A pilot study of oral tranexamic acid and Glycyrrhizin compound in the treatment of recalcitrant Riehl’s melanosis

Efficacy and safety of the combination of oral tranexamic acid and intense pulsed light versus oral tranexamic acid alone in the treatment of refractory Riehl's melanosis: A prospective, comparative study

BACKGROUND

There is no standardized and effective treatment modality for Riehl's melanosis.

AIMS

To compare the efficacy and safety of oral tranexamic acid (TXA) combined with intense pulsed light (IPL) versus TXA alone in the treatment of refractory Riehl's melanosis.

METHODS

A prospective study of 28 subjects with refractory Riehl's melanosis and Fitzpatrick Skin Types III or IV was conducted. All subjects received oral TXA 500 mg daily and 11 of them were treated in combination with monthly IPL therapy for 6 months. The primary outcome measure was mean melanin index (MI), erythema index (EI) and acquired dermal macular hyperpigmentation area and severity index (DPASI). The Physician Global Assessment (PGA) and patient satisfaction scale were documented.

RESULTS

After treatment, DPASI, mean MI, and EI were significantly reduced in both groups. The group treated with combination therapy showed better improvement according to MI (p = 0.0032) and DPASI (p = 0.00468). PGA and patient satisfaction scale showed superior efficacy in the combination group. No significant difference was observed in treatment-related side effects.

CONCLUSION

The combination of oral TXA and IPL proves to be a safe and satisfactory treatment strategy for refractory Riehl's melanosis.

Advancements in Laser Therapies for Dermal Hyperpigmentation in Skin of Color: A Comprehensive Literature Review and Experience of Sequential Laser Treatments in a Cohort of 122 Indian Patients

The heightened awareness of ethnic dermatology aligns with the growing prevalence of skin of color communities globally, where hyperpigmentation disorders pose a common dermatological challenge. Effectively addressing dermal pigmentation is challenging due to its resistance to conventional therapies and its association with impaired quality of life. This underscores the need for effective treatments and a thorough grasp of laser advancements. A relevant literature search spanning the last 7 years across the PubMed database reveals core studies, challenges, and the evolution of laser technologies tailored for various forms of congenital and acquired dermal hyperpigmentation in skin of color. This comprehensive review explores the mechanisms, applications, and recommendations for pigmentary laser technologies, highlighting the key role of Q-switched lasers in their established millisecond/ nanosecond forms and emerging picosecond lasers, fractional non-ablative and ablative lasers, Intense Pulsed Light, etc. The summary of evidence includes studies on dermal melanocytosis (nevus of Ota and Hori's nevus), tattoos, acquired dermal macular hyperpigmentation, etc., and also entities with mixed epidermal-dermal components, such as melasma and post-inflammatory hyperpigmentation. The review offers valuable insights for clinicians to make informed decisions based on diagnosis, skin type, and the latest technologies to optimize results and minimize complications, especially in darker Fitzpatrick skin types. In their five-year study with 122 Indian patients, the authors applied specific laser combinations for diverse dermal melanoses, including tattoos, dermal/mixed melasma, acquired dermal macular hyperpigmentation, and dermal nevi. Substantial pigmentation reduction, subjectively assessed by both physicians and patients, was observed across all groups. A one-way ANOVA indicated a significant difference in mean improvement scores across various pigmentary conditions (F = 3.39, p = 0.02), with melasma patients exhibiting a significantly higher improvement score than tattoos (p = 0.03). The results affirmed the safety and efficacy of sequential laser therapy for dermal pigmentation in skin of color, advocating for flexibility in approach while maintaining the rationale behind the laser sequences. Despite advancements, challenges persist, and gaps in the current literature are identified. In conclusion, this summary highlights the ongoing pursuit of optimal protocols in dermatological laser treatments for dermal melanoses, offering valuable insights for future research and clinical practice.

