A randomized, double-blind, placebo-controlled trial of oral procyanidin with vitamins A, C, E for melasma among Filipino women

Expert consensus on perioperative integrated skincare for noninvasive energy-based device aesthetic procedures in clinical practice in China

BACKGROUND

Noninvasive energy-based device (NI-EBD) aesthetic procedures has recently gained widespread usage for treating various skin conditions, enhancing skin texture and performing rejuvenation-related procedures. However, practically all NI-EBD procedures result in variable degrees of damage to the skin barrier, inducing pathological and physiological processes such as oxidative stress and inflammation, and only a small percentage of individuals possess the innate ability to restore it.

OBJECTIVE

To introduce the concept of integrated skincare and establish standardized operational procedures for perioperative integrated skincare, and furnish a theoretical basis for clinical diagnosis and treatment performed by professional medical aestheticians.

METHODS

The author leveraged domestic and international guidelines, clinical practice expertise and evidence-based research, adapting them to suit the specific circumstances in China.

RESULTS

The consensus were provided four parts, including concept and essence of integrated skincare, integrated skincare significance during the perioperative phase of NI-EBD procedures, active ingredients and functions of effective skincare products, standardized perioperative skincare procedure for NI-EBD procedures and precautions. For the standardized perioperative skincare procedure, four recommendations were listed according to different stages during NI-EBD procedures.

CONCLUSION

These recommendations create the 'Expert Consensus on Perioperative Integrated Skincare for Noninvasive Energy-Based Device Aesthetic Procedures in Clinical Practice in China'.

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.

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.

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.

Evaluation of systemic oxidative stress in patients with melasma

BACKGROUND

The significance of oxidative stress has been assessed and proven in the etiopathogenesis of many cutaneous disorders, but there are few studies that evaluated the role of only some factors involved in oxidative stress in patients with melasma.

OBJECTIVE

This study aimed to examine the role of oxidative stress in melasma and assess the relationship between systemic oxidative stress and the severity and extension of this disease.

METHODS

In this study, the serum levels of superoxide dismutase (SOD), glutathione peroxidase (GPX), catalase (CAT), malondialdehyde (MDA), protein carbonyl (PC), selenium (Se), vitamin E (vit E), and vitamin C (vit C) of fifty patients with melasma were compared with those of fifty controls.

RESULTS

The serum level of MDA was significantly higher in the melasma group (3.08 vs. 2.35 U/mL; p < 0.05), and it was positively correlated with the severity (r = 0.4; p < 0.001) and extension (r = 0.3; p < 0.05) of the disease. Furthermore, the serum level of vit C was significantly lower in melasma patients (2.16 vs. 2.57 μg/mL; p < 0.001).

CONCLUSION

Systemic oxidative stress has a key role in the etiopathogenesis of melasma. Serum concentrations of MDA and vitamin C are indicators of this impairment.

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.

Natural products in cosmetics

The global cosmetics market reached US$500 billion in 2017 and is expected to exceed US$800 billion by 2023, at around a 7% annual growth rate. The cosmetics industry is emerging as one of the fastest-growing industries of the past decade. Data shows that the Chinese cosmetics market was US$60 billion in 2021. It is expected to be the world's number one consumer cosmetics market by 2050, with a size of approximately US$450 billion. The influence of social media and the internet has raised awareness of the risks associated with the usage of many chemicals in cosmetics and the health benefits of natural products derived from plants and other natural resources. As a result, the cosmetic industry is now paying more attention to natural products. The present review focus on the possible applications of natural products from various biological sources in skin care cosmetics, including topical care products, fragrances, moisturizers, UV protective, and anti-wrinkle products. In addition, the mechanisms of targets for evaluation of active ingredients in cosmetics and the possible benefits of these bioactive compounds in rejuvenation and health, and their potential role in cosmetics are also discussed.

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.

