Melasma: Treatment strategy

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.

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.

Efficacy of topical cysteamine hydrochloride in treating melasma: a systematic review

INTRODUCTION

Melasma remains a recurrent, chronic, therapeutically challenging, and psychologically burdening condition. Several different modalities and approaches have been utilized, and some with notable success to experimentally manage the condition. Cysteamines, with their depigmentation properties, have only recently been intensely studied. One such formulation is the topical 5% cysteamine hydrochloride, the structure of which is notably more stable and with a less foul odor than its prior counterparts. We, therefore, aimed to assess the efficacy of the mentioned formulation in the treatment of melasma.

METHODS

The PubMed, SCOPUS, ISI Web of Science, and Embase, Cochrane, and Proquest databases were thoroughly searched for English studies evaluating the effects of the topical agent mentioned.

RESULTS

Eight studies (five RCTs, two case reports, and one case series) were included after three rounds of screening, most of which were carried out in Iran. Statistical significance was noted when assessing decreased melanin content and satisfaction rates.

CONCLUSIONS

It appears that the cysteamine cream could be comparably efficient in treating melasma while accompanied only by minor and transient adverse events. However, current evidence is limited by insufficient sample size, long-term follow-up, and only to epidermal melasma, highlighting the need for appropriately designed randomized controlled clinical trials to draw a conclusive image of the cysteamine's role in treating this recalcitrant condition.

Fractional Erbium:YAG Laser (2940 nm) plus Topical Hydroquinone Compared to Intradermal Tranexamic Acid plus Topical Hydroquinone for the Treatment of Refractory Melasma: A Randomized Controlled Trial

OBJECTIVES

Melasma is a chronic acquired condition characterized by grayish-brown macules and patches with a distinct border on the face. Although various treatments methods have been suggested for treating melasma, none has been completely successful. The aim of the study was to compare the efficiency of erbium: yttrium-aluminum-garnet (Er:YAG) laser and 4% hydroquinone (HQ) with the effects of intradermal tranexamic acid (TA) and 4% HQ for the treatment of refractory melasma.

METHODS

The study included 31 female patients with refractory melasma. The left or right side of the patient's face was chosen randomly to receive laser therapy with topical HQ on the one side (i.e., the laser side) and intradermal injection of TA plus topical HQ on the other side (i.e., the mesotherapy side). Digital photography was performed at baseline, at the end of the treatment, and three months after the treatment as follow-up. Two independent dermatologists evaluated the modified Melasma Area and Severity Index (mMASI) score according to the pictures. Overall, 27 patients completed the study and went through the clinical evaluation.

RESULTS

Treatment using HQ in combination with either Er:YAG laser therapy or intradermal injection of TA significantly improved the hemi-mMASI and resulted in higher patient satisfaction. While the improvement was not significantly different between the two regiments after the treatment and upon follow up and both were equally efficient in the treatment of refractory melasma (p = 1.308), recurrence rate was higher after treatment with Er:YAG laser than TA (12% vs 34%).

CONCLUSION

This study confirmed the comparable efficacy of TA plus topical HQ versus Er:YAG laser plus topical HQ for the treatment of refractory melasma. Both groups improved significantly and no subject left the treatment because of adverse effects.

The formulation and efficacy of topical Dorema ammoniacum in treating Melasma: a randomized double-blind, placebo-controlled trial

OBJECTIVES

An acquired melanin-related hyperpigmentation that occurs in sun exposure areas is Melasma which presents as gray-brown ridges and macules with prominent margins on the skin. The aim of this assay was to assess the formulation and efficacy of topical Dorema ammoniacum among Melasma patients.

METHODS

This study was a 30 days double-blind, randomized clinical trial in Melasma with a placebo group. The study was carried out on 49 patients with Melasma attending Haji Daii Nursing Center in Kermanshah, Iran. Optimized topical formulation of D. ammoniacum gum extract was prepared by evaluating the characteristics of different topical formulations of this plant. Mean Melasma severity index (MMASI) instrument was applied to assess the product effectiveness and to determine the skin stains. Patients were pursued to receive the treatment throughout the 30 days trial. This scaling was accomplished before the intervention and 30 days after the use of the herbal product. To analyze the quantitative variables, t-test and Mann-Whitney test were evaluated by SPSS 21 software, and p-value <0.05 was considered as the statistically significant.

