluate the impact of melasma on an individual's quality of life.

Disorders of Facial Hyperpigmentation

Disorders of hyperpigmentation are common and challenging conditions which can arise due to a myriad of etiologic factors. Many of them can present across skin types but are more common in skin of color individuals with Fitzpatrick skin types III-VI. Facial hyperpigmentation, in particular, can have a significant impact on the quality of life of affected individuals due to its increased visibility. This article provides a comprehensive review of disorders of facial hyperpigmentation including epidemiology, pathogenesis, diagnostic considerations, and treatment approaches for these conditions.

Skin Pigmentation Types, Causes and Treatment-A Review

Human skin pigmentation and melanin synthesis are incredibly variable, and are impacted by genetics, UV exposure, and some drugs. Patients' physical appearance, psychological health, and social functioning are all impacted by a sizable number of skin conditions that cause pigmentary abnormalities. Hyperpigmentation, where pigment appears to overflow, and hypopigmentation, where pigment is reduced, are the two major classifications of skin pigmentation. Albinism, melasma, vitiligo, Addison's disease, and post-inflammatory hyperpigmentation, which can be brought on by eczema, acne vulgaris, and drug interactions, are the most common skin pigmentation disorders in clinical practice. Anti-inflammatory medications, antioxidants, and medications that inhibit tyrosinase, which prevents the production of melanin, are all possible treatments for pigmentation problems. Skin pigmentation can be treated orally and topically with medications, herbal remedies, and cosmetic products, but a doctor should always be consulted before beginning any new medicine or treatment plan. This review article explores the numerous types of pigmentation problems, their causes, and treatments, as well as the 25 plants, 4 marine species, and 17 topical and oral medications now on the market that have been clinically tested to treat skin diseases.

Effectiveness of laser and topical tranexamic acid combination therapy in melasma: An updated systematic review and meta-analysis of randomized controlled trials

Melasma is a chronic relapsing skin condition. Laser therapy is a new advancement in treatment. Whether the topical application of tranexamic acid (TXA) increases the efficacy of laser therapy in melasma is still under debate. With recent studies yielding different results, it was imperative to compile all the available literature systematically. This meta-analysis investigates the effectiveness of a combination therapy of laser plus TXA acid for treating melasma. PubMed/MEDLINE, Cochrane Central, Google Scholar, Scopus, and the International Clinical Trials registry were systematically searched for article retrieval. Screening per PRISMA guidelines was undertaken by two independent reviewers using the Covidance database. Melasma area of severity index (MASI)/modified MASI was used as the clinical improvement outcomes. A total of nine studies that described the combined use of topical tranexamic acid with laser therapy were included for meta-analysis. These studies employed various types of lasers along with topical TXA. The results showed that the combination of both laser therapy and topical TXA significantly decreased the MASI score (P < 0.0001). Subgroup analyses revealed that fractional CO₂ laser among the laser types and monthly laser plus twice daily topical TXA were most effective in decreasing the MASI/mMASI score. The meta-analysis found that combining topical tranexamic acid and laser therapy is an effective and safer treatment option for treatment-resistant melasma. Furthermore, monthly fractional CO₂ laser and daily application of topical tranexamic acid showed high effectiveness and safety.

Liposomal stem cell extract formulation from Coffea canephora shows outstanding anti-inflammatory activity, increased tissue repair, neocollagenesis and neoangiogenesis