Antioxidant Phytochemicals for the Prevention of Fluoride-Induced Oxidative Stress and Apoptosis: a Review

Fluorosis is a major public health problem globally. The non-availability of specific treatment and the irreversible nature of dental and skeletal lesions poses a challenge in the management of fluorosis. Oxidative stress is known to be one of the most important mechanisms of fluoride toxicity. Fluoride promotes the accumulation of reactive oxygen species by inhibiting the activity of antioxidant enzymes, resulting in the excessive production of reactive oxygen species at the cellular level which further leads to activation of cell death processes such as apoptosis. Phytochemicals that act as antioxidants have the potential to protect cells from oxidative stress. Evidence confirms that clinical symptoms of fluorosis can be mitigated to some extent or prevented by long-term intake of antioxidants and plant products. The primary purpose of this review is to examine recent findings that focus on the amelioration of fluoride-induced oxidative stress and apoptosis by natural and synthetic phytochemicals and their molecular mechanisms of action.

Deleterious side effects of nutritional supplements

Vitamin and mineral supplement consumption is widespread. They are taken for a variety of conditions, including dermatologic disorders. Although consumers often assume these supplements are safe, excessive consumption of supplements may have deleterious effects. Such vitamin supplements include vitamin A, niacin, biotin, vitamin D, and vitamin E, and specific mineral supplements include zinc, copper, and iron. These supplements may have a number of potential adverse effects.

A Review of Oral Therapies for the Treatment of Skin Hyperpigmentation

This review article examines evidence supporting the use of oral therapies in treating idiopathic, actinic, and metabolically induced skin hyperpigmentation. A thorough review of the literature regarding oral treatments for hyperpigmentation was systematically conducted through PubMed. Keywords used in the primary search include "Hyperpigmentation," "Melanosis" or "Melasma," "Lightening," "Oral," and "Therapeutics." The search was limited to the English language, and no timeframe restrictions were implemented. Numerous orally administered therapies have been proposed for the treatment of skin hyperpigmentation. There is an abundant body of literature demonstrating the efficacy of orally administered tranexamic acid, glutathione, isotretinoin, and proanthocyanidin. It is reasonable to expect that the most effective oral therapies will address known underlying causes of hyperpigmentation such as thyroid disease, diabetes, and hormonal imbalance. Improvement due to oral therapy of otherwise unresponsive skin hyperpigmentation or hyperpigmentation of unknown cause is less predictable. This review is limited by the strength of evidence contained within the available studies. Clinical studies investigating the treatments discussed within this article are limited in number, at times lack blinding in the study design, and are based on small sample sizes. Based on existing research, the most promising oral remedies for hyperpigmentation appear to be tranexamic acid, glutathione, isotretinoin, and proanthocyanidin. Additional studies to better establish safety and efficacy are necessary.

Melasma treatment: a systematic review

Melasma is a common chronic refractory disorder of pigmentation affecting people with darker skin types. Overall prevalence varies between 8.8% and 40%, depending on the ethnicity of the population and the geographical area. Therapeutic management of melasma is challenging, with high recurrence rates which significant impacts on the quality of life. No single treatment is universally efficacious. Systemic treatments with tranexamic acid and polypodium leucotmatous had promising results, although the former was related to systemic side effects. Microneedling and peeling were also efficacious, although their superiority to topical hydroquinone, the gold standard in melasma treatment, remains to be established. Similarly, laser and light devices have been beneficial. However, recurrence rates remain high in all treatment groups. Combination therapies, either in double or triple combinations yielded the best results when compared to single terapies. Treatment choice should be made after Wood's lamp examination, as well as dermatoscopic evaluation, in order to select the best treatment option, targeted at each melasma subtype.

Prospective Randomized Controlled Trial on the Effects of Almonds on Facial Wrinkles and Pigmentation

Background: Almonds have long been studied as a rich source of fatty acids, phytochemical polyphenols and antioxidants such as vitamin E. A recent study compared almond supplementations to a calorie-matched intervention for 16 weeks, yielding statistically significant improvement in wrinkle severity in postmenopausal women with Fitzpatrick skin types I and II that received almonds. This study furthers that assessment with a larger population and duration of 24 weeks to assess the influence of almond consumption on wrinkle severity, skin pigmentation and other skin biophysical profiles. Objective: To investigate the effects of almond consumption on photoaging such as wrinkles and pigment intensity as well as facial biophysical parameters such as sebum production, skin hydration and water loss. Design and interventions: A prospective, randomized controlled study assessed postmenopausal women with Fitzpatrick skin types I or II who consumed 20% of their daily energy consumption in either almonds or a calorie-matched snack for 24 weeks. A facial photograph and image analysis system was used to obtain standardized high-resolution photographs and information on wrinkle width and severity at 0, 8, 16 and 24 weeks. Measurements of transepidermal water loss (TEWL), skin pigmentation, skin hydration and sebum production were also completed at each visit. Results: The average wrinkle severity was significantly decreased in the almond intervention group at week 16 and week 24 compared to baseline by 15% and 16%, respectively. Facial pigment intensity was decreased 20% in the almond group at week 16 and this was maintained by week 24. There were no significant differences in skin hydration or TEWL in the almond group compared to the control, although sebum excretion was increased in the control group. Conclusion: The daily consumption of almonds may improve several aspects of photoaging such as facial wrinkles and pigment intensity in postmenopausal women. In conclusion, the daily consumption of almonds may contribute to the improvement of facial wrinkles and reduction of skin pigmentation among postmenopausal women with Fitzpatrick skin types I and II.

