Safety and efficacy of 4% hydroquinone combined with 10% glycolic acid, antioxidants, and sunscreen in the treatment of melasma

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.

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.

Topical and Systemic Therapies in Melasma: A Systematic Review

Introduction

Melasma is an acquired disorder, which presents with well-demarcated, brown-colored hyperpigmented macules, commonly involving the sun-exposed areas such as the face. It is a chronic and distressing condition, affecting the patients' quality of life, and has been conventionally treated with "first-line" agents including hydroquinone (HQ) alone or as a part of a triple combination cream (TCC), while "second-line" options include chemical peels, and third line options include laser therapy.

Materials and Methods

A systematic search was performed for all topical and systemic treatments for melasma up till May 4, 2021, using the PubMed and EMBASE databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. The search terms "melasma" and "treatment" were used to search for the relevant articles on both these databases, and a total of 4020 articles were identified. After removing the duplicate entries and screening the titles, abstracts, and full-text articles, we identified 174 randomized controlled trials (RCTs) or controlled clinical trials.

Results

Based on our review, HQ, TCCs, sunscreens, kojic acid (KA), and azelaic acid receive grade A recommendation. Further large-scale studies are required to clearly establish the efficacy of topical vitamin C, resorcinol, and topical tranexamic acid (TXA). Several newer topical agents may play a role only as an add-on or second-line drugs or as maintenance therapy. Oral TXA has a strong recommendation, provided there are no contraindications. Procyanidins, Polypodium leucotomos (PL), and even synbiotics may be taken as adjuncts.

Discussion

Several newer topical and systemic agents with multimodal mechanisms of action have now become available, and the balance seems to be tipping in favor of these innovative modalities. However, it is worth mentioning that the choice of agent should be individualized and subject to availability in a particular country.

Photoprotection in skin of color

As populations in many parts of the world are projected to become more racially diverse over the coming decades, we must better understand the unique characteristics of the skin of populations with skin of color (SOC). This review aims to highlight important physiologic and clinical considerations of photoprotection in SOC. Ultraviolet radiation and visible light affect dark and light skin differently. SOC populations have historically not been informed on photoprotection to the same degree as their light skinned counterparts. This has exacerbated dermatologic conditions in which SOC populations are disproportionately affected, such as hyperpigmentary disorders. Patients should be encouraged to utilize multiple methods of photoprotection, ranging from avoidance of sunlight during peak intensity hours, seeking shade, wearing sun-protective clothing and wide-brimmed hat, and applying sunscreen. Ideal sunscreens for SOC populations include those with UVA-PF/SPF ratios ≥ 2/3 and tinted sunscreens to protect against VL. Although there have been increased efforts recently, more research into photoprotection for SOC and targeted public education are required to disseminate photoprotection resources that are patient-centered and evidence-based.

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.

Understanding Melasma-How Can Pharmacology and Cosmetology Procedures and Prevention Help to Achieve Optimal Treatment Results? A Narrative Review

Melasma is a chronic skin condition that involves the overproduction of melanin in areas exposed to ultraviolet radiation. Melasma treatment is long-term and complicated with recurrence and resistance to treatment. The pathogenesis of melasma is highly complex with multiple pathologies occurring outside of the skin pigment cells. It includes photoaging, excessive melanogenesis, an increased number of mast cells, increased vascularization, and basement membrane damage. In addition, skin lesions related to melasma and their surrounding skin have nearly 300 genes differentially expressed from healthy skin. Traditionally, melasma was treated with topical agents, including hydroquinone, tretinoin, glucocorticosteroids and various formulations; however, the current approach includes the topical application of a variety of substances, chemical peels, laser and light treatments, mesotherapy, microneedling and/or the use of systemic therapy. The treatment plan for patients with melasma begins with the elimination of risk factors, strict protection against ultraviolet radiation, and the topical use of lightening agents. Hyperpigmentation treatment alone can be ineffective unless combined with regenerative methods and photoprotection. In this review, we show that in-depth knowledge associated with proper communication and the establishment of a relationship with the patient help to achieve good adherence and compliance in this long-term, time-consuming and difficult procedure.

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.

Self-applied topical interventions for melasma: a systematic review and meta-analysis of data from randomized, investigator-blinded clinical trials

BACKGROUND

Melasma is a frequent dermatological condition. Although its relevance as a skin condition is primarily of cosmetic nature, it may affect the patients' well-being and quality of life. A broad range of treatment options is available, which makes it difficult to choose the most appropriate treatment.

