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.

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.

Update on Melasma-Part II: Treatment

Melasma is a prevalent chronic relapsing pigmentary disorder that affects photoexposed areas, especially in women of childbearing age. Although there is currently no curative treatment available for melasma, this manuscript critically reviews the knowledge regarding photoprotection, topical and oral therapies, and procedures such as peelings, laser, and microneedling that represent the main strategies for control and prevention of this disease. As the pathogenesis of melasma is not entirely understood, there are prospects for the development of new therapeutic strategies that might act on the pathways that promote sustained pigmentation rather than merely decreasing melanin synthesis and removing melanin from the epidermis.

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.

Systematic review of clinical studies assessing the needling for treatment of melasma: Focusing on efficacy, safety, and recurrence rate

BACKGROUND AND OBJECTIVE

Melasma is common, chronic and treatment-challenging cosmetic concern and the aim of this study was to systematically evaluate clinical studies assessing the treatment of melasma through needling while focusing on efficiency, safety, and recurrence.

METHOD

After e-search a total of 54 articles were reviewed and 12 published articles (February 2011-September 2020) in terms of content, topic, and purpose, were finalized. Articles were open pilot trials, case reports, case series, retrospective studies, quasi-experimental trials, randomized clinical trials, and split face comparative studies.

RESULTS

The highest decrease in MASI score was 85.71% and allocated to microneedling method following only 3 sessions with an interval of 30 days. On the other hand, the lowest decrease in this score was 3.7% and allocated to microneedling treatment and its use for vitamin C delivery at the end of the fourth week of treatment. No side effects were reported in included studies, and the various needling methods used were safe. Recurrence after treatment was reported in none of these articles, and only one of them reported a 4% recurrence in the second phase of treatment, but no recurrence was reported in the last phase of that study.

CONCLUSION

Non-aggressive microneedling with topical depigmenting agents was more effective than topical depigmenting agents alone, so that the mean MASI score was significantly higher than those who used lightening serum alone. So needling can be suggested as an effective and safe method with low recurrence rate for the treatment of 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.

Efficacy and Safety of Topical Therapy With Botanical Products for Melasma: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Botanical products have been increasingly popular in topical therapies for melasma, as presumed safer and milder than fully synthetic products. Although the efficacy of different topical botanicals has recently been substantiated through randomized controlled trials (RCTs), there is a lack of sufficiently pooled evidence on their efficacy and safety for the treatment of melasma. Herein, a systematic review and meta-analysis was conducted on the efficacy and safety of topical botanical products for the treatment of melasma, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). All RCTs on the use of topical botanical products for the treatment of melasma in humans were included, except for trials enrolling pregnant patients. The primary outcome was Melasma Area and Severity Index (MASI) or its variation. The secondary outcomes included Mexameter^® reading, melasma improvement evaluated by participants, and any reported adverse events (AEs). As a result, twelve eligible trials comprising 695 patients with melasma from 6 different countries were included. The topical botanical products contained active ingredients which varied among trials as follows: herb-derived molecule, extracts of a single herb, and extracts of compound herbs. Topical therapy with botanical products significantly improved melasma with a large effect on MASI reduction (SMD −0.79, 95% CI −1.14 to −0.44, p < 0.00001), and a moderate effect on Mexameter^® reading reduction (SMD −0.52, 95% CI −0.81 to 0.23, p = 0.0005), when compared with placebo. It also showed a similar improvement of melasma with a better safety profile (RR 0.37, 95% CI 0.15–0.88, p = 0.02), when compared with active-comparators. Botanical products were well-tolerated across studies, with no serious AEs reported. Despite the limitations such as small sample size, short duration of follow up and varied botanical products, this work still represents the best level of evidence currently available on topical use of botanical products on melasma. Moreover, it should be noted that more well-designed studies are needed before recommending topical botanical products as a viable treatment option for melasma.

Hyperpigmentation: Looking beyond hydroquinone

Hyperpigmentation is the most common complaint in the age group 40-45 years, seeking consultation for skin disorders. Hydroquinone is a commonly used depigmenting agent in clinical practice for treating hyperpigmentation. Prolonged use of hydroquinone has been associated with cancer risk and exogenous ochronosis. The CARES (The Coronavirus Aid, Relief, and Economic Security Act) Act of 2020 has instituted significant changes to hydroquinone containing OTC (over the counter) products, and consequently, many hydroquinone-based OTC products had to be withdrawn from the market. Henceforth, products containing hydroquinone would need US Food and Drug Administration approval via new drug application pathways for commercialization. Alternative treatment options to hydroquinone in clinical practice are reviewed in this paper with regard to their safety and efficacy vis a vis hydroquinone. Also, new potential treatment options such as thiamidol, Polypodium leucotomos, and glutathione are discussed. The review shows that these alternative depigmenting agents can be rationally combined to achieve desired treatment goals in the management of hyperpigmentation.

Lasers, lights, and compounds for melasma in aesthetics

Melasma is a chronic and relapsing skin condition. Although melasma is usually asymptomatic, it can be associated with immense psychosocial stress and greatly impact a patient's quality of life. Over the years, many different treatments have been used, ranging from daily photoprotection, topical lightening creams, and oral agents to laser and light-based therapies; however, efficacy is often limited with such treatments, and there is currently no effective modality to prevent recurrence. Although treatment strategies had originally centered on the use of hydroquinone, newer modalities now include oral tranexamic acid and lasers. We examined previous and ongoing debates related to melasma treatments and have reviewed the current efficacy and safety of available treatments. Critical components essential to the successful management of melasma are the setting of patient expectations and assurance of treatment compliance.

The pathogenesis of melasma and implications for treatment

BACKGROUND

Melasma is a complex and poorly understood disorder, with high rates of treatment failure and recurrences.

OBJECTIVES

We aimed to review the current knowledge of the pathogenesis of melasma and apply this knowledge to clinical implications on relevant therapeutic interventions.

METHODS

A systematic PubMed search was performed using the search term "((melasma[Text Word]) OR facial melanosis[Text Word]) AND (pathogenesis OR causality[MeSH Terms])" for articles published between 1990 and 2020. Included articles were then evaluated by two authors and assessed for relevant pathomechanistic pathways, after which they were divided into groups with minimal overlap. We then reviewed current treatment modalities for melasma and divided them according to the involved pathomechanistic pathway.

RESULTS

A total of 309 search results were retrieved among which 76 relevant articles were identified and reviewed. Five main pathomechanisms observed in melasma were identified: (1) melanocyte inappropriate activation; (2) aggregation of melanin and melanosomes in dermis and epidermis; (3a) increased mast cell count and (3b) solar elastosis; (4) altered basement membrane; and (5) increased vascularization. Treatment modalities were then divided based on these five pathways and detailed in 6 relevant tables.

CONCLUSION

The pathophysiology of melasma is multifactorial, resulting in treatment resistance and high recurrence rates. This wide variety of pathomechanisms should ideally be addressed separately in the treatment regimen in order to maximize results.

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.

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.