The Diverse Efficacy of Food-Derived Proanthocyanidins for Middle-Aged and Elderly Women

Middle-aged and elderly women are affected by various symptoms and diseases induced by estrogen deficiency. Proanthocyanidins, widely present in many kinds of fruits and berries, have many beneficial effects, such as antioxidative, anti-inflammatory, and antimicrobial activities. We researched the effects of proanthocyanidins for middle-aged and elderly women, finding that it has been revealed in many clinical trials and cohort studies that proanthocyanidins contribute to the prevention of cardiovascular disease, hypertension, obesity, cancer, osteoporosis, and urinary tract infection, as well as the improvement of menopausal symptoms, renal function, and skin damage. Thus, proanthocyanidins can be considered one of the potent representatives of complementary alternative therapy.

Combination treatment algorithm for pigmentary disorders of the face: A prospective observational study in Asian patients

BACKGROUND

Most patients with facial pigmentary disorders have multiple disorders. However, there is no definitive treatment algorithm improving various pigmentary disorders simultaneously.

OBJECTIVES

To investigate the clinical efficacy and safety of the combination of the Q-switched alexandrite and the carbon dioxide lasers with ZO SKIN HEALTH^Ⓡ for facial pigmentary disorders.

PATIENTS/METHODS

This prospective observational study enrolled 251 patients with at least one facial pigmentary disorder. We assessed treatment efficacy and investigated which disorders were most responsive to combination treatment and the relationship between doctors' skills, outcomes, and dropout rates.

RESULTS

There were 246 patients with lentigo senilis, 186 with moles, 79 with melasma, 53 with seborrheic keratosis, 17 with acquired dermal melanocytosis (ADM), and 16 with freckles. Overall, 227 patients completed treatment. Post-treatment outcomes were excellent in 97, good in 113, fair in 17, and poor in 0 patients. Freckles were the most responsive, and ADM was the least responsive. Patient withdrawal and treatment outcomes did not differ significantly based on the doctors' skills. Overall, 3.2% of patients had adverse events.

CONCLUSIONS

Our combination algorithm improved several pigmentary disorders of the face simultaneously, regardless of the doctors' proficiency level.

The top 10 cosmeceuticals for facial hyperpigmentation

Disorders of facial hyperpigmentation including melasma, postinflammatory hyperpigmentation and solar lentigines are common cutaneous conditions which can have a huge impact on patients' quality of life and often prove difficult to treat. The nascent market of cosmeceutical options provides a potentially safer and efficacious alternative for treating these challenging conditions. These can be used alone or in combination with other established treatments. Many cosmeceutical products are thought to work through inhibition of tyrosinase, a key enzyme of melanogenesis. We discuss the mode of action and provide an up-to-date review of the underlying evidence base for the top 10 cosmeceutical products for hyperpigmentation and melasma. Possible safer and more efficacious cosmeceutical therapies we discuss include thiamidol, kojic acid, vitamin C, arbutin, retinol, nicotinamide, ferulic acid, resorcinol, licorice root extract, and soy.

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 systemic treatments for skin lightening

BACKGROUND

Pigmentation of the skin occurs as a result of increased melanin production or deposition due to various reasons including age, hormonal imbalances, endocrine disease, inflammation, and/or exposure to damaging radiation, resulting in dermatologic conditions such as lentigines, melasma, or postinflammatory hyperpigmentation. Although numerous topical therapies exist for skin lightening, they are limited by efficacy and pigmentation recurrence after treatment cessation. New research into systemic therapies for hyperpigmentation has been promising.