OBJECTIVES

To summarise and critically appraise evidence from investigator-blinded RCTs on the efficacy and safety of self-applied topical interventions for melasma.

METHODS

We systematically searched MEDLINE and Cochrane CENTRAL for RCTs on topical, self-administered interventions for patients diagnosed with melasma. Eligibility was limited to RCTs that explicitly stated in their methods section (1) how they generated the random allocation sequence, and (2) that the study outcome assessor was blinded towards the participants' group allocation. Outcomes of interest included evaluator-assessed clinical scores (e.g., melasma area and severity index, MASI), quality of life, and patient-reported outcomes as well as safety outcomes. The study findings were meta-analysed, pooling data from studies on the same comparisons, if this was possible. We assessed confidence in the effect estimates using the GRADE approach.

RESULTS

Our searches yielded 1,078 hits. We included 36 studies reporting on 47 different comparisons of interventions. These included medical treatments such as 'triple combination cream' (TCC), over-the-counter cosmetic and herbal products, as well as sun creams covering different light spectra. Pooling data was possible for only two comparisons (topical tranexamic acid (TXA) vs. hydroquinone (HQ) and cysteamine vs. placebo). Direct comparisons were available for a variety of interventions; however, the reported outcomes varied largely. Overall, our confidence in the effect estimates ranged from very low to high.

CONCLUSION

Our findings indicate that TCC and its individual components HQ and tretinoin are effective in lightening melasma. Besides these established self-applied treatment options, we identified further medical as well as promising cosmetic and herbal product treatment approaches. Furthermore, evidence suggests that using broad-spectrum sunscreen covering both the visible and UV-light spectrum enhances the treatment efficacy of HQ. However, with mostly small RCTs comparing treatments directly, using a broad range of outcomes, further research is needed to draw conclusions about which treatment is most effective.

Treatment of melasma: a review of less commonly used antioxidants

Melasma, a common cause for seeking dermatologic care, is a chronic condition of skin hyperpigmentation. With a poorly understood pathogenesis, and no universal cure, melasma is a challenge for many dermatologists. For decades, there has been investigation into the role of oxidative stress in melasma. In this literature review, we introduce the role of oxidative stress in melasma and discuss the function of various topical and oral antioxidant therapies for patients suffering from melasma. Numerous studies have shown efficacy of various antioxidant therapies for treatment of hyperpigmentation, and in this review, we focus primarily on those with less widespread use. Vitamin E, niacinamide, polypodium leucotomos, pycnogenol, grape seed extract, amino fruit acids, phytic acid, zinc, silymarin, Korean red ginseng powder, plant extracts, and parsley all have well-demonstrated evidence of antioxidant properties, and these substances have been studied in the context of skin hyperpigmentation. Although there is conflicting evidence of their therapeutic efficacy, the use of these naturally occurring substances is promising for patients and medical providers seeking alternative therapeutic options.

Melasma Treatment: An Evidence-Based Review

BACKGROUND

Melasma is an acquired, chronic pigmentary disorder predominantly affecting women. It may significantly affect quality of life and self-esteem due to its disfiguring appearance. Multiple treatments for melasma are available, with mixed results.

OBJECTIVE

The aim of this article was to conduct an evidence-based review of all available interventions for melasma.

METHODS

A systematic literature search of the PubMed electronic database was performed using the keywords 'melasma' and/or 'chloasma' in the title, through October 2018. The search was then limited to 'randomized controlled trial' and 'controlled clinical trial' in English-language journals. The Cochrane database was also searched for systematic reviews.

RESULTS

The electronic search yielded a total of 212 citations. Overall, 113 studies met the inclusion criteria and were included in this review, with a total of 6897 participants. Interventions included topical agents, chemical peels, laser- and light-based devices, and oral agents. Triple combination cream (hydroquinone, tretinoin, and corticosteroid) remains the most effective treatment for melasma, as well as hydroquinone alone. Chemical peels and laser- and light-based devices have mixed results. Oral tranexamic acid is a promising new treatment for moderate and severe recurrent melasma. Adverse events from all treatments tend to be mild, and mainly consist of skin irritation, dryness, burning, erythema, and post-inflammatory hyperpigmentation.