Acquired dermal macular hyperpigmentation: an overview of the recent updates

Acquired dermal macular hyperpigmentation (ADMH), previously known as macular pigmentation of uncertain etiology (MPUE), is an umbrella concept that unifies the distinct but overlapping acquired dermal pigmentary disorders like lichen planus pigmentosus, ashy dermatosis, erythema dyschromicum perstans, Riehl's melanosis and pigmented contact dermatitis. All of these disorders usually lack a clinically apparent inflammatory phase, are characterised by dermal pigmentation clinically and histologically, and have a variable protracted disease course. Recently, a proposal has been made to classify these disorders into those with and without contact sensitisation. Dermoscopy is essentially similar across the spectrum of these disorders, and is useful for diagnosis and therapeutic response monitoring. Scoring system has been validated for the same. The treatment of ADMH remains challenging, with multiple topicals, oral therapies including mycophenolate mofetil, and lasers tried. Need of the hour is randomised controlled trials to enhance the therapeutic armamentarium.

The role of reflectance confocal microscopy in the diagnosis and management of pigmentary disorders: A review

BACKGROUND

Reflectance confocal microscopy (RCM) has quickly transitioned from a research tool to an adjunct diagnostic bedside tool, providing the opportunity for noninvasive evaluation of skin lesions with histologic resolution. RCM is an optical imaging technique that uses near-infrared excitation wavelengths and safe low-power lasers. En-face images of different skin layers (up to the superficial dermis) are acquired in grayscale based on the reflective indices of tissue components. Melanin has the highest reflective index (contrast) and appears bright on RCM.

AIMS

We present a review of the current literature on the use of RCM in the diagnosis and management of pigmentary disorders.

METHODS

We reviewed PubMed and Ovid Medline databases from January 2000 to June 2021, using MeSH key terms: "reflectance confocal microscopy, confocal laser scanning microscopy, pigmentary disorders, treatment, melasma, vitiligo, freckles, solar lentigo, lentigo, tattoo, complications, melanoma, skin cancers, pigmented lesions, post inflammatory, melanin, photoaging" to identify studies and review articles discussing the use of RCM in the diagnosis and management of pigmentary disorders.

RESULTS

RCM findings of pigmentary disorders were divided into the following categories: (1) disorders of increased pigmentation (post-inflammatory hyperpigmentation, melasma, Riehl's melanosis, solar lentigines, ephelides, hori nevus, naevus of Ota, café-au-lait macules, melanocytic nevus, melanoma, nevus spilus, labial mucosal melanosis, and mucosal melanoma), (2) disorders of decreased pigmentation or depigmentation (post-inflammatory hypopigmentation, vitiligo, nevus depigmentosus, halo nevus), and (3) exogenous pigmentation (tattoo, ochronosis).

CONCLUSION

RCM has been explored and proven valuable for the evaluation and management of pigmentary disorders including melasma, vitiligo, solar lentigines, tattoo, and tattoo-related complications.

Unveiling the mystery of Riehl's melanosis: An update from pathogenesis, diagnosis to treatment

Riehl's melanosis is a hyperpigmentation disorder that has a significant psychological and social impact on individuals. In the past 10 years, new categories have been developed, raising questions about how to classify Riehl's melanosis. The mechanism of this disease remains unclear, although the type IV hypersensitivity response caused by allergic sensitization, as well as genetic, ultraviolet radiation, and autoimmune factors, is to blame. Clinical manifestation, dermoscopy, reflectance confocal microscopy, patch/photopatch testing, histopathology, and a novel multimodality skin imaging system have been used for the diagnosis. A variety of therapies including topical skin-lightening agents, oral tranexamic acid, glycyrrhizin compound, chemical peels, and lasers and light therapies (intense pulsed light, 1064-nm Q-Switched Nd: YAG laser, 755-nm PicoWay laser, nonablative 1927-nm fractional thulium fiber laser, new pulsed-type microneedling radiofrequency), with improved effectiveness. The latest findings on possible biomarkers and their relationship to other autoimmune diseases were also summarized.

Research Advances in the Treatment of Riehl's Melanosis

Riehl's melanosis (RM) is a contact photodermatitis, with fast progressive gray-brown skin pigmentation as the main manifestation, which can seriously affect the psychology and physiology of patients. Currently, although the etiological factors of Riehl's melanosis is still be unknown, the existing literature proves clearly the cause of it is related to the contacting with suspected allergens. For decades, there has been no standard method for the treatment of RM, but with both conventional drug therapy and laser therapy having been attempted. Topical application of bleaching agents is mainly used as an auxiliary treatment modality. The laser treatment modality remains a hot spot, among which Q-switched Nd:YAG laser is well received for RM. Positive outcomes have been achieved by the combined treatment modalities attempted in recent years also achieve positive outcomes. The purpose of this paper is to review and summarize recent advances in the treatment of the disease.

