Q-Switched Nd: YAG Laser Versus Trichloroacetic Acid Peeling in the Treatment of Melasma Among Egyptian Patients

An Update on New and Existing Treatments for the Management of Melasma

Melasma is a chronic, acquired disorder of focal hypermelanosis that carries significant psychosocial impact and is challenging for both the patient and the treating practitioner to manage in the medium to long term. Multiple treatments have been explored, often in combination given the many aetiological factors involved in its pathogenesis. Therapeutic discoveries to treat melasma are a focal topic in the literature and include a range of modalities, with recent developments including updates on visible light photoprotection, non-hydroquinone depigmenting agents, oral tranexamic acid, chemical peels, and laser and energy-based device therapy for melasma. It is increasingly important yet challenging to remain up-to-date on the arsenal of treatments available for melasma to find an efficacious and well-tolerated option for our patients.

Does Systemic Metformin Have a Role in Treating Melasma?

BACKGROUND

Melasma is a common pigmentary condition that affects the patients' quality of life and all the prescribed treatment options till now are not satisfactory, especially in dark-skinned patients.

OBJECTIVE

To evaluate the efficacy and safety of systemic metformin (1,000 mg and 500 mg) combined with trichloroacetic acid (TCA) peeling versus TCA alone in the treatment of melasma.

PATIENTS AND METHODS

The study included 60 melasma patients divided into 3 groups: Group A received systemic metformin (1000 mg/d), Group B received systemic metformin (500 mg/d) and Group C received placebo. The 3 treatment groups were treated by TCA 25% over the whole face bimonthly for a total of 6 sessions. Melasma area and severity index (MASI), and Melasma impact Quality of life Scale (MELASQOL) were used to assess the outcome.

RESULTS

There was a statistically significant decrease in the MASI, and the MELASQOL in the 3 studied groups after treatment with significantly better improvement in Group (A) than Group (C) ( p = .045).

CONCLUSION

Systemic metformin is a safe and promising therapeutic option for treating melasma.

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.

Trichloroacetic Acid With Microneedling Versus Trichloroacetic Acid Alone for Treating Melasma

BACKGROUND

Melasma is a common acquired disorder of hyperpigmentation which is difficult to treat.

OBJECTIVE

We aim to evaluate the efficacy and safety of combined microneedling with trichloroacetic acid in the treatment of melasma.

PATIENTS AND METHODS

Forty women with facial melasma were included and randomly classified into 2 groups. Group A included 20 patients treated with bimonthly session of trichloroacetic acid 25% peeling (8 sessions) combined with a monthly session of microneedling (4 sessions). Group B included the other 20 patients that were treated by bimonthly trichloroacetic acid 25% peeling session (8 sessions) alone.

RESULTS

After 1 and 3 months of treatment, the mean melasma area and severity index, modified melasma area and severity index, and melasma severity index scores showed significant improvement in each group (p < .05 for each). At 1 and 3 months, the mean percentages of change of all scores were significantly higher in group A than group B (p < .05).

CONCLUSION

Combined trichloroacetic acid peel with microneedling is effective and a safe option for treating melasma.

Medical therapies for Melasma

Melasma is a common malady affecting all races with a higher incidence in Hispanics, Middle Eastern, Asians and African origin females (Fitzpatrick skin phototypes III-V). Women are affected much more often than men. Melasma remains a significant cause of cosmetic morbidity and psychosocial embarrassment affecting quality of life necessitating effective and reliable treatment. Unfortunately, treatment remains unsatisfactory due to limited efficacy, adverse effects and relapses after stopping treatment. Although chemical peels, laser and light therapies and dermabrasion may have utility, the evidence available for their efficacy is limited and they often cause post inflammatory hyperpigmentation particularly in individuals with darker skin types. Medical therapies remain mainstay in the management of melasma. The triple combination, hydroquinone 4%, tretinoin 0.05% and fluocinolone acetonide 0.01% (Triluma, Galderma, Ft. Worth Texas, often modified incorporating different corticosteroids) remains the only US FDA approved treatment for melasma and is the gold standard due its demonstrated efficacy across ethnicities. Oral tranexamic acid alone or in combination with other modalities has also shown significant efficacy. Several cosmeceuticals and botanical extracts used as skin lightening agents have been demonstrated to be useful. Physical sunscreens containing zinc oxide, iron oxide, titanium dioxide, and silicones provide photoprotective and camouflage effect. We propose that a multimodality approach to the treatment of melasma is the most effective treatment approach. This review is focused on the medical therapies for melasma.