CONCLUSIONS

Hydroquinone monotherapy and triple combination cream are the most effective and well-studied treatments for melasma, whereas chemical peels and laser- and light-based therapies are equal or inferior to topicals, but offer a higher risk of adverse effects. Oral tranexamic acid may be a safe, systemic adjunctive treatment for melasma, but more studies are needed to determine its long-term safety and efficacy. Limitations of the current evidence are heterogeneity of study design, small sample size, and lack of long-term follow-up, highlighting the need for larger, more rigorous studies in the treatment of this recalcitrant disorder.

The Role of Sunscreen in Melasma and Postinflammatory Hyperpigmentation

Photosensitive conditions such as melasma and postinflammatory hyperpigmentation (PIH) are exacerbated by exposure to ultraviolet (UV) rays and visible light making sunscreen use an essential component of treatment. This is especially true in skin of color patients who are less likely to use photoprotection, even if diagnosed with these photoexacerbated conditions. We aimed to evaluate the body of literature to provide evidence for the use of sunscreen in the treatment of melasma and PIH. We reviewed English articles from PubMed, Journals@Ovid Full Text, and Embase using the search terms “sunscreen” and either “melasma” “PIH,” or “post-inflammatory hyperpigmentation.” Nine relevant publications provide evidence that a broad spectrum of protection, including UVA, UVB, and visible light within sunscreens can play an adjuvant role in therapy for melasma and PIH by stabilizing and improving these pigmentary disorders in skin of color patients. This review illustrates the advantages and limitations of sunscreen use, as well as practice gaps in photoprotection in the skin of color patients with melasma and PIH.

[Hyperpigmentation]

The key diagnostic tool for hyperpigmentation is histopathology, which may be accompanied by certain laboratory tests. Hyperpigmentation may result from excess melanin (hypermelanosis), cutaneous iron deposits (hemosiderosis), cutaneous carotene deposits (carotenoderma), or cutaneous deposits of a substance not normally found in the skin (dyschromia). The different types of hypermelanosis may be classified as either localised or generalised. The former generally correspond to skin tumours and may form a cutaneous expression of complex syndromes, which most notably include cardiac abnormalities, or to pigmented forms of inflammatory and/or infectious dermatoses. Diffuse hypermelanosis is frequently a sign of systemic disease, generally metabolic or endocrine disease, or else it may result from pharmaceutical therapy. Herein we review the various causes of hyperpigmentation and the corresponding therapy.

Ascorbic acid derivative-loaded modified aspasomes: formulation, in vitro, ex vivo and clinical evaluation for melasma treatment

Vitamin C (L-Ascorbic acid) has many favourable effects on the skin such as antioxidant, anti-aging and whitening effects. Its instability and low permeability limit its pharmaceutical use in cosmetic and dermatological products. Instead, Mg ascorbyl phosphate (MAP), an ascorbic acid derivative, has the same effect with higher stability is being used. In this work, a vesicular system, aspasomes, containing MAP was developed and evaluated. Aspasomes are multilayered vesicles formed by amphiphiles molecules, Ascorbyl palmitate (ASP), in combination with cholesterol and charged lipids for drug encapsulation. Here, we investigated the use of lecithin instead of the charged lipid dicetyl phosphate for aspasomes development. Nine formulations were prepared and evaluated for their entrapment efficiency, particle size, polydispersity index (PDI) and zeta potential. Their entrapment efficiency ranged from 33.00 ± 2.27 to 95.18 ± 1.06, while their particle size was from 373.34 ± 60.85 to 464.37 ± 93.46 nm with acceptable PDI (from 0.212 ± 0.068 to 0.351 ± 0.061) and zeta potential (from -37.52 ± 2.42 to -50.36 ± 1.82). Three formulations were selected and evaluated for their drug release, permeation and retention into skin. One formulation was selected to be formulated as aspasomal topical cream and gel. The aspasomal cream was found to have enhanced drug permeation and skin retention over the aspasomal gel as well as the aspasomes formulation. MAP aspasomal cream was evaluated clinically as an effective treatment for melasma against 15% trichloroacetic acid (TCA) and the results recorded that the aspasomal cream showed the greatest degree of improvement regarding the hemi-MASI scores with 35% of patients rating it as excellent treatment. The study showed that MAP aspasomal cream can be considered a novel treatment of melasma which is free of side effects. Its efficacy as a monotherapy is superior to that of chemical peeling using 15% TCA.