Riehl’s Melanosis: A Multimodality, In Vivo, Real-Time Skin Imaging Study with Cellular Resolution Optical Coherence Tomography and Advanced Skin Diagnosis System in a Tertiary Medical Center

Background: Riehl’s melanosis is a psychologically devastating hyperpigmentary disorder that typically occurs on the face and neck. The study of Riehl’s melanosis is limited due to its rarity, variable morphology, and lack of noninvasive diagnostic tools. Recent advances in skin imaging analysis and diagnostic systems improve diagnostic accuracy and enable the noninvasive, real-time evaluation of pigmentary disease. A comprehensive study of Riehl’s melanosis clinical morphology with multimodality and in vivo skin imaging systems has yet to be reported. Objectives: To investigate the clinical features and in vivo advanced skin imaging findings of Riehl’s melanosis. Methods: We retrospectively investigated the clinical characteristics, dermoscopic, and histopathological features of Riehl’s melanosis. We further utilized multimodality skin imaging analysis systems, including a cellular resolution optical coherence tomography (OCT) and new skin diagnosis system, to investigate the features of Riehl’s melanosis. In addition, we compared OCT findings with histopathological features and clinical assessment. Results: We evaluated 30 patients with Riehl’s melanosis at a tertiary medical center from 2010 to 2022. The average age was 47.7 ± 12.3 (mean ± SD) years, predominantly female patients (female: n = 23; male: n = 7). Cellular resolution OCT imaging from lesion skin shows increased melanocyte capping, disrupted basement membrane, telangiectatic blood vessels, and melanophages in the dermis. The advanced skin diagnosis system captured subclinical erythema of the skin, highlighting the inflammatory nature of the disease. The results correlated well with histopathological findings. Limitations: This is a single-center, cross-sectional study. Conclusions: We highlight the features of Riehl’s melanosis through a novel cellular resolution OCT and photographic skin diagnosis system. A multimodality skin diagnosis system can serve as a real-time, in vivo, noninvasive method for evaluating pigmentary disorders.

Pigmented contact dermatitis: A brief review

Hyperpigmentation is one of the common pigmentary complaints that brings the patient to dermatology services. Though there are multiple etiologies for hyperpigmentation, pigmented contact dermatitis (PCD) remains a common diagnosis. The cosmetics containing dyes, preservatives, fragrances, bactericidal, emulsifiers/surfactants, and vehicles are the potential sources, and paraphenylenediamine, benzyl salicylate, brilliant lake red R, thiomersal and gallate mix are some of the most commonly implicated allergens.

The clinical manifestation includes diffuse or patchy brown to blue-black pigmentation of the cheeks, the outer surface of ears, preauricular region, temporal area, nape of the neck, and upper back. Patch testing plays a pivotal role in the diagnosis of PCD and the testing series has to be selected according to the representative population. Given the chronicity of the disease, counseling patients against the use of cosmetics is challenging as the pigmentation tends to persist for longer durations inspite of stopping cosmetics. The pillars of treatment in PCD include recognition of the culprit allergen and preventing further exposure along with pharmacological therapy. This review provides a brief overview and an insight into the etiopathogenesis and management of PCD.

Role of miRNAs in melanin metabolism: Implications in melanin-related diseases

BACKGROUND

MicroRNAs (miRNAs) are short single-stranded non-coding RNAs that regulate degradation and expression of messenger RNA (mRNA) and play a wide range of key roles in different biological processes. They mediate different stages of melanocyte differentiation, growth, and apoptosis through a variety of pathways and can mediate melanin production by targeting key enzymes.

AIMS

This article was aimed to review the role of miRNAs in melanin metabolism and to introduce the role and significance of miRNAs in melanin-related diseases.