OBJECTIVE

To summarize the current literature for systemic skin lightening therapies.

METHODS

A review of the literature surrounding systemic skin lightening therapies was completed using PubMed (US National Library of Medicine).

RESULTS

Multiple systemic therapies for skin lightening exist including oral carotenoids, glutathione, melatonin, Polypodium leucotomos hydrophilic extract, procyanidin, and tranexamic acid. Preliminary data for the treatment of hyperpigmentation are promising, and currently, these oral treatments appear safe. It is not suggested to use intravenous glutathione for skin lightening due to the increased risk of adverse events.

CONCLUSION

With the patient population seeking effective systemic treatments for skin pigmentation, it is important for dermatologists to understand the properties, the efficacy, and the adverse events profile of each compound, thus ensuring proper use by patients, and that patients are appropriately counseled regarding treatment expectation and safety.

The Effects of Acupuncture Combined with Auricular Acupressure in the Treatment of Chloasma

Objective

To investigate the effectiveness of acupuncture combined with auricular acupressure in chloasma treatment.

Methods

A prospective, randomized controlled assessor-blind clinical trial was performed and 135 patients were assigned into acupuncture combined with auricular acupressure (A), acupuncture (B), and control (C) groups, each with 45 patients. For groups A and B, body and facial acupuncture were applied for 2 months. For group A, auricular acupressure was applied concomitantly. For group C, vitamins C and E were prescribed for 3 months. Primary outcome measure was the therapeutic effects while secondary outcome measure was safety evaluation.

Results

The total effective rate was 95.6%, 91.1%, and 75.6% for groups A, B, and C (P < 0.01 between groups A and C; P < 0.05 between groups B and C). The posttreatment estradiol (E₂) levels in groups A and B were significantly decreased while the progesterone (P₄) levels were significantly increased compared to pretreatment (P < 0.01 and P < 0.05, resp.). The differences were significant compared to group C (P < 0.01 and P < 0.05, resp.). No adverse events occurred.

Conclusion

Acupuncture combined with auricular acupressure could significantly increase the therapeutic effect of chloasma treatment and could be better than vitamins C and E.

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.

Vitamin E in dermatology

Vitamin E is an important fat-soluble antioxidant and has been in use for more than 50 years in dermatology. It is an important ingredient in many cosmetic products. It protects the skin from various deleterious effects due to solar radiation by acting as a free-radical scavenger. Experimental studies suggest that vitamin E has antitumorigenic and photoprotective properties. There is a paucity of controlled clinical studies providing a rationale for well-defined dosages and clinical indications of vitamin E usage in dermatological practice. The aim of this article is to review the cosmetic as well as clinical implications of vitamin E in dermatology.

Rationale of using hypopigmenting drugs and their clinical application in melasma

Among the pigmentary disorders, melasma is the prototype disorder characterized by hyperpigmentation. Although, conventionally, triple combination creams are used, there is a need for alternatives to hydroquinone as the drug has restrictions on its widespread use. This needs an understanding of the steps involved in the melanogenesis and the drugs that inhibit the key steps. The data on in vitro inhibition need to be then translated into clinical in vivo results, before a rationale compounded fixed drug preparation is marketed that inhibits the major steps in the pigmentation pathway. There is also a need to look for drugs that are superior to hydroquinone, as only then will they have a meaningful clinical utility. For now, a few drugs like deoxyarbutin, ellagic acid, dioic acid, n-butylresorcinol and azelaic acid have such properties in clinical trials, while metformin is a recent addition.

Acquired hyperpigmentations

Cutaneous hyperpigmentations are frequent complaints, motivating around 8.5% of all dermatological consultations in our country. They can be congenital, with different patterns of inheritance, or acquired in consequence of skin problems, systemic diseases or secondary to environmental factors. The vast majority of them are linked to alterations on the pigment melanin, induced by different mechanisms. This review will focus on the major acquired hyperpigmentations associated with increased melanin, reviewing their mechanisms of action and possible preventive measures. Particularly prominent aspects of diagnosis and therapy will be emphasized, with focus on melasma, post-inflammatory hyperpigmentation, periorbital pigmentation, dermatosis papulosa nigra, phytophotodermatoses, flagellate dermatosis, erythema dyschromicum perstans, cervical poikiloderma (Poikiloderma of Civatte), acanthosis nigricans, cutaneous amyloidosis and reticulated confluent dermatitis