The Management of Melasma on Skin Types V and VI Using Light Emitting Diode Treatment

OBJECTIVE

This study investigated light emitting diode (LED) treatment for patients with melasma on darker skin types.

BACKGROUND

Melasma is a common disfiguring skin condition in women which is difficult to treat and is refractory. The cause of melasma remains unclear.

METHODS

In this study, 60 female participants aged between 25 and 60 years, who presented with melasma, were enrolled (n = 39.85). They were purposely assigned to two groups according to their skin types. Both groups received a total of 36 LED light treatments over a period of 9 months.

RESULTS

Both subjective and objective results indicated a significant improvement of melasma. Statistical analyses revealed significant improvements in both groups.

CONCLUSIONS

The results of this study suggest that LED is effective in managing melasma. These results will provide a basis for future therapeutic use of phototherapy to improve melasma.

Methyl-2-acetylamino-3-(4-hydroxyl-3,5-dimethoxybenzoylthio)propanoate suppresses melanogenesis through ERK signaling pathway mediated MITF proteasomal degradation

BACKGROUND

Microphthalmia-associated transcription factor (MITF) is regulated by expression and/or degradation pathway, controlling to the expression of melanogenic enzymes for melanin synthesis. Methyl-2-acetylamino-3-(4-hydroxyl-3,5-dimethoxybenzoylthio)propanoate (MAHDP) is reported to anti-melanogenesis effect but its mechanism remain unclear.

OBJECTIVE

To investigate the effects of MAHDP on melanogenesis and elucidate its mechanism.

METHODS

Tyrosinase activity, melanogenic proteins and gene expression levels were measured with MAHDP treatment in B16F1 cells, human melanocytes, reconstructed skin and clinical trial.

RESULTS

MAHDP attenuated melanin production in α-MSH (melanocyte stimulating hormone) stimulated-B16F1 cells. MAHDP decreased the expression of tyrosinase, tyrosinase-related protein-1 (TRP-1), and tyrosinase-related protein-2 (TRP-2). But, MADPH did not affect the phosphorylation of p38 MAPK, JNK and AKT, which are associated with the regulation of MITF expression. These results suggest that MITF downstream is regulated not transcriptionally but translationally. Treatment of MG132 (a proteasomal degradation inhibitor) almost abolished the decrease of MITF protein levels by MAHDP. Phosphorylation and ubiquitination of MITF for proteasomal degradation were increased by treatment of MAHDP. Treatment of PD98059 (an ERK phosphorylation inhibitor) abrogated ERK phosphorylation, downregulation of MITF and tyrosinase as well as the decrease of melanin contents by MAHDP. Therefore, the degradation of MITF proteins by MAHDP is regulated to the ERK signaling. Finally, MAHDP improved the pigmentation in human epidermal melanocytes, a UVB-irradiated the reconstructed skin model and clinical trial without cytotoxicity and skin irritation.

CONCLUSION

These results clearly demonstrate that MAHDP suppresses the expression of melanogenic enzymes through ERK phosphorylation-mediated MITF proteasomal degradation, and suggest that MAHDP may be efficient as a therapeutic agent for hyperpigmentation.

Fractional erbium-doped yttrium aluminum garnet laser-assisted drug delivery of hydroquinone in the treatment of melasma

Background

Melasma is a difficult-to-treat hyperpigmentary disorder. Ablative fractional laser (AFL)-assisted delivery of topically applied drugs to varied targets in the skin has been an area of ongoing study and research.

Objective

The objective of this study was to evaluate the efficacy and safety of fractional erbium-doped yttrium aluminum garnet (Er:YAG) laser as an assisted drug delivery for enhancing topical hydroquinone (HQ) permeation into the skin of melasma patients.

Patients and methods

Thirty female patients with bilateral melasma were randomly treated in a split-face controlled manner with a fractional Er:YAG laser followed by 4% HQ cream on one side and 4% HQ cream alone on the other side. All patients received six laser sessions with a 2-week interval. The efficacy of treatments was determined through photographs, dermoscopic photomicrographs and Melasma Area Severity Index (MASI) score, all performed at baseline and at 12 weeks of starting therapy. The patient’s level of satisfaction was also recorded.