Coffea canephora plant stem cells can have bioactive compounds with tissue repairing and anti-inflammatory action. This study aimed to develop a liposomal stem cell extract formulation obtained from the leaves of C. canephora (LSCECC) and to investigate its capacity to contribute to the dynamic mechanisms of tissue repair. The liposome cream was developed and characterized through the dynamic light scattering technique, atomic force microscopy, and transmission electron microscopy. The excisional full-thickness skin wound model was used and daily topically treated with the LSCECC formulation or vehicle control. On days 2, 7, 14, and 21 after wounding, five rats from each group were euthanized and the rates of wound closure and re-epithelialization were evaluated using biochemical and histological tests. LSCECC resulted in faster re-epithelialization exhibiting a significant reduction in wound area of 36.4, 42.4, and 87.5% after 7, 10, and 14 days, respectively, when compared to vehicle control. LSCECC treated wounds exhibited an increase in granular tissue and a proper inflammatory response mediated by the reduction of pro-inflammatory cytokines like TNF-α and IL-6 and an increase of IL-10. Furthermore, wounds treated with LSCECC showed an increase in the deposition and organization of collagen fibers at the wound site and improved scar tissue quality due to the increase in transforming growth factor-beta and vascular endothelial growth factor. Our data showed that LSCECC improves wound healing, the formation of extracellular matrix, modulates inflammatory response, and promotes neovascularization being consider a promising bioactive extract to promote and support healthy skin. The graphical presents the action of LSCECC in all four phases of wound healing and tissue repair. The LSCECC can reduce the inflammatory infiltrate in the inflammatory phase by decreasing the pro-inflammatory cytokines like IL-6 and TNF-α, in addition to maintaining this modulation through lesser activation and recruitment of macrophages. The LSCECC can also increase the release of IL-10, an anti-inflammatory cytokine, decreasing local edema. The increase in VEGF provides neovascularization and the supply of nutrients to newly repaired tissue. Finally, signaling via TGF-β increases the production and organization of collagen fibers in the remodeling phase.

Self-Esteem, Depression, Anxiety and Quality of Life in Patients with Melasma Living in a Sunny Mediterranean Area: Results from a Prospective Cross-Sectional Study

INTRODUCTION

Melasma is a common acquired disorder of hyperpigmentation and has a significant effect on quality of life. The aim of this prospective cross-sectional study was to assess the effect of melasma on depression, social anxiety and self-esteem in the Greek population.

METHODS

The study included a total of 254 participants: 127 patients with melasma and an equal sample of healthy controls. Both participant groups completed the following psychometric measures: the Hospital Anxiety and Depression Scale (HADS) to assess anxiety and depression and Rosenberg's Self-esteem Scale (RSES) for self-esteem. Furthermore, in patients with melasma, quality of life was assessed using Melasma Quality of Life (MELASQoL).

RESULTS

Melasma patients (7.47 ± 4.53) presented statistically significantly higher anxiety compared to healthy controls (6.06 ± 3.59, p = 0.006), while no differences emerged with regard to depression or self-esteem. It is important to note that the difference regarding anxiety remained significant (b = 1.25, p = 0.003) even after adjusting for age, depression and self-esteem. A higher disease severity (MASI) correlated statistically significantly with longer disease duration (r = 0.24, p < 0.001), higher depression (r = 0.28, p = 0.002), and a more impaired health-related quality of life (MelasQol; r = 0.29, p < 0.001). Notably, a more impaired health-related quality of life was also correlated with higher depression (r = 0.19, p = 0.027) and lower self-esteem (r = - 0.31, p < 0.001).

CONCLUSION

The results of this study highlight the importance of evaluating quality of life, anxiety and depression in patients with melasma. The therapeutic approach should not be based solely on clinical findings; it should also include an evaluation of the patient's psychological aspects. Dermatologists can further improve their patient care by being supportive or requesting psychological intervention when needed, resulting in better compliance with treatment and an improved social and psychological status.

Efficacy and safety of picosecond laser for the treatment of melasma: a systematic review and meta-analysis

Multiple laser modalities have been used for melasma treatment. However, the effectiveness of picosecond laser in treating melasma remains unclear. This meta-analysis investigated the effectiveness and safety of picosecond laser for melasma treatment. Randomized controlled trials (RCTs) comparing picosecond laser with conventional treatment for melasma were searched through five databases. The melasma area severity index (MASI)/modified MASI (mMASI) was used to quantify the degree of melasma improvement. Standardized mean differences and 95% confidence intervals were calculated using Review Manager for result standardization. Six RCTs, which used picosecond laser at 1064, 755, 595, and 532 nm wavelengths, were included herein. Picosecond laser significantly reduced the MASI/mMASI, but the results were highly heterogeneous (P = 0.008, I2 = 70%). In the subgroup analysis of 1064 and 755 nm picosecond lasers, 1064 nm picosecond laser significantly reduced the MASI/mMASI with no significant side effects (P = 0.04). Meanwhile, 755 nm picosecond laser did not significantly improve the MASI/mMASI compared with topical hypopigmentation agents (P = 0.08) and caused post-inflammatory hyperpigmentation. Other laser wavelengths could not be used in the subgroup analysis owing to an insufficient sample size. Picosecond laser at 1064 nm is safe and effective for melasma treatment. Picosecond laser at 755 nm is not superior to topical hypopigmentation agents in treating melasma. The exact efficacy of other wavelengths of picosecond laser for melasma treatment remains to be verified in large-scale RCTs.