RESULTS

The survey was performed on 40 female subjects (81.6%) and nine male subjects (18.4%) with the mean age of 32.18 ± 8.69. According to the results, the mean MSI in the drug group was significantly lower than before treatment and decreased from 86.98 ± 69.48 to 31.03 ± 32.62 (p-value <0.05).

CONCLUSIONS

In compliance with findings this survey revealed a positive effect of the cream formulation of D. ammoniacum extract on Melasma. As it was represented no side effects, this formulation is appropriate for the treatment of Melasma.

Combination of Hydroquinone and Fractional CO2 Laser versus Hydroquinone Monotherapy in Melasma Treatment: A Randomized, Single-blinded, Split-face Clinical Trial

Background:

Melasma is a chronic hyperpigmentation skin disorder mainly affecting women in the reproductive age. Available treatments for melasma do not lead to long-term satisfactory results.

Aims:

This study aimed to compare the efficacy of fractional CO₂ laser in combination with topical therapy to topical therapy alone.

Materials and Methods:

Forty women with bilateral melasma were studied in this randomized single-blinded clinical trial. Each side of the face was randomly allotted to either topical hydroquinone 4% or combination of topical hydroquinone 4% and fractional CO₂ laser. Patients received three sessions of laser therapy at 3-week intervals. Hydroquinone 4% application on both sides maintained for 3 months after the last laser session. The clinical improvement (darkness [D] and homogeneity [H] of hyperpigmentation) was measured by a blinded main investigator and an outcome assessor. Furthermore, improvement was assessed by physician's global assessment (PGA) and patient satisfaction (visual analog scale [VAS] score).

Results:

Significant reduction in D observed 3 weeks after combination therapy (P<0.001) and 6 weeks after monotherapy (P<0.001). Reduction in H became significant after 6 weeks in both groups (P<0.001). However, the two methods were not considerably different in any session (P>0.05). Furthermore, control and experiment sides were not significantly different considering VAS score and PGA (P>0.05).

Conclusion:

Considering the short-term outcome of laser and hydroquinone therapy, we can apply it to obtain earlier positive results. However, because of the lack of significant difference between the two methods and also the high cost of laser therapy, it seems better not to recommend fractional CO₂ laser to patients as adjunctive therapy for long-term treatment of melasma.

Oleoylethanolamide inhibits α-melanocyte stimulating hormone-stimulated melanogenesis via ERK, Akt and CREB signaling pathways in B16 melanoma cells

The present study aimed to examine the potential inhibitory activity of oleoylethanolamide (OEA) on α-melanocyte stimulating hormone (α-MSH)-stimulated melanogenesis and the molecular mechanism(s) involved in the process in B16 mouse melanoma cells. Our data demonstrated that OEA markedly inhibited melanin synthesis and tyrosinase activity in α-MSH-stimulated B16 cells. In addition, the expression of melanogenesis-related proteins, such as melanocortin-1 receptor (MC1R), microphthalmia-associated transcription factor (MITF), tyrosinase-related protein-1 (TRP-1) and tyrosinase, was suppressed in a concentration-dependent manner by OEA. In addition, OEA may suppress melanogenesis through a peroxisome proliferator-activated receptor α (PPARα)-independent pathway. Moreover, OEA activated ERK, Akt, p38 pathways and inhibits CREB pathway in α-MSH-stimulated B16 cells. The specific ERK inhibitor PD98059 partly blocked OEA-inhibited melanin synthesis and tyrosinase activity and partly abrogated the OEA-suppressed expression of melanogenic proteins. Furthermore, OEA presented remarkable inhibition on the body pigmentation in the zebrafish model system. Our findings demonstrated that OEA is an effective inhibitor of hyperpigmentation through activation of ERK, Akt and p38 pathways, inhibition of the CREB pathway, and subsequent down-regulation of MITF, TRP-1 and tyrosinase production.