Results

Er:YAG laser + HQ showed significantly better results (p<0.005) with regard to decrease in the degree of pigmentation as assessed on the 4-point scale than HQ alone. There was a significant decrease in MASI scores on Er:YAG laser + HQ side vs HQ side. Minor reversible side effects were observed on both sides.

Conclusion

AFL-assisted delivery of HQ is a safe and effective method for the treatment of melasma.

Medical Management of Melasma: A Review with Consensus Recommendations by Indian Pigmentary Expert Group

Melasma is one of the most common hyperpigmentary disorders found mainly in women and dark-skinned patients. Sunlight, hormones, pregnancy, and genetics remain the most implicated in the causation of melasma. Although rather recalcitrant to treatment, topical agents such as hydroquinone, modified Kligman's Regime, azelaic acid, kojic acid, Vitamin C, and arbutin still remain the mainstay of therapy with sun protection being a cornerstone of therapy. There are several new botanical and non botanical agents and upcoming oral therapies for the future. There is a lack of therapeutic guidelines, more so in the Indian setup. The article discusses available evidence and brings forward a suggested treatment algorithm by experts from Pigmentary Disorders Society (PDS) in a collaborative discussion called South Asian Pigmentary Forum (SPF).

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.

Proposing Melasma Severity Index: A New, More Practical, Office-based Scoring System for Assessing the Severity of Melasma

Background:

Melasma Area and Severity Index (MASI), the scoring system in melasma, needs to be refined.

Aims and Objectives:

To propose a more practical scoring system, named as Melasma Severity Index (MSI), for assessing the disease severity and treatment response in melasma.

Materials and Methods:

Four dermatologists were trained to calculate MASI and also the proposed MSI scores. For MSI, the formula used was 0.4 (a × p²) l + 0.4 (a × p²) r + 0.2 (a × p²) n where “a” stands for area, “p” for pigmentation, “l” for left face, “r” for right face, and “n” for nose. On a single day, 30 enrolled patients were randomly examined by each trained dermatologist and their MASI and MSI scores were calculated. Next, each rater re-examined every 6^th patient for repeat MASI and MSI scoring to assess intra- and inter-rater reliability of MASI and MSI scores. Validity was assessed by comparing the individual scores of each rater with objective data from mexameter and ImageJ software.

Results:

Inter-rater reliability, as assessed by intraclass correlation coefficient, was significantly higher for MSI (0.955) as compared to MASI (0.816). Correlation of scores with objective data by Spearman's correlation revealed higher rho values for MSI than for MASI for all raters.

Limitations:

Sample population belonged to a single ethnic group.

Conclusions:

MSI is simpler and more practical scoring system for melasma.

Brazilian consensus on photoprotection

Brazil is a country of continental dimensions with a large heterogeneity of climates and massive mixing of the population. Almost the entire national territory is located between the Equator and the Tropic of Capricorn, and the Earth axial tilt to the south certainly makes Brazil one of the countries of the world with greater extent of land in proximity to the sun. The Brazilian coastline, where most of its population lives, is more than 8,500 km long. Due to geographic characteristics and cultural trends, Brazilians are among the peoples with the highest annual exposure to the sun. Epidemiological data show a continuing increase in the incidence of non-melanoma and melanoma skin cancers. Photoprotection can be understood as a set of measures aimed at reducing sun exposure and at preventing the development of acute and chronic actinic damage. Due to the peculiarities of Brazilian territory and culture, it would not be advisable to replicate the concepts of photoprotection from other developed countries, places with completely different climates and populations. Thus the Brazilian Society of Dermatology has developed the Brazilian Consensus on Photoprotection, the first official document on photoprotection developed in Brazil for Brazilians, with recommendations on matters involving photoprotection.

Evaluation of the efficacy and safety of combinations of hydroquinone, glycolic acid, and hyaluronic acid in the treatment of melasma

BACKGROUND

Various treatments are currently available for melasma. However, results are often disappointing.

OBJECTIVES

1 To assess the efficacy and safety of combinations of hydroquinone, glycolic acid, and hyaluronic acid in the treatment of melasma after topical application. 2 To evaluate the dermoscopy as a tool in diagnosis and follow-up of melasma treatment.