Sustained Release Microneedles: Materials and Applications in Facial Rejuvenation

Wrinkled and loose skin resulting from collagen degradation along with fibers decreasing reflects the youth diminishing. Microneedles (MNs) have opened up new avenues for the development of painless and noninvasive transdermal drug delivery systems for facial rejuvenation. Encapsulated drugs or molecules are transmitted to targeted tissues via percutaneous microchannels, which eliminate potential gastric stimulation or first-pass metabolic effects, as well as boost patient compliance. Although MNs are considered effective and feasible therapeutic alternatives to metals, silicon, and polymers, traditional procedures with reduction processes continue to encounter methodological limitations. In recent years, promising additive manufacturing processes such as three-dimensional printing and two-photon polymerization manufacturing have been developed with the aim of overcoming the limitations by traditional processes to facilitate an efficient and economic production mode. This review summarizes the design, material selection, and manufacturing method for recently advanced MN systems. Furthermore, we also highlight specific polymeric or natural microneedle products, like hyaluronan, plant derivates, and vitamins, for esthetic applications in this review. Impact Statement In this review, the materials and manufactural routes of microneedles (MNs) are detailed. Moreover, similar to the diagnostic or therapeutic MNs, the feature of dispensation with training and ready-to-use is perfect for beautification and anti-aging, which necessitate repeated and long-term usage. Furthermore, the specific polymeric or natural products for esthetic applications of MNs are highlighted in this review.

A randomized controlled clinical trial to evaluate safety and efficacy of a Unani formulation in the management of Kalaf (Melasma)

OBJECTIVES

Kalaf (Melasma) is an acquired facial hypermelanism. It has direct impact on patient's quality of life and leads to development of various personality disorders. Lack of effective treatment and recurrences have drawn the attention of researcher to find alternative treatment. This study aimed to evaluate safety and efficacy of a topical Unani formulation in the management of melasma.

METHODS

We conducted a prospective randomized controlled clinical study on the participants diagnosed with melasma. The participants (n=72) randomized into test (n=36) and control (n=36) groups. Sixty participants (n=30 in each group) completed the duration of therapy. The participants of the test group were treated with a classical Unani formulation and control group with hydroquinone 4%. The primary end point was change in mean MASI score and secondary end point was improvement in quality of life after eight weeks of treatment.

RESULTS

The Unani formulation reduced 40.5% mean MASI score (17.31 ± 9.58 to 10.28 ± 5.92) in comparison to 32% reduction in mean MASI score (20.58 ± 9.49 to 13.92 ± 7.38) in the control group after eight weeks of treatment. When comparing with baseline the difference in MASI score was found statistically significant in both groups (p<0.05). On intergroup comparison, the change in MASI score between both groups was not statistically significant (p>0.05). In addition, MQOL and DQLI also improved significantly in both groups.

CONCLUSIONS

This study concluded that the Unani formulation and the control drug were equally effective and safer in the management of melasma.

A combination treatment of drug-laser-photon for melasma: A retrospective study of clinical cases

BACKGROUND

Combinational therapy such as taking tranexamic acid while using laser treatment has been proved potential efficacy by many experiments. However, there is few research which contains large samples and consistent observations.

OBJECTIVE

We evaluated clinical efficacy and safety of a new systemic treatment of drug-laser-photon therapy.