A review of laser and light therapy in melasma

Melasma is a dysregulation of the homeostatic mechanisms that control skin pigmentation and excess pigment is produced. Traditional treatment approaches with topical medications and chemical peels are commonly used but due to the refractory and recurrent nature of melasma, patients often seek alternative treatment strategies such as laser and light therapy. Several types of laser and light therapy have been studied in the treatment of melasma. Intense pulsed light, low fluence Q-switched lasers, and non-ablative fractionated lasers are the most common lasers and light treatments that are currently performed. They all appear effective but there is a high level of recurrence with time and some techniques are associated with an increased risk for postinflammatory hyper- or hypopigmentation. The number and frequency of treatments varies by device type but overall, Q-switched lasers require the greatest number of treatment applications to see a benefit. Vascular-specific lasers do not appear to be effective for the treatment of melasma. Ablative fractionated lasers should be used with caution because they have a very high risk for postinflammatory hypo- and hyperpigmentation. The use of nonablative fractionated laser treatments compared with other laser and light options may result in slightly longer remission intervals. Picosecond lasers, fractional radiofrequency, and laser-assisted drug delivery are promising future approaches to treat melasma. The goal of this review is to summarize the efficacy and safety of the most commonly used laser and light therapies to treat melasma, briefly present future laser-based treatment options for patients with melasma, and provide recommendations for treatment on the basis of the reviewed information.

Reduction of facial pigmentation of melasma by topical lignin peroxidase: A novel fast-acting skin-lightening agent

The aim of the present study was to evaluate the efficacy and safety of lignin peroxidase (LIP) as a skin-lightening agent in patients with melasma. A self-controlled clinical study was performed in 31 women who had melasma on both sides of the face. This study involved 8 weeks of a full-face product treatment. The skin color was measured at days 0, 7, 28 and 56 using a chromameter on the forehead and cheeks. Standardized digital photographic images of each side of the face of all subjects were captured by a complexion analysis system. Clinical scores of the pigmentation were determined by two dermatologists. After using the LIP whitening lotion for 7 days, the luminance (L*) values of the melasma and the normal skin were significantly increased from baseline. The L* values continued to increase at days 28 and 56. The melasma area severity index (MASI) score was statistically decreased after 28 days of treatment. No treatment-related adverse events were observed. LIP whitening lotion was able to eliminate the skin pigmentation after 7 days of treatment, and provides a completely innovative approach to rapid skin lightening. The LIP whitening lotion exhibited good compatibility and was well tolerated.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Electronic supplementary material

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

Treatment of melasma in Caucasian patients using a novel 694-nm Q-switched ruby fractional laser

Background

Melasma is a common hypermelanosis of the face. The use of a classical Q-switched ruby laser (QSRL) to treat melasma is discussed controversially and is associated with frequent adverse effects, such as hyper- or hypopigmentation. Recently a fractional-mode (FRx) QSRL was developed to minimize the adverse effects of classical QSRL. The objective of this research was to evaluate the efficacy and safety of a novel FRx-QSRL in the treatment of melasma in Caucasian patients.

Methods

We performed a retrospective study of 25 Caucasian melasma patients (Fitzpatrick skin types I to III). Patients received one to three FRx-QSRL treatments (Tattoostar FRx, Asclepion Laser Technologies, Jena, Germany) at pulse energies of 4 to 8 J/cm². Three blinded investigators independently evaluated the melasma area and severity index (MASI) score before treatment and at the four- to six-week follow-ups. At additional three-month follow-ups, patients evaluated subjective improvement, pain and over-all satisfaction with the treatment according to a numeric analogue score (NAS). Side effects were documented.

Results

At four to six weeks post laser treatment for a mean of 1.4 sessions, we observed a significant (P = 0.0001) reduction of the MASI score from 6.54 to 1.98 (72.3%). Patients rated the pain of the intervention at a mean 2.46 points (0 = no pain; 10 = maximum pain), the improvement at a mean 5.55 points (0 = no improvement; 10 = maximum improvement) and the overall satisfaction at a mean 4.66 points (0 = not satisfied; 10 = maximum satisfaction). After three months, post-inflammatory hyperpigmentation (PIH) and/or recurring melasma were observed in 7 (28%) and 11 (44%) patients, respectively.

Conclusion

The 694-nm FRx-QSRL is a safe and effective option for treating melasma in Caucasian patients. Over periods of >3 months, PIH and/or recurring melasma may develop at significant rates and may reduce patient satisfaction. Multiple treatment sessions with lower pulse energies and/or a post-interventional therapy with hypopigmenting ointments and UV protection may help to minimize these complications.

Eupafolin, a skin whitening flavonoid isolated from Phyla nodiflora, downregulated melanogenesis: Role of MAPK and Akt pathways

ETHNOPHARMACOLOGICAL RELEVANCE

In hyperpigmentation disorders marked by melanin overproduction in the skin, including melisma and freckles, melanogenesis is caused by tyrosinase overexpression. Natural medicinal resources, like Phyla nodiflora, a traditional Chinese herbal medicine, have been used for a long time to management of dermatological conditions, such as skin inflammation and melanogenesis. Eupafolin, a functional flavonoid isolated from Phyla nodiflora, is an herbal tea constituent and possesses anti-inflammatory and anticancer activities. However, molecular mechanisms of eupafolin-mediated antimelanogenesis remain unknown. We thus focused on its antimelanogenesis effects in B16F10 mouse melanoma cells.