MATERIALS & METHODS

Systematic search and retrospective review were performed on the published data.

RESULTS

This paper reviews the process of melanin synthesis and the regulatory mechanism, explores the miRNA expression profiles in different model organisms, and introduces the mechanisms of several key miRNAs participating in melanin metabolism through target genes. We also explore the potential role of miRNA as a new target for the treatment of melanin metabolism disease, including vitiligo, melanoma, and chloasma.

CONCLUSION

miRNAs play a key role in melanin-related diseases, and the miRNAs involved may be potential therapeutic targets.

Acquired Dermal Macular Hyperpigmentation: An Update

Acquired dermal macular hyperpigmentation (ADMH) is an umbrella term that includes disorders clinically characterized by small and large pigmented macules/patches and histopathologically showing an evidence of current or resolved interface dermatitis with pigment incontinence, without clinically significant prior inflammatory phase. The term intends to include diseases previously described in the literature as lichen planus pigmentosus, Riehl's melanosis/pigmented cosmetic dermatitis and ashy dermatosis/erythema dyschromicum perstans. The nomenclature and origin of these disorders have always been a matter of discussion. These disorders share many clinicopathological similarities, are difficult to treat and adversely affect the quality of life. Recent consensus points towards the need for a unifying term to facilitate research and therapeutic trials. This article aims to provide a comprehensive review of the recent advances in ADMH.

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.

An open-label, investigator-initiated, single-center, prospective, pilot clinical study to evaluate the efficacy of a skin whitening serum applied twice daily combined with a spot-preventing SPF50+ sunscreen in healthy female subjects with melasma hyperpigmentation

Background

Melasma is a common skin disorder characterized by alterations in normal skin pigmentation. The objective was to evaluate the efficacy and safety of a skin whitening serum containing niacinamide, hydroxyphenoxy propionic acid, dipotassium glycyrrhizate, glycolic acid, and 4‐n‐butylresorcinol applied twice daily combined with a spot‐preventing SPF50+ sunscreen for treatment of melasma.

Methods

Twelve healthy Caucasian women with melasma (Fitzpatrick skin types II−IV) were enrolled in this pilot clinical study. Efficacy evaluations were performed at baseline and weeks 4, 8, and 12 of treatment and included clinical and instrumental assessments.

Results

All endpoints for melasma hyperpigmentation showed a statistically significant improvement from baseline to the end of the study. There was only one dropout. No signs of irritation or discomfort were observed at baseline, w4, w8, or w12. An overall improvement in melasma was observed both clinically and on reflectance confocal microscopy (RCM).

Conclusion

This topical skin whitening serum had favorable outcomes for the treatment of melasma hyperpigmentation in adult women, as demonstrated on investigator and instrumental assessments. The results of this pilot study need to be confirmed in randomized, controlled studies with a larger sample size.

Dynamic evaluation of an in vivo postinflammatory hyperpigmentation model using reflectance confocal microscopy and spectrophotometry

BACKGROUND

Postinflammatory hyperpigmentation (PIH) reflects a dynamic process from primary injury and cutaneous inflammation to subsequent melanogenesis and hyperpigmentation, of which pathogenesis remains unclear, hindering the development of targeted therapies.

AIMS

To observe the dynamic development of PIH; determine the starting point and peak point of the inflammatory phase and pigmentary phase; and clarify the timing of anti-inflammatory and anti-pigmentary treatment.

METHODS

Thirty healthy volunteers with Fitzpatrick skin types III-IV were enrolled and underwent suction blisters. The noninvasive evaluation of inflammation and hyperpigmentation on suction blister sites were performed via spectrophotometry (CM2600d and SIAscope) and RCM for the following 24 weeks.

RESULTS

We successfully observed suction blister-induced PIH lasting over 24 weeks. The inflammatory phase started soon after the procedure and lasted for 8-12 weeks, manifested by significantly elevated a* values and erythema index detected by spectrophotometry, as well as inflammatory infiltration and angiogenesis shown in RCM images. Meanwhile, melanogenesis was accelerated after week 3 and reached peak on week 8, manifested by significantly accumulated melanin granules and bright pigment rings in different depths under RCM, which was in parallel with elevated melanin index. The darkening skin tone in PIH actually presented a mixture of inflammatory erythema, angiogenesis, and hyperpigmentation. The inflammation and pigmentation phases of PIH were not sequential but partially overlap.