METHODS

Retrospective and randomized investigator-blinded study of 75 patients with mixed type melasma was analyzed. At each visit, standardized photographs were taken using VISIA. Modified melasma area and severity index (mMASI) scores were marked using photographs by two dermatologists.

RESULTS

The mMASI score decreased significantly from 6.92 to 3.84 after the treatment. The VISIA analyze right cheek data shows: Spots (from 49.67 ± 3.43 to 56.09 ± 3.31), UV spots (from 41.39 ± 24.45 to 44.56 ± 25.86), and Brown spots (from 23.97 ± 17.89 to 28.16 ± 21.28) are statistically increased (p = 0.035, p = 0.018, p = 0.07). All patients feel varying degrees of improvement, about 10.17% felt very much improved, 30.51% felt much improved (51%-75%), 45.76% felt moderately improved (26%-50%), and 13.56% felt little improved (1%-25%).

LIMITATIONS

This study was no control group.

CONCLUSION

The efficacy and safety profile of the combination of drug-laser-photon therapy systemic treatment in melasma patients has been proved. It has potential possibility to become a new, reliable, widely suitable therapy strategy.

Use of Natural Agents and Agrifood Wastes for the Treatment of Skin Photoaging

Photoaging is the premature aging of the skin caused by repeated exposure to ultraviolet (UV) rays. The harmful effects of UV rays-from the sun or from artificial sources-alter normal skin structures and cause visible damage, especially in the most exposed areas. Fighting premature aging is one of the most important challenges of the medical landscape. Additionally, consumers are looking for care products that offer multiple benefits with reduced environmental and economic impact. The growing requests for bioactive compounds from aromatic plants for pharmaceutical and cosmetic applications have to find new sustainable methods to increase the effectiveness of new active formulations derived from eco-compatible technologies. The principle of sustainable practices and the circular economy favor the use of bioactive components derived from recycled biomass. The guidelines of the European Commission support the reuse of various types of organic biomass and organic waste, thus transforming waste management problems into economic opportunities. This review aims to elucidate the main mechanisms of photoaging and how these can be managed using natural renewable sources and specific bioactive derivatives, such as humic extracts from recycled organic biomass, as potential new actors in modern medicine.

New Mechanistic Insights of Melasma

Melasma is a common acquired disorder of pigmentation that negatively impacts quality of life. Present treatments show poor therapeutic effect with frequent recurrence. This in large part is due to the currently limited understanding of the disease's etiology. It is urgent to elucidate the pathogenesis of melasma to further the discovery of new therapeutic strategies. Recent studies show that melasma is triggered or aggravated by a variety of factors, including genetic susceptibility, ultraviolet radiation, and sex hormone dysregulation. Ultraviolet B radiation upregulates the expression of several melanocyte-specific genes and stimulates the release of key factors that participate in the synthesis of melanin. There is a significant increase in melanin in both the epidermal and dermal layers of affected skin, possibly due to abnormalities in crosstalk between the melanocytes and other cells. Melanogenesis is regulated through various signaling networks including the Wnt/β-catenin, PI3K/Akt, cAMP/PKA, and SCF/c-kit-mediated signaling pathways. In addition, inflammatory mediators, oxidative stress, neuroactive molecules, sebocytes, etc, have also been proved to be related to the pathogenesis of melasma. This review provides a comprehensive update on the current understanding of the pathogenesis of melasma.

Aesthetic considerations when treating the Latin American patient: Thriving in diversity international roundtable series

BACKGROUND

The Hispanic/Latin American population is the fastest growing non-Caucasian group in the United States. Within this group, demand for aesthetic procedures is on the rise. High ethnic variability among these patients influences treatment approaches and patient priorities. Understanding these ethnic differences is central to providing optimal care.

AIMS

To discuss similarities and differences in anatomy and treatment preferences of Hispanic/Latin American patients both within the United States and internationally and explore how these differences may influence or inform aesthetic practices.

PATIENTS/METHODS

In support of clinicians who wish to serve a diverse patient population, a 6-part, international roundtable series focused on diversity in aesthetics was conducted from August 24, 2021 to May 16, 2022. In this roundtable, held in Medellin, Columbia, expert clinicians from across Latin America and the United States were invited to contribute and share best practices.