Laser therapy in the treatment of melasma: a systematic review and meta-analysis

Melasma is a highly prevalent and cosmetically disfiguring pigmented skin disease. The post-treatment results are often unsatisfactory. A large number of clinical trials have tried to prove the effectiveness of the combination therapy involving laser therapy, but the results have been indeterminate. This study aimed to evaluate the effectiveness of laser treatment for melasma via a systematic review and meta-analysis. We respectively searched 4 databases and clinicaltrials.gov as of June 8, 2021. Two researchers independently searched for literature and extracted data. Study outcomes were computed by weighted mean differences (WMD). All statistical analyses were performed by the Review Manager version 5.3, STATA version 14 software at 95% confidence interval. We obtained 22 eligible studies which involved a total of 694 patients. After the heterogeneity test and sensitivity analysis, we took a subgroup meta-analysis on the before and after treatment of different laser types. We found that most lasers and laser-based combinations were associated with reduced melasma area and severity index (MASI), such as low-fluence Q-switch 1,064-nm Nd: YAG laser (QSNYL) (WMD: - 2.76; 95% CI: - 3.53 to - 1.99), fractional ablative CO2 laser (WMD: - 9.36; 95% CI: - 12.51 to - 6.21), and fractional ablative 2940-nm Er: YAG laser (WMD: - 2,72; 95% CI: - 3.94 to - 1.49). Significant decrease was seen in neither MASI score of non-ablative 1550-nm fractional laser (WMD: - 1.29; 95% CI: - 2.80 to 0.21) and picosecond laser (WMD: - 0.58; 95% CI: - 1.43 to 0.27), nor melanin index (MI) of low-fluence QSNYL treatment (WMD: 10.17; 95% CI: - 4.11 to 24.46). When using laser to treat melasma, various adverse reactions may occur, most of which will resolve quickly without subsequent treatment, such as edema, erythema, scaling, and burning sensation after treatment. However, for patients with darker skin, there are risks of postinflammatory hyperpigmentation and hypopigmentation. The laser and laser-based combination treatment for melasma could significantly reduce the MASI score, which was showed by our systematic review and meta-analysis.

Microdermabrasion assisted delivery of glycolic acid 70% peel for the treatment of melasma in dark-skinned patients

Melasma is a disfiguring dermatologic condition and its treatment is still considered a challenge. To evaluate the efficacy and safety of microdermabrasion (MDA) combined with glycolic acid 70% (GA70%) peel versus GA70% alone in treating melasma in dark-skinned patients. This study included 30 female patients (skin type IV and V) with melasma. After cleansing the face, 3 passes of MDA were done on one side of the face. Then, GA70% was applied to the whole face in 1-2 uniform passes. Melasma area and severity index (MASI), modified MASI and hemi-MASI scores were used to assess the outcome. A significant decline of the mean MASI, mMASI and both hemi-MASI scores following treatment (p value = 0.000 for each). Furthermore, the hemi-MASI score on the MDA/GA70% treated side showed significantly greater decrease than the hemi-MASI score on GA70% treated side (p value = 0.041). MDA enhanced the improvement of GA70% peel effectively and safely.

Modified Jessner's Solution Combined With Trichloroacetic Acid 20% Versus Glycolic Acid 70% Combined With Trichloroacetic Acid 20% in the Treatment of Melasma

BACKGROUND

Melasma is an acquired challenging pigmentary skin problem, which commonly affects the face. A wide range of therapeutic modalities is available, yet none is satisfactory.

