Comparative effectiveness and safety of topical methimazole 5% monotherapy versus combination of Q-Switched Nd: YAG Laser and topical methimazole 5% in patients with refractory melasma

INTRODUCTION

Melasma is an acquired pigmentary disorder which currently has no definitive treatment. Although topical drugs containing hydroquinone are the basis of treatments, they are usually associated with recurrence. We aimed to evaluate the effectiveness and safety of monotherapy with topical methimazole 5% versus combination of Q-Switched Nd: YAG Laser and topical methimazole 5% in patients with refractory melasma.

METHODS

A total of 27 women with refractory melasma were included. We applied topical methimazole 5% (once a day) with three passes of QSNd: YAG laser (Wavelength: 1064 nm, pulse energy: 750 mJ, fluence: 1.50  J/cm² , spot size: 4 × 4 mm, hand piece: fractional, JEISYS company) for six sessions on the right half of the face, and topical methimazole 5% (once a day) on the left half of the face, for each patient. The treatment course was 12 weeks. Evaluation of effectiveness was done with the Physician Global Assessment (PGA), Patient Global Assessment (PtGA), Physician satisfaction (PS), Patients satisfaction (PtS), and mMASI score.

RESULTS

PGA, PtGA, and PtS were not significantly different between the two groups at any time (p > 0.05). PS in the laser plus methimazole group was significantly better than methimazole group at 4th, 8th, and 12th weeks (p < 0.05). The rate of PGA improvement in the combination group was significantly better than the monotherapy over time (p < 0.001). The changes of mMASI score between the two groups did not significantly differ at any time (p > 0.05). There was no significant difference in the adverse events between the two groups.

CONCLUSION

Combination therapy with topical methimazole 5% and QSNY laser can be considered as an effective way to treat refractory melasma.

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.

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.

Efficacy of Cysteamine and Methimazole in Treating Melasma A Comparative Narrative Review

Melasma is a chronic and acquired pigmentary condition that primarily affects women and undermines patient satisfaction and confidence. Melasma mostly affects females, accounting for 90% of all cases. It affects people of all races, particularly those with skin types IV and V who live in areas with lots of UV radiation. According to the studies, Melasma lesions are seen throughout the face in centrofacial, malar, and mandibular patterns. Melasma lesions on the forehead, cheeks, nose, upper lip, and/or chin are the most prevalent centrofacial pattern. Melasma lesions can also be detected along the periorbital area, especially in Asian people. Melasma is notably resistant to treatment, with many patients experiencing only temporary relief and relapses. Combining therapies that target numerous pathologic components, including photodamage, inflammation, aberrant vascularity, and abnormal pigmentation, generally results in the most dramatic therapeutic improvements. Treatments for dark circles include topical depigmenting medicines like hydroquinone, kojic acid, azelaic acid, and topical retinoic acid, and physical treatments such as chemical peels, surgical adjustments, and laser therapy. The objective of therapy should be to figure out what's causing the hyperpigmentation and what's contributing to it. This article provides an overview of melasma therapies and the efficacy of methimazole and cysteamine for melasma therapy.

Management of hyperpigmentation: Current treatments and emerging therapies

Hyperpigmentation of the skin refers to a dermatological condition which alters the color of the skin, making it discolored or darkened. The treatments for hyperpigmentation disorders often take very long to show results and have poor patient compliance. The first-line treatment for hyperpigmentation involves topical formulations of conventional agents such as hydroquinone, kojic acid, and glycolic acid followed by oral formulations of therapeutic agents such as tranexamic acid, melatonin, and cysteamine hydrochloride. The second-line approaches include chemical peels and laser therapy given under the observation of expert professionals. However, these therapies pose certain limitations and adverse effects such as erythema, skin peeling, and drying and require long treatment duration to show visible effects. These shortcomings of the conventional treatments provided scope for further research on newer alternatives for managing hyperpigmentation. Some of these therapies include novel formulations such as solid lipid nanocarriers, liposomes, phytochemicals, platelet-rich plasma, microneedling. This review focuses on elaborating on several hyperpigmentation disorders and their mechanisms, the current, novel and emerging treatment options for management of hyperpigmentation.

Melasma: A Condition of Asian Skin

Melasma is a benign yet psychologically debilitating skin condition that is prevalent among women of darker phenotypes, and particularly in Asian women. This potentially preventable condition can lead to skin discoloration that is hard to treat and can frequently recur. This review aims to (1) highlight the pathophysiology of melasma, (2) describe its important risk factors, and (3) identify prevention methods, available treatment options, and potential complications of melasma. By raising awareness of this condition, we hope that physicians and patients will be able to be better informed to discuss screening options and to avoid preventable risk factors, especially in patients who are predisposed to the disease.