PATIENTS AND METHODS

One hundred patients with mild, moderate-to-severe melasma were divided into five groups. Group I (twenty patients were treated with cream formula containing 4% hydroquinone), group II (twenty patients were treated with cream formula containing 4% hydroquinone + 10% glycolic acid), group III (twenty patients were treated with cream formula containing 4% hydroquinone + 0.01% hyaluronic acid), group IV (twenty patients were treated with cream formula containing 4% hydroquinone + 10% glycolic acid + 0.01% hyaluronic acid), and group V (twenty patients were treated with placebo cream). All patients were subjected to dermoscopic examination and digital photographs before and after treatment. The response and side effects were evaluated.

RESULTS

Groups I, III, and IV showed highly significant changes in modified Melasma Area and Severity Index (mMASI) score after using the treatment. Group II showed significant change in mMASI score after using the treatment. The side effects were more reported in group II, followed by group IV, followed by group I, followed by group III. There was highly significant difference between the dermoscopic color findings before and after treatment. Vascularization was another dermoscopic finding.

CONCLUSION

A cream formula containing 4% hydroquinone + 10% glycolic acid + 0.01% hyaluronic acid was very effective in treatment of melasma with tolerable side effects. Dermoscope is a valuable noninvasive tool in the diagnosis and follow-up of melasma treatment.

A randomized, double-blind, placebo-controlled clinical trial on the efficacy and safety of 3% Rumex occidentalis cream versus 4% hydroquinone cream in the treatment of melasma among Filipinos

BACKGROUND

Melasma is a commonly acquired hyperpigmentation symmetrically distributed on the face, neck, and arms. The skin-lightening properties of Rumex occidentalis make it a therapeutic alternative to the reference standard treatment of hydroquinone (HQ).

OBJECTIVES

This study was conducted to evaluate the safety and efficacy of 3% R. occidentalis cream versus 4% HQ cream in the management of epidermal and mixed melasma.

METHODS

This was a randomized, double-blind, placebo-controlled trial. Forty-five subjects with epidermal and mixed melasma were recruited to compare 3% R. occidentalis cream, 4% HQ cream, and placebo cream applied twice daily for eight weeks. Changes in pigmentation were measured every two weeks using the Melasma Area Severity Index (MASI) and a mexameter. Adverse events were noted on every visit. Patient and investigator global evaluations were performed at the end of the study.

RESULTS

Overall mean MASI and mexameter readings in the three groups decreased from baseline to week 8. The greatest decline in score from weeks 2 to 6 was achieved by the HQ group, followed by the R. occidentalis group. By week 8, the R. occidentalis group showed a greater mean ± standard deviation decline in MASI and mexameter readings from baseline (MASI: 0.60 ± 0.86; mexameter: 50.56 ± 25.63) than the HQ group (MASI: 0.55 ± 0.62; mexameter: 45.89 ± 47.83). The efficacy of R. occidentalis cream and HQ cream were assessed as similarly favorable by both study subjects and investigators.

CONCLUSIONS

Rumex occidentalis 3% cream is a safe and effective skin-lightening agent for melasma and is comparable in efficacy with 4% HQ cream.

Evidence-based treatment for melasma: expert opinion and a review

Introduction

Melasma is one of the most common pigmentary disorders seen by dermatologists and often occurs among women with darker complexion (Fitzpatrick skin type IV–VI). Even though melasma is a widely recognized cause of significant cosmetic disfigurement worldwide and in India, there is a lack of systematic and clinically usable treatment algorithms and guidelines for melasma management. The present article outlines the epidemiology of melasma, reviews the various treatment options along with their mode of action, underscores the diagnostic dilemmas and quantification of illness, and weighs the evidence of currently available therapies.

Methods

A panel of eminent dermatologists was created and their expert opinion was sought to address lacunae in information to arrive at a working algorithm for optimizing outcome in Indian patients. A thorough literature search from recognized medical databases preceded the panel discussions. The discussions and consensus from the panel discussions were drafted and refined as evidence-based treatment for melasma. The deployment of this algorithm is expected to act as a basis for guiding and refining therapy in the future.

Results

It is recommended that photoprotection and modified Kligman’s formula can be used as a first-line therapy for up to 12 weeks. In most patients, maintenance therapy will be necessary with non-hydroquinone (HQ) products or fixed triple combination intermittently, twice a week or less often. Concomitant camouflage should be offered to the patient at any stage during therapy. Monthly follow-ups are recommended to assess the compliance, tolerance, and efficacy of therapy.