OBJECTIVE

To compare efficacy and safety of trichloroacetic acid (TCA) 20% peeling with either modified Jessner's solution (MJs) or with glycolic acid (GA) 70% peeling in the treatment of melasma.

PATIENTS AND METHODS

Thirty adult Egyptian women with melasma were recruited in the study. After cleansing the face, MJs was applied on one side of the face and GA 70% on the other side. Then, TCA 20% was applied in one uniform coat on both sides of the face. Assessment of the clinical response was guided by calculating the melasma area, severity index (MASI), modified MASI, and hemi-MASI scores before and after the end of treatment.

RESULTS

Both combinations showed significant reduction in MASI, modified MASI, and hemi-MASI scores (p value = .000, for each). Moreover, the hemi-MASI score after MJs and TCA20% showed a significant decrease compared with GA70% and TCA20% (p value = .013).

CONCLUSION

Both modalities are successful, safe options for treating melasma. Moreover, combining MJs with TCA 20% is more efficacious.

A split face randomized controlled trial comparing 1,064 nm Q-switched Nd-YAG laser and modified Kligman's formulation in patients with melasma in darker skin

BACKGROUND

No randomized studies compared the efficacy and safety of modified Kligman's triple combination (TC) with 1,064 nm Q-switched Nd-YAG laser (QSNYL) in melasma in darker skin.

OBJECTIVES

To compare the efficacy and safety of QSNYL and TC in the treatment of melasma in Fitzpatrick skin types IV and V.

METHODS

In this split face randomized controlled trial, participants' cheeks were randomized to receive either weekly QSNYL (group A) or daily TC (group B) for 12 weeks, followed by 12 weeks of follow-up.

RESULTS

Twenty-eight patients completed the intervention, and 21 of them completed follow-up. We found a significant but modest reduction in mean melanin index, modified Melasma Area Severity Index (MASI), and photographic and patient's assessment in both modalities (P < 0.01). No significant differences were detected between the groups. All patients had reappearance of pigmentation by the end of follow-up. Adverse reactions were significantly more in group B (P < 0.001).

LIMITATION

The desired sample size could not be achieved.

CONCLUSION AND RELEVENCE

No statistically significant differences were observed between QSNYL and TC as monotherapy in melasma. Reappearance of melasma is inevitable after stopping treatment.

Combined chemical peels versus trichloroacetic acid (TCA) for treating melasma: A split face study

Melasma is common skin condition presenting with hyperpigmentation. To evaluate the efficacy, tolerance, and complications of one session of combined chemical peels compared to traditional serial sessions of trichloroacetic acid (TCA) peeling in treating melasma. One session of combined chemical peels was carried out at the left side of the face, while six sessions of TCA 15% peel were carried out at the right side of the face every 10 days. The Modified Melasma Area and Severity Index (MASI) score was calculated at baseline (before starting peeling sessions), after one month (at the fourth TCA peeling session), and after three months (one month after the last TCA peeling session). Both sides of the face showed gradual reduction in modified MASI score throughout sessions. By the end of the study, the TCA-treated side showed slightly lower mean modified MASI score than the combined chemical peels-treated side of the face; however this difference was not statistically significant, (p = 0.405). A single session of combined chemical peels is as effective as six sessions of TCA peel in treatment of melasma. Combined chemical peels can be used as a convenient, tolerable and time saving safe procedure for treating melasma.

Laser treatment of medical skin disease in women

Laser treatment is a relatively new and increasingly popular modality for the treatment of many dermatologic conditions. A number of conditions that predominantly occur in women and that have a paucity of effective treatments include rosacea, connective tissue disease, melasma, nevus of Ota, lichen sclerosus (LS), notalgia paresthetica and macular amyloidosis, and syringomas. Laser therapy is an important option for the treatment of patients with these conditions. This article will review the body of literature that exists for the laser treatment of women with these medical conditions.