RESULTS

The results of the second roundtable in the series, the Latin American Patient, are described here. A special emphasis is placed on procedures that address the most commonly encountered concerns in these patients.

CONCLUSIONS

Hispanic and Latino patients represent a broad demographic with unique anatomical features, aesthetic preferences, and treatment priorities. Clinicians should consider these differences when treating this patient population.

Perspectives of topical formulations for melasma

Melasma is acquired hyperpigmentation that mainly affects the face, can cause negative changes in self-esteem, and mostly affects women. Treatment is difficult, and different drugs can be used in mono or combination therapy. In this article, we present a brief overview of melasma, how to evaluate it, and a synthesis of the most commonly used topical therapies and their indications, including sunscreens, pharmacological agents, and plant extracts. Hydroquinone (4%) in monotherapy or combined with corticosteroids (dexamethasone and fluocinolone acetonide) and retinoids (tretinoin); arbutin (1%); methimazole (5%); kojic (2%), azelaic (20%), and tranexamic (5%) acids are the pharmacological agents that stand out. Correct application of these substances determines a variable improvement in melasma but often causes adverse reactions such as erythema, itching, and burning at the application site. Vitamin C can contribute to the reduction of melasma and have little or no adverse effects while sunscreens are normally used as coadjuvant therapies. In conclusion, we have compiled specific topical therapies for treating melasma and discussed those that are the most used currently. We consider it important that prescribers and researchers evaluate the best cost-benefit ratio of topical therapeutic options and develop new formulations, enabling efficacy in the treatment with safety and comfort during application, through the reduction of adverse effects.

Effectiveness of combination therapy of broadband light and intradermal injection of tranexamic acid in the treatment of chloasma

OBJECTIVE

To investigate the efficacy and safety of broadband light (BBL) combined with intradermal injection of tranexamic acid for treating melasma.

METHODS

120 women with melasma admitted to our hospital from January 2021 to April 2022 were randomly categorized into the following groups: control group, treated with 250 mg tranexamic acid given orally twice daily, except during menstruation; group I, treated with BBL (Sciton, Inc., USA) monthly; group II, received intradermal injections of tranexamic acid monthly; and group III, treated with BBL with intradermal injection of tranexamic acid monthly. Treatment in each group lasted three months. The MASI (Melasma Area Severity Index) and VISIA (Canfield VISIA Complexion Analysis) were used for evaluation.

RESULTS

After treatment course, MASI scores and VISIA brown spot and red zone ranking improved in all four groups (p < 0.05). The decrease in MASI scores and improvement rates of VISIA brown spot and red zone rankings were not significantly different among the control group, group I, and group II; however, the decreased MASI scores and improvement rates of VISIA brown spot and red zone rankings were significantly higher in group III than in the other three groups (p < 0.05).

CONCLUSION

The effect of BBL combined with the intradermal injection of TA in the treatment of melasma is remarkable. This combination therapy can be an alternative and effective treatment for managing melasma.

Real-World Case Studies Showing the Effective Use of Azelaic Acid in the Treatment, and During the Maintenance Phase, of Adult Female Acne Patients

Acne Vulgaris is a chronic inflammatory skin disease, and one of the most prevalent inflammatory dermatoses among teenagers, affecting more than >95% of boys and 85% of girls. Adult female acne (AFA) is a subtype of acne, pragmatically defined as affecting women over the age of 25. The clinical presentation of AFA may be distinguished from adolescent acne according to some key clinical and psychosocial characteristics. The etiopathogenic factors and the chronic clinical course that are implicated in AFA make management complex and challenging. A frequent tendency to relapse makes the requirement for maintenance therapy highly likely. Therefore, AFA typically requires a specific, tailored therapeutic approach. This paper presents six challenging case studies that demonstrate the efficacy of azelaic acid gel (AZA) in adult female acne. The six cases use AZA as monotherapy, as part of a combination regimen at treatment initiation, or as maintenance treatment (which is frequently required in this adult population). The positive outcomes achieved in this case series demonstrate that AZA can be efficacious, result in excellent patient satisfaction in mild to moderate adult female acne, and can be effective as a maintenance therapy.