CONCLUSION

The duration of suction blister-induced PIH is more than 24 weeks. The inflammatory phase partially overlaps with the pigmentary phase, and those drugs with anti-inflammatory and anti-pigmentary dual effects are potential choices.

Clinical Evaluation of Sequential Transdermal Delivery of Vitamin B6, Compound Glycyrrhizin, Metronidazole, and Hyaluronic Acid Using Needle-Free Liquid Jet in Facial Seborrheic Dermatitis

Facial seborrheic dermatitis (FSD) is a common facial inflammatory dermatitis. Needle-free transdermal jet injection (NTJI) is a non-invasive injection of drug solution by using a high-pressure liquid injection instrument. To explore a safer, more tolerable, and convenient medical way using NTJI in the treatment of FSD, the patients were treated with vitamin B6, glycyrrhizin compound, metronidazole, and hyaluronic acid sequentially using NTJI every 2 weeks, and only those treated for more than three times were included. A VISIA facial imaging system for the evaluation of erythema, superficial lipid level, and roughness of skin surface and a CK analyzer for biophysical parameters, including the stratum corneum hydration, facial surface lipid, and trans-epidermal water loss, were applied. Erythema was significantly reduced after every treatment (weeks 2, 4, and 6; P < 0.05), whereas superficial lipid level was not improved significantly until week 6 (P < 0.05), and roughness of the skin surface was not improved significantly during the whole treatment. The stratum corneum hydration of lesional skin was significantly increased after three times of treatment (P < 0.05). No observable adverse effect, such as marked erythema, blistering, or atrophy, was observed. Sequential transdermal delivery of small molecular weight drugs (vitamin B6, glycyrrhizin compound, metronidazole, and hyaluronic acid) using NTJI is a safe, low-toxicity, and take-home drug-free therapy for the treatment of FSD.

The color of skin: brown diseases of the skin, nails, and mucosa

Brown diseases comprise disorders leading to hyperpigmentation in skin and nails. Melasma is an acquired skin disorder that is characterized by brownish macules that typically occur on the face. Schamberg disease, also known as progressive pigmented purpura, is characterized by brown pigmentation with pepper spots on their edges. We summarize the epidemiology, pathogenesis, histologic features, and treatment choices for additional brown diseases, including melasma, pigmented purpuric dermatoses, postinflammatory hyperpigmentation, drug-induced hyperpigmentation, and pigmentations due to systemic or physiologic conditions.

The emerging importance of tranexamic acid in dermatology

Tranexamic acid (TA) is an antifibrinolytic agent, increasingly recognized as being of utility for a wide variety of skin diseases. We review the evidence supporting the use of TA for a range of dermatological indications, including (among others) melasma, postinflammatory hyperpigmentation, urticaria, angio-oedema and haemostasis, in addition to practical considerations of its use by dermatologists.

Combination therapy with salicylic acid chemical peels, glycyrrhizin compound, and vitamin C for Riehl's melanosis

BACKGROUND

Riehl's melanosis is a chronic, refractory disorder, which can adversely affect patient's quality of life. Intense pulse light, neodymium-doped yttrium aluminum garnet laser, hydroquinone, tranexamic acid have been reported to treat this disease, but there have been few reports on the effectiveness of other treatments.

AIM

To assess the efficacy and safety of triple combination therapy with salicylic acid chemical peels, oral glycyrrhizin compound, and vitamin C for Riehl's melanosis.

PATIENTS/METHODS

Three patients diagnosed with Riehl's melanosis were enrolled. All patients were treated with glycyrrhizin compound (150 mg/d), vitamin C (100 mg/d), and salicylic acid 30% peels once every 2 weeks. Clinical photographs and VISIA were used to assess the efficacy.

RESULTS

All patients received obvious improvement and reported no obvious side effects.

CONCLUSION

Triple combination therapy with salicylic acid peels, oral glycyrrhizin compound, and vitamin C is a safe and effective modality for Riehl's melanosis.