Combination of Q-Switched Nd:YAG and Fractional Erbium:YAG Lasers in Treatment of Melasma: A Randomized Controlled Clinical Trial

Introduction: Ablative and nonablative lasers have been used to treat melasma. We aimed to assess and compare the combining Q-switched Nd:YAG laser (QSNYL) and fractional erbium:YAG laser (FEYL) with QSNYL alone in treatment of melasma. Methods: This randomized controlled clinical trial was performed in our Research Center during 2013-2014. Women with melasma and without a history of keloid formation, hypersensitivity to hydroquinone, or pigmentary changes due to laser therapy were randomly allocated to receive four sessions of either QSNYL-FEYL combination or QSNYL alone. All patients received topical treatment with Kligman's formula. Before laser therapy and 4 weeks after the last treatment session, patients' skin was assessed for changes in skin color, melanin content, and erythema intensity of melasma lesions quantitatively. Results: Finally, 21 patients in QSNYL-FEYL and 20 in QSNYL group (mean age, 38.57 [5.60] and 42.60 [8.44] years, respectively) completed study. The skin color had become lighter in both groups (mean [SD] percentage change of 56.95 [40.29] and 29.25 [13.20] in QSNYL-FEYL and QSNYL groups, respectively) with significantly better results in QSNYL-FEYL group (P = 0.006). Percentage of decrease of melanin content was significantly higher in QSNYL-FEYL group (22.01 [10.67] vs. 7.69 [4.75]; P < 0.001). After adjustment for baseline values, the post treatment intensity of erythema was significantly lower in QSNYL-FEYL group (P < 0.001). The patients reported no adverse events. Conclusion: QSNYL-FEYL was significantly more effective in decreasing melanin content of lesions than QSNYL and led to a lighter skin.

Lasers in Melasma: A Review with Consensus Recommendations by Indian Pigmentary Expert Group

Lasers have come up as the newest therapeutic modality in dermatological conditions including melasma. In this article, as a group of experts from Pigmentary Disorders Society in collaboration with South Asian Pigmentary Disorders Forum (SPF), we have tried to discuss the lasers which have been used in melasma and formulate simple consensus guidelines. Following thorough literature search, we have summarised the rationale of using the lasers and the supporting evidences have also been provided. It is clear that laser cannot be the first line treatment for melasma. However, it can be used as an adjuvant therapy in resistant cases, provided the selection of patient and counselling has been done properly.

Evidence-based Review, Grade of Recommendation, and Suggested Treatment Recommendations for Melasma

Treatment of melasma is known to be less satisfactory, often incomplete, and relapse is frequent. Although many treatment options are available, they are either known to be unsafe on long-term use or their long-term safety profile is unknown. Patients often use various drugs, even topical steroid-based preparation without any medical supervision for long period of time, making the skin unsuitable for many of the drugs available. Thus, there has been gross disparity among the treating physician about what drugs and what regimen are best suitable for various categories of melasma patients and in different situations. With this background, numerous newer drugs, mostly combinations of some proprietary molecules or even unknown plant extracts, have flooded the market for the management of melasma. Information on efficacy or safety of these products are almost unknown. Studies on Asian people, especially Indian population, are far less commonly available. Therapeutic guideline for use on Indian patients with melasma is almost missing. Extrapolation of data from Caucasian people for use on Asian people may not be scientifically justifiable because Caucasian and Asian people are known to have inherent difference in their response as well as tolerance to the drugs used for melasma. With this background, we have extensively evaluated, following a strict, scientifically designed protocol, all the available studies on melasma management till May 2016 and prepared this document on level of evidence, grade of recommendation and suggested therapeutic guideline for melasma as per the method proposed by Oxford Centre of Evidence-Based Medicine. Various ethical, social, logical, regional, and economic issues in the context of Indian and similar populations were given due importance while preparing the suggested therapeutic recommendation.