Intradermal Injection of 100mg Tranexamic Acid Versus Topical 4% Hydroquinone for the Treatment of Melasma: A Randomized, Controlled Trial

Objective

Melasma is an acquired and chronic hyperpigmentation disorder associated with a negative impact on patients' quality of life. This study compares the efficacy of 100mg/mL intradermal TA with 4% topical HQ on female patients presenting with melasma lesions.

Methods

In this randomized double-blind controlled trial, 48 women with melasma were allocated into two groups, treated with either 100mg/mL intradermal TA or topical 4% HQ. The MASI (Melasma Area and Severity Index) score was assessed by paired t-tests and repeated measured ANOVAs. The Dynamic Physician General Assessment (PGA) was also performed by taking photographs with a digital camera.

Results

The average MASI score for the HQ and TA groups was 7.7 (3.0 SD) and 5.9 (2.5 SD), respectively. In both groups, the MASI decreased significantly after three months of treatment; however, the decrease was not significant between the two groups (P=0.1). All participants developed mild degrees of burning pain in the injection site without serious adverse effects.

Limitations

First, we only used the MASI score to measure melasma degree. Second, this is a single-center study with a small sample size. Third, the before-after photos were not taken with a high-quality camera.

Conclusion

The results of our study showed that both TA and continuous HQ significantly reduced the MASI score of patients without any significant differences and serious side effects. Although many treatment modalities are available for melasma, this condition is still challenging for dermatologists with a high recurrence rate after treatment.

Design and development of tranexamic acid loaded film-forming gel to alleviate melasma

BACKGROUND

Melasma is a skin condition that causes increased epidermal pigmentation, enlarged melanocytes, increased melanosomes, solar elastosis, dermal blood vessels, and, occasionally, perivascular lymph histiocytic infiltrates.

OBJECTIVE

To develop the film-forming gel to alleviate melasma. Tranexamic acid was used as a model drug to evaluate the suitability of formulation to prevent symmetric hyperpigmentation.

METHODS

FFG is a hydrophilic polymeric cross-linked system loaded with an active moiety. Nine different formulations of 2% TXA were formulated using polyvinyl alcohol and hydroxypropyl methylcellulose 50 cP as film-forming polymers. Sodium carboxymethylcellulose, methylcellulose, and carbopol were used as gelling agents.

RESULTS

F7, F8, and F9 showed shorter DT, that is, 11, 8, and 12 min, respectively. The folding endurance of F7, F8, and F9 was >100 folds, and the pH of F7, F8, and F9 was >6. Among three formulations, F8 was further analyzed for in vitro drug diffusion, which showed >95% drug diffusion within 48 h. In vivo, the skin irritation potential of F8 was estimated using BAL/C mice, which confirmed the absence of skin irritation.

CONCLUSION

From the obtained results, we conclude that the FFG can be a strategic attempt to deliver the cosmeceutical drugs like TXA to alleviate Melasma with improved sustainability of the drug.

Validation of Case Identification for Melasma Using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision Codes

This cross-sectional study assesses the validity of using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) code for melasma appended to a clinic visit to identify adult patients meeting diagnostic criteria for melasma.

A Novel Furocoumarin Derivative, 5-((diethylamino)me-13 thyl)-3-phenyl-7H-furo [3,2-g] chromen-7-one Upregulates Melanin Synthesis via the Activation of cAMP/PKA and MAPKs Signal Pathway: In Vitro and In Vivo Study