MATERIAL AND METHODS

B16F10 cells were treated with eupafolin (0.01, 0.1, 1, and 10μM) in a dose-escalation-dependent manner for the determination of melanin, tyrosinase activity and melanogenesis protein levels by ELISA or western blot analysis.

RESULTS

Eupafolin treatment significantly reduced cellular melanin content and tyrosinase activity in a dose-dependent manner (P<0.05), and no cytotoxic effects were observed. Eupafolin was associated with reduction in the levels of phospho-cAMP response element-binding protein and microphthalmia-associated transcription factor (MITF), and downregulation of tyrosinase synthesis and tyrosinase-related protein expression, leading to inhibit melanin production. In addition, eupafolin significantly induced the phosphorylation of ERK1/2 and p38 MAPK, whereas the decreased effect was observed in the phosphorylation of Akt. Moreover, inhibitors of these signals recovered or attenuated the inhibitory effects of eupafolin on melanogenesis.

CONCLUSIONS

Our results seem that inhibition of Akt and activation of phospho-ERK or p38 MAPK may lead to the suppression of melanogenesis in eupafolin-treated B16F10 mouse melanoma cells.

[6]-Shogaol inhibits melanogenesis in B16 mouse melanoma cells through activation of the ERK pathway

AIM

To investigate the effect of [6]-shogaol, an active ingredient in ginger, on melanogenesis and the underlying mechanisms.

METHODS

B16F10 mouse melanoma cells were tested. Cell viability was determined with the MTT assay. Melanin content and tyrosinase activity were analyzed with a spectrophotometer. The protein expression of tyrosinase and microphthalmia associated transcription factor (MITF), as well as phosphorylated or total ERK1/2 and Akt were measured using Western blot.

RESULTS

Treatment of the cells with [6]-shogaol (1, 5, 10 μmol/L) reduced the melanin content in a concentration-dependent manner. [6]-Shogaol (5 and 10 μmol/L) significantly decreased the intracellular tyrosinase activity, and markedly suppressed the expression levels of tyrosinase and MITF proteins in the cells. Furthermore, [6]-shogaol (10 μmol/L) activated ERK, which was known to negatively regulate melanin synthesis in these cells. Pretreatment with the specific ERK pathway inhibitor PD98059 (20 μmol/L) greatly attenuated the inhibition of melanin synthesis by [6]-shogaol (10 μmol/L).

CONCLUSION

The results demonstrate that [6]-shogaol inhibits melanogenesis in B16F10 mouse melanoma cells via activating the ERK pathway.

Melanogenesis Inhibitor(s) from Phyla nodiflora Extract

Overexpression of tyrosinase can cause excessive production of melanin and lead to hyperpigmentation disorders, including melasma and freckles. Recently, agents obtained from plants are being used as alternative medicines to downregulate tyrosinase synthesis and decrease melanin production. Phyla nodiflora Greene (Verbenaceae) is used as a folk medicine in Taiwanese for treating and preventing inflammatory diseases such as hepatitis and dermatitis. However, the antimelanogenesis activity and molecular biological mechanism underlying the activity of the methanolic extract of P. nodiflora (PNM) have not been investigated to date. Our results showed that PNM treatment was not cytotoxic and significantly reduced the cellular melanin content and tyrosinase activity in a dose-dependent manner (P < 0.05). Further, PNM exhibited a significant antimelanogenesis effect (P < 0.05) by reducing the levels of phospho-cAMP response element-binding protein and microphthalmia-associated transcription factor (MITF), inhibiting the synthesis of tyrosinase, tyrosinase-related protein-1 (TRP-1), and TRP-2, and decreasing the cellular melanin content. Moreover, PNM significantly activated the phosphorylation of mitogen-activated protein kinases, including phospho-extracellular signal-regulated kinase, c-Jun N-terminal kinase, and phospho-p38, and inhibited the synthesis of MITF, thus decreasing melanogenesis. These properties suggest that PNM could be used as a clinical and cosmetic skin-whitening agent to cure and/or prevent hyperpigmentation.