Conclusion

The key therapy recommended is fluorinated steroid containing 2–4% HQ-based triple combination for first line, with additional selective peels if required in second line. Lasers are a last resort.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-014-0064-z) contains supplementary material, which is available to authorized users.

Treatment of melasma with topical agents, peels and lasers: an evidence-based review

BACKGROUND

Melasma is an acquired disorder of hyperpigmentation occurring on the face and predominantly affecting women of childbearing age. It is a chronic, often relapsing condition with a negative impact on quality of life. Current treatments for melasma are unsatisfactory.

OBJECTIVE

The aim of this article was to conduct an evidence-based review of interventions available for the treatment of melasma.

METHODS

A systematic literature search was performed using PubMed and the keywords 'melasma' or 'chloasma' in the title. The search was further refined by using a filter for 'controlled clinical trials' and 'randomized controlled trial'. The included studies were used to develop recommendations for treatment.

RESULTS

The electronic search yielded a total of 80 citations. Forty studies were included in this review, which had a total of 2,912 participants. Three different therapeutic modalities were investigated-topical agents, chemical peels, and laser and light therapies. Topical depigmenting agents were found to be the most effective in treating moderate-to-severe melasma, with combination therapies, such as triple-combination therapy (hydroquinone, tretinoin, and fluocinolone acetonide), yielding the best results. Chemical peels as well as laser and light therapies were found to have moderate benefit but more studies are needed to determine their efficacy and long-term safety. Adverse events associated with treatment were mild and short-lasting and included skin irritation, dryness, burning, and erythema. The data could not be statistically pooled because of the heterogeneity of treatments and lack of consistency across study designs.

CONCLUSIONS

Topical combination therapies were found to be more effective than monotherapy. Triple combination therapy was found to be the most effective, but approximately 40 % of patients develop erythema and peeling. Chemical peels and laser and light therapies produced mixed results, with increased risk of irritation and subsequent hyperpigmentation, particularly in darker-skinned individuals. Hence, current treatments available for melasma remain unsatisfactory. Many of the studies lacked long-term follow-up. Limitations of current literature include the heterogeneity of study designs, small sample sizes, and poor follow-up rates. Additional evidence for the effects and role of sunscreens is needed. Categorization or stratification of demographic data should also be included in future studies, such as age, melasma type, and duration of melasma prior to initiation of treatment. Patient's perception of improvement versus investigator's assessment of improvement should also be included in future studies and standardized methods of study design and assessment of outcomes are needed to form definitive conclusions on the efficacy of different treatment modalities.

Topical treatment of hyperpigmentation disorders

Hyperpigmentation has traditionally been a relatively difficult condition to treat, especially in darker racial ethnic groups. Multiple topical agents available act upon different steps of the pigmentation pathway. We review these topical agents, their mechanisms of action, and their effectiveness as monotherapy and in combination with other compounds. Ultimately, combination therapy is the most efficacious when considering overall depigmentation as well as treatment time required to achieve clinical improvement.

A Comparative Study of the Efficacy of 4% Hydroquinone vs 0.75% Kojic Acid Cream in the Treatment of Facial Melasma

Background:

Melasma is a common acquired cause of facial hyperpigmentation seen predominantly among females with significant psychological and social impact. It is often recalcitrant to treatment. Several topical hypopigmenting agents have been used to combat melasma. Hydroquinone and Kojic Acid are well established monotherapeutic agents for treating melasma.

Objectives:

This study focuses mainly on the efficacy of once daily application of 4% Hydroquinone and 0.75% Kojic Acid cream (containing 0.75% Kojic acid and 2.5% vitamin C) so as to determine an effective modality of treatment for facial melasma.

Materials and Methods:

A total number of 60 patients with facial melasma attending the Out-patient department of Dermatology, Venerology and Leprosy, Fr. Muller Medical College Hospital, Mangalore from Oct 2008-April 2010 were studied. Patients were allocated alternately to group A and group B. Group A patients received 4% Hydroquinone cream and group B patient received a Kojic Acid cream (which contained 0.75% Kojic acid and 2.5% vitamin C) and were advised to apply topically once daily at night. Patients were followed up on 4^th, 8^th and 12^th week. At each visit side effects were noted and clinical response to treatment was calculated using the MASI score.