Most worthwhile superficial chemical peel for melasma of skin of color: Authors' experience of glycolic, trichloroacetic acid, and lactic peel

Glycolic acid (GA), lactic acid (LA) and trichloroacetic acid (TCA) peels have been used in various combinations for treating melasma patients, but none of the studies have compared their therapeutic efficacy and improvement in quality of life (QOL) index with these three peeling agents in melasma. Our study aims to compare the clinical efficacy, safety, tolerability and improvement in QOL index between 30% GA, 92% LA, and 15% TCA peeling in epidermal melasma. Ninety patients were divided into three groups with 30 in each. First group was treated with 30% GA peel, second with 92% LA peel, and third with 15% TCA peel at every 2 weeks interval for 12 weeks. Melasma area severity index (MASI) and QOL index (Melasma quality of life and Health related quality of life index) were used for clinical evaluation. Patients were observed for side effects and tolerability. The mean MASI score after therapy was significantly lower in patients treated with GA and TCA peels as compared with the group receiving LA peel. However, there was no significant difference in the mean MASI scoring at 12 weeks between GA peel and TCA peel groups. The improvement in QOL index was higher among patients undergoing GA peel followed by TCA and LA peel. Adverse effects were noted mostly with TCA peels followed by GA and LA peel. Thus, GA and TCA peels were equally efficacious and more effective than LA peels. LA peel had minimum side effects and better tolerability than GA and TCA peels.

Clinical factors affecting the efficacy of melasma treatment using the Q-switched 1064 Nd: YAG laser mode in a group of Venezuelan female patients

The influence of melasma risk factors on the effectiveness of laser toning treatment in Venezuelan females was investigated. Clinical evaluation was performed (n = 64) including ultrasound and thyroid hormone profile. All patients underwent face exposure with laser toning, eight sessions weekly. VISIA percentiles corresponding to dark brown spots determined before and after treatment were compared by ANOVA. Differences between percentile values before and after treatment for each patient were calculated and expressed as percentages. An improvement of ≥30% was considered as significant. Spearman rank correlations between improvement and clinical parameters were determined. A significant increase (p > .005) of the median of the percentiles in the overall group was observed. However, only 62.5% of the patients exhibited an improvement of ≥30% at the right malar, 73.4% at the frontal and 71.8% at the left malar areas. Hormonal contraception during treatment (right malar: p < .0001 left malar: p = .0035), thyroid disorders (right malar: p < .0001; frontal: p = .011; left malar: p < .0001) and photoaging (right malar: p = .0235; frontal: p = .0237; left malar: p = .0137) were inversely associated to melasma improvement after treatment. Prolonged use of sunscreen improved significantly (right malar: p < .001; frontal: p = .016 and left malar: p = .025) treatment effectiveness.

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).

Managing the Difficult Soft Tissue Envelope in Facial and Rhinoplasty Surgery

BACKGROUND

The nasal soft tissue envelope affects the final rhinoplasty result, and can limit the expected improvement. Currently, no dependable and objective test exists to measure the thickness of the nasal skin and underlying soft tissue.

OBJECTIVES

This paper presents a simple, yet reliable method to determine the thickness of the soft tissue envelope. An algorithm is presented for treatment of the dermis and/or soft tissue apart from surgery of the underlying osseocartilaginous structures.

METHODS

Seventy-five patients presenting for primary rhinoplasty underwent visual and ultrasound assessment of their nasal soft tissue envelope. At preoperative evaluation, the Obagi "skin pinch test" was used to assess the thickness of the nasolabial fold and whether or not the skin was oily. Patients were classified based on the pinch thickness. At time of surgery prior to injection of local anesthesia, ultrasonic assessment was done at the nasolabial fold, keystone junction, supratip, and tip to measure the thickness of the nasal dermis and underlying soft tissue.

RESULTS

Patients determined to have thin, normal, and thick skin by the "skin pinch test" were found to have a nasolabial fold dermal thickness with an average of 0.7 mm (0.4-1.2 mm), 1.1 mm (0.8-1.8 mm), and 1.4 mm (0.7-2.0 mm). Patients determined to have thin, normal, and thick skin were found to have a dermal thickness at the keystone junction with an average of 0.3 mm (0.2-0.4 mm), 0.5 mm (0.3-1.1 mm), and 0.9 mm (0.6-1.2 mm), respectively. This difference in thickness also translated to the supratip and tip areas measured. However, all areas were also affected by the oiliness of the skin. Soft tissue thickness (SMAS and muscle) underlying the dermis was variable. Patients of non-Caucasian background were more likely to have a thicker soft tissue layer.

CONCLUSIONS

The "skin pinch test" is an easy and reliable way for the surgeon to evaluate the thickness of the nasal soft tissue envelope. The rhinoplasty surgeon can make decisions pre- and postoperatively to treat patients with difficult soft tissue envelopes. LEVEL OF EVIDENCE 4.

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.

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.