Aqueous Extract of Chrysanthemum morifolium ( Jú Huā) Enhances the Antimelanogenic and Antioxidative Activities of the Mixture of Soy Peptide and Collagen Peptide

The possible synergistic effect between the aqueous extract of Chrysanthemum morifolium ( Jú Huā) (AECM) and the peptide mixture (PM) containing soy peptide and collagen peptide was investigated in an ultraviolet (UV) irradiation-induced skin damage mouse model. The irradiated mice were treated with the PM or PM + AECM (containing PM and AECM), respectively. Both PM and PM + AECM groups displayed an apparent photoprotective effect on the UV-irradiated skin damage of mice. Histological evaluation demonstrated that the epidermal hyperplasia and melanocytes in the basal epidermal layer of the UV-irradiated skin in mice decreased when treated with either PM or PM + AECM. Further study showed that soy peptide, collagen peptide, and AECM also inhibited the activities of mushroom tyrosinase with IC50 values of 82.3, 28.2, and 1.6 μg/ml, respectively. Additionally, PM + AECM reduced melanogenesis by 46.2% at the concentration of 10 mg/ml in B16 mouse melanoma cells. Meanwhile, the UV-induced increase of antioxidative indicators, including glutathione peroxidase (GSH-Px), superoxide dismutase (SOD), and malondialdehyde (MDA), was reduced significantly after treatment with 1.83 g/kg/dbw of PM + AECM. This evidence supported the synergistic antioxidative effect of AECM with PM. These results demonstrated that oral intake of PM and AECM had synergistic antimelanogenic and antioxidative effects in UV-irradiated mice.

The use of botanically derived agents for hyperpigmentation: a systematic review

BACKGROUND

Hyperpigmentation disorders are common among those seeking care from dermatologists and primary care physicians. The cosmeceutical and natural product industries are rapidly growing and many botanical agents are purported to improve hyperpigmentation disorders.

OBJECTIVE

We sought to review clinical evidence for the use of botanical agents in the treatment of hyperpigmentation.

METHODS

We searched MEDLINE and Embase databases and a total of 26 articles met inclusion criteria. Study methodology was analyzed and the reproducibility of the studies was graded.

RESULTS

Several botanical agents appear promising as treatment options but few studies were methodologically rigorous. Several plant extract and phytochemicals effectively lighten signs of epidermal melasma and hyperpigmentation induced by ultraviolet radiation exposure. Results were mixed for treatment of solar lentigines or dermal hyperpigmentation.

LIMITATIONS

There were few rigorously designed studies; future research will be critical to further ascertain the discussed results.

CONCLUSIONS

The subtype of hyperpigmentation is important for treatment prognosis, with dermal hyperpigmentation less responsive to treatment. Botanical extracts may play an integrative role in the treatment of hyperpigmentation and further studies that integrate them with standard therapies are needed. Side effects, including worsened hyperpigmentation, need to be discussed when considering these therapies.

Oxidative stress status in patients with melasma

BACKGROUND

Melasma is an acquired skin disease characterized clinically by development of gray-brown macules or patches. The lesions have geographic borders and most often seen on face and less frequently on the neck and forearms. Pathogenesis has not been completely understood yet. Although the disease constitutes a very disturbing cosmetic problem, it has not obtained an efficient treatment. There were not any studies in the literature that evaluates the role of oxidative stress in melasma.

OBJECTIVES

The evaluation of the role of oxidative stress in melasma.

METHODS

Fifty melasma patients and 50 healthy volunteers were included in the study. The diagnosis was made clinically and the patients were evaluated by Melasma Area Severity Index. Superoxide dismutase (SOD), glutathione peroxidase (GSH-Px) enzyme activities and malondialdehyde, nitric oxide, protein carbonyl levels were measured both in the melasma group and the control group.

RESULTS

SOD and GSH-Px enzyme activities were significantly higher in the patient group in comparison with the control group (p < 0.001). Protein carbonyl levels were significantly lower in the patient group (p < 0.001).

CONCLUSION

The results show that the balance between oxidant and anti-oxidants was disrupted and the oxidative stress increased in melasma. These results improve the understanding of etiology-pathogenesis of the disease and its treatment.

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.