Statistical Methods:

Chi square test, student ‘t’ test.

Results:

At the 4^th week post treatment evaluation, facial hyperpigmentation responded early to 4% Hydroquinone cream than to 0.75% Kojic Acid cream. At the end of 12 week treatment period, 4% Hydroquinone cream had an overall superiority to 0.75% Kojic Acid cream as a topical hypopigmenting agent.

Conclusion:

The results of the study show that 4% Hydroquinone cream is a better topical hypopigmenting agent with rapid rate of clinical improvement when compared to 0.75% Kojic Acid cream.

Can we find the perfect oil to protect the perineum? A randomized-controlled double-blind trial

OBJECTIVE

To determine whether perineal massage during the second stage of labor using oil enriched with vitamins, increases the chances of delivering with an intact perineum as compared to perineal massage using pure liquid wax.

METHOD

A prospective, randomized, double-blind study was conducted. Women were assigned to liquid wax (jojoba oil) versus purified formula of almond and olive oil, enriched with vitamin B1, B2, B6, E and fatty acids. The caregivers used the oils during the second stage of labor.

RESULTS

A total of 164 women undergoing vaginal delivery were recruited. No significant differences regarding perineal lacerations, number of sutures and length of suturing were noted between the two groups. Likewise, while analyzing separately nulliparous and multiparous women, no significant differences were noted. Controlling for birth weight >4000 g, using the Mantel-Haenszel technique, no association was noted between perineal lacerations and the type of oil used (weighted OR = 0.9, 95% CI 0.3-2.4; p = 0.818).

CONCLUSION

The type of the oil used during the second stage of labor for prevention of perineal tears has no effect on the integrity of the perineum. Accordingly, it seems that there is no perfect oil.

Interventions for melasma

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Topical treatment of melasma

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

Melasma in Latin America: options for therapy and treatment algorithm

OBJECTIVE/AIM

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

BACKGROUND

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

METHODS

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

RESULTS

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

Management of hyperpigmentation in darker racial ethnic groups

Dyschromias, in particular hyperpigmentation, are major issues of concern for people of color. Pigmentary disorders such as melasma and postinflammatory hyperpigmentation (PIH) can cause psychological and emotional distress and can pose a negative impact on a person's health-related quality of life. The precise etiology of these conditions is unknown. Therapies for melasma and PIH target various points during the cycle of melanin production and degradation. Therapies for these conditions include topical agents and resurfacing procedures. Hydroquinone remains the gold standard of topical agents. Other efficacious agents include kojic acid, azelaic acid, mequinol, and retinoids. Cosmeceutical agents include licorice, arbutin, soy, N-acetyl glucosamine, and niacinamide. Resurfacing procedures that have been used to treat melasma and PIH include chemical peels, microdermabrasion, lasers, and intense pulsed light. These procedures are best used in combination with topical bleaching agents. Given the propensity of darker skin to hyperpigment, resurfacing procedures should be used with care and caution. Maximal results are best achieved with repetitive, superficial, resurfacing modalities. In addition, ultraviolet protective measures such as broad-spectrum sunscreens are fundamental to the successful management of these conditions.

Clinical Efficacy of 25% l-Ascorbic Acid (C'ensil) in the Treatment of Melasma

Background:

l-Ascorbic acid is used to treat melasma; however, it is quickly oxidized in aqueous solutions. Thus, C'ensil, a formulation containing 25% l-ascorbic acid and a chemical penetration enhancer, was created to promote the penetration of l-ascorbic acid into the skin.

Objective:

To evaluate the efficacy of C'ensil in patients with melasma.

Methods:

Forty subjects with melasma were treated with C'ensil during an open-label trial over a period of 16 weeks. Each subject's skin pigmentation was assessed every 4 weeks using the Melasma Area and Severity Index (MASI) and mexameter score. In addition, transepidermal water loss, skin dryness and irritation, and quality of life (Melasma Quality of Life Scale [MelasQoL]) were evaluated.

Results:

After 16 weeks, a significant decrease was noted in the degree of pigmentation based on the patients' MASI and mexameter scores. MelasQoL scores also decreased, indicating an increase in the subjects' quality of life.

Conclusion:

Our data indicate that C'ensil is an effective treatment modality for melasma.

Hyperpigmentation and melasma

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