Psoralen, a major furocoumarin component of the Fructus Psoralen (FP), in combination with ultraviolet radiation, cures abnormal pigmentation disorder. In a previous study, we synthesized a series of linear furocoumarins with different substituents, out of which 5-((diethylamino)methyl)-3-phenyl-7H-furo [3,2-g] chromen-7-one (encoded as 5D3PC) showed better pigmenting effect than others in B16 cells. In this study, we examined the mechanism underlying the melanogenic effect of 5D3PC both in vivo and in vitro. To examine the pigmentation effect, the B16 and human melanocyte cell lines, PIG1 and PIG3V melanocytes were incubated with 5D3PC. In animal experiments, C57BL/6 mice received 5% hydroquinone and were administrated with 5D3PC for 30 days. 5D3PC upregulated the melanin synthesis and tyrosinase in B16 cell, PIG1 and PIG3V. The expression level of tyrosinase (TYR), tyrosinase-related protein-1 (TRP-1) and tyrosinase-related protein-2 (TRP-2), microphthalmia-associated transcription factor (MITF), cyclic adenosine monophosphate (cAMP), phosphorylation of cAMP-responsive element binding protein (p-CREB), phosphorylation of p38 mitogen-activated protein kinase (MAPK), c- phosphorylation of Jun N-terminal kinase (p-JNK) was significantly higher in 5D3PC-treated B16 cells. The oral administration of 5D3PC attenuated the depigmentation of the C57BL/6 vitiligo mice model by increasing the numbers of melanin-containing hair follicles, melanogenic protein, and melanogenesis-relative genes expression in skin tissues.

Research-based findings on scope of liposome-based cosmeceuticals: an updated review

Background

Cosmeceuticals are cosmetic products with biologically active components that have drug-like benefits. Cosmeceuticals are currently rapidly growing segments encompassing the personal care industry and numerous topical cosmetics-based therapies for treating different skin conditions. The barrier nature of skin causes limitations to topical treatment. The effectiveness of this cosmeceutical product has been enhanced a few folds by using nanotechnological modifications.

Main body

PubMed electronic searches for the literature were performed using combinations of the following terms: “cosmeceutical,” “liposome-based cosmeceuticals,” “acne and liposome,” “photo-aging and liposome,” “hyperpigmentation and liposome,” “wrinkles and liposome,” “fungal infections and liposome,” and “hair damage and liposome” from the earliest publication date available to January 5, 2022. Among the various nanotechnological approaches, liposomes offer numerous advantages such as topical cosmeceutical products, starting from improved moisturization, biodegradability, biocompatibility, enhanced permeation and retention, improved bioavailability of the active ingredients, increased esthetic appeal of cosmeceutical products, slow and extended dermal release. This review outlines various liposome-based cosmeceutical products that has been investigated to treat skin disorders such as photoaging, wrinkles, hyperpigmentation, hair damage and fungal infections.

Conclusion

Liposome-based cosmeceuticals provide a better opportunity to deliver therapeutic moiety for various skin conditions and offer potential promise for future clinical applications.

Graphical Abstract

Evaluation of oral tranexamic acid as a novel treatment for melasma with a high benefit-risk ratio

BACKGROUND

Melasma is an acquired melanogenesis dysfunction resulting in chronic hyperpigmentation commonly affecting the face and other frequently sun-exposed areas of the body. Melasma typically presents in women of reproductive age and can significantly impact self-esteem, negatively affecting one's quality of life. In the United States, melasma is often treated with application of topical agents that interfere with melanin synthesis, lasers, or chemical peels; however, in some East Asian countries, oral tranexamic acid (TXA) is widely administered to alleviate hyperpigmentation during and after childbirth. TXA is currently only FDA-approved to treat hypermenorrhea and reduce blood loss in surgery but may offer women in the United States an additional therapeutic option to treat melasma.

AIMS

The aim of this paper is to evaluate the safety and baseline efficacy of oral transmexic acid as a treatment for melasma.

METHODS

We retrospectively surveyed 42 patients of Fitzpatrick skin types III-VI that were prescribed 650 mg of TXA ½ tablet to be taken twice daily by mouth.

RESULTS

We found majority of patients saw noticeable improvement in their melasma. Of the 42 patients, only seven experienced side effects. The side effects noted were headaches, malaise and nausea, gastrointestinal upset, congestion, numbness in legs, hypomenorrhea, and hypermenorrhea. Patients who experienced unpleasant side effects discontinued taking oral TXA and were relieved of their symptoms. No long-term side effects were discovered, and the side effects experienced may be due to other confounding factors.

CONCLUSION

From this data, we concluded oral TXA is a safe and effective treatment option for patients with persistent melasma.